CPCP: Mental Health, Mental Capacity, And Abortion by Medical Student Colette Gnade

Coming at you with yet another outstanding Clinical Problems in Consultation Psychiatry (CPCP) by a medical student. This one is on a topic much in the news lately in Iowa–mental health and decisional capacity as they relate to abortions. Colette Gnade, a senior medical student heading for a residency in Ob-Gyn, dug into the literature on this one and came up with a very enlightening presentation.

Recall that a big impetus to this instance of practice-based learning and improvement is partly driven by the recent news of Iowa Legislature Bill SF 26, “A bill for an act establishing a civil cause of action for physical injury or emotional distress resulting from an abortion,”which would allow a woman to file a medical malpractice lawsuit on the basis of emotional or mental distress at any time following an abortion. The Iowa Medical Society and many others are opposed to it and there are many groups in favor of it. The timing apparently coincides with an Iowa Republican Representative introducing a bill in Congress that would constitute a total abortion ban on a federal level.

One news item from the Globe Gazette carried the main idea, published in the Globe Gazette online Jan 17, 2017, “Abortion change would allow claim for mental damage,” by Rod Boshart. SF 26 is a bill introduced by Mark Chelgren, R-Ottumwa on 1/10/2017. Recall my comments that it probably would have a chilling effect on consulting psychiatrists who might also be named as defendants at some later date at any time with no statute of limitations after an elective abortion if they provided decisional capacity assessment consultations in this setting. Psychiatric consultants are probably asked to assist in this regard although there are no data on how often, according to Morris et al (Morris K, Savell K, Ryan CJ. Psychiatrists and termination of pregnancy: Clinical, legal and ethical aspects. Australian & New Zealand J of Psych. 46 (1); 18-27. 2012).

There probably are not a large number of psychiatric consultants willing and able to conduct these kinds of decisional capacity assessments although we’re often asked to assist in the context of other issues such as refusing surgical procedures and leaving against the hospital Against Medical Advice (AMA). Generally, psychiatrists are more familiar with how neuropsychiatric illness can substantially influence medical decision-making.

According to Morris et al, “Routine psychiatric assessment of capacity for termination of pregnancy is unnecessary.” However, there can be emotional distress and agitated behavior about abortion which can raise the Ob-Gyn physician’s concern for an underlying psychiatric illness, such as severe depression. Further, in this politically complex and highly adversarial climate in which laws are being proposed that may lead to physicians feeling more threatened than usual, there may be a reduced threshold for requesting psychiatric consultation.

Colette also summarized the latest medical evidence which tends to cast doubt on the idea that having an abortion causes long-lasting psychological distress and in fact may support the hypothesis that being denied abortion may be more troubling to women (Biggs, MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s Mental Health and Well-being 5 years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. Dec 2016. doi:10.1001/jamapsychiatry.2016.3478).

In order to be helpful as consultants in this context, psychiatrists need to be familiar with the laws governing pregnancy terminations in their jurisdiction. It’s also important to be aware that some psychiatrists will hold a conscientious objection to abortion, which could be dealt with by referring the patient to another psychiatrist–if the objector is willing to do so.

It’s understandable why Ob-Gyn physicians might feel more comfortable calling on psychiatric consultants in these situations. However, as Morris et al point out: “…there are potential pitfalls to be aware of, including the difficulty of predicting future mental health, the limitations of the research on psychiatric sequelae of termination, and the lack of clarity about what a danger to mental health might encompass.” This is something legislators would also do well to consider.

I’m very lucky to have such talented medical students and residents working with me. A lot of my colleagues don’t have that luxury. They are my copilots, not my minions.

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