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Maternal–Fetal Relationship: III. Legal and Regulatory Issues

III. LEGAL AND REGULATORY ISSUES

The intimate relationship between a woman and a fetus developing within her body has long given rise to vital questions of morality, religion, science, medicine, law, and public policy. The abortion controversy in the United States is perhaps the most easily recognized context for this debate over the extent of a pregnant woman's right to autonomy. But over the course of recent decades, this issue has extended far beyond the abortion debate to encompass numerous legal and public policy issues concerning the maternal–fetal relationship when women continue pregnancy and give birth. Courts, legislatures, state prosecutors and doctors have sought to compel women to behave in ways deemed likely to promote the birth of healthy babies. Women have faced pregnancy-related restrictions and penalties, including civil suit, criminal prosecution, and court-ordered surgery, aimed at a wide range of conduct: driving an automobile, failing to follow a doctor's advice, drinking alcohol, taking prescription and illegal drugs, among others. This entry describes the status of such efforts and explores the implications for children's well-being and women's liberty.

Biological Aspects of the Maternal– Fetal Relationship

Beliefs about the independent moral and religious status of the fetus vary widely among Americans. The physical status of a fetus, however, is clear: A fetus cannot exist apart from a particular woman prior to viability, which occurs at approximately twenty-four to twenty-eight weeks's gestational age. That a fetus does not and cannot exist wholly apart from the pregnant woman makes the maternal–fetal relationship unique.

A fetus makes unparalleled physical and psychological demands on a woman, subjecting her body to tremendous physical adjustments and creating significant risks for even the healthiest woman. Concomitantly, with the fetus completely dependent upon and entirely within a particular woman's body, her actions, experiences, and physical health during and even prior to pregnancy substantially affect fetal development and the health of her child at birth. Throughout their reproductive lives, women inevitably confront innumerable decisions, large and small, that create varying probabilities of harm or benefit to fetal development.

The biological realities of the maternal–fetal relation-ship may not dictate any particular social response, but they highlight the need to scrutinize the impact on women of any law or policy aimed at fetuses. If not formulated with care, governmental policies adopted to promote healthy births can substantially and unnecessarily intrude upon women's fundamental liberties, limiting their ability to decide how to live their lives, and creating tension between women and their healthcare providers.

Law Versus Morality

In general, women have a strong interest in giving birth to healthy children and go to great lengths to increase the likelihood that they will do so. Widespread consensus exists that a woman who chooses to bear a child has a moral obligation to consider the effects her actions will have on her future child. Current public policy recognizes a role for the government in supporting women's ability to have the healthy pregnancies they desire. Existing programs seek to help women overcome obstacles such as poverty and dangerous addictions by providing prenatal care, food, housing, and drug and alcohol treatment, though the adequacy and appropriate scope of such programs is hotly debated.

Far more controversial are the rare instances when governmental action coerces rather than supports, and seeks to compel women to change their behavior. Should the government use punitive measures to regulate women's actions in an effort to promote healthy births? Should the government thereby transform women's moral obligations into legally required standards of conduct?

In spite of the moral complexity of these issues, U.S. law is quite consistent in granting pregnant women the right to make virtually all decisions affecting their bodily integrity and the well-being of their fetuses during pregnancy. For the most part, U.S. law does not recognize, let alone privilege competing fetal rights. Women retain the freedom to make their own judgments and to balance their obligations to their future children against other responsibilities, such as to family, religion and work. This approach is consistent with women's constitutional rights to liberty, privacy, and equal protection, guaranteed by the U.S. Constitution as well as by state constitutions.

Over the course of the past several decades, this legal consensus has been tested in a variety of contexts. These tests arise out of conflicts between pregnant women and their doctors—conflicts that look to the law for resolution. (Oberman, 2000). Often termed maternal–fetal conflicts, these issues have generated a veritable cottage industry for scholars in legal, medical, ethical, religious and philosophical circles (Kolder et al.; Markens; Nelson; Reid; Roberts, 1997; Steinbock). Legal and academic debates over the clashing rights of mothers and fetuses have emerged in various contexts, including substance abuse by pregnant women, home births, mandatory HIV screening in prenatal care, and a pregnant woman's rights to utilize a living will (Balisy; Dyke; Hafner-Eaton et al.; Oberman, 1996). As before, the center of the maternal–fetal conflict debate is the question of when and whether it is appropriate for the law to dictate a pregnant woman's behavior in an effort to benefit her unborn fetus. The medical, ethical and legal literature on maternal–fetal conflict is rich in analysis of the competing rights of mother and fetus. Yet, for all their depth and diversity, the overwhelming majority of articles reach an identical conclusion: In all but the most extreme circumstances, it is impermissible to infringe upon the pregnant woman's autonomy rights (But see Finer; Parness; Robertson).

