Ethics Case #2: Rebecca

Tracy 4/13/2005
[14] comments

Here’s another ethics case entitled “When agreeing with the patient is not enough: a schizophrenic woman requests pregnancy termination” from the journal General Hospital Psychiatry (Volume 26, Issue 6 , November-December 2004, Pages 475-480.) [full text is subscription only]

Rebecca Dale (not her real name) is a 34-year-old woman with chronic paranoid schizophrenia with poor response to medical therapy and polysubstance abuse (crack cocaine, marijuana, nicotine, and alcohol). Her schizophrenia is characterized by disorganized thought (marked by tangential thoughts and derailment), disorganized speech (marked by word salad, neologisms, and rambling), auditory hallucinations, and delusional ideas. Rebecca can greet others and utter a few coherent simple sentences (e.g., “I feel good today”) before her speech becomes disorganized. Due to a combination of nonadherence and lack of access, she has not been treated for her schizophrenia for the past 10 months, when she last had contact with her mental-health caseworker. Rebecca was 14+ weeks pregnant when she presented unaccompanied to an obstetric clinic requesting an abortion, saying that she did not “want to go through that again,” referring to the custody obstacles she faced when she gave birth to her daughter, Sara, 3 years ago. Sara was removed from her custody at birth and placed in foster care. Rebecca retains supervised visitation rights but hopes, despite mounting evidence to the contrary, that she will regain full custody. She had asked the social worker about abortion in similar fashion once on the telephone the week prior. Before that, she was either ambivalent about what to do about her pregnancy or indicated she wanted to keep the baby. Rebecca lives with her boyfriend but says he is not the father. She does not or cannot identify the father.

The consulting psychiatrist requested a clinical ethics consultation to help devise a strategy to respect both the patient’s vulnerability and her reproductive freedom. The ethics consultant met with the patient and psychiatrist several days later. Rebecca then said she wanted to continue the pregnancy if “he can be with me” and “they don’t take him away.” Sometimes she seemed aware that this child would also be removed from her custody. Other times she believed the baby would stay with her. Little is known about Rebecca’s day-to-day life. She is unable to work and receives disability benefits. She has been arrested on numerous occasions for prostitution and possession of cocaine. When asked who helps her make tough decisions, Rebecca responded, “my dad.” When asked if her boyfriend helps her, she replied “no.” According to her father, Robert Dale, Rebecca was happy to be pregnant with Sara but now suffers because the child is not with her. Her social relationships are strained by her mental illness. Her father rarely sees her, and her siblings had not spoken to her in over a year. She cannot name any friends besides her boyfriend.

Robert is Rebecca’s closest relative. When called, he said he loves Rebecca but is torn about what is best for her. Robert said that he “has trouble with abortion” but saw how it could be in his daughter’s best interest, particularly if she said she wanted it. He was unable to accompany his daughter to appointments because of his advanced multiple sclerosis. He is bed bound but is responsive via telephone.

Whaddya think?

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14 Responses to Ethics Case #2: Rebecca

  1. Ambriel says:
    4/14/2005 at 2:12 am

    Having worked with Social Services, this case is not an unusual one. Cases like this happen more frequently than most people care to know or think about.

    But what I would like to discuss is the likely scenario for the baby, should she not have an abortion. Being that the mother hasn’t had treatment for her schizophrenia in 10 months, it’s likely she will also not receive prenatal care. Due to her addiction and life style it is also highly likely that her nutritional needs will also be unmet. Nothing was said about whether the mother has been tested for HIV or other sexually transmitted diseases, but that’s also a possibility. So we’re looking at a baby coming into the world most likely with low birth weight and a multitude of other health problems, in addition to being born with an addiction and possibly HIV positive to boot.

