Ethics and Decision Making for Interpreters in Health Care Settings: A Manual for Study and Practice

Sandra Gish
Western Oregon State College

Introduction | Content of Manual | Ch. 1: Course Expectations | Ch. 2: Definitions | Ch. 3: Values Clarification | Ch. 4: Historical Perspective of Health Care Ethics | Ch. 5: Ethical Issues | Ch. 6: Stress of Illness | Ch. 7: Historical Perspective of Interpreting | Ch. 8: Health Care Interpreting and the Law | Ch. 9: Group Interaction and Functional Leadership | Ch. 10: Professional Communication | Ch. 11: Problem-Solving and Decision-Making | Conclusion | Resource Bibliography | Appendix A | Appendix B | Appendix C

Introduction

Ethics and decision making have always been important to the profession of interpreting; one of the first challenges accepted by the founders of the RID was to design professional guidelines for a code of ethics. Today, the revised RID Code of Ethics is used by professional interpreters as the standard by which they measure appropriate professional behavior.
This decade brings new ethical challenges to interpreters. Consumer demands are high, legal constraints influence our behavior, and ethical decision making becomes increasingly complex. In the face of today’s demand for high-quality professional decision making, ethics involves more than just reading, memorizing, or even understanding a code of ethics. The application of ethical codes to professional practice involves a broad base of knowledge that comes from a study of ethics. That knowledge base is supported by a set of learned skills which helps decision-makers apply ethical information to daily problem solving.
For interpreters to make good decisions, they need to know what influences their decisions: personally, professionally, historically, situationally, institutionally, and legally. They need to have specific skills in human interaction, conflict resolution and problem solving. And they need professional communication skills so that they can communicate their decisions to those around them.
The purpose of this paper is two-fold. The first is to describe a study and practice manual that I developed to guide students through the process of becoming more effective and ethical problem-solvers. The manual is called Ethics and Decision Making for Interpreters in Health Care Settings. It was developed under a grant from the Fund for Improvement of Postsecondary Education (FIPSE), and accompanies the manual Interpreting in Medical Settings (Barnum, Siebert, 1988). For the purpose of this paper I will focus on a description of the information contained within the manual; it is the most tangible contribution that I may make at this time.
The second, underlying purpose of this paper is not contained within the pages of the manual. I would like to encourage educators to identify and expand our shared knowledge of ethics, decision making and professional practice. There is no ideal description of a study of ethics for interpreters; through investigation, discussion and collaboration, we will identify our course of study. What is essential to ethical growth is the commitment to explore, learn and welcome new information and perspectives. The manual is available through the College of St. Catherine’s, St. Mary’s Campus, at production cost. The prospect of building our future and growing as ethical professionals is available in our collective contributions. It is through a commitment to investigation, study, collaboration and planning that we honor the history of our profession and confirm the integrity of its future.
 