The remainder of this entry examines some forms of pregnancy-related restrictions aimed at women, including exclusionary employment policies, civil suits for prenatal injuries, criminal prosecution, loss of child custody, court-ordered surgery and HIV screening.

Civil Suits for Prenatal Injuries

Some commentators have suggested that women should be subjected to civil liability for breaching prenatal duties (Shaw), such as the "duty to bring the child into the world as healthy as is reasonably possible" (Robertson, p. 438). The only appellate court to adopt such a standard, which was in Michigan, ruled in Grodin v. Grodin (1980) that a child could sue his mother for prenatal injuries if she failed to comply with the standard of a reasonable pregnant woman.

More recently, courts have refused to impose such duties, claiming that they are inherently subjective and that they would carry with them a host of unacceptable policy ramifications. The only state supreme court to consider the issue, the Supreme Court of Illinois, ruled in 1988 that a child could not sue her mother for prenatal injuries allegedly caused when the woman was in an automobile accident while she was pregnant. In rejecting the girl's request to recognize a legal right to begin life with a sound mind and body, the Illinois court noted the serious ramifications that would result for women: "[M]other and child would be legal adversaries from the moment of conception until birth" (Stallman v. Youngquist, p. 359).

A 2002 decision of the Superior Court of Massachusetts cited Stallman and similar decisions when ruling in favor of a mother's motion for summary judgment in an action brought on her child's behalf (Remy v. MacDonald). The child, through her father and appointed guardian, alleged that her mother's negligence in operating a vehicle resulted in numerous medical complications. The Court ruled that holding a pregnant woman legally accountable to her unborn child, "would present a court with problematic and impossible tasks of determining when the duty arises and how the nature of the duty is to be defined." (Remy, p. 7–8). Moreover, the court stated that civil liability, "rather than discouraging conduct so difficult to define in terms of duty, may unwittingly have the opposite negative effect of women fearing civil liability so that they may not reveal critical facts about their condition to their physicians resulting in less than adequate prenatal care." (Remy, p. 9).

Criminal Prosecutions for Actions During Pregnancy

The most common form of adversarial governmental action against women for engaging in behavior viewed as harmful to fetal development has been criminal prosecution. State prosecutors have relied on laws that clearly were not intended to create special restrictions on women's actions during pregnancy, including laws prohibiting child abuse, distributing drugs to a minor, and murder.

Several prosecutions have been based on women's otherwise lawful actions. One of the first occurred in 1986, when a California woman was prosecuted for allegedly causing her infant son to be born severely brain damaged, and ultimately to die, as a result of her own excessive loss of blood during delivery (People v. Stewart). The prosecution claimed that, by waiting a number of hours before obtaining medical care when she went into labor and began bleeding vaginally, the woman had violated a statute that required parents to provide their children with clothing, food, shelter, and medical care.

Other prosecutions have involved alcohol use during pregnancy. A Massachusetts woman who suffered serious injuries in a car accident, including a miscarriage, was prosecuted for involuntary manslaughter of the fetus because she allegedly caused the accident by driving while intoxicated (Loth). In another reported case, a pregnant woman in Wyoming who notified the police that her husband had physically assaulted her was arrested for child abuse when they detected she had been drinking. The charges ultimately were dismissed in all three of these cases.

By far the most common reason for prosecuting pregnant women involves the use of illicit drugs during pregnancy. Of course, a woman's pregnancy does not immunize her from prosecution under generally applicable laws prohibiting the use or possession of drugs. In many cases, however, women have been subjected to special prosecutions and more severe penalties for the express reason that they were pregnant at the time they used drugs.

