8 Maternal mental health: an ethical base for good practice

In this chapter we argue that the four principles of medical ethics, beneficence, non-maleficence, respect for autonomy, and justice (Gillon 1985; Beauchamp and Childress 2001), a new Family Interest Principle (introduced later in the chapter), and a consideration of ‘capacity’ provide a reasoned practice guide for work with mothers experiencing health problems, focusing here on mental health when a parent is a patient. Our concern is the relationship of the clinician with a parent and through the parent their child. Ethics of service provision or services planning (e.g. Culyer 2001; McLachlan 2005; see also Chapter 35, this volume), or the provision of other services (e.g. education, child protection) although intensely relevant to this area are not addressed in this chapter nor will we deal with the complex aspects of medical ethics relating to the treatment of children (Baines 2008). We use the term ‘parent’ to refer to any adult person who fulfils a substantive parental role with a child. Defining what counts as a family will in certain circumstances be contentious. There are diverse patterns of family arrangements that may be influenced by cultural, political, economic, and temporal factors. For the purposes of our discussion, we define a family in terms of its role in child-rearing, as a group of at least one adult and at least one child, living together in long-term relationships on an ongoing basis, with vested interest in the well-being of each of the family members.

Mental health practice is particularly sensitive to prejudice and political influence. Parental mental health practice is even more ethically complex because of the central role of the parent–child relationship. Good mental health practice with parents requires us not just to think about the parent as a person, or about the child in isolation from the parent, but in addition to think about the quality of the parent–child relationship within which both parent and child(ren) define themselves. Our argument is based on four assumptions about the parent–child relationship which we propose are fundamental to the ethics of parental mental health practice.

The welfare of the child is held to be paramount in law in all decisions made on the behalf of the child (Children Act 1989). This principle, enshrined in family law, has assumed influence in informing generic decision-making when children’s welfare may be affected (see Jackson 2002). Commonly, this is referred to as the principle of ‘paramountcy’ of ‘the best interest of the child’ (e.g. Paul 2004). There is an extensive literature on the idea of the best interests of children (e.g. Elliston 2007), consideration of which lies beyond the scope of this chapter. What is important for our purposes is the assumption that, whichever account of the best interests of the child is settled on, the best interests of the child are primarily held within the parent–child relationship, supported through the ‘community’, i.e. formal and informal institutions for and cultural patterns of childcare. There will of course be cases where the parent–child relationship is not viable, and hence the best interests of the child are best pursued outside the parent–child relationship.

Cases before the ECtHR in relation to family life are often characterized by clashes of interest, between parents, children, and the Nation State. The ECtHR upholds the view that the interests of any child will be of paramount concern in any matters before it. Circumstances found to justify State interference in family life are primarily those that concern the physical health, welfare, and safety of a child including the child’s need for protection from serious psychological impairment, lack of care and guidance, and any serious risks to the child’s future development. The discussion of human rights for people diagnosed with mental ill health has traditionally centred on: Article 3, the right to be protected from torture or degrading treatment or punishment; Article 5, the right to liberty and security of the person; and Article 6, the right to a fair hearing. However, as legal commentators note, there is opportunity for parents who experience mental ill health and whose contact with their children has been restricted or denied by legal intervention to appeal against an interference to human rights protected by Article 8 to the ECtHR (Gostin 2000; Hale 2007). This opportunity is increasingly being taken up and judgments are highlighting that whilst the interventions by the State may be justified, the State is often found to be in violation of Article 8 by failing in its duty to support family relationships (Prior 2003).

Being a child and becoming and being a parent—while representing basic biological facts—are social roles fundamental to individual and social identity (Bowlby 1988). For women, becoming or being a mother may be a particularly significant aspect of identity that may be conflicted when women experience mental illness, by negative social and professional attitudes towards gender, mental health, and/or parenting (Krumm et al. 2006). The parent–child relationship is only one social role relationship; there are many others that people engage in during their lifetime, for example, as partner, worker, or patient. Any social interaction can at the same time be construed as a social role relationship. A parent is necessarily involved in a number of major social role relationships supporting the viability of their role as parent. Without this network of relationships the child for whom the role of child is an essential basic necessity, may be affected adversely.

