I. Overview
Mental health problems as an important public health problem and a more prominent social problem has become a consensus in China and the international community. China’s Mental Health Work Plan (2002-2010)
The “China Mental Health Work Plan (2002-2010)” proposes that China’s mental health work includes not only the prevention and treatment of all kinds of mental diseases, but also the reduction and prevention of all kinds of undesirable mental and behavioral problems, and should follow the working principles of “prevention-oriented, prevention and treatment, focused intervention, extensive coverage, and management according to the law”.
Combined, focused intervention, extensive coverage, management according to the law” principle of work, comprehensive promotion of the development of mental health work in the new century. One of the ways to reduce and prevent mental illness is to improve the quality of the population and to promote eugenics.
Schizophrenia tends to occur in young adults, and most patients are in their marriage and childbearing years when they develop schizophrenia. Can schizophrenic patients marry? Can they have and raise their offspring? This is an issue of great concern to schizophrenia patients and their families, and is also a frequent problem for psychiatrists, family planning workers and grassroots community workers in their work. How to guide the issue of marriage and childbirth of schizophrenia patients is related to the physical and mental health of the general public and the stability of society, and is of great significance in ensuring social and economic development, building a harmonious socialist society and social stability.
As people’s awareness of mental illness and legal consciousness increases, disputes arising from the marriage and childbirth of this group of people are frequently reported, and the following cases are typical representatives of the disputes.
Case 1
Zhang (male) was introduced to Tian (female) as a couple, after the marriage, Zhang found Tian abnormal behavior, often dazed, mumbling, think someone persecuted himself, chasing passers-by, repeatedly asked Tian’s family, learned that Tian was diagnosed with schizophrenia before marriage, has been taking medication, the family deliberately concealed Tian’s condition in order to cook rice, Zhang could not accept his wife suffering from schizophrenia, resorted to The law was finally ruled as an invalid marriage.
Case 2
A
A Ling (female) was introduced to Lin, a university teacher, who was so impressed with Lin’s knowledge and manners that they soon entered into a marriage.
The husband was always evasive when asked about the name of the drug and its efficacy. In addition, Lin was determined to take contraceptive measures in the couple’s life and did not want to have children. Ling was in deep pain, on the one hand, she was eager to be a mother and hated her husband for concealing his medical history before marriage, on the other hand, she could not bear to part with the marriage that she had already invested her feelings in.
Case 3
Thirty years ago, Jiang and Xu’s mother were both hospitalized for schizophrenia, and they met each other while visiting their mother. After the marriage, they had two children, and after more than 20 years, both children were diagnosed with schizophrenia as adults, and Jiang and Xu were completely devastated to see their children repeat the mistakes of their grandparents.
The three cases cited above reflect the three aspects most often involved in the issue of marriage and parenthood for people with schizophrenia: legal, ethical, and genetic.
Legal guidelines for marriage and childbirth for schizophrenic patients
Local mental health regulations in Beijing, Shanghai, Hangzhou, Ningbo, Wuhan, and other places have not made clear the legal guidelines for marriage and childbirth for schizophrenia patients.
The local mental health regulations in Beijing, Shanghai, Hangzhou, Ningbo, and Wuhan have not made clear provisions on the issue of marriage and childbirth for schizophrenics. The Law of the People’s Republic of China
The Law of the People’s Republic of China on Maternal and Infant Health Care, which was adopted at the tenth meeting of the Standing Committee of the Eighth National People’s Congress of the People’s Republic of China on October 27, 1994 and came into effect on June 1, 1995, is
It is an important legal basis for governments at all levels and health administrative departments to develop maternal and child health, strengthen maternal and child health management, and regulate maternal and child health practices.
In the revised Marriage Law of the People’s Republic of China, Chapter II, Article 7 states, “Marriage is prohibited under one of the following circumstances: (1) blood relatives in the direct line and collateral blood relatives within three generations; (2) suffering from diseases that are medically considered unfit for marriage.”
