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The Bioethics of "Baby Boxes" · Health Ethics Podcast

0:08
Speaker 1: Welcome to Health Ethics, a series of conversations with leading
0:12
Speaker 1: experts about ethical considerations associated with health and healthcare, both
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Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
0:21
Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
0:24
Speaker 1: School of Medicine. This series, like its predecessor, which focused
0:29
Speaker 1: on the COVID nineteen pandemic, relies on the idea that
0:32
Speaker 1: challenging ethical issues are best addressed by folks from diverse
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Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
0:41
Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics, philosophy,
0:47
Speaker 1: and the law. Thank you and enjoy the episode.
0:58
Speaker 2: It is my great pleasure today to speak with doctor
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Speaker 2: Laurie Bruce about the bioethics of baby boxes. Doctor Bruce
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Speaker 2: is Associate Director at the Interdisciplinary Center for Bioethics at
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Speaker 2: Yale University. She is also chair of the Community Bioethics
1:15
Speaker 2: Forum at the Yale School of Medicine and affiliated faculty
1:18
Speaker 2: at the Solomon Center for Health Law and Policy at
1:21
Speaker 2: Yale Law School. Doctor Bruce may be best known for
1:26
Speaker 2: running and directing a global and cherished summer institute, the
1:30
Speaker 2: sherwan By Newlands Summer Institute in Bioethics, and so folks
1:35
Speaker 2: like me with students, I think the applications might actually
1:37
Speaker 2: be open now. I'd encourage folks to send your students
1:40
Speaker 2: that way. Laurie, thank you so much for joining me.
1:43
Speaker 1: One of the few people I've seen doing a ton
1:45
Speaker 1: of work around what are called baby boxes. So a
1:48
Speaker 1: few years ago you highlighted this phenomenon in the US.
1:52
Speaker 1: Before we go into the details, what's going on now
1:55
Speaker 1: sort of bioethical considerations and implications. How did you come
1:59
Speaker 1: upon the and sort of what pushed you to do
2:01
Speaker 1: this kind of work.
2:02
Speaker 3: Hi, Brian, thanks so much. It's wonderful to be here
2:05
Speaker 3: with you today. That's a great question. About ten years ago,
2:10
Speaker 3: I was asked to consult on a very tragic case
2:15
Speaker 3: locally here in Connecticut of infanticide, where there was a
2:20
Speaker 3: young mother who hid her pregnancy and she ended up
2:26
Speaker 3: committing infanticide and the entire community was just bereft and
2:32
Speaker 3: filled with grief. And so in a couple of years
2:36
Speaker 3: after that happened, I was asked, in my capacity as
2:40
Speaker 3: the founder and chair of Yale's Community Bioethics Forum to
2:46
Speaker 3: consider from a diverse community perspective what kinds of policies
2:53
Speaker 3: may be more efficacious to reduce harms and to help
2:59
Speaker 3: women and families and children facing those kinds of really
3:04
Speaker 3: difficult pregnancies that are in crisis. So I've been following
3:09
Speaker 3: the laws related to infant abandonment. They are called safe
3:12
Speaker 3: haven laws, and recently these laws have been modified at
3:19
Speaker 3: the state level to have another means of surrendering an
3:24
Speaker 3: infant when a parent is unable.
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Speaker 4: To care for them.
3:28
Speaker 3: And this most recent and rather controversial, controversial change to
3:33
Speaker 3: the laws relates to being able to not just surrender
3:38
Speaker 3: an infant to a nurse within a hospital, but to
3:43
Speaker 3: anonymously surrender the infant by placing them into a metal
3:49
Speaker 3: box that's often built into the exterior wall of a
3:54
Speaker 3: fire station or medical center, and then alarms would go
3:59
Speaker 3: off to alert staff inside to retrieve the infant.
4:04
Speaker 1: The background's really helpful, especially because though we have folks
4:06
Speaker 1: from all over who tune in, we have lots of
4:08
Speaker 1: medical students who are interested to sort of knowing how
4:12
Speaker 1: and their interest in bioethics. Knowing how bioethicists sort of
4:15
Speaker 1: come upon challenging issues and how they think through them,
4:18
Speaker 1: at least how they get started is really helpful. So, uh,
4:21
Speaker 1: you guess the next question, which is what exactly are
4:24
Speaker 1: infant abandonment boxes? I mean, I know stories of strending
4:28
Speaker 1: surrendering infants and nurses and hospitals. You hear stories about
4:32
Speaker 1: going to the fire station in front surrounding it to
4:34
Speaker 1: a you know, the child to a firefighter. Can you
4:37
Speaker 1: say more about these infant abandonment boxes. So they're metal boxes,
4:41
Speaker 1: they're attached to a wall. Help our audience sort of
4:44
Speaker 1: understand what they what they look like, I guess.
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Speaker 3: Infant abandonment boxes are literally metal boxes with an exterior
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Speaker 3: door such that a parent could open the door to
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Speaker 3: place their infant inside, and then they have of an
5:00
Speaker 3: internal door that would be inside of a building to
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Speaker 3: allow for retrieval. These boxes have temperature controls, cameras, alarms,
5:13
Speaker 3: a bascinets, and a mattress to keep the baby safe.
