What's Up to Doc?

On April 8, 1986, DAVID AND GINGER Twitchell’s 2-year-old son, Robyn, died of a bowel obstruction. Last July, a jury convicted the Boston couple of involuntary manslaughter.

As Christian Scientists, the Twitchells had chosen the spiritual healing offered by their church when their son took ill instead of taking him to a doctor. Their conviction has once again focused attention on the right of parents to decide what medical care, if any, their children should receive. The Twitchell case highlights the tension between parental rights and responsibilities, the conflict between religion and medical science, and the controversy over alternative forms of medical treatment.

In the last couple of years, prosecutors have had increasing success in winning felony convictions of Christian Scientists in cases like the Twitchells’. They have done so by bringing charges of manslaughter or child endangerment, bypassing laws in more than 40 states that exempt parents who rely on prayer from prosecution for child abuse or neglect. Simultaneously, a movement to repeal these statutes has been building in the news media and many state legislatures.

Christian Scientists ardently defend their choice of faith healing for their children as a constitutionally protected right. The American Academy of Pediatrics, on the other hand, insists that religious freedom ends where accepted medical practice begins. Dr. Norman Fost, former head of the academy’s bioethics committee, has declared that the organization is interested not only in the rare cases where children die, but also in the hundreds upon hundreds of cases where children “suffer from inadequate medical treatment.” This interest represents an ambitious effort to enforce mainstream medical decisions on parents over a wide range of health issues.

When do medical authorities have the right to overrule parental treatment decisions? At one extreme are cases like the Twitchells’, in which medical treatment has been reliably demonstrated to be safe and effective, and the alternative to seeking treatment is due, perhaps fatal. Removing obstructions of the bowels, treating infections such as pneumonia or meningitis, preventing infectious diseases by inoculation, and stabilizing diabetes are examples of treatments that fall at this end of the spectrum.

But many cases where we place our faith in medicine are not so clear-cut. These include situations where one’s personal or cultural preferences may be scientifically valid and where the benefits of conventional therapy are uncertain. Part of the problem is the discrepancy between the me efficacy of many treatments and the claims made for them by medical interest groups. The state too often yields to the judgment of the most vocal and conspicuous treatment advocates, even when that judgment is no better grounded than the religious, cultural, or personal preferences of those they seek to coerce.

Consider the case in Connecticut of Juliet Cheng and her daughter, Shirley. Shirley was stricken with arthritis as an infant. Despite receiving a range of treatments, by age 7 she was confined to a wheelchair and in constant pain. A physician recommended that Shirley undergo surgery on her knees, hips, and ankles. Shirley’s mother rejected this advice, choosing instead to take her child to China for less-extensive surgery combined with traditional folk treatments. But when she went to Newington Children’s Hospital in Bridgeport last July for what she thought was a final consultation before the trip, the Department of Children and Youth Services charged her with neglect and placed Shirley indefinitely in state custody.

A juvenile court judge has approved the suggested operation, despite testimony that the procedure need not take place for two years. Cheng has appealed the decision in federal court. Carolyn Richter, an attorney who has filed a class-action lawsuit charging Connecticut’s Department of Children and Youth Services with a pattern of arrogance and insensitivity, called the Cheng case “an example of the medical establishment deciding they have the truth of the matter and totally disparaging alternate forms of medicine.”

Pregnancy and birth, not to mention abortion, been a major battleground in the conflict between personal autonomy and the state’s interest in protecting life. Many court decisions have affirmed that Americans have a fundamental right of bodily integrity. For competent adults (including hospitalized psychiatric patients), this entails the right to refuse medical treatment. In fact, courts have ruled that the imposition of treatment without consent is a form of assault. But cases involving pregnant women, who are making decisions both for themselves and for their unborn children, are more complicated.

Organized medicine uses monopolistic strategies-professional, legal, and political-to counter the economic threat posed by midwives and home birth. In 1977, the executive director of the American College of Obstetricians and Gynecologists remarked that home birth constitutes “maternal trauma” and “child abuse.” (See “Up Against the Birth Monopoly,” September 1982.)

Yet studies published in leading medical and public-health journals have shown that, for comparable populations, the outcomes of birth at home and in freestanding birth centers are not significantly different from the outcomes of hospital births. It seems that the greater comfort some women feel when they give birth at home, coupled with the extra attention of relatives and attendants, compensates for the very small added risk involved in being away from the hospital.

In the last few years, the issue of coercive intervention during pregnancy has come to a head in the controversy over court-ordered Caesarean sections. A 1987 national survey found that, in 86 percent of recorded cases, judges intervened on the side of doctors who sought to operate on a fetus over a mother’s objection. In 1987, a Washington, D.C., judge ordered a Caesarean section performed on Angela Carder, a woman facing imminent death from cancer. Doctors estimated her 26-week-old fetus had a 50-to,60-percent chance of immediate survival and an even lower chance of long-term survival.

The surgery was performed against Carder’s apparent wishes as well as those of her family and her own doctors. The baby died within a few hours, and Carder died two days later. Her parents nevertheless appealed the judge’s order, with the support of more than 100 briefs from women’s organizations, medical societies, and leading bioethicists. In April 1990, the District of Columbia Court of Appeals ruled, 7-1, that neither pregnancy nor terminal illness justifies compelling a woman to undergo surgery. How well the judicial decision is implemented in regular medical practice remains to be seen.

In contrast, there have been surprisingly few legal challenges to the growing trend to force children into treatment for alcoholism and drug abuse. Although it goes under the name of medicine, this kind of therapy is actually a folk remedy with religious overtones. Researchers have never found that inpatient treatment based on the model of alcoholism as a disease is more effective than simple counseling. The head of the government’s own National Institute on Alcohol Abuse and Alcoholism, Enoch Gordis, has declared: “In the case of alcoholism, our whole treatment system, with its innumerable therapies, armies of therapists, large and expensive programs ... and public relations activities, is founded on hunch, not evidence, and not on science.”

Aside from detoxification, most hospital treatment for chemical dependence in the United States is a thinly disguised repackaging of Alcoholics Anonymous’s 12 step approach, which strives to convince the problem drinker or drug abuser that he or she is a lifelong alcoholic or addict. More religious than clinical, Alcoholics Anonymous derives its ideas and rhetoric from the 19th-century temperance movement. A.A. 12 steps, six of which refer to God, leave no room for therapies that teach the drinker techniques of moderation or for changing the circumstances that led to the drinking problem. Yet clinical comparisons regularly show that these techniques work better than the 12 step model.