The
The so-called diseases that should not be married are not specified in the Marriage Law, according to Article 7 (3) of the Law of the People’s Republic of China on Maternal and Infant Health Care (hereinafter referred to as the Maternal and Infant Law), which stipulates that: “A man and a woman who intend to get married may suffer from diseases that affect marriage and childbirth.
Premarital medical examination must be conducted for diseases affecting marriage and childbirth, premarital medical examination includes examination of the following diseases: (1) serious hereditary diseases; (2) designated infectious diseases; (3) related mental illness. After premarital medical examination
Medical examination, health care institutions should issue a certificate of premarital medical examination.” The regulations clarify the main types of premarital medical examination includes mental illness, also means that the institution issuing the premarital medical examination certificate must bear the corresponding
legal responsibility. It is important to note that the diseases that must undergo premarital medical examination do not mean that the disease does not allow marriage. Article 9 of the Maternity and Infancy Law states: “If, after premarital medical examination, a person is infected with a specified infectious disease during the infectious period or a relevant mental illness during the morbidity period, he or she shall be subject to a premarital medical examination.
Within or related to the onset of mental illness, the physician shall provide a medical opinion; men and women who are ready to marry should suspend the marriage.” Article 10: “Premarital medical examination, the diagnosis of the medical opinion of the unsuitable for childbirth
serious hereditary diseases, the physician shall explain the situation to both men and women, and provide a medical opinion; with the consent of both men and women, who do not have children after taking long-term contraceptive measures or performing ligation surgery, they can get married.” In other words, after treatment, schizophrenic patients whose symptoms have been eliminated, whose social functioning is intact, whose self-knowledge has been restored, and who are not in an acute phase of illness, are legally allowed to fall in love and get married, and whose rights and obligations extended by marriage are protected by law.
Amended
The amended Marriage Law of the People’s Republic of China also added the content of invalid marriage, invalid marriage refers to the illegal marriage that does not have legal effect due to the lack of marriage establishment elements, that is, the union of a man and a woman because they do not meet the substantive conditions for marriage stipulated by law, and therefore do not
The marriage of a man and a woman does not have the legal effect of marriage because the marriage does not meet the substantive conditions of the law. In Chapter II, Article 10 of the Marriage Law provides that a marriage is invalid if one of the following circumstances: (a) bigamy; (b) a kinship relationship that prohibits the marriage
(c) the marriage is not yet cured after the marriage of a disease that is considered medically inadvisable; (d) the legal age of marriage is not yet reached. Case 1 in the overview belongs to the third situation, so the marriage was ruled invalid; however
However, if the patient’s mental illness is well-controlled, self-aware and capable of civil behavior before marriage, and the spouse is aware of the patient’s illness and accepts it before marriage, the marriage is valid.
In the Law of the People’s Republic of China on Population and Family Planning, patients with schizophrenia are not listed as a special group, so they should be treated together with ordinary people and enjoy the rights and obligations granted by law.
Ethical guidelines for marriage and childbirth of schizophrenic patients
”Doctor, my child has schizophrenia and his condition is stable now. I’m worried that people will know about his marriage. “Doctor, my child’s mother is now diagnosed with schizophrenia, I want to get a divorce, is it okay?” “Doctor, please help me, please tell my son’s partner that schizophrenia is a completely curable disease, and it’s okay.” These are situations that psychiatrists often encounter in their outpatient clinics, and these nagging questions involve not only legal aspects, but also ethical aspects. It is important that we approach these issues not only from a compassionate level, but also with the basic principles of ethics as a guide.
Medical
Medical ethics is a discipline that applies general ethical principles to solve medical moral problems and medical moral phenomena in the process of medical and health care practice and medical development.
It is a branch of ethics. Medical ethics is a discipline that uses theories and methods of ethics to study the moral issues of human-human, human-society, and human-nature relationships in the field of medicine. Its basic principles are: do no harm, benefit, respect and justice.