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Speaker 3: They're intended to keep the baby safe. And these are
5:23
Speaker 3: modern versions of the ancient foundling wheels, which were installed
5:29
Speaker 3: in convents starting back in the medieval ages. Because of
5:36
Speaker 3: vast numbers of abandoned infants that were being found on
5:40
Speaker 3: the streets of Rome. They then spread during the medieval
5:44
Speaker 3: times all across Europe, but they were discontinued in the
5:49
Speaker 3: eighteen hundreds. Most countries do not have abandonment boxes anymore.
5:56
Speaker 3: Most countries comply with the un rights of a child
6:02
Speaker 3: and promote as much as they can the ability for
6:06
Speaker 3: a child to know, to know their own identity, and
6:11
Speaker 3: to be raised by their parents. And so most countries
6:16
Speaker 3: have implemented a series of other policies that we can
6:20
Speaker 3: get into later, that are more in line with the
6:24
Speaker 3: views and values and preferences and wishes of families facing
6:29
Speaker 3: these circumstances.
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Speaker 1: That's helpful, and the historical context is also, i mean
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Speaker 1: really helpful. So it's back to the actually one.
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Speaker 2: Question with the history.
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Speaker 1: You noted that in foundling boxes had been going on
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Speaker 1: in existence for a bit. Why did they stop? Why
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Speaker 1: did folks stop using these?
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Speaker 3: Broadly, countries stopped using foundling wheels because they recognize the
6:53
Speaker 3: importance of keeping families together. They recognized that find finances
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Speaker 3: were the major reason that most families felt they had
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Speaker 3: to surrender. And this is true today in the United States,
7:10
Speaker 3: which we can discuss, and so countries and hospitals grew
7:17
Speaker 3: to support other policies and laws that were more in
7:22
Speaker 3: line with the families facing strife during their pregnancies.
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Speaker 1: This is heavy stuff, that's I mean, that's powerful, and
7:31
Speaker 1: I'm thinking of a number of our medical students too
7:33
Speaker 1: usually tune in, some of whom were working on some
7:36
Speaker 1: projects around challenges to dignity and healthcare relative to financial
7:40
Speaker 1: concerns and sort of what that can do to folks,
7:43
Speaker 1: especially around conceptions of humiliation. So it's the next thing
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Speaker 1: I wanted to ask about as a bioethesis, what do
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Speaker 1: you identify as the ethical issues or the ethical violations
7:55
Speaker 1: with this type of device? And you've already hit on
7:58
Speaker 1: I think a few. Do you want to summarize those
8:01
Speaker 1: quickly tiny strands to the other word and any additional
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Speaker 1: sort of bioethical considerations.
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Speaker 3: There are so many ethical considerations with these infant abandonment boxes.
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Speaker 3: But I would like to start by saying that I
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Speaker 3: lawd the advocates of boxes for their noble intentions, and
8:20
Speaker 3: indeed I share their goals for the safe care of
8:24
Speaker 3: all infants. All infants have the right to a safe home. However,
8:29
Speaker 3: as implemented, Infant abandonment boxes raise serious concerns related to
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Speaker 3: the health and safety and well being of not only
8:40
Speaker 3: that infant, but of the family and of the mother
8:43
Speaker 3: who just gave birth. I'll touch upon a number of
8:48
Speaker 3: the concerns, but one of them is you know, as
8:54
Speaker 3: a bioethicist, we are I always encourage my students to
8:58
Speaker 3: think about how good ethics relies on good data. We
9:04
Speaker 3: cannot just go out and create good policy until we
9:07
Speaker 3: think about what values do we wish to undergird our
9:11
Speaker 3: policies and identify the policy problem. And when we identify
9:17
Speaker 3: a policy problem, the folks writing the policies should not
9:23
Speaker 3: be the only ones participating in that exercise.
9:27
Speaker 4: We ought to be.
9:28
Speaker 3: Working with community members and experts who are aware of
9:34
Speaker 3: who is likely to commit infanticide, who is more likely
9:38
Speaker 3: to encounter a crisis pregnancy. And how do people even
9:42
Speaker 3: know about policies so that they know what their options are.
9:46
Speaker 4: So, when I think.
9:47
Speaker 3: About these boxes, one of the many problems with them is,
9:51
Speaker 3: as mentioned, how they are implemented. So, as I mentioned,
9:56
Speaker 3: every state already has in person surrender under safe in laws.
10:01
Speaker 3: When a state decides to permit boxes as an additional
10:04
Speaker 3: legal form of surrender. They intend to provide an additional option.
