Safe havens for addicted mothers
CMAJ 1997;157:1202
Re: Bioethics for clinicians: 12. Ethical dilemmas that
arise in the care of pregnant women: rethinking "maternal–fetal
conflicts", by Elizabeth Flagler, Françoise Baylis and Sanda
Rodgers, CMAJ 1997;156:1729-32 [full text / résumé]
In response to: A.E. Chudley; H.L. Bright; D.H. Smith
These letters illustrate the complexity of the ethical dilemmas that arise in the care of pregnant women. The topic taps into many layers of personal and professional beliefs. The assigned length and structure of articles in this series limited the discussion. However, careful reading of the paper will reveal a firm commitment to consider -- not ignore -- fetal interests within the framework of respect for the autonomy of the competent pregnant woman. The cases presented clearly relate to situations in which the pregnant women is deemed competent. Decision-making for incompetent patients (whether pregnant or not) is more fully discussed in "Bioethics for clinicians: 5. Substitute decision-making" (CMAJ 1996;155[10]:1435-7 [full text / résumé]), by Dr. Neil M. Lazar and associates.
There is a difference between rights (guaranteed under law) and interests (not guaranteed under law but deserving of consideration by those responsible). To pursue this issue further, readers are directed to the references in our article. The question is to determine who is most appropriate to speak for the interests of the fetus -- at any point during the pregnancy.
State intervention in health care decisions is a serious infringement on personal liberty and requires intense scrutiny of the associated harms and benefits. This includes critical analysis of similar situations in society. Where is the line to be drawn before forcing treatment of individuals for the benefit of others? Should the nicotine-addicted heavy cigarette smoker be incarcerated for treatment of his addiction because of the impact secondhand smoke has on his pregnant wife and their asthmatic children?
We agree that this important topic needs continued discussion and better understanding, which necessarily entails consideration of the broader social and political contxClear and compassionate thinking about these issues is essential in the development of policies such as those concerning treatment and prevention of substance abuse. The language of that debate is vital for consistency and clarity.
Elizabeth Flagler, MD
Office of Medical Bioethics
University of Calgary
Calgary, Alta.
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