Within a parent–child relationship a parent’s contribution is quintessentially their capacity for preoccupation with the child, both in terms of instrumental and emotional care (Bowlby 1969/1999; Hill 2004). The attachment relationship is an asymmetrical one, and children are primary partners in parenting as a cooperative process (James and Prout 1990). They contribute through both their responsiveness to, and the demands they make on, their parent. This means the parent has the capacity to be preoccupied with the child but does not always have to be, and the child will contribute to triggering the parent into a state of preoccupation as needed. This facet of relationship is often seen as critical in mediating effects of parental mental ill health on children. For example, severe postnatal depression may prevent a mother from being appropriately triggered into this state of preoccupation. Hence, apart from generic issues of abuse (a reversal of needs and roles by means of power) this parental availability within the parent–child relationship needs to be of concern to the professional working with issues of parental mental health.

Recovery from ill health implies resumption of social roles including that of parent, but parental ill health—including mental ill health—does not automatically imply that parenting capacity is impaired (Adshead et al. 2004; Göpfert et al. 2004b). Conceptually, recovery is complex. Recovery may be partial, the level of previous function may not always be restored, and as a dynamic process recovery may create change and support changing. It is not permissible to assume that parenting capacity will be automatically impaired as a result of parental mental ill health. However, parenting might be impaired and acknowledging the social role of parenting and the dynamic nature of parenting in the recovery process, this must be considered when working with a parent with mental health issues.

The implication of these assumptions is that instead of thinking simply about the mother, or the child, practitioners need to think about the parent–child(ren) relationship. This will often require acknowledging a complex system of variously interlinked and interdependent relationships that are likely to exist in a family situation. Parent–child relationships may be complicated further not solely by number (children as opposed to child) but also by the nature of the particular relationship (e.g. age, stage, developmental needs), culture, and by the number of adults involved in parenting roles.

Medical ethics is located within a range of force fields mainly between the poles of ‘autonomy’ and ‘paternalism/welfarism’ which is reflected in the following discussion of the four principles. This is because sometimes the health professional must act in the best interests of a patient without the patient’s explicit consent (paternalism—usually in a clinical crisis) while at other times a patient may make a decision that by medical standards and values might be considered not to be in his/her best interests (e.g. refusing a blood transfusion or rejecting psychotropic medication). With the introduction of the parenting dimension and the ‘best interests of the child’ matters can become more complex, but the four principles of medical ethics can provide some guidance.

The principle of beneficence concerns the ‘moral obligation to act for the benefit of others, helping them to further their important and legitimate interests, often by preventing or removing possible harms’ (Beauchamp 2008). It is important when thinking of the principle of beneficence to realise that we must also reflect on the appropriate scope of the principle: for instance, who is it that healthcare professionals have a duty to benefit—is it solely the parent-patient, or does it also include their children (Gillon 1994)? Should healthcare professionals be thinking even more widely so that they also think about what benefits society more broadly? And how should healthcare professionals take into account the relationships between patients and their families when thinking about benefiting them: should they view each person as an isolated individual, or should we give some intrinsic weight to the relationships through which patients define themselves?

If we take it that our focus should be on benefiting each person as an isolated individual, and that the healthcare professional’s duty of beneficence extends at least as far as the best interests of the child(ren) of the parent-patient, then it has been argued that acting in accord with beneficence for the parent-patient creates potential for professional conflict with the child’s best interest (see Weir and Douglas 1999). Some practitioners argue that in order to manage or avoid this conflict, they should not get involved with the other side of the pair and should either attend to the needs of the child, or the parent only and not overextend themselves by thinking about their relationship.

