As well as the oral presentation we presented a health promotion flyer and website about Anti-D.
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9/7/2020 0 Comments An ARGUMENT against mandatory reporting of child abuse against a pregnant woman misusing illicit drugs & alcoholIn recent years there have been fewer Australians drinking but an increased use in illicit drugs such as cannabis (+1.2%), cocaine (+1,7%) and ecstasy (+0.8%) 1. Misuse is defined as the use of these substances outside of medical prescription or law 2. When it is evident that a pregnant woman is misusing illicit drugs or alcohol, the enforcement of mandatory reporting for child abuse can seem appropriate. It is important that health care professionals (HCPs) are able to evaluate this in an ethical framework 3 to ensure their responses are based on benefit to the sick and the promotion of health and life. In this essay I will argue that enforcing mandatory reporting is not the correct course of action and in fact would create more harm than potential benefit. I will address the counter arguments and base my thesis on Beauchamp and Childress’s 3 principles of autonomy, justice, beneficence and non-maleficence. This will be done by examining the pregnant woman’s rights, where the duty of carers lies and what some of the potential outcomes may be for the mother, her foetus, her future child and the greater community. It is extremely hard to get accurate statistics about alcohol and drug use in pregnancy due to screening and diagnosis issues 4. However there is research to show that 25% of Australian babies born to mothers who consumed alcohol during pregnancy were diagnosed with fetal alcohol spectrum disorder (FASD) 5. Moreover it is estimated 10-20% of pregnant women in the USA exposed their newborns to neonatal abstinence syndrome (NAS) 6,4. It could be argued that with these statistics, all such pregnant women should be reported for child abuse because the vulnerable unborn child is at an increased risk of harm. It cannot articulate its right to life and should be protected. The argument is that ethical principles should be applied to the unborn foetus as they would to an independent human. However, this is a hard argument to put forward, as the foetus is only a future child because of the incubation of the mother’s body. To make this argument, according to Karpin 7 renders the woman’s body irrelevant and a “complex process of disappearing has to take place”. There is a long held belief that the foetus may be a human in-utero, but only gains personhood at birth 8. In Wilkinson et al.’s 5 counter argument paper about protecting future children, they propose legal actions that could be taken against the mother post-natally for in-utero harm. This could lead to a maternal decision to terminate the pregnancy. In order to avoid harm to the foetus, they also suggest termination as a possible pre-natal intervention, and instating mandatory termination where the pregnant woman has drunk heavily. These statements appear somewhat counter-intuitive to their argument for protection and only highlight the importance of the woman in this situation. Without removing the mother from the equation as Karpin 7 mentions and accepting that the foetus is connected and a part of her body 9, there is a need to ensure her autonomy is respected. Autonomy is defined as the ability to make choices about oneself that are free of any control, interference or limitations from others 10. Moreover is that these choices be morally respected and that all actions are performed with informed consent 11. Informed consent is the assumption that the person knows their choices and can refuse 12. As a HCP, autonomy may conflict with what is considered to be ‘doing the right thing’ or ‘doing no harm’ 13, however these concepts of beneficence and non-maleficence will be addressed later in the argument. Reporting this woman would be a violation of her right to autonomy as it would not be a choice she would be making freely. A woman’s right to fair justice too, is a basic human need 14. This includes the justice to receive unbiased healthcare, to offer her the best opportunity of flourishing and living without offence in society 15. This Natural Law theory also supports the double effect principle where intentionally caring for and not reporting the pregnant woman may have a foreseen outcome of continuing harm to the foetus, but is still seen as morally permissible 16. When considering what is permissible, HCPs are bound by their objective duty of care based on reason and the rules of their profession 17. Midwives are bound