임신 중 약물 사용을 형사 처벌하는 미국의 정책과 비용-효용 분석

#8 임신 중 약물 사용을 형사 처벌하는 미국의 정책과 비용-효용 분석

(Criminal Justice Prenatal Substance Abuse Policy: Based on Cost-Benefit Analysis)

 

미국의 몇몇 주에서는 임신 중에 약물 남용을 하는 경우 형사 처벌을 하는 정책을 두고 있습니다. 임신 중인 산모들만 콕 집어서 형사 처벌에의 대상으로 삼는 것인데, 그 근거는 주마다 조금씩 다르지만 거칠게 말하면 "태아에 대한 아동학대"이기 때문이라는 것입니다. 이런 정책은 타당할까요? 타당하지 않다면, 그 근거는 무엇이 되어야 하며, 어떤 방식으로 이 정책을 비판해야 할까요?

제가 이런 정책이 있다는 걸 알게 된 것은 지난 학기 들었던 한 수업에서였습니다. 중간 과제가 비용-효용 분석(cost-benefit analysis)와 관련된  분석을 하는 것이었는데, 교수님이 제공한 세 가지 제시문 중 하나가 바로 이 정책에 대한 것이었습니다. 그 제시문은, "임신 중 약물 복용(prenatal substance abuse)으로 인해 아동 복지 제도로 관리해야 하는 신생아의 수가 증가하고 있다는 증거가 있다면, 주 정부는 임신 중 약물 사용을 형사 처벌하는 정책을 폐지해야 하는가?(Should states repeal their criminal justice-related prenatal substance abuse policy when evidence suggests that it is contributing to an increase in the number of infants entering the child welfare system because of parental drug use?)"였습니다. 이 제시문을 읽고서 곧장 '이 정책은 틀렸다', 그리고 '이 제시문도 틀렸다'는 생각이 들었습니다. 

여성에 대한 차별

첫째로 '이 정책이 틀렸다'고 생각한 이유는 이것은 명백히 여성에 대한 차별이기 때문이었습니다. 똑같이 약물을 사용한 경우에 남성은 처벌받지 않고, 임신하지 않은 여성도 처벌받지 않는데, 임신 중인 여성만 처벌의 대상이 된다면, 이것은 여성을 동등한 시민으로 바라보는 것이 아니라, 아이를 임신하는 자궁으로만, 아이 생산자(baby carrier)로서 대상화한 시각을 정책에 그대로 반영한 것이 아닌가 (이 정책에 대한 저의 첫 인상을 거칠게 표현한 것입니다) 하는 생각이었습니다. 이런 시각을 가진 정책을 시행하며 여성을 처벌하는 것은 임신한 여성과, 임신할 가능성을 가진 모든 여성에 대한 억압이라고 말입니다. 

더불어, 약물 오남용은 처벌이 아니라 치료를 해야 하는 대상이 아닌가 하는 의문도 함께 들었습니다. 넷플릭스에서 볼 수 있는 스탠드업 코미디 <정상이 아니야(Not Normal)>에서 완다 사이크스(Wanda Sykes)는 인종차별을 풍자하면서 '흑인들이 많이 하는 마약(크랙코카인)은 처벌하려 하면서 백인들이 많이 하는 마약(오피오이드)는 치료하려 한다'는 말을 합니다. 임신한 여성이 약물을 사용했을 때 그를 치료의 대상으로 바라보는 것이 아니라 처벌의 대상으로 바라보는 것 또한 비슷한 맥락으로 바라볼 수 있을 것 같습니다. 

실제로 엠네스티 인터네셔널은 미국의 이러한 정책이 "임신을 범죄화(criminalizing pregnancy)"라고 말하며 이 정책이 왜, 어떻게 여성에 대한 차별인지 서술한 70페이지 가량의 보고서를 출판한 바 있습니다. (Amnesty International. (2017). Criminalizing Pregnancy: Policing Pregnant Women Who Use Drugs in the USA. Retrieved from www.amnesty.org)

차별적인 정책을 경제적 이유로 비판하는 것은 타당한가

둘째로 '이 제시문이 틀렸다'고 생각한 것은, 차별적인 정책을 시행하면 안 되는 이유는 '그 정책이 차별적이기 때문'이어야 하지 '그 정책이 경제적으로 이득이 되지 않기 때문'이 되면 안 된다고 생각했기 때문입니다. 