The Manual

Ethics and Decision Making for Interpreters in Health Care Settings was developed to help interpreting students and working interpreters become more calm, confident, ethical, and responsible professionals. It contains information and activities designed to promote ethical decision-making skills in both student and professional interpreters. The manual is specifically geared toward interpreters who are working in medical and mental health settings. However, information contained in the bulk of the manual could be applied to interpreters working in a variety of settings; the process of decision making remains the same for interpreters regardless of the settings in which they apply it.
The manual contains information related to definitions of ethics-related terms, values clarification, historical perspectives and applications of interpreter ethics, legal considerations that affect interpreters, group interaction and functional leadership, problem solving and decision making, and professional communication.
The content of the manual assumes that students have already been exposed to some basic information that affects the decision-making process. Specifically, information that should have been addressed in previous courses includes: basic knowledge of the RID Code of Ethics, information about American culture in general and American Deaf Culture specifically, and an understanding of the Deaf Community as a linguistic and cultural minority that exists within a society that has historically oppressed the language, culture and self-determination of Deaf people. Obviously, those issues are crucial to ethical decision-making and are integrated into the manual at various levels. But each of those issues is of such value that it deserves focused study of its own.
I do not claim that this manual is a definitive text on ethics and decision making for interpreters, nor do I claim to be an authority in these areas. There are scholars who devote their entire lives to the study of ethics. Rather, the manual is a collection of information, activities, and exercises that I have found helpful in introducing the relationship between ethics and decision making to interpreting students. The scope of the manual is limited in that regard, and is offered to support the ethical and decision-making instruction that is already happening in interpreter education programs and in the on-going professional development of working interpreters.
The manual is limited in its perspective as well. I am a white, hearing, middle-aged female raised in the Midwest, and the manual is certain to reflect that perspective. This limited scope does not diminish the material contained in the manual nor its potential as a teaching tool. But a broad base of study includes listening to those from a variety of cultural, racial and ethnic identifications, and an awareness of an author’s perspective serves to remind us of the cultural bias contained within.
This manual is offered as a catalyst for discussion about professional decision-making behavior. Readers will want to add, delete, change, support, augment and argue against the information contained within its pages. I believe that we want to challenge our students, and ourselves, to broaden the knowledge used in ethical decision making, to welcome new information that will affect our decisions, and to discuss ethical decision making with each other and with consumers. It is especially important that we discuss ethically-based issues with Deaf consumers, since historically they have been excluded from the decisions that we make.
At the heart of this manual is the belief that interpreters must base their ethical behavior on something much more universal than a strict set of strategies, rules or laws; it is our own personal integrity that guides us toward becoming ethical professionals. We must endeavor to behave as ethical human beings because it is the healthiest way to live as individuals, and the way in which we can make a contribution to our profession and to our society.
 

Content of the Manual

Chapter One: Course Expectations

A good place for students to start a new course of study is to reflect upon their own expectations of the learning process to come. The manual begins with providing students an opportunity to answer questions such as: What do I expect to learn from this course? In what areas would I like to improve or expand my knowledge? What personal and professional ethical and decision-making goals do I have for myself? Students are encouraged to document and discuss their own expectations and those of other students.
This chapter introduces the format of the manual: instruction, activity and discussion. The most important component of this format is teacher-student and student-student discussion. This exchange of ideas confirms our knowledge and beliefs, reminds us of our differences, and identifies future areas of discussion and study.
 

Chapter Two: Definitions of Ethics-Related Terms

Definitions of ethics-related terms provide a common understanding and vocabulary upon which to base further discussions, so the first chapter of the manual introduces the terms “values,” “ethics,” “ethical principles,” “professional ethics,” “situational ethics,” “ethical accountability,” “the universal standard,” and “decision making”. Students discuss American values and their own responses to these values, and contrast American values with those of other cultures. Students look at personal situations in which their own ethical responses were altered because of the circumstance, and they examine the ways in which people are accountable for situationally-based decisions. An important exercise is one in which students describe the underlying values of the RID Code of Ethics; the profession of interpreting requires that each member understand the values upon which our professional ethics are based.
 

Chapter Three: Values Clarification

Another chapter in the manual deals with values clarification. This unit asks students to look at their own personal values, to compare them with the values of others, and to examine values conflicts and change.
Because interpreters find themselves working with a variety of people, it is important for students to recognize that conflicts in values will certainly occur: consumers will make decisions with which we do not agree or which we do not understand; people will react to each other in ways that we do not like; and consumers will assert opinions different from our own.
Interpreters cannot allow value conflicts to interfere with their professional responsibilities; we strive to keep our personal feelings from influencing the interpreted interaction. Those interpreters who are not aware of their own values may find themselves feeling uncomfortable in some interpreted situations and yet not know why. Those who are not aware of the values conflicts that occur may find themselves losing their sense of impartiality and thereby affect both the interpreted message that they render and the interpreted interaction itself.
Those interpreters who know themselves and their value systems well are able to identify when their own values conflict with those of consumers. By identifying the source of their discomfort, they are able to make a concerted effort to prevent their feelings from influencing their professional performance. This self knowledge also helps them process their own feelings when they have finished an interpreting assignment. (See Appendix A for sample exercise.)
 

