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Schizophrenia Bulletin 2004 30(3):659-664;
© 2004 by Oxford University Press and the Maryland Psychiatric Research Center (MPRC)
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© Oxford University Press

Assisted and Surrogate Decision Making for Pregnant Patients Who Have Schizophrenia

John H. Coverdale, M.D., Associate Professor of Psychiatry, Laurence B. McCullough, Ph.D., Professor of Medicine and Medical Ethics and Frank A. Chervenak, M.D., Given Foundation Professor and Chairman
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine Houston, TX and Assistant Professor, University of Auckland Auckland, New Zealand
Center for Medical Ethics and Health Policy, Baylor College of Medicine New York, NY
Department of Obstetrics and Gynecology, Weill Medical College of Cornell University New York, NY

Send reprint requests to Dr. J. Coverdale, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030; e-mail: jhc{at}bcm.tmc.edu

Because of a dearth of literature, we developed preventive ethics strategies for managing the pregnancies of patients with schizophrenia. Schizophrenia can chronically and variably impair a woman's decisions concerning the management of pregnancy, including the decision about whether to continue the pregnancy through to viability and term. The psychiatrist must balance autonomy-based and beneficence-based obligations to the pregnant woman with schizophrenia, and both the psychiatrist and pregnant woman have beneficence-based obligations to the fetus when the fetus is a patient. We discuss the assessment of the decision-making capacity of pregnant patients with schizophrenia and describe the strategies of assisted decision making that aim to diminish chronically and variably impaired autonomy. When patients are severely impaired in decision-making capacity, as, for example, in psychotic denial of pregnancy, the standard of surrogate decision making applies. This should be guided by the substituted judgment standard. When patients' values are not known or have not been consistently held over time, surrogate decision making should be guided by the best interests standard. These strategies should substantially enhance patients' autonomy in the psychiatrist-patient relationship and contribute to the quality of their psychiatric and obstetric care.

Keywords: Schizophrenia / pregnancy / preventive ethics / chronically and variably impaired autonomy


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