Before taking a stab at an answer, let’s consider a piece of evidence that people do care about things besides obtaining pleasure and avoiding pain. The evidence is provided by the way people would choose between ordinary life and a certain hypothetical life dreamed up by the philosopher Robert Nozick. Suppose that instead of going on with your life as usual, you had a chance to plug into an "experience machine”—a machine that "fed” your brain a virtual reality that induced extreme happiness. Though you would really be lying on a table connected to the computer by hundreds of wires, you’d feel as if you were climbing Mt. Everest, or winning the Nobel Prize, or swimming with dolphins. And these particular experiences wouldn’t be foisted upon you: before you plugged in, you would have a chance to order up exactly the virtual reality that you desired. It all sounds quite enticing, but despite being given the chance to experience the life of their dreams, Nozick says most people wouldn’t plug in. He thinks this demonstrates two things: that most of us don’t just care about pain and pleasure, or happiness and misery; and that we do care about something else—namely, contact with reality.

In Nozick’s thought experiment, pleasure comes from a computer-generated virtual reality instead of from real life. But Nozick could have revealed the same truths—that we care about pleasure but also about contact with reality—using a thought experiment involving drugs instead of virtual reality. Suppose you were offered a choice between going on with life as usual and going on while receiving a continual, steady dose of a drug I will call "Happy All the Time” (HAT, for short). HAT would keep you feeling good no matter what. On HAT, you would feel happy if you burned the toast; happy if your dog died; happy if your leg was mangled in the lawnmower; happy if your house burned down.

In Nozick’s original thought experiment, your choice is between a happier life swimming with virtual dolphins and an ordinary life, where the dolphins are real but the water is painfully cold. In the HAT thought experiment, you get real dolphins and real cold water, but the cold water makes you happy, like everything else does. If you wouldn’t opt for HAT, that shows you don’t care only about pain and pleasure, happiness and misery, but it shows more. The best available explanation seems to be that we would reject HAT because we care about contact with reality. A person who is happy despite his beloved dog dying is not really in contact with his dog dying, or is at least in much less contact—he would probably think about the death much less and not notice as many features of it. You might even say the HAT user doesn’t perceive the badness of the death, like a color-blind person doesn’t see the redness of an apple.

What does this have to do with natural childbirth? Well, a perfectly effective epidural is a bit like short-term HAT—it’s like HAT for the period of time when your child is being born. And like HAT, an epidural reduces contact with at least some aspects of the birth process. It stops a woman from registering every millimeter of cervical dilation, every inch of the baby’s journey out into the world, every bit of pressure on surrounding organs and bones, every single tear. An epidural allows a woman to focus happily on her baby emerging and to be unaware of the various costs to her body of that emergence. The fact that some women do choose natural childbirth shows the same thing as Nozick’s famous thought experiment: we care about more than just pain and pleasure; we also care about having contact with reality.

If at least most of us do want contact with reality—we wouldn’t hook up to the experience machine or go permanently on HAT— and natural childbirth offers more contact, then why doesn’t everyone choose it? The answer, I think, is that they actually do—up to a point. Most women choose a more natural type of childbirth than they would, if pain avoidance were the only consideration. I don’t know of any women who would want to be knocked out for the duration of the delivery; and most would rather not be completely numb from the waist down. Many don’t want to be draped so that the goings-on are concealed from view. Mothers want to experience childbirth in a first-person fashion; they want to experience it as happening in their own bodies, not in the third-person way their partners do. Since pain relief reduces the experience of the birth process, just about everyone is concerned to avoid excessive, contact-obliterating medication.

What’s distinctive about the 10 percent or so who choose completely natural childbirth is not what they value—they value what everyone values—but the unusual way they weigh avoiding pain versus maintaining contact. They prioritize contact with birth realities over pain avoidance much more consistently than the other 90 percent do. Natural birth choosers want to be first-person aware of every aspect of the birth process, even if painfully aware, whereas others are satisfied to be first-person aware of the key events. Or at least this describes many of them. Others choose natural childbirth for health reasons, not to secure a certain sort of experience for themselves; they believe epidurals can have a negative impact on a baby’s health (a possibility I am setting aside here).

Anesthesia during surgery obliterates all awareness that you are having surgery—you lose contact with the truth that your gall bladder is being cut out of your abdomen. Analgesia afterwards obliterates awareness that you have a fresh incision and discombobulated internal organs—you lose contact with those realities. An epidural during delivery provides an appealing sort of pain control partly because it preserves some awareness—but not awareness of every single thing that’s going on. Gone is the perception of most of the pressure and stretching, the tears and abrasions. But what if a perfectly awareness-preserving epidural were available, one that obliterated none of the goings on, but merely converted pain to nonpain or even to pleasure?

When I was discussing HAT, I said you can’t really be in contact with the fact that your beloved dog died, if HAT makes you happy about it. A happy reaction to his death is like seeing carrots as being blue—it’s a misperception, a departure from reality. Can you really be in full contact with the fact that an eight-pound baby is coming out of your body if you’re aware of every aspect of her emergence, including the rips and tears, but the awareness is entirely pain free? Arguably, perfect pain relief, even if perfectly awareness preserving, would have to rob a person of some contact with reality, like HAT robs you of contact when it makes you respond joyfully or neutrally to your dog’s premature demise. So we should expect those who choose natural birth to reject not just real-world pain relief, which reduces awareness as well as pain, but also perfect pain relief, the imaginary kind that preserves perfect awareness but only eliminates pain itself.

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