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In the Name of the Children : Get Treatment or Go to Jail, One South Carolina Hospital Tells Drug-Abusing Pregnant Women. Now It Faces a Lawsuit and a Civil-Rights Investigation.

August 07, 1994|Barry Siegel | Times national correspondent Barry Siegel's last piece for this magazine was on a Georgia doctor accused of murdering an infant

IT ALL BEGAN, NURSE SHIRLEY BROWN AND HER COLLEAGUES AT THE Medical University of South Carolina now say, with the pregnant woman who appeared at the emergency room one morning in October, 1988.

The woman was suffering from abruptio placentae--an abrupt separation of the placenta before labor. Her fetus was stillborn. They'd been seeing an increasing number of these abruptions at the hospital, a state institution in Charleston serving a largely indigent black population. The usual causes were conditions such as high blood pressure or trauma such as auto accidents. But the more recent cases didn't appear to have such causes. This case didn't appear to have any cause.

Brown and her boss, Dr. Edgar O. Horger III, then head of fetal-maternal medicine at the hospital, turned to the medical literature. In both professional journals and the popular press, they found, pregnant substance abusers were a hot topic. The figures were startling: One out of 10 fetuses in the United States is exposed to cocaine in the womb, affecting 375,000 babies a year. To Brown and Horger, sitting in genteel Charleston, such numbers sounded like a big-city problem. Still, article after article was suggesting cocaine as one cause for abruptions.

So Brown and her colleagues ran a urine drug screen on their patient. The woman tested positive for cocaine.

That was ground zero, they all agreed later. Their eyes now opened, Brown and her colleagues started running drug screens on other pregnant patients. Of the first four, three tested positive. Within one year, they had 119 positives, all but 15 of them women who'd first visited the hospital at the time of delivery.

They still didn't have a solution, though. Try as she might, Brown--a manager for high-risk obstetrical cases--could not get these women to the Charleston County Substance Abuse Commission. Despite counseling and cajoling, not a single woman kept her appointment for drug treatment. Of the 15 who came in before delivery, only one even came back for additional prenatal care. The hospital next saw the others when they returned in pre-term labor and once again tested positive for cocaine.

What to do? How to stop this?

What to do, the hospital staff eventually decided, was to cross a treacherous line. Prosecutors across the country, they knew, increasingly were going after pregnant substance abusers, charging dozens with distribution to minors and child neglect. We will join them, Brown and Horger resolved. If our patients test positive and refuse treatment, we'll hand them over to the law.

At the time, it seemed an ideal, if unprecedented, solution. The goal, after all, was not to put these women in jail; the goal was to coerce them into treatment. But not everyone has applauded. Nor has everyone entirely shared the hospital's preference for treatment over jail. The decision to traffic with police and prosecutors, in fact, has drawn the hospital into an increasingly nasty quagmire, one that is as rich in calculated political posturing as in tortured ethical soul-searching.

Does society have a duty to intervene between a woman and her fetus? If so, when? Who or what public agent is responsible? What are the boundaries of government intrusion?

For having kicked up such questions, hospital and Charleston officials now face a $3-million civil lawsuit, a federal civil-rights investigation, a complaint filed with the National Institutes of Health and a chance of losing the hospital's federal funding, if not its accreditation. Everyone from the American Civil Liberties Union to the U.S. Department of Health and Human Services has rushed here to join what is at once a revealing test of difficult national issues and a scorching clash between law and medicine.

All sorts of agendas, reaching well beyond the perplexing world of medical ethics, are being played out in Charleston. New York lawyers jump off airplanes waving the Constitution and stacks of legal briefs. Southern politicians lean into microphones to orate about "personal responsibility." Feminists, hearing obvious echoes of the abortion debate, talk about control of the body and autonomy in the reproductive process. Such repercussions, coming from forces so far beyond their own world, have visibly shaken Horger, Brown and others on the hospital staff. They have not, however, persuaded them to back down.

Brown and Horger see the complexities, the imponderables, the obstacles, but they also see spontaneous abortions, pre-term deliveries, stillbirths and underdeveloped newborns with jumpy nervous systems. "It's a real difficult issue here," Shirley Brown says. "I can see both sides, I can see where everyone's coming from. But don't we finally have to make a decision? Don't we finally have to make a choice?"

IT WAS IN AUGUST, 1989, THAT BROWN MADE HER FATEFUL DECISION TO call Charles Condon, at the time the elected solicitor, or prosecutor, for Charleston and Berkeley counties.

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