Although some women charged in these cases have pled guilty in return for reduced sentences, those who have gone to trial have prevailed in the overwhelming majority of cases. This is largely due to the fact that courts find the statutes under which the women are charged were not intended to apply to prenatal behavior (Brody and McMillin). The first three high state courts that reviewed the legality of prosecution for prenatal drug use all found that the statutes had been misapplied. In 1992, the Supreme Court of Ohio dismissed an indictment for child endangerment against a woman who allegedly used cocaine while pregnant (Ohio v. Gray). Also in 1992, the Supreme Court of Florida reversed a woman's conviction under a statute prohibiting the distribution of a controlled substance to a minor and imposing a penalty of up to thirty years imprisonment. In holding that the statute was not intended to apply to prenatal behavior, the court rejected the "State's invitation to walk down a path that the law, public policy, reason and common sense forbid it to tread." (Johnson v. State, p. 1297). In 1997, the Supreme Court of Wisconsin held that the state could not initiate proceedings to remove a child from his or her mother's custody, due to the mother's use of illegal drugs, because the term child in the statute does not include a viable fetus (Wisconsin v. Kruzicki). The court reasoned that the statute would be rendered absurd if the word child included a viable fetus, because a fetus cannot be, as worded in the statute, "removed from his or her present custody" (Wisconsin v. Kruzicki, p. 736).

However, in another 1997 decision, the Supreme Court of South Carolina upheld the trial court's conviction of a mother for child abuse following the mother's use of crack cocaine during her pregnancy (Whitner v. South Carolina). The court concluded that the word child in the state's child abuse and endangerment statute includes viable fetuses. In reaching its conclusion, the court reviewed earlier South Carolina decisions recognizing a fetus's legal rights and decisions, and distinguished other states's decisions holding that maternal conduct before the birth of a child does not give rise to criminal prosecution. It concluded that those other states's decisions were distinguishable because those states had "entirely different bodies of case law from South Carolina." (Whitner, p. 782).

The Whitner court also concluded that a woman's constitutional right to privacy is not violated when she is prosecuted for using illegal drugs during a pregnancy. It stated that the state's interest in protecting the life and health of viable fetuses is compelling, and that no fundamental rights are implicated in such prosecutions. The court reasoned that the use of crack cocaine is illegal by anyone, not just by pregnant women, and the additional penalty on pregnant women "simply recognized that a third party (the viable fetus or newborn child) is harmed by the behavior" (Whitner, p. 786).

The issue of prosecuting pregnant women for drug use reached the U.S. Supreme Court, albeit indirectly, in the case of Ferguson v. City of Charleston (2001). The case involved a hospital that routinely tested pregnant women for drugs, without obtaining informed consent. The hospital then used the results of these drug screens in order to facilitate criminal prosecutions. The Court held that, as a state-operated facility, hospital staff members were actors subject to the Fourth Amendment's strictures. As such, the drug testing of pregnant women without their informed consent amounted to searches, and violated the women's constitutional rights.

Loss of Child Custody for Actions During Pregnancy

States have attempted to deprive women of custody of their children based solely on women's actions during pregnancy, rather than on the customary determination of the current ability of the woman and other family members to care for the child. While most cases involved a woman's use of illegal drugs during pregnancy, several courts have based custody decisions on activity that was lawful but seen as detrimental to fetal development. For example, in 1987 a Michigan woman temporarily lost custody of her infant and was charged with child abuse because while pregnant she had taken Valium without a prescription to relieve pain from injuries she suffered in a car accident (In re J. Jeffrey).

The first high state court to consider this issue, the Supreme Court of Connecticut, ruled in 1992 that state law did not allow the termination of parental rights based on a woman's use of cocaine during pregnancy. The court cited the legislature's determination that the threat of losing custody of their children would cause women to avoid prenatal care and substance abuse treatment, and "would lead to more, rather than fewer, babies being born either without adequate prenatal care or damaged by prenatal drug abuse.…" (In re Valerie D., p. 764). However, the Supreme Court of Ohio, in In re Baby Boy Blackshear (2000), affirmed a Court of Appeals decision, holding that it is appropriate to remove a child from his or her mother's custody when drug testing proves, after the child's birth, that the child has cocaine in his or her system due to the mother's consumption of such drug. The court reasoned that, for purposes of the state's child abuse statute, R.C. 2151.031, a child born with cocaine in his or her system is an abused child.