Chapter Four: A Historical Perspective of Health Care Ethics

In studying a historical perspective of health care ethics, students reflect upon the ways in which medical ethics have changed in response to the specialization, mechanization, and technical sophistication of modern medicine. Students examine their own personal responses to the changing medical climate and the ways in which the medical industry’s sensitivity to ethical implications has not kept pace with its technological capacity.
 

Chapter Five: Ethical Issues in Heath Care

A major course project is required in the chapter on ethical issues in health care. For this project, groups of students must research a medically-related ethical issue (e.g., euthanasia, the distribution of scarce medical resources, genetic engineering). Class presentations focus on ethical perspectives related to the issue and the potential impact on interpreters in the health care setting. (See Appendix B for sample exercise.)
 

Chapter Six: The Stress of Illness

This chapter includes information about the feelings of powerlessness that patients experience in hospital settings, the stress of hospitalization, and the impact of stress on communication. High quality interpreting is the responsibility of the professional interpreter in every setting; the compounding factors of illness, injury, medication and the health care setting demand an even greater professional commitment from interpreters in health care settings.
 

Chapter Seven: A Historical Perspective of Interpreting

In this chapter, students examine the history of interpreter education, legislation that affected the interpreting profession, and professional interpreting organizations. This chapter also looks at the ways in which relationships between the Deaf Community and interpreters have evolved over time by examining the Four Models of Interpretation: Helper, Conduit, Communication Facilitator, and Bi -lingual/Bi-cultural (Witter-Merithew, 1986). Students discuss the ways in which these models reflect the evolution of the interpreting profession, the ways in which an interpreting model choice may affect consumers and interpreters, and the conflicts that can arise as a result of a particular model choice. A study of these models assumes that students continue to examine the relationship between oppressed and oppressor peoples, their own membership in majority and minority cultures, and the ways in which power and status affect the interpreter-consumer relationship. (See Appendix C for sample exercise.)
 

Chapter Eight: Health Care Interpreting and the Law

In today’s society, legal issues play an increasing role in professional decision making, and interpreters need a working knowledge of certain legal constraints which have developed within our society.
This knowledge encourages a healthy respect for our legal limits, facilitates effective professional functioning within reasonable boundaries, and helps professionals understand the relationship between conduct and accountability. While this chapter focuses on some of the legal implications of working in a health care facility, some of the legal issues introduced may be helpful for interpreters working in non-health care settings as well. Following brief descriptions of some fundamental legal principles (Fenner, 1983), this chapter presents some of the current legal issues that face professional interpreters. These include the relationships between codes of ethics and the law, privileged communication, liabilities of professional interpreting, the reporting of sexual/physical abuse and threats of suicide/bodily harm. This chapter does not, and could not, offer easy answers to the legal problems that interpreters may encounter. It does, however, offer some recommendations for ways in which interpreters can become more aware of the legal issues that affect us, and it refers students to current literature in the area of legal aspects of interpreting.
 

Chapter Nine: Group Interaction and Functional Leadership

The inclusion of a chapter on leadership may seem strange, since interpreters have never thought of themselves as “leaders” in interpreted interactions. This problem may be a reflection of the traditional definitions of leadership more than it is a reflection of the functions that interpreters perform. Johnson and Johnson (1987) offer an alternative definition of leadership that is compatible with the role of the interpreter, and that allows interpreters to accomplish the tasks necessary to perform effectively.
Johnson and Johnson (1987) define two basic components of a group interaction: content and process. If one is focusing on content, one is involved in what is being discussed. If one is interested in process, one looks at the ways in which the discussion is being conducted. This distinction between content and process is particularly important to the interpreter: the interpreter never becomes involved in content, but the interpreter is an important part of the process.
By this definition, interpreters have been functioning as leaders for years: explaining the role and function of the interpreter when necessary; participating in pre- and post-sessions with consumers; working with consumers on placement, lighting, and an approach to the interpreting task; and asking participants to clarify or repeat communications for the purpose of interpreter understanding. According to this definition, the interpreter can perform leadership functions that relate to the interpreting process while remaining faithful to the interpreter role. If functional leadership is used well, interpreters take no power or leadership away from any of the consumers involved. Instead, they provide additional, professionally-based leadership in regard to the interpreting process.
 