However, we argue that it is a mistake to start from the assumption that the child’s best interests and the best interests of the parent-patient are separate and in conflict. This greatly underestimates the degree to which both the parent’s and the child’s best interests are held within and constituted by the best interests of the family unit that their individual interests are invested in. The mutual investment in the family unit provides a subsidy for family relationships and roles which in turn subsidize individual interests. This claim for the primacy of the relationship is based on a view of the parent role as a basic aspect of adult life (assumption 2, ‘The social role dimension’) and that the needs of the adult are met, at least in a substantive part, when the needs of their children are met. Consequently the needs of the adult have to be met in such a way that enables them to meet their obligations to the child in fulfilment of their parental role. From the perspective of the child, their primary need is for someone to be appropriately preoccupied with them; and it is reasonable to think that, apart from circumstances where the parent–child relationship is clearly nonviable (see earlier), this role will be best provided by the parent.

It follows that rather than thinking simply about what would be to the benefit of the parent-patient, and then separately about what would benefit the parent-patient’s children, it is not only legitimate but in fact ethically required to consider the best interests of the family as a unit. (We call this the Family Interest Principle, and discuss its implications in more detail later.)

The principle of nonmaleficence relates to obligations not to harm others, and in an extended sense also covers obligations not to allow others to come to harm. There will remain some cases where even with the best support that can be provided, the parent–child relationship may not be able to be made viable, and in such cases the principle of nonmaleficence comes to the fore, i.e. a principle that no harm should come to either the mother or the child.

Clearly, children can be harmed through their parent’s mental ill health (d’Orban 1979; Falkov 1996; Reder and Duncan 1999). Moreover, a mothers’ role, identity, and adult integrity (and in some instances her life), may be seriously harmed by any adversity she may cause her children. It is therefore of paramount importance that mental health professionals do not underestimate these possibilities, and act to prevent any harm to children and their mothers resulting directly or indirectly from parental mental ill health through child abuse or neglect, including consideration of treatment effects.

Respect for individual autonomy is a central principle of medical ethics and links with the legal construct of ‘capacity’ (see later). The freedom to orchestrate one’s own life is commonly considered an important part of what makes life valuable. Autonomy provides the basis for personal responsibility. What is necessary for action to be judged autonomous is that an individual can respond adequately to the requirements of a given situation; having understood, weighed up, and considered the various alternative courses of action, the person chooses to act and has responsibility for their choice, if freely made. Professional judgement made in the best interest of another person must take account of claims for autonomy (McClelland 2006).

Autonomy and beneficence are at times positioned in conflict, for example, loss of rationality is often seen as a feature of mental ill health, particularly when this is associated with distorted perceptions of reality or values as a result of a psychotic disorder. Yet social stereotypes, based upon race and gender, pervade and influence diagnostic process and perceptions of rationality. For instance, borderline personality disorder is predominantly diagnosed in women (DSM-IV). So diagnosed, women may be deemed unable to tolerate or control emotions. On that basis, women may be treated as less than fully rational autonomous human beings. This conflict may be particularly evident for parent-patients. Safeguards for ‘autonomy’ are reflected in various legal considerations, e.g. adult decision-making capacity (Mental Capacity Act [England and Wales] 2005) or independent representation of the child (Article 12, United Nations Convention on the Rights of the Child (1989)). The literature also reflects the dominant ethics discourse regarding parental duty, and children’s rights and autonomous interests (e.g. Clayton 1997; Green 1997; Jackman et al. 2007) resonating with a wider debate about autonomy and its associated conceptual dilemmas (Ruddick 2001; O’Neill 2003; Wilson 2007).

When we are thinking of the ethics of maternal mental health, the traditional debate about autonomy needs to be reconstructed. Traditional debates around autonomy often fail to take account of the importance of relationships, and view autonomy primarily in terms of independence. However, as many feminist and communitarian writers have pointed out, when a mother is invested in her parental role, her attachment to the social role of being a parent and to her children are at the core of what she reflectively values in her life. Her autonomy is thus not primarily constituted by her ability to separate herself from her children, but rather in the security of the relationship she has with them. It follows that respect for her autonomy requires supporting her role as a parent (Mackenzie and Stoljar 2000). However, it is important to recognize that a mother may not wish (or be able) to assume parental responsibilities because of illness (Thomas and Kalucy 2003), personality, or preferences. This can be particularly problematic if a mother attributes responsibility for any problem to others, including a child or professional, and this may be difficult to acknowledge, especially if the parental role is caught up in power battles with professionals. Where parental commitment is limited or absent, mediation on behalf of the child’s best interests and adult autonomy is required and legal process may be inevitable. ‘Help’ under such circumstances may be perceived by the parent-patient and/or the child as an imposition and adult claims for autonomy may conflict directly with the child’s best interests. The professional duty through beneficence is to recognize and support the parental role if viable. The emerging legal framework of ‘capacity’ deals with many aspects of autonomy (see later).

