The Gods had condemned Sisyphus to ceaselessly rotting a rock to the tap of a mountain, whence the stone would foli back of its own weight. They had thought with some reason that there is no more dreadful punishment than futile and hopeless labor.1
What are pediatricians to think and do about substance abuse in pregnancy? This twofold question poses a major ethical challenge for pediatricians faced with diagnosing and managing the care of infants born to substanceabusing mothers.
In the context of this article, ethics is not considered a question of right or wrong, bad consequences, guilt, or fixed principle, but a question of information sought, faced, and considered before action is taken.2 The ethical question then becomes: How shall we change the future in light of the present?
This article first explores the oftentimes frustrating and sometimes seemingly futile, if not hopeless, downstream labor of "rescuing" drug-exposed infants from the effects of prenatal substance abuse. It then moves upstream to examine the context of pregnancy-specifically, situations in which conflicts may develop when pregnant women behave in ways perceived harmful to their fetuses. Finally, the article moves toward bringing about change in understanding and practice.
THE PEDIATRICIAN'S DILEMMA
Pediatricians face the following reality. Approximately 375 000 babies are bom each year in this country to mothers who abuse drugs.3 Infants cared for by pediatricians and born to cocaine-using mothers face an increased risk of sexually transmitted diseases, prematurity, and growth retardation, including reduced birthweight, length, and head circumference; possibly an increased incidence of congenital malformations, especially involving the genitourinary tract, heart, gastrointestinal tract, and central nervous system; neurodevelopmental effects such as poor organizational responses, increased tremulousness, irritability, state lability, poor consolability, poor visual attention, transient developmental delays, and later more permanent disabilities such as attention deficits, difficulty concentrating, abnormal play patterns, and flat, apathetic moods; possibly the increased incidence of sudden infant death syndrome as well as the increased risk of necrotizing enterocolitis or feeding intolerance; tachycardia, tachypnea, hypertension, irritability, tremulousness, and convulsions in infants of cocaine-using breast-feeding mothers; and reports of child neglect and abuse by cocaineusing parents.4
There is a 1 per 1000 live birth incidence of fetal alcohol syndrome and a 20% to 40% rate of occurrence of fetal alcohol syndrome in chronically alcoholic women. The level of alcohol intake that is harmless during pregnancy is unknown, and ethanol is said to be the most common chemical teratogen causing malformations and mental deficiency in humans.5
The list of drugs causing passive addiction and possible neonatal withdrawal includes heroin, methadone, barbiturates, alcohol, diazepam (Valium, Roche Products, Manati, Puerto Rico), chlordiazepoxide (Librium, Roche Products, Manati, Puerto Rico), tricycitc antidepressants, hydroxyzine (Atarax, Roerig Division, Pfizer Ine, New York, New York), ethchlorvynol (Placidyl, Abbott Laboratories, North Chicago, Illinois), propoxyphene (Darvon, Eli Lilly and Co, Indianapolis, Indiana), pentazocine (Tal win, Winthrop Pharmaceuticals, New York, New York), the combination of Talwin and Pyribenzamine (tripelennamine), (also known as "Ts and Blues"), and codeine.5 The clinical manifestations of any one of these drugs may be missed due to the increasing prevalence of early discharge from the nursery.
The first victims of prenatal crack exposure are now entering kindergarten and the first grade, with many needing at minimum a well-structured, predictable environment and others needing special education classes.6
Pediatricians face this reality of drug-exposed newborns despite the feet that historically, pediatricians have received little formal education related to alcohol and other drug abuse and dependence.7 A survey of all pediatrie programs in the United States revealed the following statistics from the responding programs. At the medical student level, only 44% included formal instruction or clinical experience in substance abuse, 27% provided an elective for students, and 36% provided no pediatrie instruction related to substance abuse. At the residency training level, only 40% required some formal instruction or clinical experience in substance abuse, 34% offered some type of elective opportunity, and 45% offered no instruction in substance abuse throughout their entire 3-year curriculum for residents. At both levels, rates of participation in électives were low. For medical students, it was estimated that less than 5% of students in the last graduating class took at least one of the offered electives in substance abuse whereas for residents, only 20% of the residency programs that offered electives reported 20% or greater participation. Eighty-two percent of program respondents at both the medical student and resident level believed that elective instruction in substance abuse should be a part of the curriculum, and 80% of respondents at the medical school level and 81% at the residency level agreed or strongly agreed that substance abuse education should be incorporated into the curriculum as a requirement.
