Custody of Child by State Highlights Medical Gulf for Psychiatry
The case of Justina Pelletier brings up yet again the debate about how far the rights of parents go, and where states should interfere in the care and welfare of their minor citizens. There have been numerous cases over the years of a state taking legal custody of a minor because it has ruled that the child is in danger while remaining in the parental home. Oftentimes, this custody situation is due to a matter of obvious abuse or neglect. In cases like that of Connecticut resident Justina Pelletier, the lines are a bit fuzzier. The gulf between psychiatry and the rest of the medical establishment was highlighted when the state of Massachusetts took custody of the 15-year-old child due to a disagreement over the parents’ choice of medical treatment.
Medical professionals disagree all the time about the source of symptoms. Calls for a second opinion are not uncommon, especially as doctors will argue about diagnosis whenever there is doubt that an illness fits clearly into one category or another. When the disagreement is over whether symptoms are caused by physical illness or psychiatric disorder, the doctors in question often get caught up in a wider debate, one that has been ongoing for decades. This debate has to do with the validity of psychology as a science.
Students of psychological disciplines must learn to diagnose intangibles, disorders that often can only be identified by behavioral symptoms, or by clues in the chemical and hormonal balances in the brain. Seldom do psychological disorders show themselves organically, as in deformed structures in the brain, tumors, a failure to fire synapses in an entire and visible section of a brain structure. Psychology is an exercise in deduction; one removes the possible causes of behavior from the running one by one until one lands on the only remaining possible source of the behavior, no matter how improbable that seems.
Because of the difference between this method and the medical method, which relies on physical scientific evidence and recordable and observable phenomena, there has been a vast gulf between medical doctors and psychologists for hundreds of years regarding whether psychology can even be considered a logos, or science based in logic, at all.
Bridging the gap, the discipline of medical psychiatry was born. Psychiatrists differ somewhat from psychologists in that training is focused on neuroscience and pharmacology, in observable and recordable reactions of the brain to physical stimuli such as chemicals, hormones, and electrical activity. Psychiatrists evolved their discipline to bring the best of both worlds; medical science and the art of psychological counseling.
Both psychiatrists, who are concerned with medical treatment of the psyche, and psychologists who are concerned with the science and theory of the psyche, often hold doctorates, though psychiatrists are required to have a medical doctorate to practice, and psychologists cannot prescribe medications. Psychiatrists, who do have that training and power, often work more closely with standard medical doctors in methodology, though they share with psychologists the fact that their work is focused on intangibles.
The result is often an uneasy truce, with both clinical psychologists and psychiatrists fighting hard to be taken seriously by the medical establishment, and psychologists often disagreeing with psychiatrists on their methodology. This fight often functions to the detriment of the psychological discipline as a whole, since psychiatrists must sometimes distance themselves from psychologist and psychological methodologies in order to be seen as real doctors by their peers. This accounts for the occasional accusations of over-reliance on the use of medications for the treatment of psychiatric disorders in the field, as doctors of psychiatry fight to keep their discipline within the realm of probative science.
In the case of Justina Pelletier, who was removed from her parents to state custody last year due to a disagreement between a doctor and a psychiatrist over course of treatment, the story highlights the gulf between psychiatrists and their psychologist compatriots and the greater medical establishment. Justina was seen first by a medical doctor from Tufts University, who from the symptoms witnessed deducted that the 15-year-old could be diagnosed as having a rare mitochondrial illness that made the physical production of energy insufficient to her needs: a measurable medical phenomenon if a broad category needing more testing to define its discrete identity and parameters.
Justina was treated at Tufts Medical Center for nearly a year, when she got the flu. When she was seen on an emergency basis by another physician, from Boston Children’s Hospital, she was given a psychiatric diagnosis based on the same symptoms; a diagnosis of somatoform disorder. In other words, the second diagnosis, made from equally deductive guesswork, was that the young woman was suffering from psychosomatic symptoms in that some disorder in her thinking process was producing the very real symptoms she suffered in a mind-over-matter effect.
The two medical professionals disagreed over this second opinion, with the psychiatrist at Boston’s Children’s Hospital stating that the Tufts doctors were subjecting Justina to unnecessary medical intervention, while the Tufts doctors arguing that the psychiatric course of treatment would remove necessary medical support from the patient’s care repertoire.
Justina’s parents agreed with the first diagnosis. The psychiatrist who made the second diagnosis, concerned that Justina would be getting the wrong care if she remained in her parents’ charge, sought to have custody removed from Justina’s parents in favor of Massachusetts State.
Out of concern for the girl, the state agreed, and Justina spent nearly a year committed to the care of a locked children’s ward in Boston Children’s, where her parents were permitted to see her only when visits were approved by the hospital in concert with the Department of Children and Families. In January the Pelletiers won a minor victory and Justina was transferred back home to Connecticut, though to a residential facility in Framingham rather than back to their custody.
These events set off a greater national debate, one seen time and time again, as church officials and politicians heatedly discussed parental rights and the possible overreach exercised by the state. Due to the backlash, multiple facilities including a Merrimac foster group called Shared Living Collaborative, to which Justina’s parents sought to transfer her, have now backed out of consideration, wishing to avoid legal entanglements. A juvenile court judge is open to Justina returning to her parents’ home providing certain conditions are met. Lawyers for the family are looking into this plan and are scheduled to report back to court March 17.
Despite the fact that Justina has spent a year away from home at Tufts and at Boston Children’s Hospital, Justina’s parents have agreed to this course of action, as they have stated they feel that Justina’s condition has worsened while under the care of Children’s, and as the possible foster care situation in Merrimac has fallen through. In the meantime, the yawning gulf between psychiatric care and the rest of the medical establishment has been highlighted and remains the source of a lot of confusion and heartache, especially when the debate between the two can cause a child to be remanded to state custody for over a year.
By Kat Turner