Health professionals have a dual obligation to recognize the needs of children and parents when dealing with either child or parent as patient. Adverse effects of parental ill health may be experienced disproportionately by children, for example, if children assume age-inappropriate caring roles in order to help (Bleuler 1974; Aldridge and Becker 2003). Justice can be found in the recognition of need, validation of experiences, and the provision of practical support to both mother and child within, and additional to, the family relationship. There is a political dimension to the ethical debate of justice, involving consideration of equity and equality, reflecting the tension between paternalism and autonomy (Culyer 2001; McLachlan 2005). This is an issue of policy well beyond the ethics of the individual professional relationship with patients. However, it is important to acknowledge that the political dimension seriously impacts on what the individual professional’s options may be (see Honneth 2008).

For instance, the State has devolved the power to suspend parent–child relationships to Courts and agencies with responsibility for safeguarding children. When parenting is judged inadequate and a child is permanently removed from their parent’s care there is no continuing duty of care owed to that parent by children’s services. This may reflect an unethical position taken by the State towards women whose personal identity is bound to their parental role as mothers but have lost the care of their child.

When we are thinking about mental health practice with parents, it is helpful to supplement the four principles with a fifth, which we call the Family Interest Principle: as long as the family unit including any parent–child relationship is viable, any individual’s needs and best interests are to a significant degree constituted by the interests of the family as a whole, and so individual welfare needs will mainly be met by supporting the viability of the family as a whole. We believe that this is a principle that many practitioners use in their thinking and day-to-day practice, but which has not so far received a name. It recognizes the fact that the whole of the family (like any cohesive group) is more than the sum of its constituent parts.

The Family Interest Principle is a useful addition to the four principles because it allows us to integrate perspectives which would otherwise be in irreconcilable conflict. It does so in two chief ways. First, as we saw in the discussion of beneficence, by focusing on benefiting the family as a whole, it allows us to appropriately consider both interests of the parent-patient and their child(ren). This avoids the difficulties caused by an exclusive focus on either the interests of the parent-patient, or on the child: if professionals focus on a ‘patient’s’ best interests alone (without consideration of her role, e.g. as mother) they may deny a mother’s obligations to her child(ren), undermining her adult status, roles, and responsibilities. A similar argument can be made that any exclusive focus on the ‘best interests of the child’ without detailed consideration of the parent–child relationship may not be in the best interest of anyone (McClelland and Göpfert 2005). Hence, if we redirect our attention to that of the best interest of the parent–child(ren) relationship we will tend to better serve the interests of all provided that family relationships are in principle viable and both parent and child(ren) place value on, and are invested in, maintaining their relationship (assumption 1, ‘Where the family is viable, the best interests of the child are held within the parent–child relationship’).

Second, the Family Interest Principle allows us to find a way of valuing the perspective of the child which escapes the traditional polarization between autonomy and beneficence/paternalism where the child is either considered as a separate being or as dependent on other’s wisdom. Lee (2005) has argued that the child should not just be considered as a separate being with their own sets of rights and interests. As the child is embedded in a network of relationships and social interaction, the child can be considered as separable from the parents but not separate. Separateness can only be achieved through the child’s development. This development is dependent on the child’s togetherness with the parent who is a critical part of their social world. A parent enables their child to explore and learn about the world because they are there for the child to come back to. As the relationship between parent and child is reciprocal in a complementary manner, the parent is also required to be able to be separable without being separate; the parental capacity for preoccupation with the child can be triggered any time when needed. The Family Interest Principle thus provides an ethically effective way of taking account of the child’s need to be separable and accommodates the need to consider the child’s own needs in isolation from the parent but never as completely separated from their parent. Seeing the child as ‘separable’ enables us to consider the needs of the child as distinct from others while also considering their dependency without conceptual conflict. The matrix of mutual family roles enables fairness and justice through recognition (see also Honneth 2008).