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Speaker 3: States don't want to take away other options from families
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Speaker 3: and crisis. They don't want to discourage people from seeking
10:16
Speaker 3: face to face help, because face to face encounters open
10:19
Speaker 3: the door for crisis counseling and medical care and a
10:23
Speaker 3: discussion about options and alternatives, and indeed, at risk folks
10:27
Speaker 3: overwhelmingly prefer face to face for many reasons. For example,
10:32
Speaker 3: they want to ensure that their baby is turned over
10:34
Speaker 3: to someone who's caring incompetent, and so when boxes are implemented,
10:39
Speaker 3: the marketing, the publicity, the signs around the boxes over
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Speaker 3: emphasize the box without equally shining a light on temporary
10:47
Speaker 3: placement and family preservation options, kinship care, and open and
10:53
Speaker 3: closed adoptions. People only use options that they know about,
10:58
Speaker 3: and so if they only know about a box, they
11:00
Speaker 3: may use the box then likely experienced regret and anguish
11:05
Speaker 3: for the rest of their lives. Adoption scholars like Gretchen
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Speaker 3: Sissen tell us that relinquishment is associated with lifelong trauma.
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Speaker 3: Many women who relinquish had no idea of other options
11:21
Speaker 3: and later learned that there were resources that could have
11:25
Speaker 3: helped them to keep their baby, and that's just devastating
11:28
Speaker 3: to them.
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Speaker 4: So when a.
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Speaker 3: Fire station or a hospital or health center signs a
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Speaker 3: contract for a box, these contracts tend to have strict
11:37
Speaker 3: language controlling the signs around the boxes. So if a
11:41
Speaker 3: hospital wanted to have a sign that says come inside
11:45
Speaker 3: for medical care or something that says there are options
11:48
Speaker 3: to help you keep your baby, the providers wouldn't be
11:51
Speaker 3: able to post those messages. They can't inform a parent
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Speaker 3: of legally permissible options. For example, there is a nonprofit
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Speaker 3: that works with families nationwide when they're facing crisis and
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Speaker 3: they're overwhelmed and they need some temporary care for their child.
12:11
Speaker 3: So the nonprofit has families who care for the child
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Speaker 3: temporarily while the patients are getting help, learning about resources
12:19
Speaker 3: and getting stabilized, and then they can get their baby back.
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Speaker 3: The intention is to provide empathic support and it's helped
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Speaker 3: many children to stay with their parent. This is a
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Speaker 3: policy example that's collaborative, it's empathic, it's supportive, and it
12:35
Speaker 3: helps to empower those experiences that are experiencing crisis. A
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Speaker 3: parent approaching a box will have no idea that that
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Speaker 3: option even exists, and so when we consider the paradigm
12:47
Speaker 3: of ethical policy making, it's contingent upon listening to the needs,
12:53
Speaker 3: the views, the values, and the wishes of those who
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Speaker 3: are impacted by the policy and finding ways to collaborate
13:00
Speaker 3: and creatively reduce harms while promoting goodness or beneficence. Boxes
13:06
Speaker 3: might seem to reduce harms, but we also see ways
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Speaker 3: that can increase harms. The harms for instance, of unnecessary
13:14
Speaker 3: family separation, and boxes also may increase harms related to
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Speaker 3: lifelong trauma and grief.
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Speaker 1: To think about the informed consent, shared decision making, sort
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Speaker 1: of the bread and butter conversations bioethicists often have with physicians, students,
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Speaker 1: folks in the community. This is a case which does
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Speaker 1: not seem to avail itself of that model. Well sort
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Speaker 1: of task space here, I mean, if bioethics governed this
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Speaker 1: idea right or this box right, it's hospitals that shared
13:49
Speaker 1: decision making. We know that if it's public health, maybe
13:52
Speaker 1: there's a different set of considerations. Where does this fall?
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Speaker 1: Is that question well posed? I don't know if I'm
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Speaker 1: trying to get it like, it's a.
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Speaker 3: Great question, and I think part of what what's in
14:05
Speaker 3: conflict here is that these boxes become legal under safe
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Speaker 3: haven laws, which are not public health laws, but they
14:14
Speaker 3: are crime control laws. So they are seeking to prevent infanticides,
14:20
Speaker 3: they are seeking to prevent unsafe abandonments. And so whenever
14:28
Speaker 3: anyone were to elect a safe haven surrender, whether it's
14:32
Speaker 3: in person or to a box, they are very unlikely
14:37
Speaker 3: to be aware that their parental rights are terminated rapidly.
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Speaker 4: They do not realize that if.
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Speaker 3: They wish to regain custody of their child, or even
14:49
Speaker 3: be able to see their child akin to an open adoption,
14:55
Speaker 3: and be able to have some knowledge about that child,
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Speaker 3: they are going to face an up battle because the
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Speaker 3: law is written assuming that that person would have otherwise
15:07
Speaker 3: placed their child in a dumpster. So there are assumptions
15:12
Speaker 3: within the laws and policies about the lack of the
15:15
Speaker 3: mom's moral fitness, but that judgment isn't warranted. She's trying
15:20
Speaker 3: to do the right thing within financial, social, and legal constraints.
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Speaker 3: She's in crisis and needs help and compassion, and she
15:28
Speaker 3: needs laws and policies that support, not penalize. And this
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Speaker 3: is another great point for your medical students, Brian, because
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Speaker 3: the boxes also do not let a mother know what
15:46
Speaker 3: legal requirements she must follow in order not to be
15:50
Speaker 3: prosecuted for abandonment, And yet the marketing signs say no shame,
15:56
Speaker 3: no blame, no names.
