2001 Case 3
Treatment decision of the child of a single mother with mental Problem

The patient was 10-month-old girl who was suffering from heart failure
owing to the congenital heart disease. Although the surgical operation was
needed (the possibility of the success of the operation was 70%), but  the
mother (The first custody for this girl, but  she had an mental problem
and she was a single mother) became panic when she was going to be
told about the operation.
This mother is living with her parents (girl's grandparents), and they do
not want to care the girl whose father was unknown. The medical team
considered about the girl's social background, and did not talk the mother
with mental disorder about the possibility of the surgical operation of this
girl. The girl was given the only medical treatment and died.

(Question raised by the student)
I had an affirmative opinion to the determination of this medical team.
Was it truly good not to talk about the possibility of operation to her
mother with mental disorder?
Who can decide these difficult decision?
Should the medical staff need to consult this kind of case to the third
party such as ethics committee or court?

(I changed the case to protect the patient's privacy)

Comment from Tom Tomlinson

Dr. Shirahama, thank you very much for sending this case.

If we start with the premise that the physician's primary obligation is to
the welfare of the patient, then once it was determined that surgery was the
treatment of choice the physician had an obligation to seek to have it
provided by whatever legitimate means were available. This includes, I
think, offering it as an option to the child's mother. When this is done, it
may prove obvious that she is unable to make an informed and rational
decision because of her mental illness. But we shouldn't use the fact of her
history of mental illness as our only evidence that she is unable to make a
decision about this matter. We should give her the opportunity to show us
that she is capable.

The grandparent's wish to not have the child living with them is not a
justification for letting the child die as a means for accomplishing that
end. It does, however, present a problem for post-hospital care for this
child. If there is concern that the child may not receive proper care at
home, other alternatives should be explored. I don't know what those may be
in Japan. In the United States, the mother might get some assistance to live
on her own with her child, if her income is very low. Or, if the mother is
unable to provide proper care because of her mental illness, her child could
be taken from her by a court, and placed in foster care or put up for
adoption. Are these sort of options available in Japan? What are the social
attitudes toward them?

Tom Tomlinson

Comment from Kristine Mulhorn

This is a compelling situation and in the States could be addressed on
two levels: 1) who is legally responsible for medical decisions for
the girl and 2) is there an ethics committee responsible for
considering these kinds of decisions?

If the mother is the legal responsible party then the medical staff
must speak with her to discuss and make sure she is involved in making
an informed decision about whether to accept or deny the surgery.

Kristine Mulhorn,
University of Michigan-Flint
Health Care Dept.

If you kindly send your comments on this case, please send it to the
following mail address.

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Masashi Shirahama M.D.
Director, Mitsuse National health Insurance Clinic
Clinical Professor, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan