A lack of good data, vague clinical recommendations, rapid cultural shifts, and a complex legal and regulatory environment leave healthcare professionals and patients with questions and concerns that make ethical decision making around marijuana and breastfeeding even more complicated. This section explores some of the ethical concerns that arise, especially for nurses, in the specific context of feeding infants in the NICU and makes recommendations for practices and policies which support allowing mothers who use marijuana to make an informed choice as to how their babies may be fed, by themselves or by others.
Screening recommendations differ among professional settings, and providers may become aware of marijuana use by breastfeeding mothers via screening, toxicology testing, or patient self-report. Beneficence requires balancing risks and benefits and working to promote good health outcomes for the patient, and screening can help promote this good by encouraging disclosure of use of a substance that may be risky for mother and breastfed child. It is important to ascertain frequency and amount of use, information which toxicology reports cannot provide. Self-reports are likely to be less reliable to the extent that the patient feels judged or threatened, so paying attention to language and tone is important. Leading off with “the righting reflex”, i.e., warnings about marijuana use in the context of breastfeeding, and admonitions to stop immediately, is likely to minimize the chances of developing the kind of rapport that is necessary for working with the patient to promote beneficence (Shapiro et al. 2013). Not only that, but as we will see below, it may not be clear which course of action is “right” until more information is obtained.
It is important to try to understand why a nursing mother is using marijuana.Footnote 1 This relates to respect for patient autonomy. When the child is the patient, it relates to respecting the autonomy of the patient’s legal representative. Autonomy requires not only freedom from controlling influences, but also agency. Undue influence, coercion, and manipulation are rhetorical strategies that can be agency-defeating. Women who use marijuana while breastfeeding may believe that they are acting in a way that is, on balance, best for themselves and their baby, either directly or indirectly. The point of establishing a joint understanding about the role of marijuana use in the patient’s life is not merely, or even necessarily, greater efficacy in getting her to stop using. Understanding the mother’s beliefs, values, and goals, and how marijuana use fits into those, is respectful of her personhood, and her right to make healthcare decisions for herself and her child. Because values are often inchoate, conflicting, or just not transparent to the patient, it may be helpful to think of this as an autonomy-enhancing dialogue. Providers should approach nursing patients who use marijuana with an awareness that, depending on the particular context, there may be a range of “right” paths forward.
It is also worth reflecting on the different cultures from which healthcare professionals and some medical marijuana-using patients hail. Health care providers are working from a context in which there is, as of yet, no such thing as “medical marijuana.” Medical marijuana is “recommended,” not “prescribed” or “dispensed.” Hospital formularies in most states do not carry marijuana due to federal law and lack of FDA approval, and many hospital policies either forbid it outright, or only allow patient self-administration of cannabis products. Even those hospitals that allow staff to administer medical marijuana require charting it as “continuation of therapy” rather than “medication” (Durkin 2017). But these subtleties are lost on many patients, for whom marijuana looks an awful lot like any other prescribed treatment. So, when nursing mothers use “medical marijuana” to alleviate symptoms of anxiety, depression, or one of the many other diseases which marijuana is thought to help control, their thought process regarding continued use while nursing may be no different from deciding whether the benefits of taking prescription medications such as antidepressants outweigh the risks to their babies.
For some women, use of marijuana occurs in the context of a broader personal and cultural turn to complementary therapies, including herbal supplements. They might see it as an organic alternative, more affordable and less dangerous, than traditional medicine. These women put marijuana in the same risk category as the fenugreek, blessed thistle, and fennel they use to stimulate milk supply, herbs of unknown efficacy and safety, also unregulated by the FDA. Far from viewing it as a danger, some women use marijuana specifically to help with breastfeeding, for example, to stimulate their appetite, or to relax them and assist the let-down reflex. Others view marijuana as an indirect support for breastfeeding and mothering. They might use it to alleviate pain after delivery, believing it to be safer and less subject to abuse than prescription painkillers. They might be aware that high stress can interfere with milk production and is associated with early weaning, so they use marijuana to keep calm during a challenging adjustment to breastfeeding or in a stressful family setting. They may even believe the psychotic effects are directly beneficial to the baby, for example, to help the baby sleep. This information provides an opportunity for clinical education around safer ways to promote relaxation and sleep.
