Treatment of women patients with chronic mental illness who are at risk of unwanted pregnancies presents ethical challenges to the clinician who wishes to respect the patient's autonomy while also helping her avert the potential adverse consequences of unwanted pregnancy. The clinician who simply allows the patient to continue at risk or coerces her into using contraception may not have adequately considered the variable nature of the patient's autonomy. The authors suggest that the clinician should assess and treat conditions underlying the patient's variable impairment of autonomy to maximize her ability to participate in family planning decisions. Case examples are used to illustrate assessment of patients' decision-making capacity, development of family planning approaches that respect patients' autonomy, and use of a newly available contraceptive implant.
PIP: Chronically mentally ill women of reproductive age pose major ethical dilemmas for mental health professionals if the patient does not accept contraception. Ethically questionable responses have ranged from letting the patient continue at risk of pregnancy out of a respect for her autonomy to manipulating or coercing the patient into using contraception. A third course of action assumes that mentally ill women exhibit both chronically and variably impaired autonomy with limitations in decision-making ability manifested in varying degrees over time. 3 case histories illustrate these issues. A 38-year-old schizophrenic woman wanted to become pregnant and was having unprotected intercourse. It was questionable whether the patient could give informed consent or understand contraceptive options. This impaired autonomy might lead a psychiatrist to act paternalistically to forestall a pregnancy. An alternative to this response would be to improve the patient's capacity to participate in the informed-consent process by treating underlying factors which pose barriers to the exercise of autonomy. If impairment is too severe for this treatment, beneficence-based obligations to potential children may override concerns for the patient's autonomy. In the second case, a 30-year-old schizophrenic woman was admitted in active labor in a psychotic state. Her baby was put in foster care. When her psychosis cleared, she refused to discuss birth control. The reproductive risks encountered by chronically mentally ill pregnant women can not be predicted with certainty and are not serious enough to constitute reasons to control the mother's decision-making process. In this case, an alternative approach may be to offer only reversible methods of birth control and provide information about HIV and other sexually transmitted diseases. In a hypothetical case, a 24-year-old schizophrenic woman consented to receive a contraceptive implant at the end of a hospitalization. When she regressed into a psychotic state, she requested that the implant be removed. Her doctors chose to honor the decision she made while she was not acutely psychotic and did not remove the implant. Because the risks the patient runs without the contraceptive are preventable, reversible, or uncertain, the clinician may not be justified in every case in refusing to honor a request by a patient even when she is severely psychotic. Removal of the device may relieve the patient of anxiety, even if the anxiety is delusional. The frustration involved with these problems may lead clinicians to accept any decision made by a patient, even if the principle of autonomy is thus inappropriately applied. An awareness of the variable nature of chronic mental illness, on the other hand, may help clinicians avoid a paternalistic approach. This requires the support of hospitals and clinics which, unfortunately, sometimes override ethical considerations because they must operate with a shortage of staff and resources. With contraceptive implants now available, mental health facilities should develop guidelines which address the unique ethical issues involved in their use.