I. Overview
As an important public health problem and a prominent social problem, mental health has become the consensus of China and the international community. In the “China Mental Health Work Plan (2002-2010)”, it is proposed that China’s mental health work includes not only the prevention and treatment of various mental illnesses, but also the reduction and prevention of various mental and behavioral problems, and should follow the working principles of “prevention-oriented, combined prevention and treatment, focused intervention, extensive coverage, and lawful management”. Management in accordance with the law” principle of work, and comprehensively promote 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 get married? 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 Ling (female) was introduced to Lin Mou, a university teacher, A Ling was attracted to Lin Mou’s knowledge and manners, the two soon entered the marriage hall, after the marriage careful A Ling found that her husband secretly took some unknown drugs every day, asked about the name of the drugs and the efficacy of the husband is always evasive, in addition, Lin Mou firmly in the couple’s life to take contraceptive measures, unwilling to have children, a chance A Ling found Her husband was diagnosed as a schizophrenic before marriage and has been taking medication to maintain a stable condition and normal social functioning. On the one hand, she was eager to be a mother and hated her husband for hiding his medical history before marriage, on the other hand, she could not bear to part with the marriage 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 that have been introduced do not explicitly address the issue of marriage and childbirth for schizophrenic patients. The Law of the People’s Republic of China on Maternal and Infant Health Care, which was adopted by the Standing Committee of the Eighth National People’s Congress of the People’s Republic of China at its tenth meeting on October 27, 1994 and came into effect on June 1, 1995, is the first law in China to protect the health of women and children and to improve the quality of the birth population; it is the first law for governments and health administrative departments at all levels to develop maternal and child health care, strengthen maternal and child health care, and regulate maternal and infant health care practices. It is an important legal basis for governments and health administrative departments at all levels to develop maternal and child health, strengthen maternal and child health management, and regulate maternal and child health care 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 unsuitable for marriage.”
The so-called should not marry the disease in the “Marriage Law” does not refer to, according to the “Maternal and Infant Health Law of the People’s Republic of China” (hereinafter referred to as the Maternal and Infant Law) in Article 7 (3): “Premarital medical examination must be conducted for men and women who intend to marry may suffer from diseases affecting marriage and childbirth, premarital medical examination includes examination of the following diseases: (1) serious hereditary disease; (2) designated infectious diseases; (3) related mental illness. After premarital medical examination, health care institutions shall issue a certificate of premarital medical examination.” The regulation clarifies that the main types of premarital medical examination includes mental illness, which also means that the institution issuing the premarital medical examination certificate must bear the corresponding legal responsibility.
It should be noted that the disease must be subject to premarital medical examination does not mean that the disease is not allowed to marry. Article 9 of the Mother and Child Law states, “Upon premarital medical examination, the physician shall render a medical opinion if the person is suffering from a specified infectious disease during the infectious period or a relevant mental illness during the morbidity period; the man and woman who intend to marry shall suspend the marriage.” Article 10: “By premarital medical examination, the diagnosis of serious hereditary diseases that are considered medically inadvisable for childbirth, the physician shall explain the situation to both men and women and provide a medical opinion; with the consent of both men and women to take long-acting contraceptive measures or perform ligation surgery without childbirth, you 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 the acute onset phase, are legally allowed to fall in love and get married, and whose rights and obligations extended by marriage are protected by law.
The revised Marriage Law of the People’s Republic of China also adds the content of invalid marriage, which 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 does not have the legal effect of marriage because it does not meet the substantive conditions for marriage as stipulated by law. In Chapter 2, Article 10 of the Marriage Law provides that a marriage is invalid if one of the following circumstances exists: (a) bigamy; (b) a kinship that prohibits marriage; (c) a disease that is medically inadvisable to marry before marriage and has not been cured after marriage; (d) under the legal age of marriage. However, if the patient’s mental illness is well-controlled, self-aware and has civil capacity before marriage, and the spouse is aware of the patient’s condition 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 bear the corresponding obligations granted by law.