    From the first moment this child would take a breath, he/she will have to endure severe withdrawal symptoms, suffer from low birth weight and smaller-than-normal head size. Birth and hospital care with round-the-clock nursing, monitors, blood and urine tests, high-tech equipment and social service evaluations, costs $11,000+. Who pays the bill? Babys suffering though moderate to severe withdrawal are hard to console. Typically, these children, when held, tend to arch their backs, pull away and cry until they exhaust themselves. They cry because they are in pain and suffering. They don’t even like to be touched.

    It’s obvious that the mother will be unable to keep the child, and the child will most likely grow up being shifted from foster home to foster home. The child will be at high risk for extreme emotional and behavioral tendencies along with a low tolerance for frustration. Cocaine-exposed children are unable to deal with many different stimuli at once and tend to act out aggressively or withdraw completely when overstimulated. It’s unlikely the child would receive the necessary care due to Federal and State Health and Human Services department budgets that have been dramatically cut. Schizophrenia is also believed to be genetic, so the child will likely end up like Mom.

    Being involved in cases like this is heart wrenching, but even more so, is being involved in this childs case. One particular case comes to mind of a five year old child with AID’s who was suicidal.

    Abortion is not an easy decision and I don’t believe should be seen as a “quick fix for an unwanted problem”, but this is the hell this unborn child would have to endure. My feelings are that there are birth control implants, and after her first child this should have been mandatory. It’s much easier and cheaper to prevent the problem.

    Reply
  2. HareTrinity says:
    4/14/2005 at 6:12 am

    Didn’t occur to me that the child was likely to start off with withdrawal symptoms, but since you mentioned it, Ambriel, yeah… Plus, whatever else Rebecca’s been taking (if even she knows) probably won’t be very good for pregnancy either…

    Schizophrenia can be pretty life-wrecking, and although people who inherit it don’t always get similar symptoms to their parents (there are various categories), since Rebecca’s so bad then I wouldn’t want to hear of another of her children going into foster care…

    Question; anyone know why it was foster care? I’d have thought adoption would have been more suitable, since schizophrenia was obviously a lot more likely to occur with Rebecca’s daughter and idealy you’d want someone looking out for the early signs, or someone familiar with it to help Sara avoiding developing anything as serious as her mother’s condition.

    Perhaps it was just foster care until they could sort out an adoptive family, but I still find it strange…

    Still, back to the article; I’m hoping that she’ll get the abortion followed by some form on contraception and maybe more support from her family to help her at least cut down on her drug habits and to maintain a more stable lifestyle.

    Reply
  3. Becca says:
    4/14/2005 at 9:45 am

    If Rebecca says again that she wants an abortion, GIVE HER ONE. I don’t even see the ethical dilemma here, unless it’s that Rebecca occasionally seems confused about whether she truly wants to end the pregnancy. But if the psychiatrist can explain to her that she most likely will not be able to keep this baby, and Rebecca again asks for the abortion, then do it.

    Reply
  4. J. Matthew says:
    4/14/2005 at 6:07 pm

    As Becca referred to, what if Rebecca is having a brief psychotic break when she says she wants an abortion, and the rest of the time she wouldn’t have wanted an abortion at all? What if, a week prior and a week after her psychotic episode, she would say lucidly that she really wanted the baby?

    That’s what seems to me to be the trick. And I don’t have a clue about how to go about resolving it.

    Reply
  5. HareTrinity says:
    4/14/2005 at 7:26 pm

    Though, seeing as she wouldn’t have been able to keep it, and what would happen if it was the other way around…

    Reply
  6. HareTrinity says:
    4/14/2005 at 7:28 pm

    And by “other way around” I mean if they didn’t give her the abortion when it turned out that she really DID want it

    Reply
  7. Tracy says:
    4/14/2005 at 8:34 pm

    Ambriel, it’s true that this fetus is is grave danger of being born with one or more medical problems, including addiction and malnurishment. But that’s by no means certain.