(i) The principle of no harm (the principle of do no harm)
Do no
The principle of no harm refers to the medical staff in the process of diagnosis and treatment of its medical behavior, motives and results should avoid all harm to the patient’s body and mind, which is the basic principle that medical workers should follow. Generally speaking, all medically necessary
In general, if it is medically necessary and belongs to the indications of medical treatment, the means of consultation and treatment implemented are in line with the principle of no harm. On the contrary, if the medical treatment is not beneficial, unnecessary or contraindicated to the patient, but intentionally or unintentionally forced to implement, so that the patient suffers
The principle of do no harm is violated if the treatment is intentionally or unintentionally forced on the patient and the patient is harmed. Medical personnel in medical practice should establish the medical concept of no harm, abide by the ethical principle of no harm, reduce the harm of medical treatment to the smallest extent, and strive to obtain the most desirable treatment effect at the smallest cost.
The principle of no-harm does not require medical personnel to do no harm.
The principle of no harm does not require that medical personnel should not have any harm to patients, let alone become an excuse for doctors to pass the buck and hesitate in making medical decisions, some harm is necessary in the process of treating diseases and saving lives. Medical personnel must treat patients with schizophrenia in the acute phase with antipsychotic medication, patients who have a requirement to marry or have children should be advised to withhold marriage, and patients with schizophrenia in the acute phase who are pregnant should be advised to terminate their pregnancy, rather than following the no-harm principle as an excuse for inaction.
Worth
It is important to note that medical staff should also inform patients of their medical conditions as part of the consultation and treatment, and should also follow the principle of no harm in the process of informing them of their conditions.
The harmless principle is not only for the patient, but also for those who have an interest in the condition, such as deliberately concealing the condition from the patient’s marriage partner at the request of the family, and following the harmless principle for the patient.
The principle of “no harm” has been followed, but it is also a violation of the purpose of the principle of “no harm” to cause more harm to the people concerned.
(2) Beneficial principle
Beneficial principle refers to the medical personnel’s medical treatment behavior for the purpose of protecting the interests of patients, promoting their health, and enhancing their happiness. The results of their behavior is not only beneficial to patients, but also conducive to the development of medical career and medical science, and conducive to promoting the health of the population and human beings.
The principle of benefit requires that the medical staff’s actions do benefit the patient and must meet the following conditions: the patient does suffer from a disease; the medical staff’s actions are related to relieving the patient’s suffering; the medical staff’s actions may be able to relieve the patient’s suffering; and the patient’s benefit will not bring too much harm to others.
Beneficial
The principle of beneficence consists of two levels, the lower level requiring no harm to the patient and the higher level requiring the benefit of the patient. Beneficial includes no harm, and no harm is the minimum requirement and embodiment of beneficial. Medical personnel in the treatment process should adhere to the no-harm
The combination of beneficial guidelines, that is, its medical behavior not only to avoid bringing unnecessary physical and mental harm and pain to patients, but also should bring practical benefits. For example, if a female schizophrenic patient is pregnant in the acute stage, after termination of pregnancy, she should actively treat the patient’s illness, conduct prenatal assessment and provide genetic counseling after her illness has stabilized and remitted, and provide guidance on marriage and childbirth for schizophrenic patients.
(iii) Principle of respect
The principle of respect means that medical personnel should respect patients and their rational decisions, also known as the principle of autonomy, which means that patients have the right to make independent and voluntary decisions in the process of receiving medical treatment. The principle of autonomy reflects respect for the autonomy of the autonomous person, recognizing his or her right to make rational judgments and choices based on his or her own considerations.
It is important to note that the principle applies only to those who are capable of making rational decisions, and that medical personnel are justified in discouraging and interfering with irrational behavior as an effective protection against self-harm for those who make decisions. The implementation of the principle of deference involves informed consent, and in the case of schizophrenic patients who are not self-aware, their rational processing of the event
For patients with schizophrenia who are not self-aware, their rational processing of events, judgment, and ability to act may be affected and limited by their condition, and their family members or guardians must then make choices on their behalf.
