Adoption

Principles in Adoption

Consent of the birth mother and placing the child with suitable adoptive parents remain stable and consistent practices. However, many principles that have historically guided adoption practices are undergoing redefinition and reconsideration. The evolving context around adoption has led to new layers of complexity 1:

• Although consent of the birth mother has been a necessary precondition for adoption, presumed waiver of consent by absent birth fathers had been routine. More recently there has been an increased emphasis on the rights of biologic fathers and less reliance on a waiver process to release a child for adoption when the biologic father cannot be located.

• Historically, adoption practices were based on altruism, and all financial transactions suggestive of purchase of a child were prohibited. Presently, the unmet demand for adoptive infants, as well as more straightforward desires to support the birth mother, can lead to offers of subsidy for medical care and other support. This can raise concerns about inducements and can make the altruistic nature of adoption less clear and free of financial conflict.

• In the past, relinquishing birth mothers and prospective adoptive parents were assured that their confidentiality and anonymity would be protected. In other words, the adoptions were “closed.” However, it is no longer possible to guarantee absolute confidentiality to either birth or adoptive parents. Many states have laws that give adopted individuals access to their birth records.

• Traditionally, relationships with adoptive parents were expected to substitute entirely for relationships with biologic parents. However, in some cases, adoption may include ongoing relationships with birth parents. Even in a “closed” adoption, the adopted child and adoptive parents may need to have access to relevant genetic and medical information about the biologic parents.

• Adoptive relationships were presumed to be permanent once they were finalized in court. Adoption is usually irrevocable, but rare cases have arisen in which adoptive relationships were terminated by adoptive parents, biologic parents, or adopted children after a final adoption decree had been granted.

Models of Adoption

There are many types of adoption, and the face of adopted families is changing, including same-sex couples, single-parent families, and older relatives raising a child. In this Committee Opinion, the Committee on Ethics addresses issues regarding prospective adoptive parents and recognizes that the adoptive parent may be an individual man or woman. In addition to the classic adoption of newborns, other models of adoption are becoming more common, including kinship adoptions, relinquishment of children through social service removal, and international adoptions. Most physicians are not experts in these varied adoption processes and laws. However, it is important to be aware of these complex family dynamics and to be able to refer patients to appropriate resources.

Domestic adoptions still account for most adoptions in the United States, but international adoption is increasing in popularity 2. Children who are adopted internationally often come from developing countries that are politically and economically unstable. For this reason, the opportunities for adoption from various countries are continuously in a state of flux. International adoption is regulated by The Hague Convention as well as by each involved country’s own laws. There are a variety of organizations that specialize in international adoptions to which physicians can refer their interested patients ( see Resources).

The adoption of older children is increasing and usually involves a less-conventional model of adoption. One type of adoption is kinship adoption, whereby a relative adopts a child from another relative. Another important source of adoptive children is the foster care system. For example, it is estimated that there are more than 26,000 preteens available for adoption 3. Adoptive children enter the foster care system through either social service removal or relinquishment at safe havens. Safe havens are locations, such as hospitals or fire stations, where parents (and sometimes other individuals) may leave infants anonymously without fear of prosecution for abandonment or neglect. Most states have enacted safe haven laws, but the specifics vary by state 4.

Education and Counseling

Adoption may be relevant in myriad situations, and physicians have the responsibility to educate appropriate patients about this option. These obligations can be met, for some patients, by placing literature about adoption in the reception area, thereby validating adoption as a legitimate, respected choice. A discussion of the risks and benefits of adoption may be indicated for other patients. In some situations, a referral to another professional with relevant expertise, such as social work, may be appropriate. Regardless of how information is conveyed, it should be clear and accurate.

Physicians have a responsibility to provide information about adoption to appropriate patients. The information provided should be accurate and as free as possible of personal bias and opinions 5. Pregnant women who may be ambivalent about their pregnancies should be informed in a balanced manner about their full range of reproductive options. Physicians should not advocate for or against any particular option, including adoption. Nor should they avoid discussing these issues when they are appropriate to the patient’s situation. There is an ethical obligation to provide accurate information that is required for the patient to make a fully informed decision.

Adoption should also be considered an option for certain patients who are looking to build their families. For example, a discussion about adoption may be appropriate for patients who are infertile or for patients in whom pregnancy may be dangerous 6. Fact sheets are available to support this educational role 7 8. Patients often ask their physicians, “Doctor, what do you think I should do?” 9. There may be a temptation to advocate for a specific position, but it should be avoided. The physician’s role is to provide accurate, unbiased information that is appropriate for the situation. This may include infertility treatments, adoption, and child-free living. The patient can decide which course is most consonant with her own values and life circumstances.

Physicians may have both positive and negative personal biases about adoption for various reasons. For example, physicians with personal experience of adoption in their own families of origin, or who have chosen adoption as their own method of family building, may present this option either positively or negatively, depending on their individual experiences. Physicians should be aware of how their own experiences may influence their attitudes and should disclose this information when appropriate.