15:58
Speaker 4: However, there are men any.
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Speaker 3: Conditions that must be met which vary from state to state,
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Speaker 3: which must be met for the parent to be immune
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Speaker 3: from prosecution. For instance, they must surrender to an approved location.
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Speaker 3: They must meet the age criteria. In some states, they
16:20
Speaker 3: have a minimum of three days after birth to surrender
16:25
Speaker 3: the child. In other states it's thirty days. But if
16:28
Speaker 3: they place a child into a box that does not
16:32
Speaker 3: meet that requirement, they can indeed be prosecuted for not
16:36
Speaker 3: following the letter of the law. Additionally, every state has
16:40
Speaker 3: a harm clause, so if a child placed into a
16:43
Speaker 3: box or surrendered in the hospital is positive for a
16:46
Speaker 3: talk screen or shows other signs of harm which is
16:50
Speaker 3: never really defined, again, those.
16:54
Speaker 4: Parents can be prosecuted.
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Speaker 3: And the problem with this is that even though every
17:00
Speaker 3: state has one of these safe haven laws to permit
17:04
Speaker 3: a location or surrender, no states in this country provide
17:12
Speaker 3: a safe means of delivering these childs despite their It
17:17
Speaker 3: being common knowledge that these parents.
17:19
Speaker 4: Are giving birth alone.
17:22
Speaker 3: Outside of a hospital because they need identity protection.
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Speaker 1: I was going to ask what's right, just so we
17:29
Speaker 1: have arguments, all the arguments on the table, what's the
17:33
Speaker 1: case that can be made for these boxes? Like because
17:36
Speaker 1: you know when you when you hear the mantra of
17:39
Speaker 1: no shame and no blame, powerful points in favor of
17:43
Speaker 1: anonymity and folks making decisions for themselves right, all within
17:48
Speaker 1: bioethics and the history of bioethics. But with all the
17:52
Speaker 1: details that you just laid out, I'm having a tough
17:54
Speaker 1: time finding what the argument is in favor of them.
17:59
Speaker 1: Maybe mainly I think because it sounds like folks are
18:02
Speaker 1: not being properly informed, and so what someone might I mean,
18:05
Speaker 1: there is one narrative. I'm sure they're alternative narratives. Someone
18:07
Speaker 1: who may wish to for their child to be safe
18:13
Speaker 1: and as concerns that they're able to sort of care
18:16
Speaker 1: for the child, protect the child safety and healthy, or
18:19
Speaker 1: make sure the child's safe and healthy, try to avail
18:22
Speaker 1: themselves to one of these boxes. It's anonymous. But all
18:25
Speaker 1: the challenges, I mean, what's the best case for these
18:28
Speaker 1: boxes or is that there really isn't one.
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Speaker 3: That's a great question, and I think that when we
18:35
Speaker 3: hear in the US are thinking about the best policy
18:40
Speaker 3: responses to any problem, often we can learn a lot
18:44
Speaker 3: by looking at other countries and how they approach these challenges.
18:50
Speaker 3: Because the US clearly does not have a history with boxes.
18:54
Speaker 3: This is a very recent phenomenon that has just started,
18:58
Speaker 3: and I believe twenty sixteen was the very first box.
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Speaker 3: And now we have three hundred, over three hundred of
19:05
Speaker 3: these abandonment boxes across the country, including at least one
19:08
Speaker 3: hundred and fifty in Indiana alone.
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Speaker 4: And so and so.
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Speaker 3: One thing we can learn though is looking to other
19:17
Speaker 3: countries that are similar and not identical, but similar to US,
19:20
Speaker 3: with a longer history.
19:22
Speaker 4: Of abandonment boxes.
19:24
Speaker 3: And so there's been some wonderful research done, for instance,
19:27
Speaker 3: in Germany and Austria, who have a long history with
19:31
Speaker 3: these boxes.
19:32
Speaker 4: In more modern times.
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Speaker 3: In Germany they actually have one hundred boxes, which is
19:39
Speaker 3: very unusual. It is the only country in Europe to
19:42
Speaker 3: have so many boxes. Those boxes were not installed in
19:46
Speaker 3: response to any sort of increase in infant abandonment or infanticide.
19:51
Speaker 3: They were installed by well intended, faith based advocates to
19:55
Speaker 3: offer an additional means of surrender for those perceived to
20:00
Speaker 3: need anonymity. However, when we examine the numbers of unsafe
20:05
Speaker 3: abandonments and infanticides before and after those one hundred boxes
20:10
Speaker 3: were installed, we see no difference in unsafe abandonments. We
20:16
Speaker 3: do see those boxes being used, though, and when those
20:20
Speaker 3: boxes are used, those numbers are actually being pulled from
20:25
Speaker 3: the numbers of people who would have otherwise surrendered face
20:28
Speaker 3: to face. It is a much more popular choice to
20:33
Speaker 3: surrender face to face, and I can talk to you
20:35
Speaker 3: about the US statistics on that because it's overwhelmingly favored.
