BIOETHICS FORUMS DECISION NOTEBOOK- CONTEXTStep 1:The Context
The first step of the decision-making process is to learn more about the decision to be made.
"I tell every new employee, read this sign every day before work. The other day my best waiter refuses to serve a pregnant woman alcohol, says it's dangerous to the fetus. Today, the woman threatens a law suit, unless I fire the waiter. This time I don't know who's right. Or whose rights I'm responsible for: Customer? Employee? Fetus?"
What decision is being made?
Should the restaurant owner respect the pregnant woman's demands and fire the waiter?
Who is making the decision?
The waiter made the original decision not to serve. Now the restaurant owner must resolve the conflict.
What information is relevant?
Is it dangerous for a pregnant woman to drink alcohol? If so, are there variables that increase or decrease the level of risk? Are there legal precedents or laws to be considered? Does the restaurant have a policy about serving alcohol to pregnant women? Does the restaurant have a policy about serving alcohol? Does an individual, or society, have a right to tell a mother how to take care of her fetus?
Fetal Alcohol Syndrome
Health experts say more than 5,000 babies are born each year with birth defects caused by alcohol their mothers drank during pregnancy. The condition is called Fetal Alcohol Syndrome (FAS). These children have moderate to severe mental retardation, facial and cranial deformities, and a variety of learning and behavioral problems. The care for children and adults with this condition costs the U.S. about $1.5 billion a year.
Researchers know that mothers who drink heavily during pregnancy greatly increase their risk of giving birth to a child with FAS. Even moderate drinking has been linked to the condition, especially if it takes place early in the pregnancy when the embryo's brain is going through crucial stages of development. Many scientists studying the problem say that the danger is so great that a woman should never drink any alcohol during pregnancy.
Incidence of Fetal Alcohol Syndrome
Estimates for the incidence of fetal alcohol syndrome range between 0.33-5.0 per 1,000 live births.
The woman has good health habits--she exercises, has a low-stress job, schedules regular mammograms, has a low-fat, vegetarian diet--and schedules regular prenatal examinations. She has 1-3 drinks a week and is in the third trimester of her pregnancy.
Drugs and Pregnancy
A number of drugs, chemicals, and environmental factors can cause fetal malformations, especially during the first two months of pregnancy, when the fetal organs are forming.
One of the most famous of these drugs is thalidomide, drug given to pregnant women in the 1960s as a sedative and treatment for pregnancy-related nausea. Many children of women who took this drug were born with small, deformed arms and legs.
Another drug, diethylstilbestrol (DES), was widely used to treat pregnant women in the 1950s, 60s, and 70s. One-third of the daughters of women exposed to the drug during pregnancy were born with vaginal, cervical, and uterine abnormalities. Women who were exposed to DES while in the womb also have a higher risk of developing cervical and vaginal cancers.
Why can a mother's behavior affect her fetus? What does this imply about the physical connection between the mother's blood supply and her fetus? What do we know about the pregnant woman's behavior and health habits? How does that influence the risk to her fetus?
"Pregnant women shouldn't drink, people with diabetes shouldn't eat sugar, people with high blood pressure shouldn't work in upper management. But these are medical conditions. They require professional medical advice. It's good that the average person is more aware of FAS these days; but it doesn't qualify them to advise others on their diet or behavior."
Role of Endogenous and Exogenous Factors in FAS/FAE
Despite the fact that 60% of U.S. women report drinking at least some alcohol during pregnancy, alcohol-related birth defects are relatively rare, occurring in about 1.9 per 1,000 live births. Alcohol consumption during pregnancy alone, therefore, does not explain why some children develop fetal alcohol syndrome (FAS) or show signs of fetal alcohol effects (FAE) and others do not.
Recent studies point to a number of factors that may play a role. The finding that certain ethnic groups are at higher risk (Native Americans, for example, have a 30-times greater risk according to some studies) suggest that genetics may make some groups more or less vulnerable to the effects of alcohol during pregnancy. This could explain why some women seem to be able to drink large amounts of alcohol during pregnancy without causing detectable harm to their offspring. For example, in one study, only 10% of children of chronic alcoholics had FAS.
Other factors that may influence the risk of FAS/FAE include peak blood alcohol levels reached during drinking bouts, duration of drinking, time of the pregnancy when the heaviest drinking took place, maternal mother3s nutrition....
