We recognize that many of the issues raised are not simple. Our proposal calls for the same thoughtful deliberation applied in other settings to be brought to bear on reproductive health care. Some have already tried alternative approaches. In Albuquerque, New Mexico, a university hospital neonatologist and the district attorney have collaborated to create an alternative to sentencing program for women who are arrested for drug-related crimes and found to be both pregnant and drug addicted. Rather than proceed with criminal sanctions, these women are offered entry into a drug treatment program that is geared to families with young children and run by the pediatrics department. Here, the physician and the district attorney collaboratively responded in ways congruent with the professional integrity of each. In another example in Portland, Oregon, physicians, drug treatment providers, and child protective social service representatives cooperatively defeated a legislative proposal to mandatorily test and report pregnant women for illicit drug use and, instead, formed a task force to jointly develop state policy regarding the issue. Drug use, HIV infection, child abuse, and poverty are all cause for alarm. Yet it is critical that our frustration about these difficult problems not be translated into blaming individuals for "deviance," or into short-term inadequate responses. In developing policy we should consider the impact on the legal and ethical rights and obligations of both patient and physician. For every course, we should evaluate both immediate and long-term efficacy, the consequences for the doctor-patient relationship, and the consequences for medical integrity. In the midst of the present regulatory and fiscal turmoil affecting health care, we urge physicians to be careful and deliberate in the policies they embrace and the actions they take.
PIP: In the US, recognition of the interaction between health and social issues has led to proposed social policies that would require health care professionals to implement the goals of other social agencies in ways which might compromise the effectiveness of their own work. Physicians are asked (and in some states mandated) to test pregnant women (without seeking their specific consent) for suspected drug abuse and to report results to child protective or criminal justice authorities. Physicians have also been asked to carry out legal mandates such as the insertion of contraceptive implants in women found guilty of child abuse. Insertion of Norplant has been proposed as a requirement for continuing receipt of welfare. However, the physician-patient relationship is based on informed consent (which has always invoked when medical personnel have provided evidence in cases involving rape or assault), on confidentiality (but courts have ruled against psychiatrists who failed to release confidential information that may have prevented a crime), and on the assumption that the physician will be an advocate for the patient's well-being. This assumption is compromised when physicians are asked to comply with laws that do not advance the individual's clinical need (to insert Norplant when it is contraindicated or to submit to a "gag rule" and not provide abortion counseling and referral). Resolution of the current debate about mandatory HIV screening of pregnant women will, therefore, impact the patient-physician relationship. The blurring of professional boundaries between the field of reproductive health and child protection has occurred because of cultural assumptions justifying actions as in the best interests of the child. Efforts to achieve interdisciplinary collaboration overlook contradictions (women may avoid prenatal care if it includes drug testing). Proposed policies should be assessed for their impact on the legal and ethical rights and obligations of patients and physicians, their immediate and long-term efficacy, and their consequences for the doctor-patient relationship and for medical integrity.