20:40
Speaker 3: So in Germany that means that those who are placing
20:45
Speaker 3: an infant into a box, perhaps because they saw a
20:48
Speaker 3: sign on the highway and didn't know about other options
20:52
Speaker 3: or who knows, but when they're placing that baby into
20:55
Speaker 3: a box, that means they're not going to the hospital
20:58
Speaker 3: to receive crisis counsel, medical care, or knowledge of other options.
21:04
Speaker 3: And so this again goes back to informed consent.
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Speaker 1: The I mean, the comparisons are really really helpful in
21:10
Speaker 1: knowing that face to face surrenderers preferred. I think it's
21:14
Speaker 1: also a powerful point. I mean, this is a dark
21:19
Speaker 1: and grim ara topic in many many ways, and I
21:22
Speaker 1: want to get to what policies you think would be
21:25
Speaker 1: effective to meet the needs of this population. But before
21:28
Speaker 1: we jump there, is there anything we need to know
21:31
Speaker 1: before we think about what the right policies are current
21:35
Speaker 1: contexts in the US, any other feel I mean, you've
21:37
Speaker 1: hit so much of the ethics, the history, and the background,
21:40
Speaker 1: anything else that listeners should know before we talk about
21:43
Speaker 1: effective policies.
21:45
Speaker 3: Absolutely, I would like to make a point that these
21:47
Speaker 3: boxes are unregulated. There's no federal agency that oversees them
21:53
Speaker 3: or inspects the factory.
21:56
Speaker 4: That is why I led an.
21:58
Speaker 3: Open letter to the US Department of Health and Human
22:00
Speaker 3: Services that was signed co signed by one hundred of
22:05
Speaker 3: my colleagues and physicians and other clinicians and child welfare advocates,
22:12
Speaker 3: really sounding the alarm and pushing for oversight of these boxes.
22:18
Speaker 3: They are also not hippo compliant. Whether it's someone calling
22:21
Speaker 3: the hotline or the camera streams that are installed to
22:27
Speaker 3: beam down inside of those boxes, those are not covered
22:31
Speaker 3: by any sort of hippo compliance.
22:33
Speaker 4: However, I do want to get back before we get
22:35
Speaker 4: into which policies are effective.
22:37
Speaker 3: I do want to mention that in some states it
22:41
Speaker 3: might be that an infant abandonment box might be someone's
22:47
Speaker 3: best choice. For example, currently in Texas undocumented patients, undocumented
22:57
Speaker 3: people may fear the hospital because of recent requirements that
23:05
Speaker 3: they must be asked about their documentation status, and so
23:09
Speaker 3: in those cases, if a mother is fearful of going
23:14
Speaker 3: to the hospital worried that her family may be deported,
23:20
Speaker 3: it may be that a box might be the safest
23:23
Speaker 3: way for her to surrender the child. It certainly still
23:26
Speaker 3: puts her at medical risk, because women who give birth
23:32
Speaker 3: alone are at risk for hemorrhage and infection, certainly, depression, anxiety,
23:38
Speaker 3: lifelong grief, and trauma as discussed by Gretchen Sissen and
23:42
Speaker 3: her recent book Relinquished, which I encourage you and all
23:45
Speaker 3: of them had students here to read. There's another state
23:49
Speaker 3: that is another outlier, perhaps.
23:52
Speaker 4: In this conversation.
23:53
Speaker 3: In states like Virginia, the safe haven laws that I
23:57
Speaker 3: was talking about do.
23:59
Speaker 4: Not give parents immunity.
24:02
Speaker 3: From prosecution even if they follow the letter of the
24:06
Speaker 3: safe haven law. In Virginia, the law states that that
24:12
Speaker 3: individual can only use the fact that they used safe
24:17
Speaker 3: haven surrender as evidence during their trial. And we need
24:21
Speaker 3: to remember that these are families who are that are
24:23
Speaker 3: already in crisis. These are families that are likely surrendering
24:28
Speaker 3: because they may have other children that they're already struggling
24:31
Speaker 3: to care for. Finances, as mentioned, is the primary reason
24:36
Speaker 3: for relinquishments in at least eighty percent of cases here
24:41
Speaker 3: in the United States. And so someone facing this challenge
24:46
Speaker 3: does not have the time or the finances to wage
24:51
Speaker 3: a legal battle against the state to prove that they
24:57
Speaker 3: were doing the right thing. So in a state like Virginia,
25:01
Speaker 3: where there are already hostile and coercive conditions, it may
25:07
Speaker 3: it might be that a box might sadly be a
25:11
Speaker 3: family's best.
25:12
Speaker 1: Option challenging in grim cases. And I really appreciate how
25:15
Speaker 1: you appreciate how you highlighted the other sorts of policies
25:20
Speaker 1: structural features of the situation, And so folks may be
25:25
Speaker 1: motivated to do this in light of other kinds of
25:26
Speaker 1: things which are not sort of directly related to it.