Patients count on the guidance of physicians for medical decisions. Adoption, however, is only tangentially a medical matter, and few physicians are experts in this field. Furthermore, for the physician, the particular encounter with an individual patient or couple occurs only during a finite point in time. The patients will be living with the lifelong consequences of these decisions. Therefore, when discussing the option of adoption with patients, physicians should guard against advocating for a particular course of action. The best counsel will permit the involved parties to explore their options fully and make a decision that arises out of their own beliefs, values, needs, and circumstances.

Referrals

The physician’s role in referrals is to identify appropriate resources. Physicians often may best fulfill their obligations to patients through referral to other professionals who have the appropriate skills and expertise to address the complex issues raised by adoption. For example, referral to a mental health professional for short-term counseling provides an opportunity for both birth and prospective adoptive parents to explore their emotional reactions and the ways that different alternatives may affect their lives. Some patients may feel more comfortable having a discussion of this type with someone who is not involved with their ongoing medical care.

Physicians should be aware of adoption resources in their areas and refer patients to licensed adoption agencies 10. There are many sources of information available to assist physicians in developing their own lists of referral alternatives (see Resources). Also, many local hospitals maintain referral rosters.

Screening

When working with patients who have decided to pursue adoption, physicians are sometimes asked by those patients to fill out forms requesting information about their psychologic and medical suitability as prospective adoptive parents. The physician’s role in such cases is to provide truthful, accurate information to screening agencies, whose responsibilities are to safeguard and protect the needs and interests of adoptive children. Physicians are bound by ethical precepts to be truthful and to act in their patients’ best interests, and in some circumstances, these may be in conflict with each other. For example, a patient may request that a physician not reveal to the agency the extent of her chronic illness and its potential effect on her life expectancy. Although a physician may wish to advocate for a patient, there is an obligation to be truthful and to let patients know that relevant information cannot be hidden.

Some agency forms may request the treating physician to certify that the individual or couple is fit to parent. If the physician believes that he or she does not have enough information to make a judgment, the agency may count that as evidence against the couple. The physician must be honest and speak accurately to the questions asked with the information that is available. One approach is for the physician to disclose to the patient what will be written in the report before it is filed.

Hospital Care for Birth Mothers Relinquishing Infants

Obstetrician–gynecologists may find themselves caring for a patient who has made the choice to relinquish her child after delivery. These women should be supported in making a decision that is often extremely difficult. In addition to the usual demands of labor and delivery, she may be coping with feelings of grief and loss. This may leave the woman in a vulnerable position, and it is the physician’s duty to advocate for his or her patient and to set a kind and caring tone. A physician’s primary responsibility in caring for a woman considering adoption is to her and not to the prospective adoptive parents.

Physicians should be familiar with their hospitals’ policies regarding adoptive parents and the care of women relinquishing their infants. In the past, it was thought best to remove the baby before the woman had a chance to see or hold her infant. This was thought to make it easier for her to relinquish the child. Views on the treatment of the birth mother have significantly changed. Now, depending on her preferences, the birth mother may choose options such as holding the baby, keeping the infant with her until she leaves the hospital, or breastfeeding. Appropriate acceptance and support of the birth mother can prevent the disenfranchised grief that relinquishing an infant may cause her 11.

Limits to the Physician’s Role

Because of ethical issues related to undue influence, competing obligations, and lack of expertise, physicians should not serve as brokers of adoptions. In fact, many hospitals have bylaws prohibiting staff physicians from direct involvement as adoption brokers.

One of the reasons physicians should not act as brokers is the power of undue influence. If a physician has acted as a broker and the adoption agreement falls through, he or she will be aware of the loss experienced by the other party, may feel responsible, and may be tempted to use the power of the physician–patient relationship to influence the patient to fulfill the original promise. The physician’s ability to provide current or future medical care for this patient may be compromised by these events.

Although both birth parents and prospective adoptive parents generally view the adoption agreement as binding, either or both parties may find themselves unable or unwilling to fulfill that agreement after delivery of the child. The pregnant woman who agreed to relinquish her child may have done so in good faith with the best knowledge available to her at that time. She may not know whether she can really do what she agreed to until she has given birth to this child, held him or her, and experienced the extent of loss. The couple who agreed to accept a child may regret that decision and feel unable to keep their part of the agreement if, for example, the child is born with serious medical problems. For these and similar reasons, no adoption is final until after the birth of the child.

Physicians should avoid matching prospective adoptive parents with women who are choosing to relinquish their children and should instead refer patients to agencies or other adoption resources. Physicians should receive only the usual compensation for medical and counseling services. Referral fees and other arrangements for financial gain beyond usual fees for clinical services are inappropriate.

When physicians also are prospective adoptive parents, there may be a temptation to adopt an infant from one of their own patients. This arrangement is ethically problematic. It takes advantage of the physician–patient relationship and the power differential inherently built into this relationship. Physicians are advised to delegate to an independent authority all responsibility for matching pregnant women with prospective adoptive parents.