Pregnancy and substance use – the Norwegian z 10–3 solution.¹ Ethical and clinical reflections related to incarceration of pregnant women to protect the foetus from harmful substances

Abstract

Pregnancy and substance use -the Norwegian § 10-3 solution. 1 Ethical and clinical reflections related to incarceration of pregnant women to protect the foetus from harmful substances Research report Introduction Maternal substance addiction imposes several risks on the offspring from conception on. Most chemical components of the substances pass the placental barrier and represent a developmental hazard to the growing foetus (Moe et al. 2010). Pregnant women often find themselves torn between the wish to protect the foetus and failure to do so (Söderström 2011). The situation causes worry as well as moral in-dignation, and the welfare system is urged to act. In 1996, Norway passed a unique piece of legislation, at the time § 6-2a in the Social Service Act, now § 10-3, which made it possible to incarcerate pregnant drug-addicted women in order to protect the foetus. Although the paragraph is grounded on the ethical principle of nonmaleficence, there has been raised concern for unintended negative effects such ABSTRACT AIMS -This article highlights ethical and clinical dilemmas of incarceration of pregnant drug addicts mandated by § 10-3 of the Norwegian Municipal Health and Care Services act. MATERIAL -The material consists of two cases, Siri and Anna, and the ethical dilemmas posed by the use of § 10-3 in these cases.METHODS -Semi-structured in-depth individual interviews were conducted, audio-recorded and transcribed word for word. Transcripts were coded according to converging interests and possible ethical dilemmas and described in a case format. The practical and experiential consequences of the law are discussed in relation to the four main bioethical principles: respect for autonomy, nonmaleficence, beneficence and social justice. These are supplemented by the principles of relational ethics. RESULTS -The application of § 10-3 may lead to situations which distort the psychological preparation for parenthood and strains the helping relationship. The four principles approach seems to be an insufficient tool in grasping the complexity of the situation. CONCLUSIONS -Interventions to protect the foetus from the pregnant woman's use of substances demand elevated professional awareness of ethical and relational challenges and dilemmas. Relational ethics provides a framework to enhance reflexivity and a trusting therapeutic alliance. The potential for psychological change during pregnancy should be invested in. Hence, we suggest that during incarceration according to § 10-3, foetal protection and the promotion of parental competences should be given equal priority. KEY WORDS -Addiction, coercive treatment, ethical dilemmas, motherhood, pregnancy, relational ethics.

Neonatal outcomes following in utero exposure to methadone or buprenorphine: A National Cohort Study of opioid-agonist treatment of Pregnant Women in Norway from 1996 to 2009

“…If a professional knows that a pregnant woman is using harmful legal or illegal substances, he/she has to ensure that the woman stops using drugs, either through voluntary measures on the part of the woman or by the use of the Norwegian Social Service Act. A section of this Act makes it possible to detain pregnant women using drugs or alcohol [86]. This Act was amended in 1996.…”

“…The professional opinion in Norway is that pregnant women should not use any illegal drugs or alcohol. Further, in Norway, there exists an Act making it possible to treat pregnant drug users compulsorily, if they use drugs which could harm their unborn babies [86,179]. The Act states that voluntary measures should always be taken first.…”

Pregnant substance abusers in voluntary and coercive treatment in Norway: Therapists’ reflections on change processes and attachment experiences

“…The ethical dilemmas have been discussed from a legal perspective (Nilssen, ; Søvig, ). During the 21 years of the law's existence, two papers have been published, one a case study about two client's experiences and one qualitative study of pregnant women with SUDs in coercive treatment (Myra et al., ; Söderström & Skolebekken, ) .…”

Patterns of polydrug use among pregnant substance abusers

“…However, it may be that social services are more inclined to plan commitments of women they already know are severe drug users and where a possible pregnancy has come to their attention. The process in these cases will often depend on when and how the pregnancy is verified as well as if, within the time limits for abortion, it is clear that the woman will go through with the pregnancy (Reitan, 2016a;Söderström & Skolbekken, 2012).…”

“…Second, many women have problems relating to the pregnancy for a long time. Third, when this knowledge does sink in (Myra et al, 2016;Söderström & Skolbekken, 2012) -often after the first ultrasound screening -they will often attempt to reduce their drug use or adapt to their new circumstances in other ways. This may, in turn, reduce contacts with drug-using networks, and as the pregnancy becomes more ''obtrusive'', women may also be excluded from previous supply networks hesitant to provide drugs to a pregnant woman (Roberts & Pies, 2011).…”