경제적 관점으로 어떤 정책에 대해 비용-효용 분석을 한다는 것은, 분석 결과 효용이 더 크다면 그 정책을 시행하겠다는 의도가 담겨있다고 생각합니다. 따라서, 임신 중 약물 남용을 형사 처벌하는 정책처럼 이미 그 의도와 내재된 시각이 차별적인 정책을 가지고 비용-효용 분석을 한다면 그는 이 정책에 도덕적 타당성을 승인해주는 행위나 마찬가지라고 생각했습니다. 

차별적인 정책이 입안되려 할 때 "이건 차별적이어서 옳지 않다"는 말만으로 막지 못하고, "당신의 세금이 낭비될 것입니다"와 같이 경제적 근거를 가지고 와야만 통하는 사회는 도대체 어떤 사회란 말인가요. 

하지만, 좋은 것이 왜 좋은 지를 쓰는 것보다 싫은 것이 왜 싫은 지를 쓰는 것이 훨씬 더 쉽고 몰입하기 쉽기 때문에 저는 이 과제에서 임신 중 약물 남용에 대한 이 주제를 골랐습니다. 

비용 - 아동 복지 비용 증가

이 보고서에서 비용을 다루는 부분에서는, 지문에서 물어본 내용을 다루기 위해 중 약물 사용을 형사 처벌하는 정책은 아동 복지에 드는 비용을 증가시킨다는 증거를 들어 해당 정책은 비용을 증가시킨다는 주장을 했습니다. 

Sanmartin et al. (2019)는 2005년-2016년의 관련 데이터를 분석 해, 임신 중 약물 사용에 대해 형사 처벌을 하지 않는 주에 비해 형사 처벌하는 정책을 시행하고 있는 주에서 신생아의 위탁 보호율(foster care admission)이 2.46 퍼센테지 포인트 가량이 높았다는 것을 발견했습니다. 

위탁 보호가 증가하는 데에 따른 비용을 운영 비용, 사회적 비용, 건강 비용 세 가지로 나누어 설명했습니다. 우선, 위탁 보호율이 증가하면 위탁 보호를 운영하기 위한 비용이 증가합니다 (Alexander, 2018; Zill, 2011). 또한, 위탁 보호를 거쳤던 아이들은 교육을 덜 받고, 고용이 되지 않고, 수감될 가능성이 더 높았습니다. 우울, 불안, ADHD, 천식, 발달 지연 등 정신 건강 및 신체 건강에서 좋지 않은 건강 상태를 갖고 있을 가능성도 높았습니다(Turney & Wildeman, 2016). 

효용 - 치료에의 장벽으로 작용하므로 효용은 제한적

효용을 다루는 부분에서는, 해당 정책은 임신한 여성들이 약물 이용을 치료받는 데에 장벽으로 작용하여 실제로 임신 중 약물 이용을 줄이는 데에는 전혀 효과가 없으므로 이 정책이 만들어내는 효용은 거의 없는 것이나 마찬가지라고 주장했습니다. 

관련 연구들을 살펴보면, 오히려 형사 처벌 정책이 있는 주에서 신생아금단증후군(neonatal abstinence syndrome) 발생률이 더 높았습니다(Faherty et al., 2019). 신생아금단증후군 발생률은 임신 중 약물 사용의 대리 지표라는 점을 생각하면, 형사 처벌 정책은 임신한 여성의 약물 사용을 줄이기는 커녕 늘리고 있었던 것입니다. 

그 이유는 임신한 여성들이 형사 처벌 받을 것을 두려워 해 약물 사용과 관련한 의료적 도움을 받지 못하는 데에 일정 부분 기인합니다. 임신 중 약물 사용 정책을 형사 처벌하는 주에서는 약물 사용 장애 치료를 받은 사람들 중 임신한 여성의 비율이 유의미하게 낮았습니다(Kozhimannil et al., 2019).

