Down the rabbit hole of ‘reasonable’

Before investigating whether vaginal birth is a reasonable option for women with a breech baby at term (for my undergraduate midwifery dissertation) I should really understand what constitutes ‘reasonable’. Or could I just presume a consensus understanding of the term and get to bed at a reasonable time?

You know you’ve fallen down a rabbit hole hole when you’re reading papers like Credo of a ‘reasonable choice’ modeler by A. Wuffle (1999) and Reasonable doubts about rational choices (Houghton, 1995) in theoretical politics and philosophy journals, alone in the hospital library at 00.00 hours. I guess this is the type of thing I should have defined upfront, before doing my meticulously methodical and transparently replicable (ahem) literature search.

Back to Wuffle.

According to political scientist, Wuffle, ‘reasonable’ and ‘rational’ are related, but distinct, theoretical bedfellows. He thinks that ‘most human behaviour is rational; some isn’t’ and in his highly original and entertaining paper he proffers ‘reasonable choice’ as a middle ground between the dogma of rational choice models that ‘explain’ all aspects of human behavior, and other political science work which suggests rational choice is utterly useless at explaining human behaviour.

Houghton (1995) too, considers some problems with rational choice or rational decision-making. He assumes that people want to make the best choices and that those choices ‘have to do with what will bring greater net benefit or have greater net value than any alternative course of action available’. Interestingly for my midwifely quest, he suggests that we are more likely to make the best choices if we make informed choices (informed choice being an essential tenet of midwifery) although he goes on to argue that the best choices need not and cannot be the best-informed choices. Houghton is intrigued by the nuances of decision-making and information gathering. He suggests that in order to arrive at decisions, the rational decision-maker would survey possibilities and rank them in order of preference, assessing the likelihood of each, considering all possibilities and outcomes – which is not possible as these would be infinite, leading to an unsatisfyingly inconclusive hole within a hole: that reasonable choices are essentially, unreasoned.

Curiouser and curiouser…

By wondering if ‘reasonable’ is essentially borrowed from law, I find myself in a common law part of the warren, where ‘reasonable’ is used in relation to behaviour that is seen as ‘uniform, foreseeable and neutral’.

Trying to get to the maternity department, I make a detour via the Equality and Human Rights Commission’s sensible discussion of what is meant by ‘reasonable’, this time in relation to adjustments made by employers to accommodate disabled workers. Although their definition of what is considered reasonable relates to workplace issues, I see how the concept is multifactorial and dependent on the individual situation. In the case of adjustments, what is reasonable ‘will depend on all the circumstances of the case including the size of an organisation and its resources, what is practicable, the effectiveness of what is being proposed and the likely disruption that would be caused by taking the measure in question as well as the availability of financial assistance’ (Equality and Human Rights Commission)

In order to apply this multifaceted approach to ‘reasonable’ in a maternity context – specifically breech decision making – I visit the US Department of Health and Human Services Consensus Development Program, which produces unbiased, evidence-based assessments of controversial medical issues important to researchers, healthcare providers, policymakers, patients, and the general public. They don’t have a consensus statement on breech, but their consensus statement on Vaginal Birth After Caesarean (VBAC) is gratifyingly enlightening, as VBAC is a comparable dilemma to breech for the woman, as well as practitioners, in which ‘benefits for her may come at the price of increased risk for the baby, and vice versa’ (NIH, 2010)

To assess if VBAC (read vaginal breech birth) is a reasonable choice, the NIH panel recommends using responses to the following 6 questions (especially 3 and 4) to incorporate an evidence-based approach into the decision making process and the woman’s preference should be honoured.

Medical-legal considerations add to the barriers to VBAC (read vaginal breech birth).

(For the purpose of my investigation into what constitutes a reasonable birth choice for women with a term breech baby, I have replaced ‘VBAC/trial of labour after previous caesarean’ with ‘vaginal breech birth’. The rest of the wording is unchanged)

1. What are the rates and patterns of vaginal breech birth in UK?
2. Among women who plan vaginal breech birth, what is the vaginal birth rate and the factors that influence it?
3. What are the short- and long-term benefits and harms to the mother of attempting vaginal breech birth versus planned caesarean section, and what factors influence benefits and harms?
4. What are the short- and long-term benefits and harms to the baby of vaginal breech birth versus planned caesarean section, and what factors influence benefits and harms?
5. What are the nonmedical factors that influence the patterns and utilization of vaginal breech birth?
6. What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

This is an interesting framework for assessing ‘reasonable option’ as it asks about gaps in the evidence and non-medical factors as well as considering the existing and emerging evidence base. And it’s how I find my way out of philosophy and theoretical science, back to the outcomes that matter to women when making choices and to maternity in offering choices.

I now understand that ‘reasonable option’ is closely related to informed choice, the bedrock of our maternity system, which supposedly puts the woman at the centre of care, empowered to make decisions about her individual pregnancy and birth options, based on reliable evidence that has been presented in a balanced unbiased way, right?

Wrong. In reality options are presented in a way that belies real choice. I mean, when women with breech presenting babies at term are offered only ECV or planned caesarean section because no one is able (or willing) to support vaginal breech birth, could there possibly be a reasonable option missing? Is true choice being offered and delivered?

MIDIRS informed choice leaflets (2008) were an excellent resource for midwives and women for reliable evidence based information to support maternal choice and decision making, although sadly they are not being updated or republished. The breech leaflet clearly sets out options in a balanced way, taking into account some of the variables within the available information, including planned location for the birth and availability of skilled attendants. These variables are consistent with an evidence-based approach to decision making recommended by the NIH consensus statement on VBAC.

Decision Making in Midwifery Practice (Raynor, Marshall and Sullivan, 2005) could have been a more relevant place to start, but I’m here now, back on ground level, via theoretical science, philosophy, common law and equallity and human rights.

Blinking in the light, I emerge unsure if that was a useful exercise or just an excellent bit of procrastination. But at least now I can return to frantic colour-coding of themes in studies with highlighter pens, safe in the knowledge that I have investigated ‘reasonable’ to death.