    As it turned out in this case, the medical team decided NOT to give her an abortion, and she ended up having a perfectly healthy boy that was placed in foster care:

    Reply
  8. Ambriel says:
    4/15/2005 at 12:05 am

    Thanks Tracy for letting us know how this turned out and that the baby was born healthy. But it isn’t a happy end of the story by any means, and only the beginning of the story for the child. You addressed the mother’s rights, but there was no mention of the child’s rights. So while talking about potential outcomes, here’s the potential outcome for the baby. This case is about a lot more than Rebecca’s rights and wishes. This is about a child who is being held hostage by a drug addicted schizophrenic! I think that we should be asking “what do we as a society morally owe to this child?”

    From the case profile, there was no mention of the court stepping in and terminating the mother’s rights to the child, which keeps the child from being placed for adoption. Being that Rebecca was 34 at the beginning of her pregnancy, and given that treatment in her last month was involuntary because of her continued drug abuse, and there was no mention of improvement in her mental state, I don’t think it likely that Rebecca will ever be able to care for either child. I believe that her rights to the children should be terminated. There was also no mention of counseling Rebecca to give the child up for adoption.

    There are over half a million foster children in the United States today. It is practically a guarantee that the child will suffer once placed in the care of the state. A major issue is the shortage of caring foster homes. Foster parents are in short supply, especially in large cities. While the number of foster children has increased, the number of foster homes decreases. Foster children are three to six times more likely than children not in care to have emotional, behavioral and developmental problems including behavioral disorders, depression, difficulties in school, serious health problems, and damaged social relationships. Foster children often do not get routine health screenings and checkups. A growing concern is that the system is quick to prescribe drugs to foster children; studies find that children in group and foster homes are increasingly being given medications such as Ritalin just to keep them obedient and subdued for their overburdened guardians. As far as education, the majority of children in foster care are moved into unfamiliar homes and unfamiliar schools several times in one year. This requires weeks, or even months, of adjustment. Another result of being bounced from home to home is that many children emerge years later unable to love or trust anyone. For the youngest children, foster care defies basic underlying pediatric principles, that infants and small children require nurturing, stability, consistency, and a reliable opportunity to connect with a responsible adult.

    Emotional and physical abuse in foster homes is widespread. Abusive foster parents consist of the usual bad apples as well as those pushed to the limit by difficult children or frustration at the system and lack of support. Children are more than twice as likely to die of abuse in foster care than in the general population and sexual abuse is four times more likely in foster homes.

    When foster children turn 18 while in care, it is called ‘aging out of the system’. The transition is incredibly difficult, especially for those who have been dependent on the state throughout most of their childhood. All of a sudden, these foster kids are expected to pack their belongings and hit the road so to speak with not support. Homelessness and incarceration rates are high among former foster children. Former foster kids are three times more likely than the general population to become homeless. The sad reality is that many former foster children have children that go through the same system they did – the cycle repeats itself across generations.

    What truly frightens me are the lost children. The death of Florida’s Rilya Wilson in the spring of 2002 brought to public attention the issue of children “missing” from foster care. It first came to light that the state of Florida had managed to lose track of 500 of its foster care children. Los Angeles County Department of Children and Family Services reported in August of 2002 that 740 foster children were missing from its system. Shortly thereafter, Michigan foster care officials announced that 300 foster children were missing from their foster care system. In November of 2002, 20 foster children were missing from Tennessee’s foster care system. It’s ironic too how Tennessee officials arrived at their “20” figure, saying that 98 percent of the actual 496 “lost children” were adolescent runaways.

    Reply
  9. HareTrinity says:
    4/15/2005 at 3:19 am

    Definitely interesting information you have there, Ambriel… At least the boy was born healthy, though? Pity about the high chances of him getting schizophrenia later on…

    Hm. Wonder what the UK statistics for the “lost” foster care children is…

    Reply
  10. Tracy says:
    4/15/2005 at 9:48 am

    Thanks for the very interesting comments, Ambriel! This is a great example of the tremendous tension between the best interests of the child (not being subject to foster care and all its anguish) and the best interests of the woman (not being coerced into a medical procedure without true informed consent). Although I think it’s fair to note here that a lot of people wouldn’t see an abortion as in the best interests of the child!

