The curious case of Mary Moe has garnered significant ethical discussion, but most of the ethical discussions regarding this case seems to ignore some major ethical issues and questions. It will be the task of this blog post to highlight some of the pressing ethical issues regarding this case.
First, I will briefly describe the case. For those interested in reading the actual description and ruling of the case, they can go here. Mary Moe, a pseudonym for a 32 year old woman with schizophrenia and/or schizoaffective disorder and bipolar mood disorder, showed up in a hospital and was discovered to be pregnant (the combination of the two mental conditions can significantly alter one’s decision making capacity). Moe has been pregnant twice before, the first pregnancy she had an abortion, and the second pregnancy she gave birth to a boy. The boy is currently in the parent’s custody. At a court hearing last December the state Department of Mental Health asked that her parents be made her guardians. The parents think that abortion is the best option for their daughter. At some point between Moe’s previous abortion and the birth of her son, Moe had a “psychotic break” and has since been hospitalized numerous times for mental illness suggesting that Moe’s condition has become so severe that Moe has lost touch with reality. Presumably Moe’s decision making capacity has significantly been compromised. In December (post psychotic break) Moe describes herself as “Very Catholic” and said “she would never have an abortion”, when asked about an abortion at the December hearing, she replied that she “wouldn’t do that”. Norfolk judge, Christina Harms, ruled that Moe was not competent to make a decision about an abortion. Harms cites “substantial delusional beliefs” and concluded that Moe would choose to abort her pregnancy if she were competent. A further suggestion was made by judge Harms that Moe be sterilized “to avoid this painful situation from recurring in the future”, and the parents be appointed co-guardians to consent to both the sterilization and abortion. What isn’t mentioned, and seems to be important, is whether the parents want Moe to be sterilized. Since Harms’ decision a Massachusetts appellate court overturned the lower court on both the abortion issue and sterilization issue stating that “the personal decision whether to bear or beget a child is a right so fundamental that it must be extended to all persons, including those who are incompetent.” Neither option of abortion or sterilization appears to be available for Moe or her decision making surrogates.
The first ethical issue that immediately arises with the case is whether Moe could make her own decisions for herself given that she has an underlying psychological condition which might imply that Moe has lost some decision making capacity. The fundamental question is whether Moe’s condition is so severe that her decision making capacity regarding her own well being has been compromised. Indeed, ethical issues regarding mental health are extremely complicated, in part, because certain disorders of consciousness can affect our decision making capacities.
According to Dr. John Grohol’s breakdown of the issues here, it seems to be assumed that Moe has a fundamental right to decide what to do with her own body, just like everyone else. But, the central ethical issue that is ignored by Grohol is whether Moe actually has the capacity to make decisions regarding her own well being, given her underlying mental conditions. If Moe does not have the capacity to make decisions about her own body’s well being, it might be argued that the responsibility of making decisions regarding her own body should be handed over to a surrogate that is capable of making decisions on her behalf. Having a decision making surrogate in place concerning one’s own well being is a current practice in cases where it can be proven that one actually loses one’s capacity to make decisions (for example in the later stages of dementia, cases of severe autism, cases of severe Cerebral Palsy, or persistent vegetative states).
It can plausibly be assumed that prior to Moe’s psychotic break, Moe would be the sort of person that would decide to have an abortion in certain circumstances, since Moe actually had an abortion in the past. So the second ethical issue that is ignored is what sort of decision Moe might make if she did not have the mental disorder that she currently has, and whether this has anything significant to contribute to the ruling. At one point in my life I had worked in a hospital that cared for patients in the later stages of Alzheimer’s and I observed that one important way that decision making surrogates made decisions for their relatives was to consider who the patient was in the past, prior to their debilitating condition. This practice was done in order to make medical decisions for the current well being of the patient. It was in this way that the relatives felt like they were including the person in the decision making process. It seems to me that many commenting on the issue are assuming the parents of Moe are ignoring their daughter entirely and the parents are making overly paternalistic and wrong decisions for their daughter. What needs to be acknowledged, I think, is that it could be the case that the parents are undergoing an arduous decision making process that is attempting to be inclusive towards Moe.
This raises a third ethical issue about Moe: who is the best option to make decisions for Moe? Is it Moe’s parents? Is it a judge who has never known Moe? Is it an ethicist who keeps a ethical blog that also doesn’t know Moe or her parents? Some would argue that the best option to make decisions for Moe would be Moe’s parents or relatives because they knew Moe best, and they are intimately related to Moe. The hope is that the parents, based on their knowledge of Moe, would make a decision regarding Moe’s body that she would make if she did not have her condition.