Despite this apparent endorsement of substance abuse education as part of the curriculum, major impediments were identified. Medical students identified curriculum time constraints (86%), lack of a qualified instructor (55%), and lack of patients with substance abuse-related problems (41%) as major impediments whereas residents identified curriculum time constraints (68%), lack of a qualified instructor (50%), lack of funds to care for such patients (33%), and the lack of patients with substance abuse-related problems (33%) as major impediments.
At the continuing medical education (CME) level, only 65% of CME program respondents indicated that they had offered some type of substance abuse education within the past 2 years. Seventy-three percent of CME programs that did not offer substance abuse education agreed that such teaching should be incorporated into CME programs. The most frequently listed impediments to substance abuse education included lack of time (45%), lack of participant interest (41%), and lack of a qualified instructor (36%). Thus, the majority of pediatrie programs devoted little time to educational experiences related to substance abuse, and the main impediments included lack of time, lack of qualified instructors, and perceived lack of patients with substance abuserelated problems.
In light of this depiction of substance abuse education in pediatrics and the previous depiction of neonatal substance-related problems faced by pediatricians, it is understandable that the busy office-based pediatrician might feel especially frustrated and even angry with the dilemma in which they find themselves and society. Like Sisyphus, some pediatricians may, at times, feel like they are engaged in futile and hopeless labor.
There is a story that tells of someone who is walking alongside a river and sees someone drowning. This person jumps in, pulls the victim out, and begins artificial respiration. While this is going on, another person calls for help; the rescuer jumps into the water again and pulls the new victim out. This process repeats itself several times until the rescuer gets up and walks away from the scene. A bystander approaches and asks in surprise where he is going, to which the rescuer replies, Tm going upstream to find out who's pushing all these people in and see if I can stop it!"8 In spending a great deal of time in direct contact with the tragedies of substance abuse, pediatricians typically work "downstream," treating the casualties of ill-functioning substance-abusing families and then sending them back to the same settings or on to overcrowded foster homes. It should not be surprising that successfully treated "cases" often return from these settings in 6 months, 1 year; or 2 years with even more severe problems.
Let's move upstream, from the newborn period to pregnancy, and see who is pushing all of these babies in the water and what is being done to stop it.
Most pregnant women go to great lengths to ensure that their babies are born healthy.9 They seek prenatal care, maintain healthy diets, modify their consumption of tobacco, alcohol, and drugs, and are almost always willing to undergo self-sacrifice to benefit their fetuses. However when focusing on pregnancies in which abortion is not an issue, conflicts may develop between the interests of pregnant women and their fetuses. These conflicts can be divided into two categories: 1 ) pregnant women who refuse therapies perceived to possibly benefit the fetuses and (2) pregnant women who behave in ways perceived to possibly harm their fetuses.10
Although the former category lies outside the scope of this article, it seems important for pediatricians to be aware of the following trend: increasing numbers of obstetricians are seeking court orders to force interventions such as caesarean section on their patients on behalf of fetuses perceived to be in danger; and almost all of these reported physician-initiated court actions have involved pregnant women who were black, Asian, or Hispanic - all of whom were poor.11
This trend has occurred in the face of an American College of Obstetrics and Gynecology (ACOG) Commirtee on Ethics recommendation that encourages communication between the doctor and patient as well as the use of ethics committees for persistent disagreements, and discourages obstetricians from going to court.12 Similarly, the American Academy of Pediatrics (AAP) Committee on Bioetbics also has encouraged doctor-patient communication and the use of ethics committees, but it suggests that doctors may persist if there is substantial likelihood that the fetus will suffer irrevocable harm without the intervention, if the intervention is clearly appropriate and will likely be efficacious, and if the risk of forced intervention to the woman is low.
Thus, in rare cases, recourse to the courts might be considered.13 Although neither committee directly addressed the issue of substance abuse during pregnancy, the trend toward obstetrician-initiated court actions and the AAP's "rare recourse to the courts" clause eventually may lead to an increasing number of court-ordered treatments for substance-abusing pregnant women as well.
'HARMFUL' MATERNAL BEHAVIORS
Many people are answering "yes" to the question, "Is it appropriate to force a pregnant woman to behave in a manner believed beneficial to her fetus?" For example, a judge in Washington, DC recently sentenced a pregnant, 30-year-old, substance-abusing woman found guilty of passing forged checks to prison until her due date.14 Even though the judge admitted that the mother's first time offense would normally not bring jail time, the judge wanted to protect her fetus from her cocaine addiction.
In Los Angeles, pregnant probationers are more likely to go to jail for drug abuse than other probationers.14 According to a narcotic consultant for the probation department, "They want the mother clean so that the baby will come out clean."
