Classrooms of the 21st Century
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Bioethics Forums
Decision Notebook
Fetal Alcohol Syndrome

Fetal Alcohol Syndrome: Maternal Responsibility
Forum: Should a mother be held responsible for for the health of her fetus.

Step 1:

The Context

What decision is being made?

Who is making the decision?

What information is relevant?

Step 2:

The Stakeholders

Restaurant Owner
"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?"

Why is he/she a stakeholder?

What values does he/she hold?

Beneficence is doing good for others. There are several different kinds of beneficence. Individual beneficence is doing good deeds for individuals--someone you know or a stranger. Kinship beneficence is doing good deeds for relatives-- members of the immediate family, the extended family, or social organizations like tribes, clans, or races. Social beneficence is doing good deeds for society as a whole.

Economic Efficiency
Many people feel that it is important to use money efficiently, and make decisions with that in mind. To some, economic efficiency means spending as little money as possible on a problem; others point out that larger initial expenditures may be more efficient by reducing later or hidden costs. Some people consider economic efficiency to be an absolute value; for them it is the main consideration in making a decision. Others consider economic efficiency a relative value; they try to minimize costs but do not consider saving money to be the most important part of a decision.

What are his/her immediate objectives?

What information is relevant?

Tavern Sued in Drunk Driving Death
The family of a man killed when he drove his car into an irrigation canal last August has filed suit against a local tavern where he had been drinking shortly before the accident. According to court papers, the family seeks $5 million in damages from Dalto's Suds 'n Jazz, charging that the bartender shouldn't have served the obviously intoxicated victim.
The man, who had a history of drunk-driving arrests and was driving without a license, had visited several bars the afternoon before his death, according to police. He drank three beers at Dalto's around 6 p.m., according to the bartender, who defended his actions, insisting, "He looked fine to me. Anyway, people get real mean when you cut them off." The victim left Dalto's around 7 p.m. and was never seen alive again. Police divers found the man's car in 10 feet of water. He had apparently driven off the road.

Pregnant Woman
I can't wait for my baby -- three more weeks. This hasn't been a picnic. I've been sick, tired, sure I'm happy, but everybody and his little brother thinks he knows what's best for me. Look, when I found out I was pregnant, I quit smoking, I started taking vitamins, I get plenty of sleep, and by-and-large, I don't drink. This know-it-all sticks his nose in my business, in front of my friends. Implies I'm careless or irresponsible. It's too much. I want him canned.

Why is he/she a stakeholder?

What values does he/she hold?

Many people believe that individuals have a right to keep information about themselves private if they wish to do so. An information issue related to privacy is the belief that people have a right to information about themselves.

Autonomy is having control of your own fate and making your own decisions. It includes freedom of action as well as control of information about oneself. Individual autonomy is when a person has control of his or her own decisions and destiny. This includes religious beliefs, the right to work, and rights guaranteed by the social contract. Family autonomy is control of the decisions within the family. It includes reproductive decisions, disciplinary measures, and consenting to medical procedures. Corporate autonomy is when businesses make their own decisions without outside interference. The doctrine of free enterprise states that the market is the best control of businesses and corporations, not outside regulators. National autonomy is when a nation has control of its decisions and destiny, free from interference from other nations or international organizations like the United Nations or the World Bank.

Personal Ethics
Personal ethics are sets of rules that guide people through life's difficult decisions. They vary from person to person, and are derived from many sources including religion, philosophy, and the social contract.

Four common personal ethics are honesty, respect, honor, and fairness. Honesty means telling the truth and not breaking an agreement. Some people believe they should always tell the truth, even if nobody asked for it or if it hurts someone. Others give the truth only when asked to do so, or when it will save someone from harm.

Respect and honor are ways of recognizing another person's autonomy. To respect and honor a person is to recognize that person's ability to make decisions for himself and to not interfere once the decision is made.

Fairness is an attempt to make sure everyone has what they need without interfering with the autonomy of others.

What are his/her immediate objectives?

What information is relevant?