The medical staff has the obligation to provide the decision maker with sufficient medical information to make a rational choice. At the same time, the medical staff should respect the rational decision of the decision maker based on the understanding that he or she has sufficient medical information. If a person in probation
If a patient with a previous diagnosis of schizophrenia who is in a period of probation plans to have offspring, the medical staff will conduct genetic counseling, explain the powerful relationship, give advice, and let the person decide whether or not to adopt it, the medical staff should reflect the principle of respect and respect their final decision, and not interfere through administrative or legal means.
Medical
Medical personnel respect the autonomy of the patient in no way means to give up their responsibilities, and must deal with the relationship between patient autonomy and the absence of harm and benefit. Respecting the patient includes helping, persuading, or even limiting the patient to make choices. Physicians must help
Help the patient choose a reasonable consultation and treatment plan as well as a scientifically based marriage plan, and must provide the patient with information that is correct, easy to understand, appropriate, and conducive to patient confidence. When the patient is well informed and understands the information about his or her condition
When the patient is well informed and understands the information about his or her condition, the patient’s choices and the physician’s recommendations are often consistent. When the patient’s choices are beyond the realm of reason, it is more important to take into account the principles of no harm, no gain. No harm, no benefit is not only narrowly defined as no harm or benefit to the patient, but also as no harm to the patient.
The term “no harm, no benefit” is not only narrowly defined as no harm or benefit to the patient’s interests, but also includes the broader sense of no harm or benefit to the patient’s family and social interests. When the patient’s choice is potentially life-threatening, the physician should actively counsel the patient to make the best choice. When the patient’s
（When the patient’s (or family’s) independent choice conflicts with the interests of others or society, the physician should fulfill his or her responsibility to others and society, and also minimize the patient’s loss.
(iv) Principle of fairness
Medical
The principle of justice in health care means that everyone in society has equal access to health resources, i.e., equal access to health care, and also has the right to participate in the use and distribution of health resources. It can also be understood as the right to be treated in accordance with the right to life, in accordance with reasonable or acceptable conditions.
It can also be understood as the right to receive the medical care that each person deserves, in accordance with the right to life and in accordance with reasonable or ethical principles that are acceptable to all. In medical practice, justice is not only formal justice, but also content justice. For example, in the allocation of scarce health resources
In the distribution of scarce health resources, it must be based on the actual needs, abilities and contributions to society of each individual. The same people should be treated equally and different people should be treated differently in the distribution, burden and benefit. In the practice of medicine, the principle of equity should pay attention to the content of
wholeness, priority order, and the gap between content and actual fulfillment.
The principle of fairness is also reflected in the attitude of medical personnel to treat patients fairly, and patients with schizophrenia and patients with other diseases should be treated fairly, and treated fairly between patients who have been cured, those who have not been cured, and those who are refractory. We should assess the patient’s condition and heredity and inform the person concerned in a factual manner. We should not absolutely deprive the patient of his or her reproductive and parental rights simply because he or she has schizophrenia, regardless of the severity of the condition and the actual situation.
IV. Genetic guidelines for marriage and childbirth in schizophrenia patients
There is a Chinese proverb: “A dragon gives birth to a dragon, a phoenix gives birth to a phoenix, and a mouse’s son makes a hole in the ground!” fully reflects the role of heredity in racial continuity. “A mother gives birth to nine sons, and each of the nine sons is different!” again reflecting the influence of environment on genetic factors.
Studies on the etiological mechanisms of schizophrenia have been described in detail in the previous chapters, and only those aspects related to genetic counseling will be described here. Since the last century, rapid advances in molecular biology techniques and the results of schizophrenia genealogy studies have demonstrated a genetic link between the occurrence of schizophrenia. In a genealogical survey of schizophrenia, it was found that the prevalence rate of first-degree family members of psychiatric patients was 6.2 times higher than that of the general population, and that 16.4% of children born to schizophrenic patients married to healthy individuals had schizophrenia, while 39.2% of children born to both men and women with schizophrenia had schizophrenia. Thus, schizophrenia does have a genetic predisposition, but not all children born to schizophrenics have schizophrenia.