In Nassau County, New York, the social service department views the presence of illegal drugs in the urine of newborn infants as evidence of fetal abuse, which they equate to an act of child abuse requiring immediate removal of the infant from the mother's care.14
Joan Beck, a syndicated columnist, recently devoted her column to a letter from the adoptive mother of a 13-year-old boy with fetal alcohol syndrome (Akron [Ohio] Beacon Journal. February 22, 1990:A14). Says the adoptive mother:
I tried to explain to him when he was a first -grader why he couldn't learn. Now 1 am still trying to explain to him as he enters junior high in a special educational class why he is not able to remember simple facts such as his birthdate and is stuck reading at a second grade level, making him functionally illiterate. His frustration is enormous and his life is a mighty struggle to compete with and be accepted by his peers. I consider myself a feminist, am proabortion, and pro-civil rights. But I am also pro the rights of every child who is not aborted to have the best chance to be bom whole and undamaged by his mother's irresponsible behavior. I believe a woman while pregnant should be required by law not to place her unborn child in peril by her use of drugs and/or alcohol. Imprisonment should be an option if she willfully ignores all warnings and engages in this truly criminal behavior.
In Ohio, Senator R. Cooper Snyder has introduced a bill in the Ohio legislature that would create a new offense of prenatal child neglect for which women convicted of giving birth to a drug-exposed baby would be guilty (Akron [Ohio] Beacon Journal. March 1, 1990:D1). Under Snyder's proposal, these mothers could choose to enter a drug-addiction program, elect to have a tubai ligation, or use an implanted contraceptive that would be monitored for 5 years by the courts. If a woman then gives birth to a second drug-exposed infant, she could choose to have a tubai ligation or use monitored contraceptives. If she could not prove to the court that she had been drug-free for 5 years, she would be required to have a tubai ligation. Offenders would pay for contraceptives, tubai ligation, or treatment programs. If they are indigent, county services would pay.
On the other hand, many are answering with a concerned "no" to the question, "Is it appropriate to force a pregnant woman to behave in a manner believed beneficial to her fetus?" For example, researchers in Philadelphia have studied the occurrence of violence experienced by drug-dependent women in Family Center, a comprehensive program established to provide obstetric and psychosocial services as well as methadone maintenance for pregnant women addicted to opiates, alcohol, or combinations of psychotropic drugs.15
Subjects included 178 pregnant drug and/or alcohol dependent women who completed a violence questionnaire. Fifty-six percent were black, 39% white, and the remaining 5%, Hispanic. The majority of women were from urban Philadelphia, and 95% listed welfare as their source of financial support. For comparison, 70 pregnant but drug-free women attend' ing the same prenatal clinic and of comparable age, race, and socioeconomic status also completed the violence questionnaire.
Of the 178 pregnant, drug-dependent women, 19% reported being severely beaten during childhood versus 16% of controls, 70% reported being severely beaten as an adult versus 17% of controls, 15% reported being raped as a child (defined as <16 years of age) compared with none of the controls, 21% reported being raped as an adult versus 4% of controls, and 28% reported being molested as a child versus 7% of controls.
Of the 178 pregnant, drug-dependent women, 107 (60%) were raising their children whereas 71 (40%) had at least one child in some type of foster placement or with relatives. Some were voluntary placements while others were placed in foster care through legal intervention. Of the 178 pregnant, drug-dependent women, statistically significant associations were found between being raped as a child, being raped more than once, and being molested as a child and out-of-home placement.
The data suggest a relationship between the occurrence of violence OT abuse during childhood and subsequent drug abuse, and that childhood sexual trauma and the presence of drug abuse disrupts a woman's parenting ability. In several cases, the authors believed that drugs had been used to cope with the trauma of sexual experience during childhood.
The authors recommended the following treatment approach - social work and psychiatric intervention for drug-dependent women geared toward the monitoring and treatment of depression and states of confusion, the restoration of self-esteem, intervention in episodes of spouse or child abuse, and group sessions to promote better parenting skills. If the woman is uncooperative or if evidence of child abuse surfaces, she is referred to a local child protection agency. The staff is vigilant about maternal abuse by significant others. Drug addiction per se is not an indication for automatic removal of a child from the home in the state of Pennsylvania. Instead every effort is made to involve the family in services to enhance parenting and prevent neglect or abuse.