According to Grohol’s breakdown, judge Harms, didn’t take what Moe said seriously during the hearing because Harms ruled that Moe was not competent to make a decision about an abortion, citing “substantial delusional beliefs.” But it seems that Harms did take what Moe said into account, contra Grohol. If Moe had said “she wouldn’t do that”, or said she “would never have an abortion” one could wonder what happened to the Moe that did have the abortion in her distant past. Indeed, it seems that if these were, in fact, Moe’s words Moe could be so disconnected from reality that she couldn’t even remember who she was prior to her so called “break down.” Again, the actual case description can be found here. In the description, Moe also asserted that she was not pregnant, she erroneously said that she met the judge before, and erroneously believed that she had previously given birth to a girl named Nancy. Furthermore, part of Moe’s delusions after she suffered her psychotic break included believing people “were staring at her and stating that she killed her baby.” Moe also became “extremely agitated and emotional” when discussing the pregnancy that ended in termination. It seems that Moe’s delusions could have actually been, at least in part, responsible for Moe’s statements and corresponding beliefs about not wanting an abortion. Moe could have felt shame and stigma from erroneously perceiving that people were habitually judging her for a past decision she made which in turn has lead in her change in attitudes regarding abortion.
This brings up another ethical issue that is raised by Moe’s case concerning the following point: a person with mental and neurological conditions can and do have significant alterations in their beliefs that could be, in part, due to their mental condition. If one suddenly suffers from a condition that causes significant alterations in beliefs from who they were in the past, should one take the current altered beliefs or dispositions as morally or legally relevant regarding one’s medical decisions, and if so how morally relevant are they? Instead Grohol asks, ” What do delusional beliefs have to do with wanting or not wanting a baby?” This seems to miss the key issues and arguments. If one suffers from a psychological pathology that significantly alters their ethical disposition from what they once were (for example from being okay with abortion to having a disorder and then subsequently not being okay with abortion), should those new delusional beliefs be morally and legally relevant? This sort of concern is equally relevant for patients with advanced Alzheimer’s, because patients with later stages of Alzheimer’s can have significantly altered states of consciousness that may not cohere with who they once were prior to their condition.
According to Dr. Art Caplan’s breakdown of the issue here, it is concluded that it is a hopeless quest to try to attempt to guess what Moe might want if she were competent using some statements made by Moe (and presumably past statements and actions) to guide them. But, people do use past and present statements and actions to guide ethical decisions when someone’s state of consciousness has been significantly altered (most notably in cases involving Alzheimer’s patients or persons in persistent vegetative states). Using past and present statements made by patients to guide medical ethical decisions includes the patients in the decision making process, and it is important to respect the autonomy and agency of the patient in whatever way one can. Why? Because it was the violation of a persons autonomy, in the most personal sense, that occurred in past sterilization movements that many found so morally appalling.
Caplan argues that sterilization should not be an option because of the past abuses of sterilization by the United states and other countries, and there shouldn’t be an option for Moe’s guardians to sterilize her. Caplan suggests that Moe should be put on permanent birth control (presumably an IUD) and her dosage should be lowered to lessen the risk to the fetus. When the baby is born and if her parents or Moe can’t care for it, then adoption is the best road to follow. But Caplan ignores the fact that when a person is significantly cognitively impaired (and does not have the capacity to make their own decisions) and still has sex, parents do choose to sterilize their children so that their children can still enjoy a sexual life. Why? Usually the option of permanent birth control becomes problematic (for example, some patients try to remove the IUD themselves due to not knowing what it is or having delusional beliefs about the IUD) and the parents have difficulty managing other forms of birth control for their children. In addition, within the context of contemporary sterilization involving those with neurodevelopmental disorders, the person with the significant cognitive impairment is incapable of raising and caring for a child. Contemporary cases of sterilization for persons with cognitive disabilities or neurological conditions are far removed from past eugenic ideologies, and should be treated as such. The issue is whether Moe’s parents should be given this option of sterilization for their daughter and whether Moe’s parents should be her decision making surrogates regarding this matter.
Another issue arises about whether lowering Moe’s dosage puts Moe’s mental health at risk, and if her mental health is at risk, then the fetus could also be put at risk. Suggesting that Moe carry her baby to term and have the baby be put up for adoption is also still extremely complicated. Moe believes that she is not pregnant and has “refused obstetrical care and testing”. Does one force Moe to have obstetrical care and testing? Does one force Moe to have permanent birth control? Caplan’s suggestions are wrought with difficulties.
Caplan, concludes that there is a lot to think about in the case of Moe, but forced sterilization and non-consensual abortion should not be part of that thinking. I’m not so sure I agree with Caplan on the abortion and sterilization issue. In particular, a better examination of her case is in order regarding sterilization which should include careful considerations of: Moe’s decision making capacity, the consequences of reproduction and pregnancy for Moe, the alternative means available to Moe, and the applicable laws.
The case of Mary Moe is extremely complicated, and a goldmine for ethical controversy, but I think that the discussions regarding her case so far have ignored significant ethical issues. It is my hope, that this blog post illuminated the issues for the readers even if it did make things more complicated. In cases like these one should be reminded that the ethical issues regarding Moe’s case and other cases that include persons with neurological disorders are deeply complicated, and these complications should not be ignored when considering the ethical issues.