Press Secretaries and Prenatal Diagnosis

The prevailing psychological paradigm views the human mind as two different interacting agencies – the unconscious and the conscious. The influence of the unconscious on the conscious mind began receiving scientific attention in the 19th century, reaching a critical juncture with Sigmund Freud’s deep dive into the murky and lurid waters of the unconscious. While many of Freud’s theories have not stood the test of time, his core concept that our unconscious mind is driven by darker instincts that our conscious mind tries to cover over is still widely accepted. And, in a sort of cosmic joke, it is extraordinarily difficult for us to know our own minds because our brains were shaped by evolution to deceive us into thinking we are good people who are conscientious members of society. We are really good at lying to, and believing, ourselves. I like the imagery employed in Kevin Simler’s and Robin Hanson’s recently published book The Elephant in The Brain that compares the conscious mind to a press secretary that tries to positively portray the less saintly aspects of the unconscious mind. Think of a governmental press secretary who has to explain a leader’s questionable statements and decisions without always being aware of what the leader is saying or doing.

So what does the deep mind and its personal Press Secretary have to do with genetic counseling? Well, a lot actually. In previous posts, I have discussed how the unconscious mind can influence genetic counselors’ perceptions of their conflicts of interest, how the pauses in a conversation between speakers can subliminally communicate meaning, and how I sometimes struggle to not let my darker thoughts insinuate themselves into my interactions with patients. In this posting, I look at the role of the unconscious mind in patients’ decisions to accept an offer of prenatal screening for Down syndrome and in deciding whether to continue a pregnancy in which a fetus has been diagnosed with this condition.

There is a common and deep negative attitude toward people with disabilities, even among their care providers, that sometimes borders on fear. Pick your reasons for this – ego threat, announcing to the world your reproductive unfitness, an assault on your concept of an ideal child and family, selfishness to prevent the loss of how you want your life to play out, rejection of those different from us. Readers more astute than I at probing the unconscious can probably think of others. This negative attitude is the driving engine of the prenatal screening train – given a choice, many people do not want to raise a child who will have significant cognitive or physical impairments. Some of this stems from misunderstanding and misinformation about disability. But decisions are typically based on the darker motives of the unconscious mind, not on information.

Here is where the Press Secretary comes in to play. People prefer not to admit to these less socially acceptable thoughts. Instead, they manufacture very plausible explanations to justify their decisions. Mind you, I am not implying that people are liars, hypocrites, or morally derelict. Rather, the unconscious mind usually rules the roost and leaves it to the Press Secretary to put a positive spin on it. This is how the human mind works, and it is crucial to understanding how patients make difficult and morally ambiguous decisions. It is like a role reversal in the Wizard of Oz.* Professor Marvel, Acclaimed by the Crown Heads of Europe, isn’t behind the curtain. Instead, the flaming, smoking, blustering, self-important gigantic head of The Great and Terrible Oz is back there. Oz doesn’t have the heart or courage to fight the Wicked Witch of the West and manipulates Professor Marvel to impart the task to Dorothy the Small and Meek (and, yes, Toto too). Professor Marvel is a bad wizard trying to pass himself off as a good man.

 

For example, what I often heard from patients as an underlying reason for a decision to proceed with testing or terminations shifted the focus from darker to more personally and socially acceptable reasons:

  • “We wouldn’t want our other children to bear the burden of caring for a disabled sibling after we are gone.”
  • “It would be unfair to our other children if we had to devote so much attention to a disabled sibling.”
  • “My doctor thinks it is the right thing to do and really wants me to have the test.”
  • “The world can be cruel to people who are different. I remember how a boy with Down syndrome was mercilessly teased in my neighborhood when I was growing up. I would not want to put my child through that.”
  • “It would put too much of a strain on our marriage. I know I could deal with it, but it would be devastating to my spouse.”
  • “I want to take advantage of advances in medical testing and information to make sure my baby is healthy.”

As a counselor, there is nothing to be gained from criticizing any of these as being invalid justifications. Indeed there is a measure of truth to them that provides plausibility. Patients are not concocting nonsense reasons or blatant falsehoods. But they also transform the less desirable urges of the unconscious mind into a message that allows the conscious mind to maintain its self-image of a Good Person and to avoid the negative judgment of family, friends, and social networks. On top of this, a well-oiled medical and economic machinery capitalizes on negative attitudes toward disability and reinforces the idea that prenatal screening is a wise choice for responsible parents.