Drink To Your Health!
Those of us who like to savor a glass of fine wine with our meals or finish off a delightful evening with a snifter of brandy can take heart from the latest medical findings: moderate drinkers live longer than those who drink too much or those who drink not at all.
According to an 11-year study conducted by researchers at Harvard Medical School, men who drank about two to four drinks a week had the lowest death rate of all groups studied. Even those bon vivants who swilled six glasses a week lived longer (and, no doubt, more pleasurable) lives than those who denied themselves such simple joys.
Not only were moderate drinkers found less likely to die from the nation's biggest killer, heart disease, but they were also less likely to die from violence, accidents, and suicide.
For those who drink more than a glass a day, however, the prospect is less salubrious: their risk of death from heart disease remained low, but they

I'm not allowed to serve a drunk; I'm not allowed to serve somebody without shoes, I'm not allowed to serve teenagers, but I'm supposed to serve a pregnant woman? Give me a break. I wasn't rude; I merely suggested she might prefer ginger ale instead of wine. But when she got so mad at me, I decided, no way. I didn't say she was an alcoholic, how could I know that? All I know is with a pregnant woman, I'm serving two people and one of them is definitely under age.

Why is he/she a stakeholder?

What values does he/she hold?

Sanctity of Life
Many people believe that life (human life, usually) is sacred. They believe it is wrong to end a life, and some believe that all possible measures should be taken to keep a person alive as long as possible.

Religious Traditions
Religious traditions are sets of beliefs and rules that guide people through life and its many difficult decisions. Religious beliefs tend to be more absolute than personal values. Religious traditions include the great world religions, such as Buddhism, Christianity, Hinduism, Islam, and Judaism, as well as many religions with fewer adherents.

Nonmalificence means not causing harm. Some people think the duty of nonmalificence means not hurting others. Others think the duty extends to preventing people from being harmed by third parties.

What are his/her immediate objectives?

What information is relevant?

Serving Alcoholic Beverages
As a facility licensed to serve alcoholic beverages to the public, we have a legal responsibility to refuse to serve alcohol to customers when it is apparent that doing so puts either them or others in danger. Allowing a customer to become intoxicated puts this establishment at risk for lawsuits, criminal prosecution, and loss of licensure.
Therefore, before serving any alcoholic beverages to any customer, all wait persons, bartenders, and other restaurant employees must determine whether there is any indication that allowing the customer to drink will endanger either the customer or others. You will find that the most common indication will be signs of intoxication. Be sure to confirm the customer's age if there is any doubt that he or she is above the legal age for consuming alcoholic beverages.

This is a school, I'm an educator, I'm supposed to educate. There's no education going on here. We've got our hands full just keeping order. Society hands over its children. All its children. We get kids with emotional problems, family problems, medical problems, drug problems. We're supposed to heal them and teach them. We try, but these kids don't need teachers. They need doctors, social workers, and psychologists. The result is nobody's getting an education here. Nobody.

Why is he/she a stakeholder?

What values does he/she hold?

Beneficence is doing good for others. There are several different kinds of beneficence. Individual beneficence is doing good deeds for individuals--someone you know or a stranger. Kinship beneficence is doing good deeds for relatives-- members of the immediate family, the extended family, or social organizations like tribes, clans, or races. Social beneficence is doing good deeds for society as a whole.

What are his/her immediate objectives?

What information is relevant?

Special Education Costs
Special Education Costs

Sign In Restaurant

Societal Costs Associated with Fetal Alcohol Sydrome
Societal Costs associated with FAS.

Societal Costs Associated with Alcohol Abuse
Societal Costs associated with alcohol abuse.

Step 3:

Alternatives and Tradeoffs

Desribe the alternative action

How would each Stakeholder be affected

Step 4:

Propose a solution and defend

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.

Insurance Agent
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.

The developing embryo is vulnerable to the slightest chemical changes in the mother's bloodstream. As soon as there's a possibility of pregnancy, a woman must consider her behavior. A single drink of alcohol, for example, can seriously affect development during the early weeks of pregnancy, and can cause FAS. Babies with FAS are often premature, weigh less, and can suffer varying degrees of mental retardation.

Civil Rights Lawyer
This is an adult woman. Adult. She's in charge of her body and that of her fetus, not anybody else, particularly some stranger, some waiter. What's he gonna do next? Refuse to serve an overweight person dessert? Refuse french fries to a person with skin problems?

