Substance abuse during pregnancy: Clinical and public health approaches

Journal of Law, Medicine and Ethics

Volumn 31, Issue 3, 2003, Pages 340-350

  Jos, Philip H ^a,b,c   Perlmutter, Martin ^a,h,i,j   Marshall, Mary Faith ^d,e,f,g  

^a School of Business and Economics   (United States)

^b UNIVERSITY OF SOUTH CAROLINA   (United States)

^c WESTERN KENTUCKY UNIVERSITY   (United States)

^d Department of Medicine ^*

^e UNIVERSITY OF KANSAS MEDICAL CENTER   (United States)

^f Natl Hum Res Protections A

^g UNIVERSITY OF VIRGINIA   (United States)

^h Deptof Philos and Relig Studies

ⁱ UNIVERSITY OF ILLINOIS AT URBANA CHAMPAIGN   (United States)

^j CITY COLLEGE OF NEW YORK   (United States)

more..

Author keywords

[No Author keywords available]

Indexed keywords

BEHAVIOR; CHILD ABUSE; CONCEPT FORMATION; ECONOMIC ASPECT; FETUS; HEALTH HAZARD; HUMAN; MOTHER; PATIENT; POLITICS; PRACTICE GUIDELINE; PREGNANCY; REVIEW; SOCIAL ASPECT; SUBSTANCE ABUSE; ADDICTION; DRUG EFFECT; ECONOMICS; ETHICS; FEMALE; GENETICS AND REPRODUCTION; HEALTH CARE AND PUBLIC HEALTH; METHODOLOGY; PREGNANCY COMPLICATION; PREGNANT WOMAN; PSYCHOLOGICAL ASPECT; PUBLIC HEALTH; PUBLIC HEALTH SERVICE; STANDARD;

GENETICS AND REPRODUCTION; HEALTH CARE AND PUBLIC HEALTH;

FEMALE; FETUS; HUMANS; POLITICS; PREGNANCY; PREGNANCY COMPLICATIONS; PREGNANT WOMEN; PUBLIC HEALTH; PUBLIC HEALTH ADMINISTRATION; SUBSTANCE-RELATED DISORDERS;

EID: 0642307865     PISSN: 10731105     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1748-720X.2003.tb00098.x     Document Type: Review

References (103)