This also has implications for critics of prenatal testing who claim that if pregnant women better understood the quality of the lives of people with disabilities, then more people would reject prenatal screening. This is true only to an extent. The unconscious mind is not usually persuaded by mere facts and will ignore them, reframe “truth” to make it more compatible with the motives of the unconscious, or filter out the parts that it doesn’t want to hear. Bias against physically and cognitively different people is found in all cultures and over time, though there is variation as to which conditions are the focus of a society’s prejudices and fears. People with albinism have been traditionally well-integrated into Hopi society and often play special roles in ceremonial dances; in parts of Africa they fear for their lives. Education alone is unlikely to alter attitudes. Change will require large-scale cultural shifts in views towards specific disabilities and conditions.

Unless we appreciate how the unconscious mind drives behavior and choices, we will never understand our patients – or ourselves.


  • – The day after I drafted an early version of this posting, I came across the same allusion to the Wizard of Oz in Leonard Mlodinow’s Subliminal – How Your Unconscious Mind Rules Your BehaviorIncidentally, in L. Frank Baum’s Oz books, Professor Marvel explains that his full name is Oscar Zoroaster Phadrig Isaac Norman Henkle Emmannuel Ambroise Diggs, the acronym of which is OZPINHEAD. In yet one more example of bias towards people with disabilities, he chose his name by using the first two letters of that acronym – Oz – and dropping the “pinhead” part.

4 Comments

Filed under Robert Resta

4 responses to “Press Secretaries and Prenatal Diagnosis

  1. Mike

    Hi Bob,

    Interesting post. I actually think it’s important for us to go deeper with our patients/clients and perhaps unearth some of those ‘dark thoughts’ about their decision. It’s harder to put it into practice because we often see the obvious discomfort in going down that path, and none of us want to make our patient’s/clients feel bad. Additionally, I think we need to be wary of thinking we are so important that a woman needs to ‘justify’ her decision to us.

    But my bigger question is: what shall we do when we unearth these biases? Tell people they need to be corrected? After all, ‘bias’ is pretty much universally considered a bad thing. And are we to assume that if ‘bias’ is eliminated, nobody will terminate an affected pregnancy?

    Some of these questions are rhetorical but they were what came to mind.

    • Robert Resta

      Mike

      It is a dilemma, and, as such, I don’t have a pat answer. In my experience, patients typically offer these justifications spontaneously. It’s not as if we force them to explain their decisions. They are just being human, like the rest of us. I would never attempt to correct a bias (other than blatant misunderstandings of the nature of a condition, such as saying something like “Most babies with anencephaly survive a long time.”). Really, the goal of the posting is to help counselors recognize the deeper layers to patient’s decisions.

      Thanks for sharing your thoughtful thoughts.

  2. Seth

    Thanks for the post Bob,

    What you’re describing is a coping mechanism. Carl Rogers talked about it as incongruence. The need for such a mechanism only occurs when there is incongruence between the person’s action and the person’s beliefs. If a person believes they are making the right choice, there should be no need to apply this mechanism. Indeed, the goal of genetic counseling in my mind is to ensure that patients have the information they need to make the decision they feel is best aligned with their own personal beliefs, and put the press secretary out of a job. There are at least three exceptions to this though. Those who must make a decision they do not agree with, those who feel they made the wrong decision, and those who are being otherwise directed or coerced. The latter is something we all try to watch for and address. As genetic counselors it is also our job to minimize the first two and help patients understand their motivations, come to peace with them, and avoid regret whenever possible. Sometimes we can, and sometimes we can’t. If the reasons you mentioned are given after effective counseling, I have to believe they represent the patient’s true beliefs and not a guise, or at least the best way they have identified to cope.

    Societal bias is changing too. These days, as social media continues to narrow our social networks, societal bias may be more aptly described as social circle bias?

    Just my thoughts.

    • Robert Resta

      Seth

      You are right that it is a coping mechanism. Probably some regret over a difficult decision will always linger, but we want to try to reduce regret and help them manage their complicated emotional reactions to their decisions. I thin that having an understanding of how the unconscious mind works can be helpful to those ends. Though I don’t think we will ever put the Press Secretary on the Neurological Unemployment Line.

      Bob

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