Studies of dizygotic twins with schizophrenia have shown that the rate of schizophrenia homozygosity in dizygotic twins is 15%, and even in identical twins with 100% identical genetic profiles the rate of schizophrenia homozygosity is only 53%, suggesting that about 50% of the pathogenesis of schizophrenia is due to life events, i.e., environmental factors. This result is further supported by studies of foster children, in which the incidence of schizophrenia in children of biological parents with schizophrenia genes who were adopted by healthy families was 18.8%, while the incidence of schizophrenia in children of healthy parents who were adopted by parents with schizophrenia was 10.7%, both much higher than the 1% incidence rate in the general population.
Therefore, it is now accepted that schizophrenia is a disease caused by the interaction of environmental factors and genes.
Environmental factors influence the coding of genes, increase the susceptibility of genes to schizophrenia, and finally lead to the development of the disease. Individuals with susceptibility genes are affected by external environmental influences during maternal neurological development, such as advanced parental age, parental substance abuse, fetal malnutrition and hypoxia, maternal intrauterine
The abnormal development of the nervous system of the brain can be caused by the influence of the external environment, such as high parental age, parental substance abuse, fetal malnutrition and hypoxia, intrauterine viral infections, changes in the maternal immune system during pregnancy, birth in the cold season, and obstetric complications at birth. In the last two years
Nicodemus reported four candidate genes associated with the pathogenesis of schizophrenia that act in the hypoxic environment of the body, namely AKT1, BDNF (brain-derived nerve growth factor), GRM3 (prometabolic glutamate receptor 3), and DTNBP1. In a study of the pathogenesis of schizophrenia in patients with and without obstetric complications, these genes were found to play a role in the interaction with the external environment showed a high correlation in the presence or absence of interactions between
Developmental
If the neurological system of an abnormally developed brain is further adversely affected by the external environment during subsequent growth and development, such as by a major stressful event, the individual is likely to develop brain dysfunction and psychiatric symptoms at the macroscopic level, and at the microscopic level, in the form of apoptosis.
Microscopically, this is reflected in apoptosis of nerve cells, retraction of dendrites, abnormal synaptic connections, abnormal differentiation, rearrangement and remodeling of nerve cells, which finally leads to neurodegenerative changes and chronic pathological processes.
Gender and marital status also have an impact on the onset of schizophrenia. Epidemiological surveys have shown that the age of onset of schizophrenia in men is 2-3 years earlier than in women, and it is assumed that estrogen may have a protective effect on the organism during the onset of schizophrenia. The risk of developing schizophrenia is up to 50 times higher in men who have never been married compared to married men, and about 15 times higher in women.
In addition, immigration factors and being an ethnic minority also play a role in the development of schizophrenia, with the prevalence of schizophrenia among the descendants of Caribbean immigrants to the United Kingdom being 10 times higher than in the original country of residence. The incidence of schizophrenia among ethnic minorities living in the United Kingdom is
The prevalence of schizophrenia among ethnic minorities living in the UK is three times higher than that of the general population. Some experts have hypothesized from these epidemiological findings that socio-cultural changes and rapid social development are among the reasons for the increasing incidence of the disorder, that industrialization has led to changes in the nutritional profile during pregnancy, and that the incidence of schizophrenia during pregnancy has increased.
Changes in the nutritional profile during pregnancy, increased exposure to more novel infections during pregnancy, and exposure to more social stressors as first- and second-generation immigrants, with the result that gene-environment interactions finally lead to an increase in the incidence of schizophrenia.
The most influential environmental factors in the development of schizophrenia remain obstetric complications such as pre-eclampsia and perinatal brain injury, unplanned pregnancies, poor nutrition during the first trimester, cold season births, and maternal influenza virus infection during pregnancy are all high risk factors for the development of schizophrenia, in addition to maternal education, the presence of social anxiety, living alone, or maternal skill immaturity all contribute to The mother’s education, social anxiety, solitude, or immature maternal skills all have a predisposing effect on the onset of schizophrenia.