1. A recent study found that in 1995 almost two-thirds of the states reported positive newborn toxicology results to child protection services or the Department of Health. Ten states required that such results be reported to law enforcement officials. See W. Chavkin et. al., "National Survey of the States: Policies and Practices Regarding Drug Using Pregnant Women," American Journal of Public Health, 88 (1998): 117-19. For a review of the diverse approaches taken by the states, see L.M. Paltrow, D.S. Cohen, and C.A. Gray, Year 2000 Overview: Governmental Responses to Pregnant Women Who Use Alcohol or Other Drugs, Report of the Women's Law Project and National Advocates for Pregnant Women, available through 〈www.advocatesforpregnantwomen.org/ articles/index.htm〉.
2. A recent study found that in 1995 almost two-thirds of the states reported positive newborn toxicology results to child protection services or the Department of Health. Ten states required that such results be reported to law enforcement officials. See W. Chavkin et. al., "National Survey of the States: Policies and Practices Regarding Drug Using Pregnant Women," American Journal of Public Health, 88 (1998): 117-19. For a review of the diverse approaches taken by the states, see L.M. Paltrow, D.S. Cohen, and C.A. Gray, Year 2000 Overview: Governmental Responses to Pregnant Women Who Use Alcohol or Other Drugs, Report of the Women's Law Project and National Advocates for Pregnant Women, available through 〈www.advocatesforpregnantwomen.org/ articles/index.htm〉.
3. "Illicit Drug Use By Pregnant Women," (Policy Statement 9020) American Journal of Public Health, 81 (1991): 253.
4. "Legal Interventions During Pregnancy: Court-Ordered Medical Treatments and Legal Penalties for Potentially Harmful Behavior by Pregnant Women," (Board of Trustees Report) JAMA, 264 (1990): 2663-70.
5. American Nurses Association, Opposition to Criminal Prosecution of Women for Use of Drugs While Pregnant and Support for Treatment Services for Alcohol and Drug Dependent Women of Childbearing Age (position statement) (April 15, 1991).
6. The American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Guidelines for Prenatal Care (1992); Committee on Substance Abuse, American Academy of Pediatrics, "Drug-Exposed Infants," Pediatrics, 86 (1990): 639-42.
7. The American Academy of Pediatrics and The American College of Obstetricians and Gynecologists, Guidelines for Prenatal Care (1992); Committee on Substance Abuse, American Academy of Pediatrics, "Drug-Exposed Infants," Pediatrics, 86 (1990): 639-42.
8. Guidelines for Prenatal Care, supra note 5; The American College of Obstetricians and Gynecologists, Cocaine Abuse: Implications for Pregnancy (Committee Opinion 81) (1990).
9. Guidelines for Prenatal Care, supra note 5; The American College of Obstetricians and Gynecologists, Cocaine Abuse: Implications for Pregnancy (Committee Opinion 81) (1990).
10. The American Society of Addiction Medicine, Public Policy Statement on Chemically Dependent Women and Pregnancy, (September 25, 1989).
11. National Association of Public Child Welfare Administrators, Guiding Principles for Working with Substance-Abusing Families and Drug-Exposed Children: The Child Welfare Response, (approved by the Executive Committee at the National Council of State Human Services Administrators, January 1991).
12. W. Chavkin "Drug Addiction and Pregnancy: Policy Crossroads," American Journal of Public Health, 80 (1990): 483-87; R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," Journal of Legal Medicine, 14 (1993): 73-92; C.R. Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge, MA: Harvard University Press, 1993); D. Mathieu, "Mandating Treatment for Pregnant Substance Abusers: A Compromise," Politics and the Life Sciences, 14 (1995): 199-208; "Symposium: Pregnancy and Substance Abuse," Politics and the Life Sciences, 15 (1996): 49-82; P.H. Jos, M.F. Marshall, and M. Perlmutter, "The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale," Journal of Law, Medicine & Ethics, 23 (1995): 120-128.
13. W. Chavkin "Drug Addiction and Pregnancy: Policy Crossroads," American Journal of Public Health, 80 (1990): 483-87; R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," Journal of Legal Medicine, 14 (1993): 73-92; C.R. Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge, MA: Harvard University Press, 1993); D. Mathieu, "Mandating Treatment for Pregnant Substance Abusers: A Compromise," Politics and the Life Sciences, 14 (1995): 199-208; "Symposium: Pregnancy and Substance Abuse," Politics and the Life Sciences, 15 (1996): 49-82; P.H. Jos, M.F. Marshall, and M. Perlmutter, "The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale," Journal of Law, Medicine & Ethics, 23 (1995): 120-128.