그러니 이 정책은 그 자체로 차별적인데다가, 원래의 의도대로 임신 중 약물 사용을 줄이지도 못하면서 (오히려 늘리면서) 아동 복지에 들어가는 비용도 증가시키는 정책이라고 할 수 있겠습니다. 

이 정책은 비용은 큰데 효용은 매우 적으니 폐지해야 한다는 결론을 내면서, 이 글에서 말한 저의 고민 - 차별적인 정책, 인권 침해적인 정책을 경제적으로 분석해도 되는가 - 에 대한 고민도 마지막에 다루면서 보고서를 마무리했습니다. 경제적 분석을 하기에 앞서 여성의 인권과 자기결정권이 이 정책으로 인해 침해되는 것이 아닌지에 대한 논의가 먼저 이루어져야 한다고 말입니다. 이 과목 교수님으로부터는 impressive analysis라는 긍정적인 코멘트는 받았으나 이런 고민에 대한 답변이나 의견은 받지 못했습니다. 

전략적 선택?

이 보고서를 쓰려고 여러 논문을 찾아보고 글을 구성하면서는, 이런 경제적 분석이 인권과 평등을 근거로 싸우는 것보다는 잘 먹히기는 하겠다는 생각을 했습니다. 인권과 평등을 이야기하면 "뭬이얏~!~~~!!! 여남 평드응~~~!?!!??~~~?? 페미니즘~~~??!!!"하면서 눈과 귀를 막아버리고 아무 말도 통하지 않게 되는 경우가 너무 많기 때문입니다. 그 대신 '이거 봐봐라, 이 정책을 시행하면 당신의 세금을 엄한 데 낭비하게 되고 다른 더 좋은 데 쓰여야 할 국가 재원을 낭비하는 것이다'라고 말하며 이 이슈를 프레이밍하면 원하는 바(차별적 정책 폐지)에 더 쉽게 다가갈 수 있을 것 같았습니다. 목적을 이루기 위한 전략적 선택으로서 이러한 경제적 분석을 이용할 수도 있겠다는 생각이 든 것인데요. 하지만, 이것이 정말로 전략적인 선택이 될 것인지, 경제적 분석을 하는 것 자체가 도덕적 당위성에 승인하는 것이나 마찬가지이진 않은지, 차별적인 정책을 차별적이라는 이유만으로는 막지 못하고 경제적 근거를 가져와야만 한다면 그 사회는 너무나 불건강한 것이 아닌지, 하는 의문들은 여전히 남아있습니다. 

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(아래는 과제로 제출했던 보고서를 그대로 가져왔습니다.)

Policy Issue: Should states repeal their criminal justice-related prenatal substance abuse policy when evidence suggests that it is contributing to an increase in the number of infants entering the child welfare system because of parental drug use?

Criminal Justice Prenatal Substance Abuse Policy: Based on Cost-Benefit Analysis

              As the opioid crisis threatens public health in the United States, pregnant women have also been widely affected by the crisis. From 2004-2005 to 2014-2015, opioid-related deliveries increased more than four times (Admon et al., 2019). To date, states have introduced various sets of prenatal substance use policies to address the increasing number of opioid-related pregnancies. The prenatal substance use policies could be classified into three categories: treatment and supportive services, criminal justice-related initiatives, and health care provider reporting requirements (Sanmartin, Ali, & Lynch, 2019).

              Many states have adopted criminal justice-related policies as a means to reduce prenatal substance use. The ground for the punitive approach is to consider substance use during pregnancy as child abuse or neglect in 23 states and the District of Columbia or as civil commitment in 3 states (Guttmacher Institute, 2020). In addition to civil child abuse charges, some states have charged women with criminal offenses for substance use during pregnancy, such as criminal child endangerment in California, criminal child abuse in Florida, and manslaughter in Hawaii. Tennessee has explicit laws to criminalize illicit substance use in pregnancy (Angelotta et al., 2016).