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.

Police Officer
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.

Mother With PKU Who Has a Child
I have a genetic disease called phenylketonuria. I'm okay, I just have to be careful about what I eat. But when I was pregnant, I had to be really careful, scrutinize what I ate, because the food that hurts me, would devastate my baby. It was hard, but a mother does what she has to for her baby or her fetus. A mother is the best and final judge.

Our Code does not allow us to give advice. We give information. Then our clients make up their own minds. Sometimes it's tough because I do have opinions. When an alcoholic mother, or drug addict, or an abusive personality walks in the door, it's hard not to suggest that they stop having kids. You only have to look at the messed-up homes these children are born into to be concerned. How can an impaired woman take care of a child when she can't take care of herself? But I avoid being directive. I point out that having a baby is a lot of work and can cause stress.

Mother Sues Distiller for FAS
A 39-year-old mother has filed suit in U.S. District Court against a major distilling company, charging that the company is responsible for her child's birth defects because the company failed to place labels on its products to warn customers of the dangers of drinking alcohol during pregnancy.
The woman, who admits she is an alcoholic, told the court that she would have stopped drinking alcohol during her pregnancy, if she had known that drinking could have harmed her unborn baby.
The woman's 4-year-old son has been diagnosed with fetal alcohol syndrome (FAS), which causes mental retardation, learning disabilities, and facial and cranial deformities.
"I had no knowledge of any damage that could be done (from alcohol), and if I had, I would have quit," she told the court. The mother has stated that on some days during the pregnancy she would split a fifth of whisky with her husband.
A company executive testified that he

Am I An Alcoholic?
One of the most difficult obstacles the alcoholic must overcome is denial. We say that we drink to relax, drink to have fun, drink to be social. We say anything to justify our drinking, rather than admit that we drink to get drunk. The first step, often the hardest step, on the road to sobriety is admitting to yourself that you are an alcoholic.
These questions may help you determine whether you have an alcohol problem:
- Do your ever wake up in the morning feeling you need a drink?
- Have your family, friends, or coworkers ever asked you to cut down on your drinking?
- Do you find yourself longing for a drink?
- Has drinking ever caused you trouble on the job, led to family fights, or gotten you in trouble with the law?
- Have you ever been in an accident or been ticketed because you drove your car under the influence of alcohol?
- Have you ever had a "blackout," a period in which you could not

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, a 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.

Protect the Baby in Your Womb
Tobacco Tobacco is a dangerous drug containing harmful chemicals that can harm a growing fetus. Smoking during pregnancy will increase the risk that your baby will be born prematurely or dangerously small, and, after birth, to at high risk for sudden infant death syndrome (SID).
Cat Litter Even healthy cats can carry a parasite that causes toxoplasmosis. Infection by this parasite during pregnancy can cause severe fetal injury, brain damage, or death. Avoid handling cat litter boxes or soil contaminated with cat feces.
Alcohol Drinking alcohol during pregnancy has been linked to fetal alcohol syndrome (FAS). Babies with FAS can suffer mental retardation, attention deficits, learning disorders, and cranial or facial deformities. Since no safe dose of alcohol has been determined, most doctors recommend that you do not drink at all during pregnancy.

The High Cost of Mainstreaming
The goal of the Individuals with Disabilities Education Act is admirable. The federal law requires that "to the maximum extent appropriate, children with disabilities...are (to be) educated with children who are not disabled." This is called "mainstreaming," and the idea is to ensure that disabled children have the same chance of receiving a good education as other children have.
But the cost of mainstreaming is staggering. There are now 5.17 million disabled students in our schools, including 2.33 million with learning disabilities, 990,000 with language impairment, 484,000 with mental retardation, and 368,000 with serious emotional disturbances.
To meet the special needs of these children, many of whom are disruptive, cash-strapped schools have had to hire specially trained staff, purchase new equipment, and build new facilities. On average, it costs $10,675 per year to educate a disabled student, almost twice the

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.

Cocaine-Using Mother Charged in Death
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.

