How dare lactation professionals force an unconscious woman to breastfeed?

Ethics card in hands of Medical Doctor

Medical patients are uniquely vulnerable.

Ill, in pain and immersed in a system where the professionals seem to speak a foreign language, hospitalized individuals require special ethical and legal protections to make sure healthcare providers do not take advantage of them.

That’s especially true for unconscious individuals who are incapable of speaking for themselves. There is a specific ethical and legal standard used for making healthcare decisions about unconscious individuals, the substituted judgment standard. It requires that healthcare professionals choose NOT what the providers believe to be in the best interest of the patient but — as far as can be known — what the patient would choose for herself.

An infant’s benefit should NEVER be the determining standard for the mother’s medical care.

Therefore, it is appalling that a group of lactation professionals had the temerity to violate those ethical and legal principles to force an unconscious woman to breastfeed. Those professionals are so woefully ignorant about their ethical and legal violations that — amazingly — they published a paper to report them.

The paper is Who Makes the Choice: Ethical Considerations Regarding Instituting Breastfeeding in a Mother Who Has Compromised Mental Capacity. The answer is both simple and obvious to anyone with a basic understanding of medical ethics: the providers are REQUIRED to choose what the patient would have chosen for herself. But that’s not what the lactation professionals decided; they decided to FORCE the patient to breastfeed.

According to the authors:

A 25-year-old G4P3003 pregnant female was brought to the emergency department after being struck by a motor vehicle as a pedestrian. There was minimal past medical history available and no record of prenatal care in the electronic medical record, except report of her being ‘‘6 months’’ pregnant.

The mother had sustained a head injury, a fractured leg and there was evidence that the fetus was compromised by an abruption of the placenta.

On ultrasound, fetal biometry con- firmed an approximate 35 weeks of gestation with a weight of ~2,500 g, and a hematoma in the amniotic fluid with a thickened placenta consistent with abruption. The fetal heart rate was 75 beats per minute with minimal variability, and no fetal movement was seen on ultrasound. The patient was taken for an emergency cesarean delivery and exploratory laparotomy. A viable male infant was delivered with APGARS of 2 & 2 was brought to the neonatal intensive care unit (NICU) for care.

The decision to treat the abruption with surgical delivery of the baby (as well as the other treatment decisions) are entirely consistent with what any patient herself would choose since the abruption puts the mother’s life in danger.

In contrast, the authors have absolutely no reason to believe that this woman would have breastfed. No matter. They simply decided they could force her to do so.

The Lactation Medicine physician reviewed maternal medications, noted her history of illicit substance use, lack of prenatal care, homelessness, and placement of two prior children in foster care through Child Protective Services. Through network record sharing with other hospitals, the provider noted that the mother had provided breast milk to a prior child.

“Providing breastmilk” is not the same as breastfeeding; it sounds like something she was pressured to do during a previous maternity hospitalization. There is precisely zero evidence that this poor, homeless, substance abusing woman struggling desperately to survive would have chose to breastfeed this baby. But the well-educated, well-off lactation professionals thought they knew better.

How SHOULD the providers have determined what to do in this situation?

According to Substituted decision making and the dispositional choice account published in the Journal of Medical Ethics.

…[T]he surrogates should attempt to reconstruct the decisions the patient herself would have made, if she were capable, in the circumstances at hand… This standard is commonly justified by the principle of respect for autonomy. It has been suggested that when the patients are incapable of making the relevant decisions, their autonomy can still be indirectly respected by reconstruction, to the greatest possible extent, of the autonomous decisions they would have made if they had been able to make decisions.

The lactation professionals — in contrast — used a wholly inappropriate standard: the best interest of the baby.

The first question is if breastfeeding is the best option for the baby.

You don’t have to have a degree in medical ethics to know that not only is that not the first question; it isn’t an appropriate question at all. We don’t make medical decisions for one patient by what is best for ANOTHER patient.

As breastfeeding is the physiological norm and prevents infant morbidity and mortality one could argue that infants have an ethical right to human milk.

Even if the physiological claims were true — and there’s no evidence that they are true for 35 weekers — the authors are on extremely dangerous philosophical grounds when they imply that the baby’s interests are more important than the mother’s interests. The infant’s benefit should NEVER be the determining standard for the mother’s medical care; that would be both unethical and illegal.

An infant has no “ethical rights” vis a vis the mother’s body. If they did, mothers could be forced to give up kidneys or other organs to their offspring and their behavior could be regulated on an ongoing basis by society if it determines that certain behaviors are in the best interest of their children.

It’s difficult to imagine that the authors don’t know this. Had the mother told them she didn’t want to breastfeed, they would be REQUIRED to respect her wishes regardless of what they deemed in the best interest of the baby. Had the baby’s father or grandmother told them that the mother didn’t want to breastfeed they also would have been REQUIRED to respect the mother’s wishes.

This woman wasn’t merely unconscious, she was a member of a vulnerable economic class and was rendered even more vulnerable by having no family members to speak for her. And because of her profound vulnerability the authors had no compunction in ignoring what she might want.

And she made it clear what she wanted when she regained consciousness:

The mother in our case made the decision to stop breastfeeding due to nipple pain and engorged breasts… The mother then became engorged when she declined pumping due to nipple pain. She required multiple interventions to prevent mastitis…

Even now the authors – engaged in massive self-deception — fail to understand that their behavior was profoundly unethical.

Our case discusses the decision to initiate pumping for a comatose mother using biomedical ethical principles: (1) beneficence (breastfeeding is likely be good for the infant and mother); (2) nonmaleficence (breastfeeding might cause undue stress for a critically ill mother: there are risks of complications); (3) patient autonomy (preserving the choice to lactate preserved the mother’s ability to self-determination and avoidance of provider assumptions and bias); and (4) justice (attending to biopsychosocial features of the care, including potential biases, to promote a fair decision-making process). We believe beneficence, nonmaleficence, and justice may be met while preserving patient autonomy best by initiating pumping for comatose mothers.

But forcing a woman to breastfeed does NOT respect patient autonomy. Moreover, justice requires treating this poor homeless woman exactly the way they would have treated a well-educated, well-off woman who had a supportive family. I doubt they would have dared to substitute their judgment for hers had they thought she had the ability to hold them to account for what they did — using the fact that she was unconscious to force her to breastfeed.