Because marijuana and alcohol are increasingly perceived as similar in their effects, social acceptability, and legal status, women who use marijuana might believe that the advice to wait two hours after drinking a glass of wine or beer before nursing, also applies to marijuana. Of course, marijuana stays in the body for longer than alcohol and it has not been determined what, if any, waiting period might reduce harm. It is important to educate patients regarding differences between metabolization of alcohol and marijuana so that when they make choices, they are informed ones. Again, this enhances patient autonomy.
Understanding the role marijuana use plays in a nursing mother’s life can point providers to alternatives for managing her symptoms that are less risky to herself and to her baby. However, for some women, it may be the case that continued use of marijuana is, while nursing, on balance less risky than using formula. In those situations, healthcare professionals can help their patients practice harm reduction strategies, for example, avoiding smoking near the baby and minimizing use. The Academy of Breastfeeding Medicine recommends that clinicians counsel patients to “carefully weigh the risks of initiation and continuation of breastfeeding while using marijuana with the risks of not breastfeeding while also considering the wide range of occasional, to regular medical, to heavy exposure to marijuana” (Reece-Stremtan et al. 2015).
So far, this section has emphasized gaps in patient appreciation of risks and knowledge of alternatives to marijuana. While it is common to focus on gaps in patient knowledge and lapses in patient reasoning, clinical uncertainty has recently gained increased attention (Han et al. 2011). Health care providers can find it challenging to accept uncertainty, but avoiding addressing uncertainty has been associated with detrimental effects on patients (Simpkin and Schwartzstein 2016). Withholding the ambiguous state of current evidence can lead to premature closure of important conversations, foreclosing opportunities for mutual education. Worse, it may create openings for unconscious biases to influence attitudes of providers. The absence of a strong evidence base for recommending for or against breastfeeding of neonates in the NICU when breast milk may contain THC should be made manifest and included as part of the overall process of shared decision-making. In this way, uncertainty can enhance the mother’s autonomy, which is especially important for a subgroup of patients already subject to stigmatization and lack of parenting confidence. Admitting that there is not enough evidence as yet to make a strong clinical recommendation can also increase patient trust in providers.
Moreover, a growing literature suggests that medical decision-making of healthcare professionals is subject to certain context-specific cognitive biases. All humans use heuristic strategies (decisional short cuts), which can lead to systematic errors in judgment. In the present context, a loss/gain framing bias—the tendency to view losses as larger than gains—may lead clinicians to overvalue the avoidance of harms from THC in breast milk relative to the gain in continuing to breast feed over substituting with formula (Blumenthal-Barby and Krieger 2015). To counteract the cognitive bias that may overemphasize the potential harms of breast milk containing amounts of THC, a review of American Academy of Pediatrics (AAP) Policy Statement on Breastfeeding and the Use of Human Milk offers a countervailing reminder of the strong evidence base for the benefits of breast milk over formula (Eidelman and Schanler 2012). Exclusive breastfeeding significantly decreases rates of obesity, diabetes, celiac disease, childhood leukemia, gastrointestinal tract infections, necrotizing enterocolitus, sudden infant death syndrome, and infant mortality. Exclusive breastfeeding is also correlated with significant positive effects on long-term neurodevelopment. Other advantages to breastfeeding include health benefits to the lactating women, economic benefits to her household, and psychological and emotional benefits for both mother and child. For all of these reasons, the AAP, the American College of Obstetricians and Gynecologists (ACOG), and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) are among the many healthcare organizations that recommend exclusive breastfeeding for newborns as the normative standard for infant feeding and nutrition and deem it an important public health goal.