It is important to note, however, that the Family Interest Principle will provide appropriate guidance only where the family relationship is viable. Dealing with a non-viable family as if it were viable may be damaging for individual family members. It may be difficult in some situations to conclude that a family unit is no longer viable: this might be particularly the case where family secrets such as abuse or incest exist. However, consideration of the Family Interest Principle is dependent on the existence of a family unit that is invested in the welfare, safety, and well-being of all its members. When the protection of a child from harm cannot be sustained by the family, and additional support from services to the family is rejected by the family or cannot be sufficient to protect family members from harm, then the family relationship is no longer viable (see discussion earlier). However, even in this case it is important to some degree to keep the family as a whole in mind in order to address the needs of individual family members. For instance, a child might be feeling anxious and troubled about the fate of their parent(s) but the knowledge that they are given appropriate help and support can make an essential contribution to the child’s psychological welfare by alleviating guilt. Similarly a mother who has failed in her parental role may find it easier to deal with the consequences if she knows that her child is well looked after. Family members continue to carry the family they belong to in their minds, even if it does not exist as a living group anymore.

The four principles, when combined with the Family Interest Principle are a helpful guide to identifying and categorizing the kind of ethical issues which arise in maternal mental health (and probably generally in parental health), but it is important to recognize that they represent a framework for moral thinking, rather than an algorithm (Beauchamp and Childress 2001, p.15). These principles on their own will not tell us what to do when we are faced with a moral dilemma; but they will at least enable us to see clearly what the source of the dilemma is, and to think more reasonably and defensibly in deciding which option to take. Further guidance comes from consideration of the legal position on mental capacity.

It is important for professionals dealing with mothers and their children to understand the issues of mental capacity and competence as these concepts influence our work. There are unresolved issues in terminology (e.g. Bielby 2005) which can be particularly pertinent in clinical practice in situations involving mothers with mental health issues. Competence may be defined as either task-specific or agent-related, and capacity as defined in the Mental Capacity Act refers to the person’s capacity to make specific decisions (overlapping with task-specific competence), as well as to the transferable ‘capacity’ in the strict legal sense where, for example, legal capacity can be exercised through ‘Lasting Power of Attorney’.

When we are thinking about the ethics of mental health practice with parents, issues of competence and capacity arise in at least three different directions simultaneously. First, there is the question of the mental capacity of the parent to consent to decisions about their own treatment; second, there is the question of the parenting capacity of the parent; and third, there is the question of the capacity of the child. In addition, it is easy for issues of capacity and competence to get confused, to contaminate one another and lead to pseudo-legal solutions of relationship conflicts when it would clearly be most appropriate for parent and child to work out a joint decision (Paul 2004). Legally, ‘parenting capacity’ falls under the framework of the Children Act 1989 only, therefore the more legal arguments about issues of capacity and competence—while conceptually relevant to issues of parenting—are not dealt with here in any detail but the conceptual issues will be referred to in outline.

In England and Wales the Mental Capacity Act 2005 provides a legal framework through which proxy decision-making on behalf of people over 16 years who do not have capacity to make those decisions for themselves is authorized. The Act provides some legal safeguards for both those making decisions and those on whose behalf the decisions are made. The jurisdiction of the Mental Capacity Act can encompass children under the age of 16 years if they lack capacity and are likely to continue to lack capacity beyond the age of 18 in relation to their property and affairs. With regard to young people aged 16–17 there are specific considerations in the Mental Capacity Act; for example, a person under 18 years may not make a legally binding advance decision. Professionals will need to continue to be mindful of the range of legislative powers that may apply in their work with young people and may need to consider the Children Act 1989 and the Mental Health Act 1983 (particularly relevant following the amendments in 2007) in their practice.