Although the use of illegal drugs during pregnancy may at first glance seem to be the strongest justification for punitive governmental action such as the imposition of enhanced criminal penalties or deprivation of child custody, these approaches have been widely repudiated. The government clearly has a strong interest in preventing pregnant women from using dangerous drugs. With remarkable consistency, experts agree that this interest is best pursued through programs that help women overcome drug and alcohol dependencies and obtain prenatal care. Entities such as the U.S. General Accounting Office (GAO) and the American Medical Association (AMA) have argued that fear of prosecution and loss of custody of their children will discourage women from seeking care and increase the number of unhealthy births. As the Florida Supreme Court noted, "Rather than face the possibility of prosecution, pregnant women who are substance abusers may simply avoid prenatal care or medical care for fear of being detected. Yet the newborns of these women are, as a group, the most fragile and sick, and most in need of hospital neonatal care" (Johnson v. State, p. 1295–1296).

Court-Ordered Cesarean Sections

Courts in at least eleven states have ordered women, against their wishes, to give birth by cesarean section rather than vaginal delivery (Kolder et al.). The severe bodily intrusion of this court-ordered surgery contrasts sharply with our legal system's general refusal to order invasive medical procedures or to force one person to assume any personal risk to save the life of another. Although judicial opinions are rare in these time-pressured cases, three published appellate court decisions illustrate both the motivations behind and the harm caused by such court orders.

In the first published appellate court decision, the Supreme Court of Georgia in 1981 declined to lift a court order authorizing the performance of a cesarean section against a woman's religious objections where the examining physician found a "ninety-nine percent certainty" that the child would not survive a vaginal delivery and a 50 percent chance the woman would die (Jefferson v. Griffin Spalding County Hospital Authority, p. 459). With no analysis of the constitutional and policy implications, the court granted temporary custody of the fetus to the state and gave it full authority to make all surgical decisions concerning the birth. In the end, a court-ordered cesarean section was not performed; despite the physician's predictions, the woman gave birth by vaginal delivery to a healthy baby without adverse effects.

More recent appellate court decisions have ruled that compelling a pregnant woman to undergo a cesarean section against her will violates the woman's fundamental constitutional rights. (In re A.C.; Baby Boy Doe v. Mother Doe). In the most widely cited case, in re A.C., a three-judge panel of the District of Columbia Court of Appeals ordered a woman who was twenty-six weeks pregnant and terminally ill with cancer to undergo the surgery. The woman did not consent to the cesarean and her husband, parents, and attending physicians all opposed it on the ground that the woman's health and comfort should be the first priority. The cesarean section was performed nonetheless. The fetus was not viable and did not survive. The woman died two days after the cesarean section.

Following her death, the full Court of Appeals reversed the panel's decision, ruling that "in virtually all cases the question of what is to be done is to be decided by the patient—the pregnant woman—on behalf of herself and the fetus" (In re A.C., p. 1237). The court found that a court order compelling a woman to have a cesarean section violates her rights to bodily integrity and to refuse medical treatment, which are protected under both common law and the U.S. Constitution. The court graphically described the violent bodily intrusion that would be required to enforce an order against a woman who resisted: "[She] would have to be fastened with restraints to the operating table, or perhaps involuntarily rendered unconscious by forcibly injecting her with an anesthetic, and then subjected to unwanted major surgery. Such actions would surely give one pause in a civilized society…" (In re A.C., p. 1244, n. 8). Indeed, in another case a court-ordered cesarean section was performed by tying the woman to the operating table and forcibly removing her husband from the room (Kolder et al.).

An Illinois appellate court similarly ruled in 1994 that ordering a woman to give birth by cesarean section would violate her constitutional rights. Citing In re A.C., the court held that "a woman's competent choice in refusing medical treatment as invasive as a cesarean section during her pregnancy must be honored, even in circumstances where the choice may be harmful to her fetus" (Baby Boy Doe v. Mother Doe, p. 330).