              Even though the punitive policies were enacted with an intention to reduce maternal opioid use and related adverse health outcomes to infants, many of previous work suggest little evidence that the criminal justice-related prenatal substance use policies are effective in achieving the goal, but instead found a substantial degree of unwanted consequences. One example of the undesirable consequences is that the number of foster care admissions was higher among the states with criminal justice policies (Sanmartin et al., 2019), which would cause financial and societal costs. Moreover, the punitive prenatal substance use policies have exceedingly minimal benefits in serving the goal of decreasing prenatal substance use by deterring pregnant women from accessing medical support for substance use.

              This paper discusses evidence in the unwanted consequence of the increased number of foster care admissions and the costs incurred from excess foster care admissions. Then, this paper claims that there are limited benefits in terms of its original goal to reduce prenatal substance use by creating barriers in seeking substance use treatment for pregnant women. By doing so, this paper concludes that the costs of the punitive policies dominate the benefits. Lastly, this paper closes with the limitations of cost-benefit analysis when accessing prenatal substance use policies.

Unwanted Consequences with Increased Foster Care Admissions

              Sanmartin et al. (2019) provided evidence that states with criminal justice prenatal substance use policies are more likely to have increased foster care admissions. Analyzing the data from the 2005-2016 Adoption and Foster Care Analysis and Reporting System, this paper examined if states with criminal justice policies are associated with a higher number of parental drug or alcohol use-related foster care admissions, compared to the other states without criminal justice policies.

              The results showed that the states with punitive policies had 2.46 percentage-point increase (standard error (se), 0.97) in infant foster care admissions related to parental drug or alcohol use per year. A 2.46 percentage-point increase is, on average, equivalent to 9 new infant admissions per state per year. When expanding the population of interest from infants to children of all ages, the increase is even greater: 7.06 percentage-point higher of new foster care admissions related to parental substance use. There would be some instances with opioid-using mothers that child removal is essential to protect the children. However, the excessive foster care admissions imply that some of the cases might not have been necessary or in the best interests of the child or the mother (Sanmartin et al., 2019).

Substantial Costs Incurred from Excessive Foster Care Admissions

              The increased number of foster care admissions incur a substantial amount of costs: operation cost, social cost, and costs from worse health outcomes. First, the excessive number of foster care admissions leads to imposes financial burdens in operating, which is interpreted as a direct cost in cost-benefit analysis. In New York City, the average administrative and maintenance costs were estimated at $45,625 per year per child in 2015 (Alexander, 2018). Assuming the cost for New York City was the case for the whole New York state, nine additional infant admissions, as suggested in Sanmartin et al. (2019), would have been incurred $410,625 of extra costs per year to the state, if New York state had enacted criminal justice policies. As of 2011, more than nine billion dollars of the federal budget were nationally spent on foster care under Title IV-E of the Social Security Act alone (Zill, 2011), which was already a great burden to the federal budget, and the criminal justice would only add to the financial burden by increasing foster care admissions.

              Furthermore, increased foster care admissions are costly in the perspective of indirect costs imposed on the individuals admitted to foster care and on society. Former foster youth are more likely to have less educational attainment and to be unemployed than their peers. According to the data from Midwest Evaluation of the Adult Functioning of Former Foster Youth, Midwest former foster youth were three times more likely not to have a high school diploma or GED and twice more likely to not have ever held a job (Underhill, n.d.). The higher possibilities for low education and high unemployment lead them to face higher risks to be low-income, which would have detrimental impacts on the individual and induce higher costs for welfare programs. Also, former foster youth are more likely to be engaged in illegal activities or to be incarcerated, resulting in higher incarceration costs. From a report from Chmura Economics and Analysis, the incarceration costs from former foster youth were estimated at $481,608 per year in Virginia (Underhill, n.d.).

              In addition, evidence suggests that being raised with foster care adversely affect individuals’ health both during childhood and after adulthood. Worse health outcomes incur intangible costs in terms of lower quality of life as well as indirect costs in terms of increased medical utilization. Children in foster care were more likely to suffer from poor mental and physical health, including learning disability, ADD or ADHD, depression, anxiety, behavioral problems, developmental delay, asthma, speech problems, and activity limitation, compared to children in the general population who were not placed in foster care. The higher risks were more pronounced in ADD or ADHD (odds ratio (OR), 4.29; 95% Confidence Interval (CI), 2.68-8.88), depression (OR, 8.88; 95% CI, 4.84-16.28), behavioral problems (OR, 7.63; 95% CI, 4.45-12.74) (Turney & Wildeman, 2016).