25:29
Speaker 1: So if you are afraid of deportation, this might become
25:32
Speaker 1: your best option, not because it's the best option for
25:34
Speaker 1: you as a person, as a member of a family
25:36
Speaker 1: in terms of your health, but for other reasons. And
25:38
Speaker 1: so and for folks who listen to the podcast regularly.
25:41
Speaker 1: You'll recall a chat that we had with j O'Brien
25:45
Speaker 1: on the horrific maternal mortality rate in the US and
25:48
Speaker 1: the worthless to do if folks haven't heard it yet,
25:51
Speaker 1: And the point I wasn't aware of from the chat
25:53
Speaker 1: with Jay was that concerns about maternal mortality and the
25:57
Speaker 1: newest extend to a full year postpartum, which.
26:00
Speaker 2: I had not.
26:00
Speaker 1: I mean, I always think about it in the hospital challenges,
26:02
Speaker 1: So this, I think is a case which highlights that
26:05
Speaker 1: in the opportunities if you're surrendering a child in person
26:09
Speaker 1: at a hospital, options for care, anything else, before we
26:12
Speaker 1: get up to what the best policies or better policies
26:16
Speaker 1: should be, what policies will meet the needs of this population.
26:19
Speaker 3: One point I'd like to make for there is a
26:21
Speaker 3: perception from those who advocate for the box, or at
26:26
Speaker 3: least some of those who advocate for boxes, that some
26:30
Speaker 3: women just simply need a place to put their child,
26:37
Speaker 3: similarly to dropping off a book to the library drop box. However,
26:42
Speaker 3: this is never some sort of clinical decision for any parent.
26:47
Speaker 3: Any parent who relinquishes is plagued by unrelenting grief for
26:52
Speaker 3: the rest of their life.
26:54
Speaker 4: That child too, we know.
26:57
Speaker 3: From adoptee advocacy and child we Will welfare organizations very
27:02
Speaker 3: much wishes that they could have stayed with their birth parents.
27:07
Speaker 4: And I think what's really.
27:09
Speaker 3: Missing from this conversation is the knowledge that these are
27:14
Speaker 3: parents who really wish to keep their children. We can
27:18
Speaker 3: again look at history. London is one of the locations
27:24
Speaker 3: for a foundling museum. In London's Foundling Museum, they have
27:29
Speaker 3: literally tens of thousands of artifacts or tokens that parents
27:36
Speaker 3: would create, sometimes by hand, to pin to their child
27:43
Speaker 3: before they surrendered them, creating some kind of unique embroidery,
27:48
Speaker 3: sometimes beautiful, painstakingly created hearts out of beads with sometimes
27:56
Speaker 3: arms open wide as if they're giving their child a hug,
28:00
Speaker 3: And they would pin these very unique tokens onto their
28:04
Speaker 3: child's clothes because they wished to have some kind of
28:08
Speaker 3: unique identifier that they could someday reference when they come
28:12
Speaker 3: back to reclaim their child. There are literally tens of
28:17
Speaker 3: thousands of these artifacts in museums across the globe. Sometimes
28:22
Speaker 3: people would take coins and cut them in half in
28:26
Speaker 3: a unique way, and then make holes in each half
28:30
Speaker 3: and attach one half to the child's clothes and then
28:33
Speaker 3: string the other half and wear it close to their
28:35
Speaker 3: heart until they someday are reunited with their children. And
28:39
Speaker 3: the reason why I talk about these tokens is to
28:42
Speaker 3: emphasize that parents wish to be with their children and
28:46
Speaker 3: wish to be reunited with their children, but are often
28:50
Speaker 3: facing social and financial situation, circumstances that are frankly achievable,
28:58
Speaker 3: and a number of policies that we already have in
29:02
Speaker 3: place but they might just not know about, which is
29:05
Speaker 3: why again, face to face surrender is so important, and
29:09
Speaker 3: face to face crisis support is so important.
29:12
Speaker 1: The artifacts, I mean, I think they help give sort
29:15
Speaker 1: of context and picture to the points that you've already
29:18
Speaker 1: raised that most folks would prefer not to if they
29:21
Speaker 1: had better options to abandon their or surrender their child.
29:26
Speaker 1: Eighty percent of the folks who do this in the US,
29:28
Speaker 1: it's due to financial challenges. And it sounds like the
29:32
Speaker 1: folks who put these boxes together you mentioned earlier, have
29:35
Speaker 1: or manufactured the boxes, have good intentions. It sounds like
29:38
Speaker 1: policymakers folks have good intentions, And I wonder, yeah, well,
29:43
Speaker 1: I guess we'll get to this with what the policies
29:45
Speaker 1: are that we need because it seems like everyone's aiming
29:48
Speaker 1: for the benefit of the family and the child and
29:51
Speaker 1: the health of all. It's just I don't know, is
29:53
Speaker 1: this just too unrealistic? I mean, would someone say so
29:55
Speaker 1: one more question before the policies, Laurie. This all sounds great,
29:58
Speaker 1: but we're dealing a real, realistic school. We're just trying
30:03
Speaker 1: to have some sort of a means to address the
30:06
Speaker 1: challenges that are being faced. Yeah, we could do something else,
30:09
Speaker 1: but like, that's not the what's the line, that's not
30:12
Speaker 1: the real world. There are kids are being abandoned and
30:14
Speaker 1: this is a safe place?
