2. CASE: Treatment and/or Termination? Tough Choices

Melanie is a 21 year old who was recently involuntarily committed after she started a serious fight at a local shelter, thinking that one of the leaders was trying to steal her favourite T-shirt. Melanie has schizophrenia and is well-known to both the police and mental health care providers. She has been living on and off the streets since she left home when she was 16 years old, and has a rather strained relationship with her parents. They have been trying to support her and often provide money for her medications. When Melanie is taking her medications, she is able to find work and has talked about going back to school. However, Melanie finds the side effects of the medications awful and stops taking them, leading to being kicked out of apartments or friends’ places when she gets too aggressive.

In doing Melanie’s work-up upon admission, it was discovered that she is about 7-8 weeks pregnant. While trying to determine what to do with respect to the pregnancy, she is placed on medications that minimize teratogenic effects for the fetus, and that may have some success in stabilizing Melanie’s condition (although it is recognized that this is not the “gold standard” treatment). Melanie’s mother, Krystine, was named by Melanie as her substitute decision-maker (witnessed by her psychiatrist at the end of her previous admission), despite some of the challenges in their relationship, and she endeavours to do the best for her daughter. The team has been in discussion with Krystine about treating Melanie and about her pregnancy.

Melanie has indicated that she doesn’t know who the father is, as she has had several partners over the last few months. She also alternates between saying that she wants the baby to saying that the baby is cursed and she should be rid of it. Krystine indicates that Melanie has not talked to them about having children, only about trying to get well to go back to school.

Both Krystine and the health care team have some questions and concerns about how to move forward with Melanie’s treatment. The health care team calls for a clinical ethics consultation.

  • If the medication regime doesn’t stabilize Melanie, would it be ethical to move to a different treatment plan, knowing that this might cause substantial harm to the fetus?
  • Should the possibility of terminating the pregnancy be discussed further?
  • Should an attempt be made to find and notify the biological father?
  • How do the dynamics if Melanie’s family relationships factor into this case?
  • Can or should someone other than Melanie make these decisions?

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Living at risk
  • Vulnerability
  • Patient-family relationships
  • Substitute decision-makers
  • Beneficence and non-maleficence
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