At least one federal court has disagreed with the state decisions holding that court-ordered cesarean sections violate women's constitutional rights. In Pemberton v. Tallahassee Memorial Regional Medical Center, Inc. (1999), a federal district court held that a court-ordered cesarean section did not violate the mother's substantive constitutional rights. Pemberton was advised by a number of doctors that a vaginal delivery would likely harm the newborn. However, Pemberton opposed having a cesarean section. She returned to the hospital following a full day of labor and requested an IV because she had become dehydrated. Pemberton was denied an IV, and then returned home against the wishes of doctors at the hospital. Following a hearing conducted at the hospital, Pemberton was returned to the hospital, against her will, where her child was delivered via cesarean section.

Pemberton sued, claiming that numerous substantive constitutional rights were violated by the court-order. However, the court stated, "Whatever the scope of Ms. Pemberton's personal constitutional rights in this situation, they clearly did not outweigh the interests of the State of Florida in preserving the life of the unborn child" (Pemberton v. Tallahassee Memorial Regional Medical Center, Inc., p. 1251).

A number of medical and public-health organizations have opposed court orders overriding a pregnant woman's decision concerning medical treatment. The AMA is among the organizations that has endorsed respect for women's constitutional right to bodily integrity: "[D]ecisions that would result in health risks are properly made only by the individual who must bear the risk. Considerable uncertainty can surround medical evaluations of the risks and benefits of obstetrical interventions. Through a court-ordered intervention, a physician deprives a pregnant woman of her right to reject personal risk and replaces it with the physician's evaluation of the amount of risk that is properly acceptable" (AMA, p. 2665). The practice of seeking court orders not only violates women's right to evaluate the risks and uncertainties involved in their medical care, it is counterproductive to the goal of promoting healthy pregnancies and births because it causes women to distrust physicians. Citing a case in which a woman left the hospital to avoid a court-ordered cesarean section, the AMA expressed concern that "women may withhold information from the physician.… Or they may reject medical or prenatal care altogether…" (AMA, p. 2665–2666). Furthermore, AMA Policy H-420.969 states as follows, "Judicial intervention is inappropriate when a woman has made an informed refusal of a medical treatment designed to benefit her fetus." Paragraphs 2 and 3 of H-420.969 further provide, "The physician's duty is to provide appropriate information, such that the pregnant woman may make an informed and thoughtful decision, not to dictate the woman's decision. A physician should not be liable for honoring a pregnant woman's informed refusal of medical treatment designed to benefit the fetus."

Exclusionary Employment Policies

In an effort to reduce perceived liability risks, some employers have sought to restrict the access of pregnant, or even fertile, women to jobs that might expose them, and consequently, their fetuses, to potentially hazardous conditions. In a unanimous decision, the U.S. Supreme Court ruled that such policies violate federal anti-discrimination law. The policy at issue in the case prohibited fertile women from working with lead in the production of batteries. The Supreme Court acknowledged that holding such jobs "late in pregnancy often imposes risks on the unborn child," but found that "Congress made clear that the decision to become pregnant or to work while being either pregnant or capable of becoming pregnant was reserved for each individual woman to make for herself." (International Union, United Auto Workers v. Johnson Controls, Inc., p. 205–206).

Mandatory HIV-Testing and Treatment of Pregnant Women

Approximately 4 million women give birth each year in the United States. Of these, approximately 7,600 women are HIV-infected, and run the risk of passing on the fatal virus to their fetuses. (Eden, p. 661).

In 1994, a study known as Protocol 076, administered by the Pediatric AIDS Clinical Trials Group (PACTG), demonstrated a two-thirds reduction in perinatal transmission of HIV by administering Zidovudine (AZT) to pregnant women and newborns, reducing rates from approximately 25 percent to 8.3 percent. (Connor). Later studies demonstrated that the perinatal transmission rate may be as low as 3 percent when mothers are treated with AZT. (Eden, p. 661).

Most states reacted to this news by enacting statutes delineating procedures for doctors to counsel and test pregnant mothers for HIV. Some called for the mandatory HIV testing of all pregnant women, but a broad coalition of physicians, policy-makers, lawyers and public health specialists warned that such a move would discourage at-risk women from seeking prenatal care. As a result, no state mandates HIV testing for pregnant women.

Interestingly, at least two states mandate HIV testing of all newborns. (See N.Y. Public Health Law § 2500-f, for New York; and C.G.S.A. § 19a-55, for Connecticut). Because a newborn will not test positive for HIV unless his or her mother is infected with the virus, the HIV testing of newborns is effectively a test of the mother, as well. The ostensible purpose of such laws would be to notify the new mother of her HIV status, so that she might avoid transmitting the virus to her newborn via breast-feeding, and so that the infant might begin antiviral medications.

