Behind the screen: legal and ethical considerations in neonatal screening for prenatal exposure to alcohol.

I. Foreword In a recent Motherisk Clinical Practice Update published in Canadian Family Physician, the authors presented the following question from a family physician: have several patients whom I suspect are drinking during pregnancy. How can I find out for sure if they are? (1) In response, the Motherisk Update advised the use of brief standardised alcohol-use questionnaires that can be used to screen women for risk drinking during pregnancy, and of a screen that can be conducted using an infant's first stool that may be indicative of prenatal alcohol exposure. The Update acknowledged that clinicians do not routinely ask patients about alcohol use. The Motherisk Clinical Practice Update raises a number of important questions: Why is the physician concerned about alcohol use during pregnancy? What sort of maternal characteristics might make a physician suspect their patient is drinking during pregnancy? What methods are available to screen for prenatal alcohol exposure? What are the ethical and legal considerations in screening for prenatal alcohol exposure? Are there legal cases that we can learn from in the area of perinatal screening regarding substances of abuse? II. Introduction Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term describing the range of physical, cognitive and neurobehavioral effects that can occur in an individual whose mother consumed alcohol during pregnancy. (2) This is concerning as approximately 15-45% (3,4,5) of women in Canada consume alcohol during pregnancy despite recommendations that women abstain. (6) FASD is thought to be the most common non-genetic cause of mental, learning and behavioural disabilities in North America and is a serious lifelong condition. (7) The impact of FASD is wide reaching, touching the life of the individual and the lives of family members and society as a whole. (8,9) In contrast to other birth defects and genetic conditions, FASD has received attention from medical and public health professionals because it is a preventable condition. (10) In Alberta, an estimated 29% of children in government care and at least 60% of the prison population have some sort of deficit associated with alcohol exposure, highlighting the need for members of the legal profession to have a better understanding of these conditions. (11) Early diagnosis, a supportive environment, and early intervention have been identified as crucial factors to optimise outcomes for affected individuals. (12,13) However, the diagnosis of any given FASD is complex and often does not occur until school age, if at all, at which point maximal benefit from early intervention and support may not be achieved. (14) The use of fatty acid ethyl ester (FAEE) testing in infant meconium and scalp hair to screen for prenatal exposure to alcohol is a fairly recent scientific phenomenon (15,16), which has been proposed as an aid to medical professionals in the early identification of children who may be at risk for a FASD, thus enabling health care professionals to diagnose earlier. This paper presents an overview of FASD, reviews FAEE screening, and then focuses upon the ethical and legal challenges inherent in the new screening technologies as they relate to providing care to women and their infants. This is followed by an analysis of a recent US Supreme Court case involving screening of pregnant women for the use of cocaine, which is relevant to the discussion. An American case is used to highlight the ethical and legal issues as no recent Canadian case was identified as pertinent to screening. While screening for FAEE in hair or meconium are the examples used for this discussion, the issues raised are not unique to these screening modalities. This paper argues that cautious consideration of the ethical and legal issues in caring for both women and their infants is required prior to drafting policies and practice guidelines for the use of screening for prenatal exposure to alcohol. …

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