Despite the uniformity and strength of this recommendation in the U.S., among infants born in 2013, 20% did not breastfeed at all, about half were breastfeeding at 6 months, and most (about 70%) were not breastfeeding at 1 year (U.S. Government, National Center for Chronic Disease Prevention 2016). The literature shows that professional support increases initiation and continuation of breastfeeding. Moreover, perception about infant nutritional benefits is a key factor in determining whether a mother initiates and continues breastfeeding. Some researchers recommend that health professionals explicitly enumerate the risks of formula feeding in addition to the benefits of breastfeeding, because otherwise women gain the impression that they are of about equal value (Radzyminski and Callister 2016). Healthcare professionals should reframe their attitude towards maternal marijuana use to adequately take into consideration these factors, especially when low rates of breastfeeding are already a public health concern.
The NICU is a setting where maternal use of marijuana is especially fraught. Individual hospitals may test all mothers, mothers who self-report drug use, have tested positive for drug use in the past, present with preterm labor, and/or those with no prenatal history. Infant signs of withdrawal such as irritability, shakiness, or prolonged distress may also trigger testing. After a THC-positive test, some nurses are reluctant to personally administer expressed breast milk, even when they otherwise support the mother in establishing breastfeeding. To some nurses, the right of a mother to breastfeed her own infant should be trumped by their own right to refuse to engage in administering potentially harmful substance to their patient. A refusal to administer breast milk in these situations feels like a natural extension of the nurse’s duty to protect the health of very vulnerable infants in the NICU.
These nursing concerns in the NICU setting should be addressed with the larger legal, clinical, and ethical context of maternal marijuana use in mind. Neonatal nurses are also charged with promoting breastfeeding: “Neonatal nurses have a responsibility to facilitate, through support and evidence-based information, the provision of human milk and breastfeeding. It is essential to ensure that infants receive human milk through hospital discharge and that mothers have the opportunity to reach their personal breastfeeding goals” (Spatz and Edwards 2016). As discussed previously, the risks to breastfed infants of maternal marijuana use are unknown, while the benefits of breastfeeding over formula feeding are well established. Because marijuana can linger in urine for up to thirty days, and even longer for casual users, a single positive THC result provides no indication of how recently the mother used marijuana, or of how heavy the mother’s marijuana use is, nor does it offer information about the mother’s perception of how marijuana might contribute to her own mental and physical well-being. Nurses in the NICU should be encouraged to frame their ethical concerns in the context of both their responsibility to promote the health of the patient, and in the context of shared decision making and family-centered care. It is important for nurses to understand that by substituting formula, they are withholding a benefit—breast milk—and, more importantly, potentially sabotaging the establishment or continuation of a successful nursing bond between mother and child.
Mothers whose infants are in the NICU are already vulnerable to post-traumatic stress, feelings of inadequacy, depression, and anxiety (Obeidat et al. 2009) The attitudes and behaviors of healthcare professionals can have a disproportionately large impact on nursing mothers, despite comprising a fraction of the time these women will spend breastfeeding their child. For mothers who experience premature delivery, providing their own milk may feel like the only way they can care for their child, can help them connect, and can minimize guilt (Rossman et al. 2013). Nurses themselves may be concerned about personal legal liability in areas where marijuana in any form is illegal, or they may fear running afoul of reporting requirements. Hospital administration should clarify reporting requirements for nurses and notify them of institutional protection for employees from personal liability.
Some hospitals address these concerns by allowing individual nurses to opt out, substituting formula for breast milk when infants cannot nurse. However, the unintended negative consequences of such a policy should be carefully considered. First is the aforementioned negative impact on the establishment of breastfeeding for this already vulnerable mother-infant dyad. Second is the patient and mother experience of inconsistency that occurs when feedings depend on which nurse is on duty in the unit. Third is the potential violation of the mother’s right to determine how her baby is fed, traditionally an ethically protected space for parents to exercise their judgment based on their own values and the child’s best interests. Ethicists have long argued that parents should make decisions about the medical care of their children based on the best interest standard, which includes the emotional, social, and spiritual well-being of the child (Kopelman 2007). The evidence that feeding breast milk with THC violates a reasonable conception of the infant’s best interests is not strong enough to override the mother’s rights.