14. W. Chavkin "Drug Addiction and Pregnancy: Policy Crossroads," American Journal of Public Health, 80 (1990): 483-87; R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," Journal of Legal Medicine, 14 (1993): 73-92; C.R. Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge, MA: Harvard University Press, 1993); D. Mathieu, "Mandating Treatment for Pregnant Substance Abusers: A Compromise," Politics and the Life Sciences, 14 (1995): 199-208; "Symposium: Pregnancy and Substance Abuse," Politics and the Life Sciences, 15 (1996): 49-82; P.H. Jos, M.F. Marshall, and M. Perlmutter, "The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale," Journal of Law, Medicine & Ethics, 23 (1995): 120-128.
15. W. Chavkin "Drug Addiction and Pregnancy: Policy Crossroads," American Journal of Public Health, 80 (1990): 483-87; R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," Journal of Legal Medicine, 14 (1993): 73-92; C.R. Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge, MA: Harvard University Press, 1993); D. Mathieu, "Mandating Treatment for Pregnant Substance Abusers: A Compromise," Politics and the Life Sciences, 14 (1995): 199-208; "Symposium: Pregnancy and Substance Abuse," Politics and the Life Sciences, 15 (1996): 49-82; P.H. Jos, M.F. Marshall, and M. Perlmutter, "The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale," Journal of Law, Medicine & Ethics, 23 (1995): 120-128.
16. W. Chavkin "Drug Addiction and Pregnancy: Policy Crossroads," American Journal of Public Health, 80 (1990): 483-87; R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," Journal of Legal Medicine, 14 (1993): 73-92; C.R. Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge, MA: Harvard University Press, 1993); D. Mathieu, "Mandating Treatment for Pregnant Substance Abusers: A Compromise," Politics and the Life Sciences, 14 (1995): 199-208; "Symposium: Pregnancy and Substance Abuse," Politics and the Life Sciences, 15 (1996): 49-82; P.H. Jos, M.F. Marshall, and M. Perlmutter, "The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale," Journal of Law, Medicine & Ethics, 23 (1995): 120-128.
17. W. Chavkin "Drug Addiction and Pregnancy: Policy Crossroads," American Journal of Public Health, 80 (1990): 483-87; R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," Journal of Legal Medicine, 14 (1993): 73-92; C.R. Daniels, At Women's Expense: State Power and the Politics of Fetal Rights (Cambridge, MA: Harvard University Press, 1993); D. Mathieu, "Mandating Treatment for Pregnant Substance Abusers: A Compromise," Politics and the Life Sciences, 14 (1995): 199-208; "Symposium: Pregnancy and Substance Abuse," Politics and the Life Sciences, 15 (1996): 49-82; P.H. Jos, M.F. Marshall, and M. Perlmutter, "The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale," Journal of Law, Medicine & Ethics, 23 (1995): 120-128.
18. D. Mechanic and M. Schlesinger, "The Impact of Managed Care on Patient's Trust in Medical Care and Their Physicians," JAMA, 275 (1996): 1693-97; S.M. Shortell, T.M. Walters, K.W.B. Clarke, and P.P. Budetti, "Physicians as Double-Agents: Maintaining Trust in an Era of Multiple Accountability," JAMA, 280 (1998), 1102-1108; M.G. Bloche, "Clinical Loyalties and the Social Purposes of Medicine," JAMA, 281 (1999): 268-74.
19. D. Mechanic and M. Schlesinger, "The Impact of Managed Care on Patient's Trust in Medical Care and Their Physicians," JAMA, 275 (1996): 1693-97; S.M. Shortell, T.M. Walters, K.W.B. Clarke, and P.P. Budetti, "Physicians as Double-Agents: Maintaining Trust in an Era of Multiple Accountability," JAMA, 280 (1998), 1102-1108; M.G. Bloche, "Clinical Loyalties and the Social Purposes of Medicine," JAMA, 281 (1999): 268-74.
20. D. Mechanic and M. Schlesinger, "The Impact of Managed Care on Patient's Trust in Medical Care and Their Physicians," JAMA, 275 (1996): 1693-97; S.M. Shortell, T.M. Walters, K.W.B. Clarke, and P.P. Budetti, "Physicians as Double-Agents: Maintaining Trust in an Era of Multiple Accountability," JAMA, 280 (1998), 1102-1108; M.G. Bloche, "Clinical Loyalties and the Social Purposes of Medicine," JAMA, 281 (1999): 268-74.
21. R.H. Blank, "Maternal-Fetal Relationship: The Courts and Social Policy," The Journal of Legal Medicine, 14 (1993): 73-92.
22. There is, of course, a growing literature that tried to assess the relative threats posed by a wide variety of legal and illegal behaviors. In general, research on the negative effects of tobacco and alcohol has been more conclusive and the research on the use of cocaine and other drugs has generally found that adverse"effects are not nearly as severe as many predicted. See, for example, H.H. Hurt et al., "Children with In Utero Cocaine Exposure Do Not Differ From Control Subjects on Intelligence Testing," Archives of Pediatrics and Adolescent Medicine, 151 (1997): 1237-42 and H. Hurt et al., "A Prospective Comparison of Developmental Outcome of Children With In Utero Cocaine Exposure and Controls Using the Battelle Development Inventory," Journal of Developmental and Behavioral Pediatrics, 22 (2001): 27-34.