    I come down on the side the doctors chose for the reasons they stated: not because I’m against abortion, but I because I don’t believe that Rebecca really understands what an abortion is or what it means. But I come down on that side only by a hair’s breadth and with a lot of difficulty. I think cases like this are so tough because the interests of two people are really opposed to one another and their futures are inevitably tied to one another.

    Just as a thought experiment, let me make an anology to this case:

    There’s a person who needs a kidney transplant or they will remain very sick, and maybe die. This person is the analogy to the child in Rebecca’s case. The only person who can provide the matching kidney is a mentally ill person who cannot provide informed consent because they’re psychotic. This person is analogous to Rebecca. Now, in this case, we do NOT coerce the mentally ill person to undergo a kidney removal even though the kidney-sick person will likely suffer terrible consequences because of our refusal to do the procedure. It is widely (and rightly, I believe) perceived as wrong to force people into medical procedures even if it means that others will suffer because of our refusal.

    In other words, criminals aside, we shouldn’t violate someone’s rights to alleviate the suffering of others.

    Reply
  11. Tracy says:
    4/15/2005 at 9:56 am

    And just to clarify, we shouldn’t violate a criminal’s rights either to alleviate the suffering of others. It’s just that rights are different once a person becomes a criminal.

    Reply
  12. Tracy says:
    4/15/2005 at 10:04 am

    This is a good example of an outcome-based approach (Ambriel’s) vs. a rights-based approach (mine). The trick is to find a good balance between the two approaches.

    I usually come down on the side of a rights-based approach although I recognize the difficulties of it. Despite the difficulties, I believe that when aggregated across the whole society, a rights-based approach actually produces better outcomes.

    Reply
  13. HareTrinity says:
    4/15/2005 at 11:17 am

    I think we’re agreed that what Rebecca wanted was more important in this case than the outcomes it may or may not produce, just that Ambriel gave us a rough idea of how this probably isn’t the “happy outcome” or such, and a bit of encouragement for why we should remember that abortions early on should always remain a woman’s right.

    After all, a lot of the anti-abortion people will try to convince you that it’s being “irresponsible” to not bring an unwanted child into the world, and that putting them up for foster care or adoption’s a much better option than abortion.

    I know someone whose mother is one of the people who looks after foster children… She’s pretty good at it too, from what I’ve heard (and her son not only now looks forward to having kids himself but also seems to have a rough idea of what foster care children are like), but even for her the “problem cases” (children from abusive families, etc) are a strain… She has her own kids and, as I recall, supports them and the foster children by herself.

    At least some of the foster parents really try, but it seems unfair to imply that they can handle every kid that comes along…

    Reply
  14. Ambriel says:
    4/15/2005 at 11:17 am

    Tracy, just for the record, if this was just about medical ethics, I would side with you. As far as social ethics I disagree. I’m not quite sure that Rebecca was truly informed as to the consequences of her having the baby and what her decision would mean for the child either. Did she truly understand that the child would be taken from her? She stated that she did not “want to go through that again,” referring to the custody obstacles she faced when she gave birth to her daughter. So was this decision truly in anyones best interest? Once the child was born, the doctors don’t have to deal with it. They’re off the hook.

    The issue as I see it, and this is where we disagree, is that her lack of cognitive abilities limits her in making an informed decision. For the same reason, children are given only partial rights. This is why parents must sign for medical procedures and make these decisions for their children. I’m curious how much say Robert,her father, had in the making of this decision. If Robert had been able to be more physically present, this may have turned out differently.

    As far as the right to lifers who wouldn’t see an abortion as in the best interests of the child, I don’t see them stepping up to the plate to care for these children, raise them and give them loving homes.

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