Of missing voices and the obstetric imaginary: commentary on Jankowski and Burcher.

In this commentary, I respond to an ethical analysis of a case study, reported by Jankowski and Burcher, in which a woman gives birth to an infant with a known heart anomaly of unknown severity, at home, attended by a midwife. Jankowski and Burcher argue that the midwife who attended this family acted unethically because she knowingly operated outside of her scope of practice. While I agree that the authors' conclusions are well supported by the portion of the story they were able to gather, the fact that the midwife and mother declined to engage in the ethics consult that informs their piece means that critical segments of the narrative are left untold. Some important additional considerations emerge from these silences. I explore the implicit assumptions of the biotechnical embrace, the roles of the political economy of hope and the obstetric imaginary in driving prenatal testing, and institutional blame for the divisiveness of the home-hospital divide in the United States. The value of Jankowski and Burcher's case study lies in its ability to highlight the intersections and potential conflicts between the principles of beneficence, patients' autonomy, and professional ethics, and to begin to chart a course for us through them.