The Mental Capacity Act 2005 imposes a decision-specific and functional approach to capacity. The following principles apply regarding capacity:

The Act takes capacity to be decision specific. Before any adult can be declared to lack capacity to make a particular decision, it must be established that the person ‘is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain’. More specifically, capacity is tested by whether the person can understand information given to them, retain that information long enough to be able to make a decision, weigh up the information available to make a decision, and communicate their decision.

The Mental Capacity Act has specifically refrained from extending powers under this Act for proxy decision-making related to particular family relationships. The particular decisions excluded in the Mental Capacity Act include:

The exclusions acknowledge the particular nature of these decisions, which are distinct from care treatment and property decisions and that other jurisdictions can provide better safeguards.

In clinical practice the assessment whether a parent-patient has mental capacity to consent to matters relating to their children’s care may present particular complexity. For example, a mother who is a single parent with no extended family support who experiences a severe mental health crisis that necessitates admission to hospital is inevitably placed in a dilemma in relation to her children’s care. The mental health crisis may not impair mental capacity for parental decision-making. Her options are:

In this example as the mother has parental responsibility and if her mental capacity for decision-making in relation to her children is unchallenged she can enter into an arrangement with the local authority to provide temporary care for her children (Statutory Instrument 1991/890, reg 3). Whilst she may fear this may result in the permanent loss of her children, and research would indicate these fears are not without some evidential justification (see Barn 1993; Howard et al. 2001; Stanley et al. 2003; Park et al. 2006), she retains the legal power to remove her children from local authority care at any time (Section 20(8), Children Act 1989). In clinical practice, as we argued earlier, mental health professionals have an ethical obligation through beneficence and respect for autonomy to incorporate a commitment to the patient’s parental role. In this scenario this would apply to all the potential options outlined earlier. This obligation would also apply if this scenario included some consideration of Community Treatment Orders introduced by the recent amendments to Section 17, Mental Health Act 1983. The Family Interest Principle applied in this instance would enable professionals to ensure consideration of, and support for, the parent–child relationship in planning and delivering services to the family.

In clinical practice, parent-patients may at times lack capacity to make some decisions or consent to the provision of any services considered (by professionals) necessary for their own care or treatment or the welfare of their children. This adds a further dimension of ethical complexity. For example, consider a mother who has a learning disability and a diagnosis of borderline personality disorder. She experiences fluctuating changes in her state of mind that influence her decision-making and she does not always sufficiently comprehend and retain information to weigh it up and make a decision. She also has difficulty in communicating and sticking to her decisions in a reliable manner over a period of time. Her capacity for decision-making is clearly an issue. For professionals the task in working with the mother is to balance competing ethical claims of autonomy (which depends on capacity) and beneficence when we act in our patient’s best interests. In working with the parent-patient the Mental Capacity Act (2005) excludes proxy decision-making on behalf of her children’s interests (i.e. her parental role and responsibility) from its applications and therefore the main legal framework for decision-making remains the Children Act.

If in this scenario, as a consequence of some mental health crisis, the mother’s admission to hospital is thought necessary, the consideration of mental capacity creates a potential for different options and outcomes from those outlined earlier. In this instance she may also refuse admission to hospital, wishing to care for her children (prioritizing her children and neglecting her own needs). Similarly she may risk compulsory detention through the provisions of the Mental Health Act 1983 but there will be an additional option for professionals provided through the Mental Capacity Act (from April 2009). If her mental health crisis does not warrant over-riding autonomy through a compulsory admission (Section 2, 3, Mental Health Act 1983), but she is judged not to have the capacity to make a decision about admission that professionals believe to be in her best interest, she may be deprived of liberty and admitted to hospital through Section 4, Mental Capacity Act 2005. In this instance the judgement of capacity to make decisions about her own care and treatment is likely to remove the option of an informal admission too. The law compels practitioners to act in accord with beneficence.

