Enfants à protéger, des parents à aider : deux univers à rapprocher

Chapitre 8_Mothers with serious mental illness and their fetuses: Competing or conjoint rights?

C H A P I T R E 8 MOTHERS WITH SERIOUS MENTAL ILLNESS AND THEIR FETUSES Competing or Conjoint Rights? Mary V. Seeman, M.D. Centre for Addiction and Mental Health 150 DES ENFANTS À PROTÉGER – DES PARENTS À AIDER ABSTRACT This paper will consider the mental health worker’s role vis-à-vis women who, because of severe mental illness and incapacity to make competent decisions, may require, when pregnant, ethically-sensitive interventions such as: (a) involuntary hospitalization, (b) involuntary treatment for psychosis, (c) abortion counseling, (d) involuntary HIV testing, (e) involuntary prenatal care including drug abuse treatment or, when postpartum , (a) mediation of child custody disputes, (b) management of confidentiality issues, and (c) contraceptive advice. Such women require comprehensive services operating within a clear ethical framework that facilitates decision-making. RÉSUMÉ Ce chapitre est consacré au rôle que joue l’intervenant en santé mentale auprès des femmes enceintes qui, en raison de graves problèmes de santé mentale ou d’incapacités de prendre des décisions judicieuses, pourraient nécessiter des interventions sensibles sur le plan éthique comme : a) l’hospitalisation involontaire ; b) le traitement involontaire d’une psychose ; c) le counseling en matière d’avortement ; d) le dépistage involontaire du VIH ; e) des soins prénataux involontaires comprenant le traitement de la toxicomanie. Après l’accouchement, les interventions possibles sont : a) la médiation dans le contexte de disputes sur la garde de l’enfant ; b) la gestion de questions liées à la confidentialité ; c) des conseils sur les méthodes de contraception. Ces femmes ont besoin de multiples services offerts selon un cadre éthique clair qui facilite la prise de décisions. MOTHERS WITH SERIOUS MENTAL ILLNESS AND THEIR FETUSES 151 Pregnant women suffering serious mental illness enjoy the same rights as all other individuals to privacy of mental health information, to decisional autonomy when competent, and to liberty when not at imminent risk to self or others. Such rights, however, are in potential conflict with the rights of the fetus to be born healthy since fetal health is readily compromised by a pregnant woman’s lack of prenatal care, improper dietary intake, exposure to toxic substances, undue stress, physical trauma, or infection. An analogy can be made to the right of a parent to the unfettered exercise of parental authority as long as s/he is not neglecting or abusing her/his children. In the advent of abuse or neglect, child rights routinely preempt parental rights because the child is seen as the more vulnerable. The vulnerability of the fetus, on the other hand, can be neglected when pregnant women make decisions about their health care because the fetus, by Canadian law, is not yet a person and therefore has no legal standing. The conflict can be seen as one of competing rights, but this is not the only way of approaching the clinical dilemmas that ensue. Relational ethics, defined by Sherman (1998) as moral responsibility within a context of human relations, recognizes the connectedness of mother and fetus (Zohar, 2003) and the reciprocity within which a pregnant woman’s autonomy is embedded. Relational ethics is practiced when the clinician asks the patient “what should we together decide to do now?” in contrast to the statement “this is what you should do now.” The focus in relational ethics is on what is best for the patient not as a stand-alone entity but in the context of and in connection with her family and community (Gadow, 1999; Hess, 2003; Romyn, 2003). Relational ethics is based on principles similar to those of Confucianism, as described by Tsai (2001, 2005). In this philosophy, a person is seen not only as a rational, autonomous agent but also as a relational, altruistic being who promotes the welfare of his fellow persons. In Eastern thinking, individuals are never viewed as separate; they are always regarded as rooted in a network of reciprocal obligations. Personhood thus involves a process of engagement with others within the context of one’s social roles and relationships. The boundaries between self and others in Eastern philosophy are not always distinct. But also in the West, clinicians understand that when a person exercises autonomy, he or she makes choices on the basis of how these choices affect others, especially vulnerable others (Lutzen and Nordon, 1994; Zaner, 2000). Because a pregnant woman and her...