Especially in states where marijuana is legal, fairness dictates consistency in treating potentially harmful substances in breast milk (Krening and Hanson 2018, p. 47). This includes looking carefully at how marijuana policies differ from those around other legal, but potentially harmful substances such as nicotine, alcohol, and even prescribed medications. If hospitals are unwilling to reflect on how breastfeeding policies in the NICU cohere with policies on other potentially harmful substances, such as nicotine, then they do not have good grounds for singling out marijuana. A prohibition on administering breast milk which contains THC must follow from a transparent decision matrix for determining whether the risk of providing mother's own milk (MOM) is outweighed by the benefits for a particualr patient. Management should support nurses who experience distress with education, peer support, and other tools. It may help to emphasize that consistency of care within and across patients has many health and social benefits for patients and family. It can encourage better connections which improve the health of patients. It can allow for the development of trust relationships that lead to better adherence to provider recommendations (in particular, the recommendation to stop using marijuana). And, it can generate feelings of satisfaction in mothers with their hospital experience.
Another strategy is to increase the availability of donor human milk (DHM) to substitute for MOM when nurses decline to use the mother’s expressed breast milk. Again, this must be an evidence-based decision where known benefits and risks should be evaluated. Recent studies suggest that the multiple benefits of MOM cannot be generalized to DHM: “In particular, there is lack of fit between preterm MOM and DHM during the early critical post birth window when nutritional and immunomodulatory programming and select organ growth via MOM components are thought to occur” (Meier et al. 2017). Another consideration is the cost of DHM to hospitals, which is much higher than MOM. Given the harm-benefit scenario described at length above, hospitals’ investment in DHM clashes with their responsibility to be good stewards of scarce resources. A better hospital investment would be education of NICU staff, patients, and the community.
Some nurses may frame their refusal to administer expressed breast milk after a positive test for THC in terms of conscientious objection. Professional conscientious objection is a refusal to comply with professional obligations as stated by law or institutional rule, by claiming moral or conscientious reasons. Conscientious objections are widely recognized across the profession, including by the Joint Commission and the American Nurses Association (Waller-Wise 2005; American Nurses Association 2015). The most common objections relate to a conflict between the nurse’s religious beliefs and abortion, euthanasia, and patient refusal to accept treatment (Toto-Flores et al. 2017). A recent phenomenological study indicates that nurses themselves view conscience as something that allows them to discern right from wrong, and compels them to act accordingly (Lamb et al. 2017). A conscientious objection is different from mere disagreements with patients’ or surrogate decision-makers’ choices (Lachman 2014). To act against one’s own conscience in this sense is to betray one’s deepest beliefs and risk one’s own integrity.
Despite widespread recognition, conscientious refusal itself is controversial and conceptually contested, not least because health care providers have freely chosen their career, and thus implicitly accept the professional norms which guide it (West-Oram and Buyx 2016). Its inclusion in codes of professional ethics creates inherent tension with the primary injunction to place the well-being of patients above one’s own personal beliefs (Stahl and Emanuel 2017). The right to conscientious objection is not unqualified. The ANA is clear that, “Conscience-based refusal to participate exclude personal preference, prejudice, bias, convenience, or arbitrariness” (American Nurses Association Center for Ethics and Human Rights 2011). Mothers with substance use disorder experience lack of empathy from nurses for their disease, lack of trust from nurses, and the need for separation from their infant due to perceived negative judgment from nurses (Reyre et al. 2014). The refusal to feed expressed MOM to infants in the NICU is most likely related to lack of education, bias, and prejudice. In many cases, education, not conscientious refusal, is the path towards better nurse-mother relationships, and, by extension, better mother–child relationships.
Prior to accepting a staff member’s request not to participate in an aspect of a patient’s care, the hospital should ascertain whether it is genuine. Fear of being sued, distaste for a procedure, or worries about public disapproval, are not claims of conscience. The hospital should also consider what impact the refusal will have on the patient’s well-being, whether the objector’s claims are evidence-based, and to what extent conscientious refusal further disadvantages an already disadvantaged patient and family. Women who use marijuana are more likely to be less educated, poor, and use other substances, all additional factors associated with stigmatization. In most cases, a nurse’s claim of conscience in this matter should not be honored.