30:16
Speaker 3: Is that?
30:16
Speaker 1: I mean, what's the Is there a response to that
30:19
Speaker 1: idea of those folks wrong? Do the statistics not bear
30:23
Speaker 1: it out? I mean, what's sort of before the policies?
30:25
Speaker 1: Is there a response to that?
30:27
Speaker 3: Great question? In person surrender works really well in the
30:31
Speaker 3: United States. Each year we have around two hundred and
30:34
Speaker 3: thirty in person face to face surrenders. Sometimes the numbers
30:40
Speaker 3: drop off a little bit because there isn't enough public
30:44
Speaker 3: awareness of the options. That's when you might see more
30:47
Speaker 3: infants left, for instance, in an apartment building or at
30:50
Speaker 3: a church.
30:52
Speaker 4: People will only use options.
30:53
Speaker 3: That they know about, and sometimes states may not consistently
30:59
Speaker 3: reserve reserve to help people understand what their options are.
31:04
Speaker 3: So perhaps, especially in this post stops climate, it may
31:08
Speaker 3: be important to help people know what their options are.
31:12
Speaker 3: I think again, though, to your question, part of what's
31:16
Speaker 3: also really important is to circle back to this idea
31:19
Speaker 3: of informed consent the way boxes are currently implemented. In
31:24
Speaker 3: the training videos which I have watched, there is this
31:29
Speaker 3: specific directive to never ask a parent. If you see
31:33
Speaker 3: the parent, never ask them why they are choosing to
31:38
Speaker 3: place a child in a box. In fact, that is
31:42
Speaker 3: framed as what is the one question you would never
31:44
Speaker 3: ask a parent? You should never talk to them about
31:48
Speaker 3: other options if they're not explicitly asking for them themselves.
31:53
Speaker 3: And so again, this just echoes back to the idea
31:57
Speaker 3: of meeting people where they're at and not thinking about
32:01
Speaker 3: what's wrong with them, but what's going on for them
32:05
Speaker 3: And so for your students, that's what's referred to within
32:09
Speaker 3: bioethics as a trauma informed approach. It is collaborative, it
32:13
Speaker 3: is focused on mutuality, and it really helps to support
32:17
Speaker 3: someone where they're coming from. And everything within bioethics is
32:21
Speaker 3: really centered around not just harm reduction, certainly harm reduction,
32:26
Speaker 3: but also helping people know where they're coming from and
32:30
Speaker 3: helping them understand what options are available to them so
32:33
Speaker 3: that they can make choices and not feel like the
32:37
Speaker 3: box is their only solution.
32:38
Speaker 1: Thank you for tharing that. In terms of medical students,
32:40
Speaker 1: I mean, they're going to be all over me with
32:42
Speaker 1: once they know that it's non hippo compliant, because they
32:45
Speaker 1: get there's a ton on that relative to sort of
32:48
Speaker 1: social media and everything else that they've run into. And
32:51
Speaker 1: I mean this point about trauma informed conversations that they
32:55
Speaker 1: do a bunch of work and motivational interviewing, all these
32:57
Speaker 1: kinds of things to not be able to try to
33:00
Speaker 1: help a patient sort of through this by eliciting their
33:03
Speaker 1: own values and really having a conversation. I mean, that's that.
33:07
Speaker 1: I appreciate that point. Have belabored it enough. Now, what
33:10
Speaker 1: kind of policies do you think would be best for
33:13
Speaker 1: most effective to meet the needs of this population.
33:16
Speaker 3: There are other policies that are very helpful and rooted
33:21
Speaker 3: in evidence based medicine that we can really look to.
33:27
Speaker 3: And again we can look at what other countries have done,
33:30
Speaker 3: but also what hospitals within the US have already done
33:34
Speaker 3: very effectively, and I am referring to a policy called
33:39
Speaker 3: supported birth, sometimes it's called confidential birth, and that means
33:45
Speaker 3: helping these at risk, vulnerable populations of women who are
33:51
Speaker 3: about to give birth or who may have just become pregnant,
33:54
Speaker 3: to give them the means of receiving prenatal care andor
34:00
Speaker 3: and delivery services with an extra layer of identity protection,
34:06
Speaker 3: because sometimes we are talking about women who have experienced
34:11
Speaker 3: incest or who may be pregnant because of a sexual assault.
34:16
Speaker 3: They may be survivors or currently trafficked. They may be
34:23
Speaker 3: facing very harsh conditions. They may have a spouse that
34:26
Speaker 3: does not want them to be pregnant. They may simply
34:30
Speaker 3: be unable, already facing severe financial strain and feeling like
34:37
Speaker 3: they can barely care for their current children and not
34:41
Speaker 3: know about family preservation funds that do exist to help
34:46
Speaker 3: care for them. And indeed, Gretchen Sissen, this wonderful adoption
34:51
Speaker 3: scholar who did research on why children are relinquished by
34:56
Speaker 3: their parents, found that sometimes it's all they need really
35:01
Speaker 3: to enable their family to stay together is to have
35:05
Speaker 3: one or two thousand dollars or sometimes even enough to
35:09
Speaker 3: pay for a car seat. That alone would make the
35:13
Speaker 3: difference of helping to keep some of these families together.