In the last
The concept of plasticity in nerve cells was introduced in the last century, suggesting that nerve cells do not remain unchanged after maturation and can change in response to different stimuli from the external environment. Currently, there are also
A similar hypothesis has been put forward, suggesting that individual genes may undergo DNA methylation modification during development and in adulthood in response to changes in the external environment, and that the methylation-modified DNA can weaken the neuronal function of the GABA-ergic system and the neuronal function of the GABA-ergic system.
neuronal function of the GABAergic system, as well as potentially affecting the 5-HTergic and DA neurotransmitter systems, which have been shown to be closely associated with the development of schizophrenia.
Few domestic studies have reported on the correlation between environment and schizophrenia, and most of the studies that have been reported have been conducted from the perspective of a single environment, the family. Lv Feng et al. used the Chinese version of the Family Environment Scale to test 100 schizophrenia patients and 100 normal individuals, and performed stepwise multiple regression analysis on each factor affecting the family environment of schizophrenia patients, respectively. The results found that schizophrenia patients’ families exhibited low intimacy, low family density, and low self-esteem.
Families of schizophrenic patients showed low intimacy, low emotional expression, low success, low organization, and high ambivalence and poor control. The study also found that families with cadre status and intellectual fathers had high intimacy and emotional expression, while
The study also found that families with cadre fathers and intellectuals have high intimacy and emotional expression, and at the same time, may reduce family conflict to a certain extent, which is conducive to children’s growth and physical and mental health, and that families with cadre mothers, intellectuals and non-divorced marital status can form a better cultural atmosphere and have better entertainment.
The mother’s cadre status, intellectual family, and the patient’s non-divorced marital status can make the family form a better cultural atmosphere and have better entertainment. In addition, it was mentioned in the study that the patients’ place of residence and level of education had an impact on family ambivalence, but what the impact was was not further clarified in the paper.
At present, genetic counseling for schizophrenia patients in China mostly follows the genetic counseling form for schizophrenia developed by Fushu Cha et al. The form was prepared by Zhang Huasong of Shanghai Jiaotong University using computer technology based on genetic epidemiological data of schizophrenia in 15 provinces and cities across China.
The table was mainly used to estimate the risk of schizophrenia in children born under various conditions. The number of sick parents in the table: 0, 1, and 2 indicate normal parents, one sick parent, and both sick parents, respectively; the number of normal and sick (maternal) grandparents indicates the number of normal and sick siblings out of 4; and the number of normal and sick siblings indicates the number of normal and sick siblings of the consultee. If there were schizophrenic patients among the uncles, aunts, and uncles of the consultee, additional numbers were used, and the so-called additional numbers referred to the number of patients among the uncles, aunts, and uncles of the consultee.
If the risk of re-emergence is more than 5%, it is better not to have children, and if it is more than 10%, it is better to advise them not to have any more children. If they insist on having children, they should pay attention to the health care during pregnancy and improve the environment of growth and development to minimize the negative impact of the environment on the disease.
If a patient has schizophrenia and his wife is normal, the number of sick parents is 1. If one of the patient’s parents is sick and the parents-in-law are normal, the number of normal grandparents is 3 and the number of sick parents is 1. If one child is normal, the number of normal siblings is 1 and the number of sick siblings is 0. In addition, if one of the future child’s uncles, aunts and uncles had schizophrenia, the additional risk was 1.46%, and the total risk for the future child was 4.23% + 1.46% = 5.69%, with a risk of revelation of more than 5%. In this case of whether both parents have a positive family history, some experts suggest that it is better not to have any more children, but most psychologists and legal experts also suggest that it is still more humane to respect the free choice of the patient’s family to have children after understanding the pros and cons, with the percentage of risk being informed.