23. There is, of course, a growing literature that tried to assess the relative threats posed by a wide variety of legal and illegal behaviors. In general, research on the negative effects of tobacco and alcohol has been more conclusive and the research on the use of cocaine and other drugs has generally found that adverse"effects are not nearly as severe as many predicted. See, for example, H.H. Hurt et al., "Children with In Utero Cocaine Exposure Do Not Differ From Control Subjects on Intelligence Testing," Archives of Pediatrics and Adolescent Medicine, 151 (1997): 1237-42 and H. Hurt et al., "A Prospective Comparison of Developmental Outcome of Children With In Utero Cocaine Exposure and Controls Using the Battelle Development Inventory," Journal of Developmental and Behavioral Pediatrics, 22 (2001): 27-34.
24. Consider, for example, the Bush administration's recent decision to broaden the definition of a child to include the prenatal period from conception for the purposes of determining eligibility for the Children's Health Insurance Program. R. Pear, "Bush Plan Allows States to Give 'Unborn Child' Medical Coverage," New York Times, July 6, 2001, at A1.
25. For a discussion of how popular images of client groups can influence policy, see A. Schneider and H. Ingram, "Social Construction of Target Populations: Implications for Politics and Policy," American Political Science Review, 87 (1993): 334-47. For discussions of race and policies regarding mothers, see K. Beckett "Fetal Rights and 'Crack Moms:' Pregnant Women in the War on Drugs," Contemporary Drug Problems, 22 (1995): 587-612; D.E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York, NY: Pantheon, 1997).
26. For a discussion of how popular images of client groups can influence policy, see A. Schneider and H. Ingram, "Social Construction of Target Populations: Implications for Politics and Policy," American Political Science Review, 87 (1993): 334-47. For discussions of race and policies regarding mothers, see K. Beckett "Fetal Rights and 'Crack Moms:' Pregnant Women in the War on Drugs," Contemporary Drug Problems, 22 (1995): 587-612; D.E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York, NY: Pantheon, 1997).
27. For a discussion of how popular images of client groups can influence policy, see A. Schneider and H. Ingram, "Social Construction of Target Populations: Implications for Politics and Policy," American Political Science Review, 87 (1993): 334-47. For discussions of race and policies regarding mothers, see K. Beckett "Fetal Rights and 'Crack Moms:' Pregnant Women in the War on Drugs," Contemporary Drug Problems, 22 (1995): 587-612; D.E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York, NY: Pantheon, 1997).
28. Five years after implementing the Interagency Policy, the Medical University agreed to discontinue the program in an agreement with the Civil Rights Division of the Department of Health and Human Services (DHHS). DHHS investigated charges that the policy, implemented in a federally-funded facility, was racially discriminatory. The charges included both discriminatory application of the policy to black women who were screened and arrested more frequently than white women, and arbitrary selection of the illegal drugs that were tested for and for which women were arrested, crack cocaine being the most frequent drug resulting in arrest. A subsequent investigation by the Office of Protection from Research Risks (OPRR) of the National Institutes of Health found that the Interagency Policy involved research on human subjects without their consent and without the requisite Institutional Review Board evaluation and approval. As a result, the OPRR deferred renewal of the Medical University's Multiple Project Assurance for one year, thereby threatening millions of dollars in federal funds if the Interagency Policy were continued.
29. Ten of the women arrested under the Medical University policy brought charges against the Medical University, the police department, and the prosecutor alleging racial discrimination, unlawful search and seizure, violations of confidentiality and the right to refuse medical treatment, and a series of other charges. In Ferguson v. City of Charleston, No. 2-93-20242-2 (D.S.C. filed Oct. 5, 1993), a federal jury dismissed all charges against the hospital, the police, and the prosecutor. Proponents of the policy claimed vindication for their approach.