However, mental capacity is decision specific: if she has mental capacity to make decisions about her own care and treatment and does not meet the legal criteria to justify compelling her admission she is free to refuse this (or agree to informal admission). But consideration of any risk to her children will still be required as part of a mental health service responsibility. As in the scenario described, the local authority children’s services are likely to become involved to assess the children’s needs. Here the differences in the scenarios may begin to emerge more clearly in relation to parental responsibility. Assessments of mental capacity may be required here in relation to the mother’s mental capacity in her parental role to make decisions on behalf of her children. At each decision the test of mental capacity applies. In the context of parenting decisions the assessment of mental capacity is highly complex.

The principle of ‘parental responsibility’, whilst undefined in English law by the Children Act 1989, is implicitly rooted in a model of human development where the assumption is of a requirement for parental care and substitute decision-making (care-taking) whilst capacity for autonomy and independence develops in the child (Baines 2008). The Children (Scotland) Act 1995 has made an attempt to define parental responsibility and sets out the intended scope for parental responsibility recognizing the changing balance of this as the child matures. Parental responsibility creates a moral and legal duty for the ‘best interests’ or ‘welfare’ of the child to be of paramount concern for the parent until such time when the child is judged a fully autonomous agent and then no longer has an entitlement to parental action on their behalf. At this time, parental responsibility as a legal obligation ends although parents are likely to feel a moral duty for much longer.

In the case of the child, ‘best interest’ is variously and sometimes idealistically defined (Elliston 2007), but a common working assumption is that a parent will make decisions about a child’s best interest based on what that child would decide for themselves if they had adult capacity. For example, the mother who compels her child to comply with a feared dental examination acts in their child’s future interest in having teeth in adulthood to justify over-riding the wishes of the child in the present.

Parental responsibility then, is based on the assumption of a child’s inherent lack of mental capacity. However, this is modified by the principle of children’s rights, and notions of ‘Gillick competence’ that apply to children who have reached sufficient understanding to make up their own mind in relation to a particular issue, usually regarding medical treatment or intervention. Gillick competence requires the child to have sufficient understanding and intelligence to enable him or her to understand fully what is proposed, and the consequences of refusing. There are a number of issues and potential discrepancies with the question of Gillick competence. For instance, Elliston (2007) points out that in England (differently from Scotland) there is a difference in practice between the right to refuse any treatment (e.g. life-saving blood transfusion) and the right to consent to treatment (e.g. contraception). This seems to hold for parents’ refusal of treatment of their child as well in the case of the refusal of treatment by a child against the parents’ wishes, e.g. in the case of life-threatening anorexia. The details of the argument are beyond the scope of this chapter but it is clear that the reasoning may vary across a range of considerations of capacity. For example, for children it has also been argued that they may lack the capacity to make decisions with long-term consequences in the here-and-now because they may not have developed sufficient wisdom, or sufficient stability of opinion/values. This introduces the wisdom of decision-making and maturity as requirements for a child to have capacity which in effect sets a different and inequitable standard to the test of mental capacity for decision-making for adults where the wisdom of a decision is not at issue. These issues await further clarification (Elliston 2007).

At the start of this discussion of mental capacity we referred to a problem in misunderstanding terminology between competence and mental capacity. In working with parent-patients there is potential for further confusion through the use of the term ‘parenting capacity’. The framework for the assessment of children in need (Department of Health 2000) incorporates an assessment of parenting capacity. This focuses specifically on a parent’s ability to respond to and meet their children’s needs. Critical dimensions of capacity include a parent’s ability to provide basic care, warmth, stimulation, stability, guidance, and boundaries. Although in principle outside the scope of this chapter, some fundamental differences between concepts of mental capacity and parenting capacity need to be highlighted. In the Mental Capacity Act 2005 a person lacks mental capacity in relation to a matter if, at that time, the person is unable to make a decision in relation to the particular matter because of an impairment of, or disturbance in, the functioning of the mind or brain. It does not matter if the impairment or disturbance is permanent or temporary. There is a diagnostic threshold for mental capacity judgements. Judgements of parenting capacity do not overtly incorporate any diagnostic criteria. However myth and stigma associated with mental health diagnosis are pervasive and are likely to influence judgements. It might also be argued that whilst assessments of mental capacity are not based on the perceived wisdom of a decision, assessments of parenting capacity demand that parents act wisely in regard to the decisions they make about their children. In making judgements about mental capacity there is a need to optimize opportunity and capacity for decision-making, this may involve taking time. In making judgements about children’s needs the focus may relate to speed, as a child’s needs related to their development cannot wait for their parent’s recovery.

