Ethical and Legal Aspects of Women’s Mental Health

1.1. You discuss both the risks of continuing carbamazepine and the risks of stopping the medication during pregnancy with Mrs. A. She is adamant that she wishes to continue on carbamazepine despite a full understanding of these risks. The bioethical principle that underlies Mrs. A’s legal right to make this choice is

1.2. Mrs. A explains that her husband is opposed to her continuing carbamazepine during pregnancy due to the known risks, so she is concealing her decision from him. She asks for assurance that you will not share this information. You should respond that

1.3. Mrs. A further explains to you that she works as a party planner and that she occasionally uses illicit drugs, including cocaine and 3,4-methyl​enedioxy​-methamphetamine (MDMA), with her clients. She states that she has tried to “cut back” since deciding to have a child. She is interested in outpatient substance use treatment, but fears that if she fails and tests positive during pregnancy, she might have her baby taken away from her or even be arrested. What advice can you give her?

1.4. Which of these steps is ethically acceptable?

2.1. Upon evaluation by Dr. X, Ms. Y is found to be expressing a clear, consistent choice to leave the hospital and appreciates the risks of doing so for both her and her child. Thus, Dr. X believes that she meets the clinical standards for capacity regarding these decisions. She also states that her intention is to call a taxicab and travel to a different hospital across the city for further care. Which of the following is correct?

2.2. Allowing Ms. Y to leave the hospital AMA, but not allowing her to take her child with her, is most consistent with the final court decision in the case of which of the following?

2.3. Dr. X ascertains that the reason Ms. Y wishes to leave the hospital AMA is because, after the delivery, her care was assigned to a male OB/GYN resident. For religious reasons, she objects to having her body touched by a male provider. She explains that she is happy to remain if she is cared for only by female doctors. How should the care team respond to this request?

2.4. Ms. Y explains to the care team multiple times during the course of her hospitalization that she is a devout Jehovah’s Witness and that she would choose death over the religious consequences of an allogenic blood transfusion. The day after her delivery, she suffers an internal hemorrhage and requires both emergency surgery and donor blood to survive. She remains conscious and continues to object to a transfusion. How should the hospital proceed?

1.1. The answer is E. Autonomy is one of the four core principles of contemporary medical ethics first proposed by Beauchamp and Childress in 1979 (13). It refers to self-determination based upon informed consent and is arguably the dominant ethical value in Western medicine today. Equity is the goal of ensuring that all individuals, regardless of their starting points and circumstances, are treated fairly (choice A). Mutualism is an approach to ethical issues that emphasizes the importance of relationships (14) (choice B). Teleology (choice C) is a model of ethics that focuses on the ends or outcomes of an action; utilitarianism is likely the most well-known of such approaches. Beneficence, another of Beauchamp’s and Childress’s four principles, refers to the duty of physicians to serve the interests of their patients (choice D). These interests may or may not accord with a patient’s preferences.

1.2. The answer is C. As a general rule, physicians may not share personal health information of their patients with third parties except in extremely rare circumstances such as a threat of physical direct harm to that third party. Both federal and state laws codify these protections, as do the ethical codes of many professional organizations. A husband or the father of a woman’s baby has no right to access her private health information (choice B). Although physicians may be legally required to report certain dangers that a fetus faces to the state in some state jurisdictions, these rules do not apply to prescribed medications (choice A) nor is the husband of a woman who has decisional capacity ever the correct person with whom to share this information (choice E). The Supreme Court decision in Jaffee v Redmond addresses therapist-patient privilege and refers to the authority of patients to prevent their mental health providers from testifying against them in court (choice D). This decision lies entirely with the patient and not with the clinician.

1.3. The answer is C. Although a medical provider might decline to offer a patient guidance on what is essentially a legal question, physicians who do offer advice have an obligation to ensure that it is accurate. Several states—including South Carolina and Alabama—have successfully prosecuted women for illicit substance use during pregnancy (15) (choice B). Other states, such as Wisconsin, have held women accused of substance use during pregnancy in civil detention (16). Although hospitals cannot constitutionally test pregnant patients for drug use without consent or a warrant seeking evidence of a crime (17), that does not mean that the results of such tests, if conducted with consent, cannot be used in criminal prosecutions (choice D). Many jurisdictions will use positive drug test results against parents in custody matters (choice A). Whether a patient pursues substance use services as an inpatient, instead of as an outpatient, should have no bearing on either civil prosecution or civil custody matters (choice E).

