“Harms of Formula” Vs “Benefits of Breastfeeding” : Why we don’t “know” how to talk about the effects of different ways of feeding babies

By Fiona Woollard

I’m sitting in a room filled with people who care deeply about mothers and babies.  Many of them have dedicated their lives to improving support for new mothers to have the chance to feed their babies in the way they want.  Someone is talking about cuts to breastfeeding support or about information provided to parents about health benefits of breastfeeding.  Then the speaker adds, almost as an aside, “Of course, we know that it is really ‘the harms of formula’ not ‘the benefits of breastfeeding’.”  There is a general nodding of heads.  It seems to be accepted by almost everyone in the room that this is something that we know.  It is ‘known’ that any differences in outcomes between babies fed with infant formula and breastfed babies should be described as ‘harms of formula’.

I’ve watched this scene many times.

As a philosopher, I feel a sort of territorial annoyance.  This is a deeply complex philosophical question.  It is not something that we should confidently claim to know as if there were a simple answer.

As a mother who has both breastfed and used formula, I feel worried about the effects the use of harm and risk based language may have on vulnerable new mothers.

Whether we frame infant feeding decisions in terms of harming or benefit, protection or risk matters because these distinctions are generally morally significant.  There are much stronger constraints against harming or risking harm than against merely failing to benefit.  To describe a mother as ‘harming’ or ‘risking harm’ to her baby is to present her as infringing the very strong duty not to harm or risk harm.  It is to suggest that she should feel guilty.

Guilt for using infant formula is widespread and can be devastating.  Describing infant formula as harmful is not only likely to contribute to mothers’ guilt for using infant formula; it has an even more insidious effect by suggesting that guilt is appropriate. If guilt about using formula is seen as appropriate, then its effects on maternal wellbeing may be wrongly dismissed as morally unimportant.

For all these reasons, we should be very careful about using morally loaded terms like, ‘harm’ and ‘risk’ to describe the use of formula.

The general acceptance of harm-based language traces back to Diane Weissinger’s hugely influential article “Watch Your Language”.  Weissinger argues that health comparisons always use a biological norm as the baseline for comparison.  Breastfeeding is the biological norm. Talking about the benefits of breastfeeding treats formula as the baseline.  Weissinger argues we should treat breastfeeding as the baseline and talk about the harms of formula.

Weissinger’s interpretation of public health practice and of anthropology has been challenged.  However, as I argue in my paper, even if she is right about general practice, this does not settle how we should talk about formula.  Because breastfeeding deeply implicates the mother’s body and agency, positioning breastfeeding as the moral baseline is problematic even if it is the biological norm.  To do so takes the mother’s body and agency for granted. It does not fit with our use of the concepts of harm and benefit in other situations.  In general, we think of harming someone as making them worse off than a neutral state of non-interference.  Even if it is the biological norm, breastfeeding cannot be characterised as a neutral state of non-interference.

Applying the harm/ benefit distinction to infant feeding decisions is extremely difficult.  Like many moral concepts, the harm/ benefit distinction is designed for interactions between independent adults who can, by and large, leave each other alone in a neutral state of non- interference. We don’t have this kind of baseline state of non-interference when it comes to mothers and infants.

So we don’t know that it is correct to refer to “the harms of formula” rather than “the benefits of breastfeeding”.  Both ways of talking are philosophically worrying because they appeal to a harm benefit/ distinction that doesn’t apply well in this context.

Pragmatic considerations don’t provide an easy answer either.  Just as those who use infant formula (and those who care about them) have reason to object to framing infant formula as harmful, breastfeeding mothers and supporters have reason to object to framing breastfeeding as ‘beneficial’.

Helen Calvert has written movingly on support for breastfeeding on the children’s wards in hospitals.  She connects the ‘Breast is best’ rhetoric to an attitude that breastfeeding is an optional extra which mothers cannot expect busy health professionals to do much to support.

Framing breastfeeding as beneficial may discourage mothers who are failed by insufficient support to become angry and to demand better support.  If we see ourselves as having lost out on the ‘best’ then we might not see this as a big problem.

And, of course, this isn’t a simple case of the interests of one group of mothers (formula feeders) versus the interests of a completely separate group (breastfeeders): one and the same mother may both use formula and breastfeed, either at the same time or at different times.


Paper title: Should we talk about the ‘benefits’ of breastfeeding? The significance of the default in representations of infant feeding

Author(s): Fiona Woollard

Affiliations: University of Southampton

Competing interests: None.

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