Drug-Abusing Mother Charged Under Drug
A 24-year-old woman has been charged with illegally delivering drugs via the umbilical cord after she admitted to police that she smoked crack cocaine shortly before delivering her son last August.
Under the law, which was designed to punish drug dealers, the woman faces a maximum 20 years in prison and a $25,000 fine. The penalty is far more severe than she would face for personal possession or use of an illegal substance.

Drug Addict Mothers
The doctors at the local university are doing something about our epidemic of drug- and alcohol-damaged infants. They have set up a free prenatal program for poor women. Women who sign up for the program are tested for drug use. If a woman tests positive, she is confronted with a choice: enter drug treatment or go to jail.
Most people would find the decision easy, but so far over 40 of these mothers9despite the fact that they are endangering their unborn children9have refused to get drug treatment and have been sent to jail.
Clearly, these women are unfit to be mothers. We suggest that these women, who cannot avoid drugs even to protect their unborn children, should be encouraged to have abortions or be sterilized.

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."

Mother Considered Guilty of Child Abuse
A woman who used cocaine during pregnancy, even hours before giving birth, was convicted of prenatal child abuse and neglect. "This is a case of giving drugs to a child, plain and simple," commented Judge Lutwak, "It is the duty of the state to protect the child from this kind of exposure."
The mother's attorney argued that state child abuse laws deal only with minors under 21 years old and not fetuses. The judge admitted that the attorney was correct but argued that he "had to take a stand for the safety of the fetus."
Extensive testing showed the baby developed no signs of addiction or serious health problems from exposure to the drug.

Dealing with PKU
Phenylketonuria (PKU) is an inherited disease in which an enzyme needed to metabolize the amino acid phenylalanine is defective. As a result, phenylalanine reaches toxic levels in the blood, causing damage to developing brain and nerve cells.
Without treatment, children with PKU develop severe mental retardation and other nerve problems. This can be prevented if the child is put on a special low-protein diet soon after birth. The diet will provide enough phenylalanine to allow normal growth but not enough to reach toxic levels.
Grown women with PKU who plan pregnancy should strictly adhere to the PKU diet before conception and throughout pregnancy because high blood levels of phenylalanine in their blood can hurt a fetus. If they do not, 90% of the time their children will be severely retarded and have heart abnormalities and other birth defects.

PKU Dietary Guidelines
Phenylalanine is an amino acid needed to build proteins, so all children, even those with phenylketonuria (PKU), need it to grow. The PKU diet can supply your child with all the phenylalanine he or she needs to grow strong and healthy but not so much as to cause the blood levels that can harm your child's brain development.
Your child must avoid protein-rich foods such as meat, fish, eggs, and dairy products. Instead, your child will get protein from a specially prepared protein supplement with small amounts of phenylalanine.
Although such a diet might seem impossible to stick to, there are many commercial products that can make a phenylalanine diet varied and interesting. There are low- protein breads, cereals, and pastas; low-protein wheat products for baking cakes and pies; low-protein egg substitutes; even low-protein "gelatins" for making desserts.

Teen Pregnancy Program Under Fire
When the long-acting contraceptive Norplant became available, social workers were excited. Teen pregnancy is a major problem among the poor, forcing many young women to quit school and often condemning them to a life on welfare. The contraceptive, implanted under the skin, prevents pregnancy for five years. Many thought that if poor young women could be encouraged to have the implants, they would have a chance to finish school and get a job before starting a family.
But some community leaders suspect that the government intends to use Norplant to reduce the size of the U.S. African-American population by "chemically sterilizing" young black women. Their suspicions were heightened when a major East Coast metropolitan newspaper ran an editorial suggesting that Norplant could help eliminate the "underclass."

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.

Incidence of Fetal Alcohol Syndrome
Incidence of FAS during past 25 years. (PERCENTAGE IN POPULATION)

Alcohol Consumption for Men
percentage of alcohol users in US 25 years (never/monthly/weekly/daily)

Alcohol Consumption for Women
percentage of alcohol users in US 25 years (never/monthly/weekly/daily)

Doctor's Report
Include woman's drinking habits. (one or two drinks a day)

Stated Reasons Why Women Choose Abortion
Stated reasons why women choose abortion

Cost of Screening v. Cost of Treatment
Cost of screening vs treatment for PKU.

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