              The experience of being placed in foster care affects not only the health status during the placement but also after adulthood. Young adults formerly in foster care were more likely to have chronic conditions including hypertension, asthma, and ADHD, with the highest odds ratio for ADHD of 85.60, compared to young adults from economically secure backgrounds in the general population (Ahrens, Garrison, & Courtney, 2014). These results imply the need for policies and programs that addresses the specific health needs of foster youth, which will bore an additional burden on the social welfare system and health care system.

No Evidence on Benefits: Limited Contribution to Reducing Prenatal Substance Use

              While the undesirable consequences of increased foster care admissions bare considerable costs to the pregnant women, the children, and society, there is a paucity of evidence that criminal justice policies are effective in reducing prenatal substance use. Previous studies suggested that criminal justice policies may be associated with even higher substance use during pregnancy.

              Analyzing the State Inpatient Databases from eight U.S. states from 2003 to 2014, Faherty et al. (2019) found that states with criminal justice policies had significantly higher odds of neonatal abstinence syndrome both during the first year after enactment (OR, 1.25; 95% CI, 1.06-1.46) and after more than first full year from enactment (OR, 1.33; 95% CI, 1.17-1.51). The adjusted rate of neonatal abstinence syndrome was 60 (95% CI, 56-65) neonates per 10,000 live birth in states with criminal justice policies after more one year from enactment, while the rate was 46 (95% CI, 43-48) neonates per 10,000 live births in states without criminal justice policies. According to the analysis, criminal justice policies may be attributed to an excess of 14 neonates with neonatal abstinence syndrome per 10,000 live births. Given the rate of births with neonatal abstinence syndrome is a proxy indicator of substance use among pregnant women, the evidence suggests that the criminal justice policies make strikingly limited contributions to reducing prenatal substance use, but instead increasing it.

Additional Barriers for Access to Substance Use Treatment Among Pregnant Women

              Previous studies suggest that increased neonatal harms may be ascribed to the barriers that criminal justice policies might impose on pregnant women when seeking substance abuse treatment. Analyzing 2004-2012 Treatment Episode Data Set-Admissions, Kozhimannil, Dowd, Ali, Novak, & Chen (2019) investigated how states’ implementation of prenatal substance use policies influence pregnant women on accessing substance use disorder treatment. State policies that focus only on criminal justice prenatal substance policies were significantly associated with lower proportions of substance use disorder treatment admissions among pregnant women, compared to states with no prenatal substance use policies (OR, -0.010; se, 0.004) and states with provider reporting requirements and treatment support services (Kozhimannil et al., 2019).

              According to another study examined the Treatment Episode Data Set-Admissions in 2012, only 33.15% of women used medication-assisted treatment in states with punitive policies, while 51.33% of women used medication-assisted treatment in the other states.  After adjusting, state criminal charge laws were associated with higher odds of 1.43 (se, 0.09) for a treatment plan to miss medication-assisted treatments. Since medication-assisted treatments have been demonstrated to have positive effects, such impediments on access to the treatments might be critical for pregnant women with substance use disorders (Angelotta et al., 2016). The evidence from previous researches shows that criminal justice-focused prenatal substance use policies may deter women from receiving pertinent treatment and care during pregnancy.

Criminal Justice Policies Should be Repealed

              Even though criminal justice prenatal substance use policies were introduced to reduce prenatal substance use and related potential harm to children, the policies hardly meet the goal or provide benefits, but only incur unwanted consequences and subsequent costs. Thus, considering that the costs dominate its benefits, criminal justice-focused prenatal substance policies should be repealed.

              As alternatives, states should take supportive approaches that can genuinely helpful for pregnant women. Faherty et al. (2019) claimed some of the possible alternatives, such as alerting providers in prescribing opioids to women of reproductive age, providing comprehensive physical and behavioral care, and enhancing access to family planning services considering that 90% of pregnancies with opioid use disorders are unplanned. States are required to pursue eliminating the root cause of prenatal substance use, which is the opioid crisis across the whole country, rather than criminalizing pregnant women for substance use by only impeding pregnant women to seek appropriate care and increasing foster care admissions.