by their code to place the interests of the woman before all else, share the decision making and support her right to refuse 18. Along with other human rights of freedom 19, these form part of what can be explained as the theory of Deontology. This theory is based on intellectual moral obligations of right and wrong and the binding duty to uphold them 17. These duties help ground the argument against mandatory reporting and are also supported by legal regulations. The foetus has no legal rights as a child until they are born alive 20 and there are no rules in Australia implementing mandatory reporting for an expectant mother who misuses alcohol or illicit drugs. There is an exception only in Tasmania in conditions where there is a high likelihood of severe neglect and harm to the future infant 21. In situations where an expectant mother is found to be misusing illicit drugs and alcohol, the HCP has the opportunity to ‘do good’ by providing appropriate treatment that will benefit the woman 16. This principle of doing good is known as beneficence 3 and can be used to build a therapeutic relationship based on trust 22. Patients respond more favourably to recommendations when they trust their professional and feel less vulnerable 23. Providing transparency, confidentiality and avoiding harm and abandonment are ways to reduce the feeling of vulnerability in the woman, gain her trust and increase her honesty 24. Barnard 24 also mentions that “[b]ehaviors alone do not give us all the information we need to make accurate judgments” and this increased connection can open opportunities to get to the origin of the misuse. Counselling, support and education are widely supported measures that may ultimately lead to better outcomes for the mother 5 and consequently, the foetus and future child. This way of ethically looking at the overall, ultimate outcome of a situation where the ends justifies the means and where more good will be produced than harm, is called Consequentialism 17. This theory can be applied to the greater community where it can be assessed if reporting the woman would be better for society or not 25. Mandatory reporting would impact others in the mothers’ family, social group and the greater public 26. Depending on the type and level of usage, negative impacts like those of displacement of other family members, legal proceedings, job disruptions, emotional trauma and a greater societal resource expense of reporting management need to be considered. Avoiding these negative impacts can be defined as ‘doing no harm’ which is the principle of non-maleficence 26. The harms of reporting the mother can be weighed against the principle of beneficence to produce a net benefit over harm 27. In this situation maleficent acts on the mother may include being judgemental, patriarchal, stigmatising and removing her autonomy. Should a person be deprived of what they most value, this deprivation is “often worse than the disease we are attempting to cure” 28. While the arguments have been focused on respecting the pregnant woman and acknowledging the duty of care towards her, it is worth still recognising the impact of the situation on the unborn and future child. Even though the foetus has no legal status, it is still significant in a moral sense and worth considering 5,29. Whether an HCP has a legal duty or not, they may still want to think of themselves as ‘doing the right thing’ ethically for the foetus. This principle is known as Virtue Ethics and focuses on the act of enabling human flourishing, in this case the foetus 16,26. This can be done by finding the middle path and avoiding any extremes 17. This has been accomplished in the previous arguments where focussing on the wellbeing of the woman ultimately has the best chance of the un-born child having more favourable outcomes. Clearly then, there is no reason mandatory reporting for child abuse should be a requirement for pregnant women who misuse alcohol or drugs. It has been shown that the abuse is not imposed on a child, but on an unborn foetus and therefore, by definition, the woman herself. Using Childress & Beauchamp’s 10 four principles as an acceptable basis for medical ethics evaluation 13, it was argued that a woman’s autonomy and right to fair justice should be respected and that the HCP has an obligation to respond within their duty of care and legal parameters. However, it was also identified in research that the HCP has a unique opportunity to therapeutically support the woman’s situation through gained trust, to increase her potential for healthier outcomes. By refraining from reporting, no intentional action of harm has been made and the outcomes for both mother, foetus and future child have been improved. References