Ethical guidelines for marriage and childbirth of schizophrenic patients
”Doctor, my child has schizophrenia and his condition is now stable. I am worried that others will know about it and it will affect his marriage. “Doctor, my child’s mother is now diagnosed with schizophrenia and I want to get a divorce, is that okay?” “Doctor, please help, please tell my son’s date that schizophrenia is a completely curable disease, it’s not related.” These are situations that psychiatrists often encounter in their outpatient clinics, and these nagging questions involve not only legal aspects, but also ethical aspects. We should not deal with this aspect only on a compassionate level, but should be guided by the basic principles of ethics.
Medical ethics is a discipline that applies general ethical principles to solve medical ethical problems and medical ethical phenomena in the process of medical and health care practice and medical development. 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)
The principle of do 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 medical necessity, belong to the medical indications, the implementation of the means of diagnosis and treatment is in line with the principle of no harm. On the contrary, if the means of diagnosis and treatment is not beneficial to the patient, unnecessary or contraindicated, and intentionally or unintentionally forced to implement, so that the patient is harmed, it is contrary to the principle of no harm. Medical personnel in medical practice activities 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 not have any harm to the patient, let alone become an excuse for doctors to pass the buck and hesitate when making medical decisions, some harm is necessary in the process of treating disease 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 already pregnant should be advised to terminate their pregnancy, rather than following the no-harm principle as an excuse for inaction.
It is worth noting that the medical staff’s notification of the patient’s condition is also part of the diagnosis and treatment, and the principle of no harm should also be followed in the process of informing the patient of the condition. If the marriage object deliberately conceals the disease at the request of the family, the patient follows the principle of no harm, but causes more harm to the relevant personnel, which is also a violation of the purpose of the principle of no harm.
(ii) Beneficial principle
Beneficial principle refers to the medical personnel’s medical treatment behavior to protect the interests of patients, promote the health of patients, and enhance their well-being. 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 actions of medical personnel do benefit the patient and must meet the following conditions: the patient does suffer from a disease; the actions of medical personnel are related to relieving the patient’s suffering; the actions of medical personnel may be able to relieve the patient’s suffering; and the patient’s benefit will not bring too much harm to others.
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, no harm is the minimum requirement and embodiment of beneficial. Medical personnel in the treatment process should adhere to the combination of harmless and beneficial guidelines, that is, their medical behavior not only to avoid unnecessary physical and mental harm and pain to patients, but also should bring practical benefits. For example, if a female schizophrenic patient in acute pregnancy is terminated as a last resort, the patient’s illness should be actively treated, prenatal evaluation and genetic counseling should be provided after her condition has stabilized and remitted, and guidance on marriage and childbirth for schizophrenic patients should be done.
(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 respect involves informed consent. For patients with schizophrenia who are not self-aware, their rational processing, judgment, and ability to act may be affected and limited by their condition, and their family or guardian must make choices on their behalf. At the same time, the medical staff should respect the decision maker. At the same time, the medical staff should respect the rational decision made by the decision maker based on the understanding that he or she has sufficient medical information. If a patient in remission with a previous diagnosis of schizophrenia is planning to have offspring, the medical staff should conduct genetic counseling, explain the powerful relationship, give advice, and let the person decide whether to adopt it.
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 no harm and benefit. Respecting the patient includes helping, persuading, or even limiting the patient to make choices. To help patients choose a reasonable consultation and treatment plan as well as a scientifically based marriage plan, physicians must provide patients with information that is correct, easy to understand, appropriate in amount, and conducive to patient confidence. When patients are well informed and understand the information about their condition, the patient’s choices and the physician’s recommendations are often consistent. When the patient’s choices are beyond the realm of reason, we need to take more into account the principles of no harm, no gain. This means not only in the narrow sense of no harm or benefit to the patient’s interests, but also in the broader sense of no harm or benefit to the patient’s family and society. 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 (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 as well as minimize the patient’s loss.
(iv) The principle of justice
The principle of justice in medical treatment means that everyone in society has equal access to health resources, i.e., equal access to medical treatment, and also has the right to participate in the use and distribution of health resources. It can also be understood as giving each person the medical services he or she deserves according to the right to life and in accordance with reasonable or acceptable ethical principles. In medical practice, justice refers not only to formal justice, but also emphasizes the content of justice. For example, the allocation of scarce health resources must be based on the actual needs, abilities and contributions to society of each individual. When allocating, burdens and benefits, the same people are treated equally and different people are treated differently. In medical practice, the principle of equity should pay attention to the holistic nature of content, priority order, and the gap between content and actual delivery.
