care nursery (ICN). Sharon herself is in a methadone treatment program and has admitted that she still sometimes smokes marijuana. The baby's urine tested positive for marijuana metabolites at birth. The doctors and nurses who are caring for the baby have several worries, but the one they are most perplexed by—the question they bring to the Ethics Committee—is whether they should encourage Sharon to breast-feed her baby.

Neonatologist William Edwards, M.D., heads the infant-care arm of the Ethics Committee. Recently, he sought the full committee's input about the breast-feeding dilemma his team had faced with Sharon. She wanted to breast-feed her baby, he explained, and DHMC's practice is to strongly encourage new mothers to breast-feed. But since it was likely that Sharon would continue to use marijuana, should she still be encouraged to breast-feed? On the one hand, Edwards pointed out, breastmilk is superior to formula. But on the other hand, could it offer more harm than benefit in this case?

Edwards added that he felt Sharon wanted to do what was best for her baby. "But when she's stressed," he said, "it's hard for her not to smoke marijuana. Should we ever be complicit in recommending something that puts the baby at harm of illegal drugs?" He noted that the evidence is unclear regarding the effect on a baby of marijuana in breast milk, though some studies have suggested that it makes babies irritable. He also mentioned, in relation to the baby's premature arrival, that other studies have shown an association between marijuana use and low birth weight.

"It might be good to encourage her to

Peggy Plunkett: "Sometimes an ethics consult can break this logjam"

In 1991, the Veterans Affairs Medical Center in White River Junction, Vt., which is affiliated with Dartmouth-Hitchcock Medical Center, was chosen as the site of the VA's National Clinical Ethics Center.

The cases that come before the committee are heart- rending for everyone involved. "There's never an ethics consult that isn't upsetting," says one committee member. The decisions can be tough, painful, overwhelming, emotionally charged, and even nightmarish at times.

quit," suggested a member of the committee. But another member worried that Sharon could be alienated fromthe health-care systemif her caregivers were too heavyhanded about her marijuana use.

"When this mom takes her baby home, what do you have control over?" asked someone else.

"Nothing," Edwards answered.

"Have other risks been evaluated?" The committee was full of questions for Edwards.

She might be arrested, he responded, clearly concerned. "Or she might get stoned and crash her car."

A neonatal nurse who had accompanied Edwards to the meeting spoke up, explaining that "there's a lot of emotions among the nursing staff if they are compelled to go along with something they're not comfortable with."

"Tell the mother we don't know the harms of marijuana, but that she . . . shouldn't smoke it," suggested a committee member.

"Do I send her on a path to breast-feed or not?" persisted Edwards, trying to pull the discussion back to the question of most concern to the neonatologists.

Several members noted that it was difficult to justify advocating against something without solid evidence of harm. "If you knew the mother was going to drink [alcohol] during breast-feeding, would you still set her on a road to breast-feeding?" asked a committee member.

"Yes," Edwards admitted.