As implemented, there are several problems with these laws, stemming largely from the lack of appropriate training and funding for those who implement them. First, many women who have been indirectly tested for HIV via the testing of their newborns never receive appropriate counseling. Years of work with HIV patients demonstrates that preand post-test counseling is vitally important in assuring that infected individuals will obtain the information and treatment necessary to protect themselves and others (McGovern). Second, no mechanisms exist for monitoring the medical privacy of mothers of newborns who test positive for HIV. In virtually all other contexts, the law recognizes this loss of privacy as a grave risk, and vigorously protects the confidentiality of an individual's HIV status (McGovern). Finally, as late as 2003, the efficacy of these laws has been hampered by slow response times, such that mothers do not learn of the HIV status for several weeks after giving birth (McGovern).

Mandatory testing policies, whether directed toward pregnant women or newborns, are predicated upon the belief that the benefits of testing and treating the children outweigh the risks to their mothers. This reasoning rests on somewhat shaky scientific knowledge, as the long-term side effects of AZT on both the mother and child are not clear. In 2003, however, it seems that AZT does not inhibit cognitive function, growth, cause cancer, or impair immune function (Culnane et al., p. 152). Nonetheless, this risk-benefit calculus treats pregnant women (or new mothers) differently from the rest of the population, according them fewer rights, simply by virtue of the fact that they have given birth. As in other contexts, this treatment suggests that pregnant women are uniquely incapable of making morally trustworthy healthcare decisions, and that the state is therefore entitled to intervene. If the knowledge of one's HIV status were indeed so vitally important, one would expect to see widespread calls for mandatory testing of the entire population. Well into the third decade of HIV-related policy making (in even the first years of the twenty-first century), there has been no real effort in that direction.

Racial Disparities

In addition to the concerns about gender discrimination raised by pregnancy-related restrictions and penalties, virtually all of these pregnancy-related legal interventions have a disproportionately negative impact upon women of color. A 1987 survey of court-ordered cesarean sections published in the New England Journal of Medicine found that 80 percent of the women against whom orders were sought were African American or Asian (Kolder et al.). A 1990 study, also published in the New England Journal of Medicine, found that African-American women were ten times more likely than white women to be reported to health authorities when they tested positive for illegal drug use during pregnancy (Chasnoff et al.). Another 1990 survey of forty-seven women prosecuted for behavior during pregnancy found that 80 percent of the prosecutions were against women of color (Paltrow). As Dorothy Roberts effectively demonstrates in her book, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty, these policies not only are problematic in terms of law, ethics and policy, but also they reflect a sentiment that the women of color are somehow public property. In a sense, these fetal-protection policies may be viewed as the contemporary legacy of slavery.

Conclusion

Attempts to impose special pregnancy-related restrictions or penalties on women have been relatively rare and typically have been invalidated by courts and opposed by interested organizations and most commentators. The threat of criminal prosecution, loss of custody of children, and court-ordered medical interventions risk deterring those women who are most at risk of poor birth outcomes from seeking prenatal care and drug and alcohol treatment.

The government can, however, do a great deal to improve the health of children by helping women to have healthy pregnancies. For example, experts agree that the high rate of infant mortality in the United States can be drastically cut by providing prenatal care to the approximately one-third of American women who receive inadequate or no prenatal care. Drug treatment programs routinely turn away pregnant women, and the few that will treat women during pregnancy have long waiting lists. Government studies have shown that expending the funds necessary to provide these services would actually save taxpayers three to four times as much in reduced infant healthcare costs.

While creating legal conflicts between a woman and the fetus within her is ineffective and even counterproductive, laws and policies that respect women's rights can effectively promote the healthy pregnancies and births that are in the interests of all.

dawn e. johnsen (1995)

revised by michelle oberman

SEE ALSO: Beneficence; Coercion; Communitarianism and Bioethics; Conflict of Interest; Conscience, Rights of; Fetal Research; Genetic Testing and Screening: Reproductive Genetic Screening; Infanticide; Infants;Insanity and the Insanity Defense; and other Maternal-Fetal Relationship subentries

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INTERNET RESOURCE

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