It is important in such situations that adult mental health and disability services become active and engaged in supporting parent-patients and local authority children’s workers in assessing mental and parenting capacity. The local authority requires parental consent in order to provide services to the children. If, as a consequence of mental health and/or disability, a mother experiences difficulty in understanding or retaining information or her affective state influences decisions, tensions are likely to emerge between the mother and services as her mental capacity related to specific parenting decisions will also be changeable. This is likely to influence judgements about her parenting capacity. In this situation the likelihood that formal legal proceedings will be taken by the local authority to assume parental responsibility is increased. Acting in accord with beneficence and adopting a Family Interest Principle through assessment and practice may provide a framework for mental health practitioners to use as a guide to the ethical dilemmas they will inevitably face in such situations.

The Family Interest Principle is important to consider in practice with mothers with mental health problems in a number of issues:

Family care plans have been found to be an ethically-based means for managing complexity and ensuring adequate mental health and social care of parent and child (Reupert and Mayberry 2007; Reupert et al. 2008). An adapted version of the ‘best interest checklist’ required by the Mental Capacity Act could be integrated into this and be very helpful to professionals and families alike. In the United Kingdom we also have guidelines on considering the parental role of patients for use with the revised care programme approach (Department of Health 2008).

We know that many women with mental health issues are mothers (Jenkins et al. 2003; Singleton et al. 2003; Skapinakis et al. 2003) but our understanding of the relationship between gender, mental health, and parenting remains limited (Reupert and Mayberry 2009). Collectively we often regard women and men as both different, when they may not be, e.g. legal position of infanticide (Dobson and Sales 2000), and similar, when there may be fundamental gender differences, e.g. formation of attachment patterns (Minnis et al. 2007). Therefore mental health practice has a limited although expanding evidence base (see Chapter 3, this volume) and traditionally has largely ignored the parenting role. We hold that this is ethically unacceptable and have proposed principles of good practice when dealing with mothers with mental health issues. Becoming a father is a very different process from becoming a mother. The process of how something comes about partially determines the outcome hence the relationship between mother and child is intrinsically different from that of father and child. We do not yet know how this should be considered in mental health practice but we do know that we are currently most commonly dealing with mothers when parental mental health issues need to be considered. Gendered service provision remains a complex issue (see Chapter 35, this volume) and difficult to address. Attending to the mother–child relationship as a central concern in adult mental health will not only assist in gender-appropriate service provision but also in improving family life and child mental health. We outlined an argument for the abandonment of individual claims for primacy of best interests in favour of developing an alternative claim for the family’s best interest, a Family Interest Principle. This acknowledges that best may well not be ‘the best’ but as good as it can be within the parameters of finding the best balance between benefit and harm. Principles of medical ethics can be helpfully extended to the parent–child relationship. This has implications for theory of medical ethics, requiring greater inclusion in training and policy development, to inform ethical practice. Much of this is in keeping with recent United Kingdom and Australian government policies (Department for Children, Schools and Families 2003; Australian Government 2004; Social Exclusion Task Force 2007).

The following have made substantial contributions by way of comments to the content of this chapter: Paul Baines, Alder Hey Hospital, Liverpool; Anne Morris, University of Liverpool; Julia Nelki, Alder Hey Hospital, Liverpool; David Pilgrim, University of Central Lancashire. James Wilson’s contribution to this work was undertaken at UCLH/UCL who received a proportion of funding from the Department of Health’s NIHR Biomedical Research Centres funding scheme.