This initial effort in Philadelphia has been extended to the Hutchinson Program called "Breaking the Cycle" which was initiated in 1989 (Akron [Ohio] Beacon Journal. November 1, 1990:AI2). The centerpiece for this program is Hutchinson Place, a converted warehouse where drug-dependent pregnant women are offered a drug-free place to live under supervision while undergoing counseling. The women who go there for 6-month stays have hit bottom - they are addicted, homeless (or nearly so), and either pregnant or already the mothers of preschool-aged children. So far, all 20 babies born to mothers who completed the program in Hutchinson Place have had normal birthweights and have gone home from the hospital within 2 days. All tested negative for drugs. Thus, it would appear that if substance-abusing mothers are given a safe, secure, drug-free place to live, they can have drug-free babies. As one mother said, "I learned something here. I learned responsibility. I learned to accept structure in my life. I learned that 1 can be a good mother, I can be a good person."
TOWARD BRINGING ABOUT CHANGE
Where alcoholism, drug addiction, smoking, and compulsive gambling were once viewed as separate entities, there is a growing trend to speak of "addictive behaviors" as including all of these.16 Moreover, the concept of "pure addiction" is giving way to a reality that many addictive behaviors consist of poly-drug use in the same person. Perhaps these are not different diseases but different manifestations of the same problem - addiction. Thus, a psychodynamic viewpoint holds that the addict turns to a chemical to feel in control. The only significant difference between the various addictions is which chemical will provide the greatest subjective feeling of being in control.
Further evidence of the unitary nature of addictive disorders might be found in the observation that addicts, as a general rule, use the same psychological defense mechanisms of denial, rationalization, projection, and minimization to justify their increasingly narrow interests in only themselves and their chemicals. It may be difficult for those who have never been addicted to understand the importance that the addict attaches to the chemical. Addicts may be so preoccupied with their chemical use that it is not uncommon for cocaine addicts, for example, to admit that, if it came down to a choice, they would choose cocaine over friends, families, or developing fetuses. However, until well into treatment, addicts usually won't admit this because to do so would be to accept the reality of personal addiction. No price is too high nor is any behavior unthinkable if it provides the drug. As the economic, personal, and social costs of continued drug use mounts, individuals will He, cheat, steal, and even engage in homosexual or heterosexual prostitution to maintain their addiction.
In light of this reality, it seems understandable that many substance-abusing women who become pregnant may not seek prenatal care. If they do seek prenatal care, they often deny drug use. If they have a positive urine screen for drugs, they often refuse treatment options and then avoid further prenatal care, delivering at home or returning to the hospital in labor, often with complications.
How might the problem of substance abuse in pregnancy be resolved for the benefit of pregnant women and their babies? One possibility has a twofold response. First, we might move further upstream to the period prior to conception and actively seek to understand the social structures within which people live out their lives and the places where addictive behaviors take root, to begin to see the issue of substance abuse not as pregnancy complicated by substance abuse but substance abuse complicated by pregnancy, to see the issue of substance abuse not as one of criminalization versus rehabilitation but one requiring a public health approach, whereby pediatricians join with other community leaders to work toward preventing substance abuse in the first place. Second, pediatricians would continue working downstream with other professionals, actively dealing with the ongoing crisis of substance abuse in pregnancy, drug-exposed neonates, their families, and their care.
The American Academy of Pediatrics Committee on Substance Abuse has developed recommendations concerning drug-exposed infants that might prove useful.17 These recommendations include the following:
* Universal neonatal screening for illicit drugs is not recommended.
* It is essential that pediatricians recognize drugexposed infants. Obtaining a thorough maternal history from all women in a nonthreatening, organized manner is the key to diagnosis.
* Because infants of substance-abusing parents are at increased risk for abuse and because many child protective agencies are overburdened and unprepared to deal with the increasing volume of drug-exposed babies, pediatricians should work with their state social service agencies and state legislatures to extend the assistance now available through child protective services. Simultaneously, pediatricians should work with their local child protective services agencies to encourage multidisciplinary treatment and support for the affected mother, child, and family.
* Chapters of the Academy and local pediatricians should discuss with all professionals and agencies involved how multifaceted problems resulting from drug exposure in utero might best be addressed in their communities. In general, a coordinated, multidisciplinary approach to the development of a plan without criminal sanctions has the best chance of helping children and families.
This article has conceptualized substance abuse in pregnancy as a major ethical challenge for pediatricians. At the outset, it was suggested that ethics need not be a question of bad consequences, right or wrong, guilt, or fixed principles, but a question of information sought, faced, and taken into account in action. Hopefully the information contained in this issue of Pediatrie Annals will shed new light on the present, thus enabling pediatricians to reconceptualize their downstream efforts on behalf of drug-exposed infants and their families as something other than futile and hopeless labor and encourage pediatricians to move further upstream and join in a public health effort to prevent substance abuse in the first place.
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