(1) Australian Institute of Health & Welfare. National Drug Strategy Household Survey 2019: In Brief. 2019, 104. https://doi.org/10.25816/e42p-a447. (2) World Health Orgnization. Lexicon of Alcohol and Drug Terms Published by the World Health Organization. 2006 http://www.who.int/substance_abuse/terminology/who_lexicon/en/ (accessed Sep 7, 2020). (3) Beauchamp, T.; Childress, J. Principles of Biomedical Ethics, 7th ed.; Oxford University Press: New York, 2013. (4) Price, H. R.; Collier, A. C.; Wright, T. E. Screening Pregnant Women and Their Neonates for Illicit Drug Use: Consideration of the Integrated Technical, Medical, Ethical, Legal, and Social Issues. Front. Pharmacol. 2018, 9, 961. https://doi.org/10.3389/fphar.2018.00961. (5) Wilkinson, D.; Skene, L.; De Crespigny, L.; Savulescu, J. Protecting Future Children from In-Utero Harm: Protecting Future Children from In-Utero Harm. Bioethics 2016, 30 (6), 425–432. https://doi.org/10.1111/bioe.12238. (6) Wabuyele, S. L.; Colby, J. E.; McMillin, G. A. Detection of Drug-Exposed Newborns. Ther. Drug Monit. 2018, 40(2), 166–185. https://doi.org/10.1097/FTD.0000000000000485. (7) Karpin, I. The Uncanny Embryos: Legal Limits to the Human and Reproduction Without Women. 2006, 28, 26. (8) Jarvis Thomson, J. A Defense of Abortion. Philos. Public Aff. 1971, 1 (1), 47–66. https://doi.org/10.2307/2265091. (9) Savell, K. The Legal Significance of Birth. Univ. New South Wales Law J. 2006, 29 (2), 200–206. (10) Childress, J.; Beauchamp, T. Principles of Biomedical Ethics, 5th ed.; Oxford University Press, 2001. (11) International Confederation of Midwives. International Code of Ethics for Midwives https://www.internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf. (12) Frye, A. Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice; Labrys Press: Portland, Oregon, USA, 1995. (13) Gillon, R. Defending the Four Principles Approach as a Good Basis for Good Medical Practice and Therefore for Good Medical Ethics. J. Med. Ethics 2015, 41 (1), 111–116. https://doi.org/10.1136/medethics-2014-102282. (14) Johnstone, M.-J. Nursing and Justice as a Basic Human Need: Nursing and Justice as a Basic Human Need. Nurs. Philos. 2011, 12 (1), 34–44. https://doi.org/10.1111/j.1466-769X.2010.00459.x. (15) Ozolins, J. Ethical Principlism. In Foundations of healthcare ethics : theory to practice; Cambridge University Press: Port Melbourne, Vic., 2015. (16) Kerridge, I.; Lowe, M.; Stewart, C. Principle-Based Ethics. In Ethics and law for the health professions; The Federation Press: Leichhardt, NSW, 2013. (17) Ozolins, J.; Grainger, J. Foundations of Healthcare Ethics : Theory to Practice; Cambridge University Press: Port Melbourne, Vic., 2015. (18) Nursing and Midwifery Board of Australia. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018. (19) United Nations. Universal Declaration of Human Rights https://www.un.org/en/universal-declaration-human-rights/index.html (accessed Aug 29, 2020). (20) Forrester, K.; Griffiths, D. Manipulation of Life. In Essentials of law for health professionals; Elsevier Australia: Chatswood, NSW, 2010. (21) Heyes, N. Mandatory Reporting of Child Abuse and Neglect CFCA Resource Sheet; Australian Institute of Family Studies, 2020; p 10. (22) WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience; World Health Organization, Ed.; World Health Organization: Geneva, 2016. (23) Paulsen, J. E. Ethics of Caring and Professional Roles. Nurs. Ethics 2011, 18 (2), 201–208. https://doi.org/10.1177/0969733010392302. (24) Barnard, D. Vulnerability and Trustworthiness: Polestars of Professionalism in Healthcare. Camb. Q. Healthc. Ethics 2016, 25 (2), 288–300. https://doi.org/10.1017/S0963180115000596. (25) Mandal, J.; Ponnambath, D.; Parija, S. Utilitarian and Deontological Ethics in Medicine. Trop. Parasitol. 2016, 6(1), 5. https://doi.org/10.4103/2229-5070.175024. (26) Freegard, H. Ethics in a Nutshell. In Ethical practice for health professionals; Cengage Learning Australia, 2012. (27) Gillon, R. Medical Ethics: Four Principles plus Attention to Scope. BMJ 1994, 309 (6948), 184. https://doi.org/10.1136/bmj.309.6948.184. (28) Handerson, V. The Nature of Nursing : A Definition and Its Implications for Practice, Research, and Education : Reflections after 25 Years; National League for Nursing Pres: New York, N.Y, 1991. (29) United Nations. Convention on the Rights of the Child https://www.ohchr.org/en/professionalinterest/pages/crc.aspx. |
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