1.4. The answer is D. Abandoning a patient who does not have access to necessary care is unethical and the grounds for professional discipline. Although Dobbs v Jackson (2022)—the United States Supreme Court overturning of Roe v Wade and a woman’s constitutional right to abortion—allowed states to criminalize abortion, some states (including the one in the scenario) have chosen not to do so. Thus, Mrs. A’s conduct would be legal (choice A). Telling her otherwise would be both dishonest and unethical. The claim that the psychiatric risks of abortion exceed those of normal delivery have been debunked (18) (choice B). Offering to assist the patient with adoption if she did not pursue an abortion would risk both coercion and also inappropriate entanglement in a nonclinical matter (19) (choice E). Once a physician has prescribed medication for a patient in an outpatient setting, courts and state medical boards will generally recognize this to be a doctor-patient relationship and not merely a consultation (choice C).

2.1. The answer is C. Patients who have decisional capacity are legally entitled to make their own medical decisions, including the right to leave a hospital AMA (20). The wisdom of such decisions is not for physicians to determine (choice A) and the decision does not require a judicial determination for authorization (choice D). However, parents do not have the right to make medical decisions for their children if those decisions place the lives of their children in jeopardy (choice B). Although Ms. Y is at higher risk of postpartum psychosis on the basis of her family history, no evidence is presented that she is currently symptomatic (21). Although further monitoring might be in her best interests, it cannot legally or ethically be forced upon her against her will (choice E).

2.2. The answer is A. Prince v Massachusetts (1944) is a United States Supreme Court decision that distinguished between the rights of parents to make decisions for themselves and to make decisions for their children, and that has significant implications for health care law. In the majority opinion, Justice Wiley Rutledge wrote, “Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves” (22). The case limited the ability of parents to make decisions for their children that put those children at significant risk. Jacobson v Massachusetts (1905) is another U.S. Supreme Court case that upheld the authority of the state of Massachusetts to impose compulsory vaccination during a smallpox outbreak, even over religious objections (choice B). Tarasoff v Regents of the University of California (1976) (choice C) and Volk v DeMeerleer (2016) (choice D) are state court cases from California and Washington, respectively, that address the circumstances under which mental health providers must warn and/or protect third parties after patient threats. Kansas v Hendricks (1997) (choice E) is a U.S. Supreme Court decision that set the parameters for when states can hold sex offenders deemed dangerous in indefinite civil commitment.

2.3. The answer is A. If reasonably possible, the hospital should attempt to accommodate Ms. Y’s sincere, faith-based request. Unlike requests based on other factors such as race and religion, some flexibility is generally accorded gender-based requests that are concordant with widely held social values, particularly in areas of sexual health and reproductive care (23). Title VII of the Civil Rights Act of 1964 prohibits discrimination in the workplace based on a range of protected characteristics including sex, but has not been interpreted to require that female obstetrics patients agree to accept care from male providers (choice D). Both Meritor Savings Bank, FSB v Vinson (1986) and Harris v Forklift Systems, Inc. (1993) are U.S. Supreme Court decisions that clarify Title VII’s application to workplace sexual harassment (choices C and E). In the absence of concerns for psychosis or incapacity, it would be inappropriate for medical providers to investigate Ms. Y’s sincerely held religious beliefs or whether her beliefs are fully concordant with those of her religious community (choice B).

2.4. The answer is E. Although states vary in their rules regarding whether a pregnant patient can be given a life-saving blood transfusion without consent, current law is clear that after delivery, women are able to make these decisions for themselves. This reflects the bioethical value of autonomy. Capable adults may turn down transfusions on religious grounds even if their lives are placed in jeopardy as a result (choice A). If a capable patient is expressing a clear, consistent wish, neither the absence of a written advance directive nor the preferences of third-party decision-makers is relevant (choice C). In the case of Application of the President and Directors of Georgetown College, Inc. (1964), Judge J. Skelly Wright ruled in a similar case that the involuntary transfusion should go forward because the state would “not allow a parent to abandon a child” and that as a parent, the patient “had a responsibility to the community to care for her infant” (24). However, that case is no longer followed widely in light of subsequent legal developments (choice B). The U.S. Supreme Court decision in Washington v Glucksberg (1997) rejected a right to so-called physician-assisted suicide, an active process, which the courts view as fundamentally distinct from the recognized right to refuse unwanted treatment (choice D).