Limitation of Applying Cost-Benefit Analysis to Prenatal Substance Use Policies

              Although cost-benefit analysis helps provide practical ground for implementing and evaluating policies, conducting a cost-benefit analysis could sometimes be misleading by giving impressions as if the policy is legitimate. Broader social debates, not only economic evaluations, are essential regarding criminalizing prenatal substance use of pregnant women.

              The criminal justice-focused prenatal substance use policies are based on the patriarchal perspective that does not view pregnant women as equal citizens but more as carriers of babies, and that is more protective of the babies and the pregnant women. The approach to punish women for not protecting the fetus by applying unique laws is to prioritize the fetus or infant over women, and thus, it is discrimination against women. Implementing such policies can be interpreted as the state abdicating its obligation to protect its people and promote their health. Rather, the policies violate the right to the highest attainable standard of health, right to privacy, and the right to equality of pregnant women (Amnesty International, 2017).

              Along with discussing the costs and benefits of the policy, we should consider whether the policy violates the fundamental human rights of women and self-determination on their own bodies. A cost-benefit analysis would not be enough to reflect the value of equality and human rights.

References

Admon, L. K., Bart, G., Kozhimannil, K. B., Richardson, C. R., Dalton, V. K., & Winkelman, T. N. A. (2019). Amphetamine- and opioid-affected births: Incidence, outcomes, and costs, United States, 2004–2015. American Journal of Public Health, 109(1), 148–154. https://doi.org/10.2105/AJPH.2018.304771

Ahrens, K. R., Garrison, M. M., & Courtney, M. E. (2014). Health Outcomes in young adults from foster care and economically diverse backgrounds. Pediatrics, 134(6), 1067–1074. https://doi.org/10.1542/peds.2014-1150

Alexander, M. (2018). Data Before Dollars. Are Child Welfare Preventive Services Worth the Investment? Retrieved from https://cbcny.org/research/data-dollars

Amnesty International. (2017). Criminalizing Pregnancy: Policing Pregnant Women Who Use Drugs in the USA. Retrieved from www.amnesty.org

Angelotta, C., Weiss, C. J., Angelotta, J. W., & Friedman, R. A. (2016). A Moral or Medical Problem? The Relationship between Legal Penalties and Treatment Practices for Opioid Use Disorders in Pregnant Women. Women’s Health Issues, 26(6), 595–601. https://doi.org/10.1016/j.whi.2016.09.002

Faherty, L. J., Kranz, A. M., Russell-fritch, J., Patrick, S. W., Cantor, J., & Stein, B. D. (2019). Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome. JAMA Network Open, 2(11). https://doi.org/10.1001/jamanetworkopen.2019.14078

Guttmacher Institute. (2020, April 1). Substance Use During Pregnancy. Retrieved April 27, 2020, from https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy

Kozhimannil, K. B., Dowd, W. N., Ali, M. M., Novak, P., & Chen, J. (2019). Substance use disorder treatment admissions and state-level prenatal substance use policies: Evidence from a national treatment database. Addictive Behaviors, 90, 272–277. https://doi.org/10.1016/j.addbeh.2018.11.019

Sanmartin, M. X., Ali, M. M., & Lynch, S. (2019). Foster care admissions and state-level criminal justice-focused prenatal substance use policies. Children and Youth Services Review, 102, 102–107. https://doi.org/10.1016/j.whi.2016.09.002

Turney, K., & Wildeman, C. (2016). Mental and physical health of children in foster care. Pediatrics, 138(5), e20161118. https://doi.org/10.1542/peds.2016-1118

Underhill, C. (n.d.). Measuring the Costs of Foster Care and the Return on Investment for the “Great Expectations.” Retrieved from http://www.fostercareandeducation.org/DesktopModules/Bring2mind/DMX/Download.aspx?EntryId=1591&Command=Core_Download&method=inline&PortalId=0&TabId=124

Zill, N. (2011). Better Prospects, Lower Cost: The Case for Increasing Foster Care Adoption. In Adoption Advocate (Vol. 35). Retrieved from www.adoptioncouncil.org