Objectifying the Patient
Physicians should be careful of the labels they attach to patients. We all know of harried residents who refer to the man with coronary disease as "the heart in room 36" or the woman with an ulcerous condition as "the stomach." This objectifying dehumanizes the patient and erects a wall between us and the people we touch and serve.
This also applies in day-to-day practice. For example, take the term "diabetic." We don't think twice about referring to a person with symptoms of diabetes as a "diabetic." However, look at the range of symptoms. The moment patients become "diabetics," they cease to be individuals. We consider their complaints and concerns through the filter of the label. Instead of hearing what the individual patient has to tell us, we interpret it as the talk of a "diabetic."
The article on drugs and pregnancy points to the difficulty of determining a cause-and-effect relationship between drinking while pregnant and fetal alcohol syndrome. It also notes some of the variables involved. The physician believes that ordinary individuals are not qualified to give medical advice. The article on objectifying patients applies to people who aren't doctors too--do we sometimes make hasty judgments about a person without knowing all the information? Did the waiter do this with the pregnant woman?
Cocaine-Using Mother Charged in Death of Newborn
The State Attorney has charged a 24-year-old mother with involuntary manslaughter after an autopsy concluded that her 2-day-old infant died because the mother had used cocaine during the pregnancy.
State officials said legal action was necessary to protect other fetuses from the illegal behavior of drug-addicted mothers. In some city hospitals, as many as one in four newborns shows signs of fetal drug exposure, according to a recent study.
Women's health advocates, however, denounced today's criminal charges. Fear of arrest will keep drug-using mothers from using health clinics for prenatal care, thus reducing the chances that they will get drug treatment, they said.
"We can't let pregnant women have drinks. (frustrated) I mean, you can print all the warning labels and signs you want -- you can't make people read or understand them. Fetal alcohol syndrome is no joke. Do you have any idea how expensive it is to take care of a baby with FAS? Who pays? The insurance company. Ultimately, you and everybody else when rates go up. If society is paying, then society has the right to make a few rules."
Many people believe that society must prevent pregnant women from drinking alcohol. Their reasons for believing this vary depending on their values and may include the health of the fetus, the social costs of fetal alcohol syndrome, the belief that the fetus has rights, or other considerations. Do these articles change your opinion of the woman's actions? What about your opinion of the waiter's actions? How might they affect the owner's decision?
"If this was a law that a pregnant woman was not allowed alcohol -- how would we enforce it? Give every woman a pregnancy test when she orders a drink? Put an ID sticker on her forehead? Throw her in jail if she cheats? We don't have enough jail space now. (deep sarcasm) Or maybe not let women order drinks at all, just to be sure. We can't get into these privacy issues. They're unenforceable."
Special Children Special Parents
The Smiths say taking care of little Robert, with all his problems, has made their life immensely rich. "We were devastated when the doctors told us that Robert would never be normal. And we blamed ourselves. We thought maybe we weren't careful enough during the pregnancy. Our friends said we should have had more tests done to make sure the fetus was all right," says Robert's father.
But when they took little Robert home from the hospital, their despair faded away as their love for this very special child grew. "It was his smile that won our hearts. And his determination. He's a brave little guy," says Robert's mother.
The police officer notes how difficult it would be to enforce a law preventing pregnant women from drinking. Is it possible to enforce such a law? How might the enforcement of such laws violate a person's civil rights? The article on special children points out that we sometimes think of only the bad things associated with birth defects and learning disabilities. It reminds us that people with these disabilities are unique individuals that can live worthwhile lives and make significant contributions to society.
Alcohol Consumption for Men
The most recent figures show that 12% of men drink alcohol on a daily basis, 37% drink weekly, 16% drink monthly, 10% drink yearly, and 24% abstain from alcohol entirely. The figures have varied over time; the numbers of abstainers stayed about the same and the number of daily drinkers declined from its peak in 1979.
Alcohol Consumption for Women
The most recent figures show that 4% of women drink alcohol on a daily basis, 21% drink weekly, 20% drink monthly, 19% drink yearly, and 36% abstain from alcohol entirely. The figures are much lower than similar statistics for men. The figures have varied over time; the numbers of abstainers and daily drinkers decreased slightly and the numbers of monthly and yearly drinkers declined.
The use of alcohol is quite common in our society. Women are more likely to abstain than men, and tend to drink less frequently. Is this because of the dangers of drinking during pregnancy? Are other factors involved? Do you think we drink too much alcohol as a society? Should alcohol be banned or should the government act to reduce the amount that people drink? Why do people drink?