Ethical challenges of decision making with pregnant patients who have schizophrenia

Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex., USA.
American Journal of Obstetrics and Gynecology (Impact Factor: 4.7). 10/2002; 187(3):696-702. DOI: 10.1067/mob.2002.125767
Source: PubMed


Because there is a dearth of literature, we developed an ethical framework to guide decision making about the management of pregnancy of patients with schizophrenia.
We review pertinent literature on schizophrenia and pregnancy, including information on maternal and fetal risks and outcomes, and relate this information to ethical concepts.
The ethical framework has five components: the concept of chronically and variably impaired autonomy, assisted decision making, surrogate decision making, strategies for dealing with the physician's feelings in response to these patients, and the concept of the fetus as a patient. We apply this ethical framework to clinical challenges of decision making during pregnancy with this patient population.
The preventive ethics strategies of assisted and surrogate decision making can be used to prevent ethical conflicts in decision making about the management of pregnancy of patients with schizophrenia. These preventive ethics strategies should contribute significantly to reducing the vulnerability of these patients and therefore to enhancing their autonomy in the physician-patient relationship.

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    • "Psychiatrists understandably may experience frustration when patients exhibit inconsistent attitudes and views about the issues at stake, or foreboding about any patient's ability to make safe decisions for the fetus as a patient and prospective child. Such strong feelings can sometimes unhinge clinical judgment and the implementation of the strategies of assisted decision making (McCullough et al. 2002). "
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    ABSTRACT: Because of a dearth of literature, we developed preventive ethics strategies for managing the pregnancies of patients with schizophrenia. Schizophrenia can chronically and variably impair a woman's decisions concerning the management of pregnancy, including the decision about whether to continue the pregnancy through to viability and term. The psychiatrist must balance autonomy-based and beneficence-based obligations to the pregnant woman with schizophrenia, and both the psychiatrist and pregnant woman have beneficence-based obligations to the fetus when the fetus is a patient. We discuss the assessment of the decision-making capacity of pregnant patients with schizophrenia and describe the strategies of assisted decision making that aim to diminish chronically and variably impaired autonomy. When patients are severely impaired in decision-making capacity, as, for example, in psychotic denial of pregnancy, the standard of surrogate decision making applies. This should be guided by the substituted judgment standard. When patients' values are not known or have not been consistently held over time, surrogate decision making should be guided by the best interests standard. These strategies should substantially enhance patients' autonomy in the psychiatrist-patient relationship and contribute to the quality of their psychiatric and obstetric care.
    Schizophrenia Bulletin 02/2004; 30(3):659-64. DOI:10.1093/oxfordjournals.schbul.a007113 · 8.45 Impact Factor
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    ABSTRACT: The authors provide an account of their 20-year-old history of collaborative research and publication at Cornell University on ethics in fetal diagnosis and therapy. This research first developed and applied a conceptual framework for ethics in maternal-fetal medicine based on the concept of the fetus as a patient. The basic elements of this framework are described, as well as their application to fetal diagnosis and fetal therapy. Related topics, including obstetrics and gynecology, clinical medicine, managed care, and the ethical dimensions of medical leadership, are also briefly described.
    Fetal Diagnosis and Therapy 07/2003; 18(4):217-22. DOI:10.1159/000070798 · 2.94 Impact Factor
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