Ethical Issues Project
Ethical Decision – Making in Nursing
NURS 412
Old Dominion University
In our current national environment there are numerous ethical and legal dilemmas associated with the opioid crisis. No one among them is as heated a debate than the screening of pregnant woman for illicit drug use and what to do with them if they test positive. The federal Treatment Act and child abuse prevention laws mandate all states to have policies in place notifying Social Services of any newborns testing positive for illegal substances (Terplan and Minkoff, 2017). I have been indirectly affected by this ethical situation working at Boxwood detox. I have worked with women, who a few days after delivery, were forces by the state of Virginia into a treatment program due to their addictions, and their newborns placed in foster care until proof of abstinence was met. One young lady was so devastated and distraught being separated from her baby, she was extremely emotionally upset. It was difficult for her to focus on treatment when she was so newly postpartum. In general there is still a misunderstanding about addiction and substance use in the medical profession complicated by the inclusion of mothers and infants (Price, Collier, and Wright, 2018). I will hypothetically review this ethical dilemma and show there are more humane and therapeutic alternatives in the handling of pregnant woman with addictions than criminalization.
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Substance use disorders (SUD) occurs in every socio-economic class and in every culture (Wright, et al., 2016) (Price, et al., 2018). An estimated 10% of all births in the United States are impacted by illegal drug use or alcohol use (Price, et al., 2018). Substance abuse during pregnancy is as common place today as numerous other medical issues identified through routine screenings (Wright, Terplan, Ondersma, Boyce, Yoners, Chang and Creanga, 2016) (Price et al., 2018). There is no universal screening questionnaire given to all pregnant woman. Screening is bases on whether a clinician believes there are preexisting risk factors, to include late prenatal care and prior low birth weights, which has developed into stereotyping and discrimination against woman of color and woman living in poverty (Stone, 2015) (Wright, et al., 2016) (Hui, Angelotta, and Fisher, 2017). Urine testing and toxicology reports are done to detect SUDs leading to possible legal consequences for the woman and her family (Wright, et al., 2016) (Price, et al., 2018). The individual’s Fourteenth Amendment rights may be violated by drug testing in pregnancy with it possibly being interrupted as unreasonable search and seizure (Hui, et al. 2017). The current approach to SUDs in pregnancy deters woman from seeking out prenatal care due to possible punitive outcomes (Wright, et al., 2016) (Angelotta, and Appelbaum, 2017) (Price, et al., 2018). The principle of “respect for autonomy” with consideration for the patient to be treated in an environment which empowers them to make informed decisions is violated when the patient perceives barriers to care (Price, et al., 2018).
There are numerous stakeholders involved in this ethical and legal dilemma. The state and local governments, obstetricians, pediatricians, nurses in the birthing centers, pharmacists/scientists, social services, foster care families, law enforcement, and the families of the pregnant addict. Currently, 18 states in the U.S. interrupt substance abuse while pregnant as child abuse and three states use it as the bases for civil prosecution (Angelotta and Appelbaum, 2017) (Terplan and Minkoff, 2017). A lack of collaboration between physicians and pharmacists/scientists to develop good valid detection testing, along with lack of agreement on when the testing should be done, who should be tested, “with” or “without” consent and how the results are to be used adds layers of complications to the dilemma (Price, et al., 2018). Most healthcare professionals are poorly trained on how to treat individuals with SUDs (Wright, et al., 2016) (Price, et al., 2018). The therapeutic alliance between doctors, nurses and their patients are threatened when a punitive approach is taken (Wright, et al., 2016) (Campbell, 2018). Physicians, and nurses are mandated to report illicit drug use by their pregnant patients, inadvertently becoming agents of the state (Wright, et al., 2016) (Hui, et al., 2017) (Campbell, 2018). These requirements are in direct conflict with the ethical principle “do no harm” the responsibility of a nurse to reduce harm and provide care that does not coerce, stigmatize or criminalize (Campbell, 2018). Obstetricians and pediatricians are in the best positions to intervene at the beginning of treatment, starting a process of assistance with recovery for the mother and child, minimizing the impact of damage on the entire family (Terplan and Minkoff, 2017) (Campbell, 2018). In birthing centers nurses are conflicted between the best interests of two patients, with the priority falling toward protection of the child (Price, et al., 2018). Social workers become responsible for placing infants either with other family members, or into an overburdened foster care system (Terplan and Minkoff, 2017) (Price et al., 2018). The legal consequences and the involvement of law enforcement increases the mental and financial stress with the addition of court costs and loss of income if the mother is incarcerated (Price, et all, 2018).
