Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether doctors should report a mother's prenatal drug use.
Yes: 49%
No: 51%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt adapted from his book, .
Among pregnant women, many activities may have an impact on fetal life or health. Alcohol exposure in utero can cause intellectual disabilities in offspring. Smoking cigarettes can lead to miscarriages and underweight babies. The use of common pharmaceuticals can result in devastating birth defects. High-risk behaviors, such as motorcycle riding and mountain climbing, may also increase the likelihood of fetal injury.
The government has generally sought to inform pregnant women of various potential threats, allowing them to make their own determinations about risk. Of course, all of these activities are legal. In contrast, some state governments have severely penalized women whose use of illicit drugs has allegedly led to injury or the death of the fetus.
In 2014, the New Republic reported that 16 states treat in utero exposure to illicit drugs as a form of child abuse; 14 require physicians to report such use. Several states, most notably South Carolina, have prosecuted women for exposing fetuses to cocaine. In 2001, Regina McKnight was convicted of homicide and sentenced to 12 years in prison for delivering a stillborn fetus after using the drug. Advocates for such laws argue that exposing a fetus to potentially deleterious drugs is no different from other forms of child abuse.
Surely, nobody would object to prosecuting a parent who allowed her 1-year-old to snort cocaine, do meth, or to shoot heroin. The purpose of laws such as South Carolina's is to prevent children from suffering the often-devastating consequences of exposure to various illegal substances.
Yet critics of such laws argue that mothers like Regina McKnight are suffering from addiction -- a medical condition -- and are being punished for their inability to refrain from drug use. Opponents also note that these rules fall most heavily upon impoverished women and racial minorities, and that prosecutorial discretion often shields middle- and upper-class mothers from similar charges. A genuine concern exists that if such laws were to become widespread and well-known, some pregnant women would forgo prenatal care entirely in an effort to avoid toxicology testing -- undermining the welfare of the fetuses that the laws are intended to protect.
While the state may have the right to enact such laws, whether doctors should comply -- in situations where they are afforded discretion -- is another matter entirely. Physicians must weigh the benefit that reporting individual drug abusers would achieve against the systematic damage that such disclosure would wreak upon overall physician-patient trust. Some doctors might decide that disclosure is never worth the cost -- that reporting addicted mothers is simply one of those requests with which doctors should never comply. Others might fear for the welfare of the particular infant in front of them and decide to protect that child at all costs, no matter the long-term consequences for confidence in the medical profession.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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