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89. S. Kar, "Primary Health Care: Implications for Medical Education," Academic Medicine, 65 (1990): 301-306; P. Lee and D. Paxman, "Reinventing Public Health," Annual Review of Public Health, 18 (1997): 1-35.
90. Only about one-sixth of the years of life expectancy gained in this country during this century can be attributed to the beneficial impact of medicine, medical care, and medical research. "Medicine and Public Health, Ethics, and Human Rights," Hastings Center Report, 27, no. 3 (1997): 6-13.
91. Whitner, supra note 17. Whitner was actually heard twice by the supreme court. The first opinion was issued in July 1996; but in an unusual procedural move, the Court granted an amicus curiae's motion for rehearing. The opinion was amended and refiled on October 27, 1997. A petition for certiorari to the United States Supreme Court on behalf of Ms. Whitner was denied by the Court in May 1998; as cited in L.J. Nelson and M.F. Marshall, An Ethical and Legal Analysis of State-Compelled Loss of Liberty as an Intervention to Reduce the Harm of Perinatal Substance Abuse and Drug Addiction, final report from a project sponsored by the Robert Wood Johnson Foundation Substance Abuse Policy Research Program (August 12, 1998), at 65.
92. Some rule out any such tradeoffs as inconsistent with the rights of the mother and/or the prerogatives of the physician. But this is a difficult position to defend, since community well-being does require some restriction of individual autonomy. So, some balancing of privacy rights and society's interest in healthy newborns is necessary.
93. Although South Carolina ranks twenty-third in the percentage of two-year-olds immunized and twelfth in child support enforcement, and federal initiatives have allowed some expansion of Medicaid coverage for children (enactment of the state Children's Health Insurance Program (CHIP) enabled South Carolina to extend Medicaid coverage to children in families who earn up to 150 percent of the federal poverty level), South Carolina ranks fiftieth in infant mortality, Children's Defense Fund. The State of Children in America's Union (2002), available through 〈www.childrensdefense.org/data.php〉, at 47, forty-eighth in the incidence of low-birth weight babies, id. at 45, fortieth in the incidence of prenatal care, id. at 58, thirty-sixth in child poverty, Kids Count, State Profiles of Child Well-Being (2003 Data Book), available through 〈www.aecf.org/kidscount/〉, at 69, thirty-ninth in teenage deaths due to accident, homicide, and suicide, id. at 64, and thirty-fifth in the percentage of teens who drop out of high school, id. at 66.
94. Although South Carolina ranks twenty-third in the percentage of two-year-olds immunized and twelfth in child support enforcement, and federal initiatives have allowed some expansion of Medicaid coverage for children (enactment of the state Children's Health Insurance Program (CHIP) enabled South Carolina to extend Medicaid coverage to children in families who earn up to 150 percent of the federal poverty level), South Carolina ranks fiftieth in infant mortality, Children's Defense Fund. The State of Children in America's Union (2002), available through 〈www.childrensdefense.org/data.php〉, at 47, forty-eighth in the incidence of low-birth weight babies, id. at 45, fortieth in the incidence of prenatal care, id. at 58, thirty-sixth in child poverty, Kids Count, State Profiles of Child Well-Being (2003 Data Book), available through 〈www.aecf.org/kidscount/〉, at 69, thirty-ninth in teenage deaths due to accident, homicide, and suicide, id. at 64, and thirty-fifth in the percentage of teens who drop out of high school, id. at 66.
95. Although South Carolina ranks twenty-third in the percentage of two-year-olds immunized and twelfth in child support enforcement, and federal initiatives have allowed some expansion of Medicaid coverage for children (enactment of the state Children's Health Insurance Program (CHIP) enabled South Carolina to extend Medicaid coverage to children in families who earn up to 150 percent of the federal poverty level), South Carolina ranks fiftieth in infant mortality, Children's Defense Fund. The State of Children in America's Union (2002), available through 〈www.childrensdefense.org/data.php〉, at 47, forty-eighth in the incidence of low-birth weight babies, id. at 45, fortieth in the incidence of prenatal care, id. at 58, thirty-sixth in child poverty, Kids Count, State Profiles of Child Well-Being (2003 Data Book), available through 〈www.aecf.org/kidscount/〉, at 69, thirty-ninth in teenage deaths due to accident, homicide, and suicide, id. at 64, and thirty-fifth in the percentage of teens who drop out of high school, id. at 66.