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Addicted pregnant woman have been found guilty and charged with any number of criminal acts by state and local governments ranging from illicit substance use while pregnant, child abuse, assault, manslaughter and murder (Angelotta and Appelbaum, 2017). Many of the states who choose to prosecute addicted pregnant women also don’t have the resources to address their drug treatment needs (Campbell, 2018). The punitive response to the addicted pregnant woman is thought by the government to have some motivating force toward abstinence promoting the common good, but no evidence of improved outcomes for the mother or the newborn have been proven (Hui, et al., 2017). One alternative approach to the treatment of individuals with SUD’s while pregnant is through an early mediation process of screening, brief intervention (BI), and referral to treatment (SBIRT) (Wright et al., 2016). Screening all patients using an assessment questionnaire about their SUD use, combined with patient-centered counseling sessions to encourage behavioral changes is BI, and providing referrals for specialized treatment for detoxing pregnant woman is the final piece to completing the SBIRT process (Wright et al., 2016). The use of SBIRT as part of perinatal care reduces the consequences of untreated substance abuse while pregnant and the risk to the infant at delivery (Wright et al., 2016). Several studies and clinical trials have been completed supporting the benefits of SBIRT showing improved birth outcomes, incidences of low birthweight have been reduced, minimizing the occurrences of premature labor and reducing the need for neonatal intensive care (Wright et al., 2016).
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Another treatment option is based on the principles of harm reduction, Perinatal Addiction Treatment Clinics (PATH) which provide addiction treatment, perinatal care, family planning, child-care, social services, job training and transportation (Hui et al., 2017) (Price et al., 2018). SUDs are part of a bigger picture which requires support of the whole person and family by the community (Hui et al., 2017). The PATH approach has produced better pregnancy outcomes, lower rates of illicit drug use, increased self-esteems, and improved parenting skills (Price et.al. 2018). Therapeutic alliances between physicians, clinicians and their pregnant patients demonstrate the ethical principal of “respect for the person”, a shared responsibility for healthy babies reducing the medicalization, criminalization and stigmatization of SUDs for woman (Wright et al., 2016) (Campbell, 2018) (Price et al., 2018).
References
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Angelotta, C. and Appelbaum, P. S. (2017). Criminal charges for child harm from substance use in pregnancy. The Journal of American Academy of Psychiatry and the Law. (Vol. 5).
Campbell, N. D. (2018). When should screening and surveillance be used during pregnancy? Medicine and society. American Medical Association Journal of Ethics. (Vol. 20). (pp. 288-295) Retrieved from http://www.amajournalofethics.org
Hui, K., Angelotta, C. and Fisher, C. E. (2017). Criminalizing substance use in pregnancy: misplaced priorities. Society for the Study of Addiction. doi: 10.1111/add.13776
Price, H. R., Collier, A. C., and Wright, T. E. (2018). Screening pregnant women and their neonates for illicit drug use: Consideration of the integrated technical, medical, ethical, legal, and social issues. Frontiers in Pharmacology. doi: 10.3389/fphar.208.00961
Stone, R. (2015). Pregnant women and substance use: fear, stigma, and barriers to care. Health & Justice, a Springer Open Journal. Lowell, MA. doi: 10.1186/e40352-015-0015-5
Terplan, M. and Minkoff, H. (2017). Neonatal abstinence syndrome and ethical approaches to the identification of pregnant women who use drugs. The American College of Obstetricians and Gynecologists. Wolters Kluwer Health, Inc. (Vol.129). (pp. 164–167). doi: 10.1097/AOG.0000000000001781
Wright, T. E., Terplan, M., Ondersma, S. J., Boyce, C., Yonkers, K., Chang, G., and Creanga, A. A. (2016). The role of screening, brief intervention and referral to treatment in the perinatal period. Special Report. American Journal of Obstetrics and Gynecology. (pp. 539-547). doi: 10.1016/j.ajog.2016.06.038