35:16
Speaker 3: But if they never receive crisis counseling, if they're never
35:20
Speaker 3: told of options such as family preservation funds, if they
35:24
Speaker 3: don't know about this nonprofit that can take their infant
35:28
Speaker 3: for a while so that they can get on their feet,
35:31
Speaker 3: they're not going to ever know to ask for those options.
35:34
Speaker 3: And so confidential or supported birth provides an extra layer
35:39
Speaker 3: of identity protection so that they can go and receive services.
35:43
Speaker 3: And this has already been done in some hospitals in
35:47
Speaker 3: the United States, and I'm working with other hospitals to
35:50
Speaker 3: help put this in place. Sometimes hospitals say that's way
35:54
Speaker 3: too complicated, it's impossible to do with our current insurance system,
35:59
Speaker 3: there's no way to do it. However, we already offer
36:02
Speaker 3: this service to a number of patient populations. For instance,
36:08
Speaker 3: UCLA has an ALIAS policy for famous people. So a
36:14
Speaker 3: famous actor might need surgery and they go to their
36:18
Speaker 3: hospital and they say, I need a little bit of
36:20
Speaker 3: extra identity protection, and.
36:22
Speaker 4: We say, of course, you deserve that.
36:24
Speaker 3: We want to keep you safe in the hospital setting. Similarly,
36:28
Speaker 3: sometimes survivors of sexual assault need an extra layer of
36:32
Speaker 3: identity protection, and we already have.
36:34
Speaker 4: That in place.
36:36
Speaker 3: Hartford Hospital System here in Connecticut had a policy like this.
36:41
Speaker 3: I'm not sure if it's still in effect, but they
36:45
Speaker 3: had local gangs and when gang members needed medical attention,
36:51
Speaker 3: they wanted to keep them safe, and they wanted to
36:53
Speaker 3: keep clinicians safe within the hospital. So again there's a
36:57
Speaker 3: way of using an ALIAS within the hospital setting to
37:01
Speaker 3: provide protection. Confidential or supportive birth is also possible through
37:05
Speaker 3: the use of temporary Medicare to cover all of the
37:10
Speaker 3: costs associated with this care. It's been done many times
37:14
Speaker 3: here in the US recently. So this is the kind
37:18
Speaker 3: of care that promotes informed consent, provides crisis counseling, and
37:22
Speaker 3: indeed helps to keep families together. It was recently rolled
37:28
Speaker 3: out in Japan and of thirty eight recent cases within
37:33
Speaker 3: one hospital in Japan over the last three years, as
37:38
Speaker 3: they came when they were in crisis and they were
37:42
Speaker 3: still hiding their pregnancies, they gave birth through confidential birth,
37:47
Speaker 3: and nearly forty percent of those women ended up keeping
37:52
Speaker 3: their children because they learned about services that were available,
37:56
Speaker 3: because they received crisis counseling, because they with clinicians that
38:01
Speaker 3: cared about them.
38:02
Speaker 1: I mean, a great set of cases, and I appreciate
38:06
Speaker 1: the international comparisons. It sounds like these are the policies
38:08
Speaker 1: that would most effectively meet the needs of the population.
38:12
Speaker 1: And hopefully I mean, I know you're doing a bunch
38:14
Speaker 1: of advocacy work around this topic, and hopefully you know,
38:19
Speaker 1: more folks hear you. And again, because it seems like
38:22
Speaker 1: lots of people are aiming for the good of those involved.
38:26
Speaker 1: It's just in attempts to do it given certain structures. Yeah,
38:32
Speaker 1: everyone's not on the same page. So Laurie, I really
38:35
Speaker 1: appreciate the time today. Good luck with the advocacy work.
38:39
Speaker 1: We hope that you are successful, and thank you for
38:42
Speaker 1: shedding light on this topic that not as many other
38:44
Speaker 1: people in bioethics have noted. So for everyone listening, I'm
38:48
Speaker 1: speaking with Laurie Bruce, Associate director of the Interdisciplinary Center
38:52
Speaker 1: for Bioethics at Yale University in the chair of Community
38:56
Speaker 1: Bioethics Forum at the Yale School of Medicine. Laurie, thank you,
39:00
Speaker 1: thank you so much.
39:01
Speaker 3: Thank you Brian, it's been a pleasure.
39:04
Speaker 1: This podcast series is a production of the Health Ethics
39:07
Speaker 1: Lab and I am grateful to colleagues in the Department
39:09
Speaker 1: of Medical Sciences, the IHS Library, and the Hackensack Ready
39:13
Speaker 1: in the School of Medicine for making this collaboration possible.
39:16
Speaker 1: To learn more about our work or to engage with
39:19
Speaker 1: the series content, reach out to me Brian Pilkington at
39:22
Speaker 1: Brian dot Pilkington at hmh N dot org.