96. Although South Carolina ranks twenty-third in the percentage of two-year-olds immunized and twelfth in child support enforcement, and federal initiatives have allowed some expansion of Medicaid coverage for children (enactment of the state Children's Health Insurance Program (CHIP) enabled South Carolina to extend Medicaid coverage to children in families who earn up to 150 percent of the federal poverty level), South Carolina ranks fiftieth in infant mortality, Children's Defense Fund. The State of Children in America's Union (2002), available through 〈www.childrensdefense.org/data.php〉, at 47, forty-eighth in the incidence of low-birth weight babies, id. at 45, fortieth in the incidence of prenatal care, id. at 58, thirty-sixth in child poverty, Kids Count, State Profiles of Child Well-Being (2003 Data Book), available through 〈www.aecf.org/kidscount/〉, at 69, thirty-ninth in teenage deaths due to accident, homicide, and suicide, id. at 64, and thirty-fifth in the percentage of teens who drop out of high school, id. at 66.
97. Although South Carolina ranks twenty-third in the percentage of two-year-olds immunized and twelfth in child support enforcement, and federal initiatives have allowed some expansion of Medicaid coverage for children (enactment of the state Children's Health Insurance Program (CHIP) enabled South Carolina to extend Medicaid coverage to children in families who earn up to 150 percent of the federal poverty level), South Carolina ranks fiftieth in infant mortality, Children's Defense Fund. The State of Children in America's Union (2002), available through 〈www.childrensdefense.org/data.php〉, at 47, forty-eighth in the incidence of low-birth weight babies, id. at 45, fortieth in the incidence of prenatal care, id. at 58, thirty-sixth in child poverty, Kids Count, State Profiles of Child Well-Being (2003 Data Book), available through 〈www.aecf.org/kidscount/〉, at 69, thirty-ninth in teenage deaths due to accident, homicide, and suicide, id. at 64, and thirty-fifth in the percentage of teens who drop out of high school, id. at 66.
98. Although South Carolina ranks twenty-third in the percentage of two-year-olds immunized and twelfth in child support enforcement, and federal initiatives have allowed some expansion of Medicaid coverage for children (enactment of the state Children's Health Insurance Program (CHIP) enabled South Carolina to extend Medicaid coverage to children in families who earn up to 150 percent of the federal poverty level), South Carolina ranks fiftieth in infant mortality, Children's Defense Fund. The State of Children in America's Union (2002), available through 〈www.childrensdefense.org/data.php〉, at 47, forty-eighth in the incidence of low-birth weight babies, id. at 45, fortieth in the incidence of prenatal care, id. at 58, thirty-sixth in child poverty, Kids Count, State Profiles of Child Well-Being (2003 Data Book), available through 〈www.aecf.org/kidscount/〉, at 69, thirty-ninth in teenage deaths due to accident, homicide, and suicide, id. at 64, and thirty-fifth in the percentage of teens who drop out of high school, id. at 66.
99. W. Chavkin et. al., "National Survey of the States: Policies and Practices Regarding Drug Using Pregnant Women," American Journal of Public Health, 88 (1998): 117-19.
100. National Center on Addiction and Substance Abuse at Columbia University, Shoveling Up: The Impact of Substance Abuse on State Budgets (January, 2001).
101. K. Harris, "5.6 Billion Budget Compromise Has Unprecedented Cuts," The State, June 15, 2001. at A1.
102. A. M. Pagliaro and L.A. Pagliaro, "Teratogenic Effects of in Utero Exposure to Alcohol and Other Abusable Psychotropics," in M.R. Haack, ed., Drug Dependent Mothers and their Children: Issues in Public Policy and Public Health (New York, NY: Springer Publishing Co, Inc., 1997); 31-63.
103. And so, the criminalization of substance abuse among pregnant women may offer the worst of both worlds. On the one hand, it weakens the effectiveness of the clinical encounter by seriously eroding trust between the caregiver and the patient, further alienating individuals from the health-care system, and reinforcing the idea that the object of our efforts is the isolated individual in need of treatment or incarceration. On the other hand, it fails to make good on its promise of promoting the health and well-being of future citizens by neglecting to address the full range of threats to newborns and children and by ignoring the social and economic context that gives rise to many of those threats.