The principle of fairness is also reflected in the attitude of medical personnel to treat patients fairly, and patients with schizophrenia and 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 to treatment. 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 his or her condition and the actual situation.
IV. Genetic guidelines for marriage and childbirth in schizophrenia patients
There is a Chinese saying: “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 etiologic mechanisms of schizophrenia have been detailed in 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 the genealogical data 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, and 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, and that some genetic and non-genetic factors work together in the development of the disease. Individuals with susceptibility genes can develop abnormalities in the neurological system of the brain if they are influenced by the external environment during neurological growth and development in the mother, such as: advanced parental age, or the presence of parental substance abuse, fetal malnutrition and hypoxia, intrauterine viral infections in the mother, changes in the maternal immune system during pregnancy, birth in the cold season, and the presence of obstetric complications at birth. In the last two years Nicodemus reported that there are four candidate genes related to the pathogenesis of schizophrenia that act in the hypoxic environment of the organism, namely AKT1, BDNF (brain-derived nerve growth factor), GRM3 (prometabolic glutamate receptor 3), and DTNBP1. In the study of the pathogenesis of schizophrenia patients with or without obstetric complications, it was found that these genes have a significant role in relation to the presence of interactions between the external environment showed a high correlation.
If the neurological system of the brain with abnormal development is further adversely affected by the external environment during subsequent growth and development, such as experiencing a major stressful event, individuals are likely to develop brain dysfunction and psychiatric symptoms at the macroscopic level, which are reflected at the microscopic level by apoptosis of neuronal cells, retraction of dendrites, abnormal synaptic connections, abnormal differentiation, rearrangement and remodeling of neuronal cells, and finally leading to neurodegenerative changes and chronic pathological process.
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 that in women, and it is assumed that estrogen may have a protective effect on the body 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 UK being 10 times higher compared to the population in their country of origin. The prevalence of schizophrenia among ethnic minorities living in the UK is three times higher than in 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 tendency to increase the incidence of the disorder, that the process of industrialization leads to changes in the nutritional profile during pregnancy, that there is an increased likelihood of exposure to more novel infections during pregnancy, and that as first and second generation immigrants, more social stressors are encountered, with the result that gene-environment interactions finally lead to increased 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 The onset of schizophrenia has a predisposing effect.
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. A similar hypothesis has been put forward, suggesting that the genes of individuals may undergo DNA methylation modifications during development and in adulthood in response to changes in the external environment, and that the methylation-modified DNA may diminish the neuronal function of the GABAergic system, as well as potentially affect the 5-HTergic and DA neurotransmitter systems, which have been shown to be closely related to the development of schizophrenia. .
Few domestic studies have reported on the relevance of environment to 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 families of schizophrenia patients exhibited low intimacy, low emotional expression, low success, low organization, and high ambivalence and poor control. The study also found that families with cadre fathers and intellectuals had high intimacy and emotional expression, which may also reduce family ambivalence to a certain extent and facilitate children’s growth and physical and mental health, and that families with cadre mothers, intellectuals, and non-divorced marital status resulted in a better cultural atmosphere and better recreation. In addition, it was mentioned in the study that patients’ place of residence and level of education had an effect on family ambivalence, but the effect was not further elucidated in the paper.
Currently, genetic counseling for schizophrenia patients in China mostly follows the genetic counseling form for schizophrenia developed by Fushu Cha et al. This 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. In the table, the number of sick parents: 0, 1 and 2 indicate that both parents are normal, one is sick and both have the disorder, respectively; the number of normal and sick (maternal) grandparents indicates the number of normal and sick among 4 persons; the number of normal and sick siblings indicates the number of normal and sick among the 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 exceeds 5%, it is better not to have children, and if the risk exceeds 10%, to advise them not to have any more children, and if they insist on having children, to pay attention to the health care during pregnancy and to improve the environment of growth and development, so as to minimize the negative impact of the environment on the disease.
Example.
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 (grand)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.