Chapter Ten: Professional Communication

Because interpreters need to communicate effectively with a wide variety of consumers, the manual includes a chapter on professional communication. As interpreters, our main concentration is on the interpreting process, and it is often hard to adjust to speaking for ourselves about interpreting issues. Cassell (1983) offers several reasons for interpreters to master professional communication: interpreting is a personal contact profession; effective communication builds trust; interpreters are responsible for guiding consumers toward an understanding of our role and the interpreting process; effective communication is essential for successful problem solving. This chapter offers information about sending and receiving messages effectively, hints for communicating in conflict situations, and a professional response model (Cassell, 1983) that helps guide interpreters in professional communication.
 

Chapter Eleven: Problem-Solving and Decision-Making

The last chapter of the manual focuses on problem-solving and decision-making. Throughout the manual, students are working to acquire the knowledge and skills that provide a base for problem solving; at this point, students go through a practical application of their skills.
It is important for students to understand that whenever people work together to share ideas, information, reactions, and resources, problems and conflicts inevitably arise. It takes two or more people to create a conflict of interest, and interpreted interactions always involve at least three people: the Deaf consumer, the interpreter, and the hearing consumer. Controversies are inevitable, but conflicts over ideas and opinions can lead to creative problem solving. In fact, successful problem solving can lead to increases in motivation, creativity, reasoning, mastery, cooperation, and perspective taking (Johnson and Johnson, 1978). In this chapter, students are introduced to information on creative problem solving that helps them to understand the nature of problems and to discover sound, professional solutions. Students examine the steps of problem solving, potential blocks to problem-solving effectiveness, ways to foster a cooperative atmosphere, and what to do when solutions don’t work.
For the first time, students develop scenarios that describe interpreting-related ethical dilemmas, and the chapter culminates with an exercise that challenges students to solve these dilemmas following a practical problem-solving strategy. (See Appendix D for sample exercise.)
 

Conclusion

The manual Ethics and Decision Making for Interpreters in Health Care Settings has been designed to help students and working interpreters explore the skills necessary for ethical decision making. It was also written to help sensitize interpreters to the complexity of ethics and ethical behavior, and to help them develop confidence in the application of ethical standards to professional life.
The manual is only an introduction to the skill areas and knowledge necessary for professional decision making. This means that we need to encourage our students, and ourselves, to continue our study of ethics: through coursework, workshops, reading, discussion, and the achievement of academic degrees. For a profession to reach maturity, its members must have a collective consciousness and a collective knowledge base. May this manual be a springboard for further exploration into the sometimes frustrating, often rewarding, and always fascinating study of ethics.
In our on-going study, we must look and listen to other professionals to find out what they are doing in their pursuit of ethical behavior and what problems they encounter. We have much to learn from the academicians and practitioners in other fields, just as they have much to learn from us.
As we explore the meaning of cross-cultural mediation and decision making, we must recognize that one of our greatest resources is the Deaf Community. We must talk with Deaf colleagues, consumers and friends about the challenges that we face. We need to ask Deaf people what they think and what they want, and let them know that their perspectives are vital to our collective growth. Then, we must be prepared to listen to what they say. We must no longer be guilty of designing strategies without them; instead, we must let their knowledge, experience and wisdom guide our growth.
This manual is offered as a catalyst for discussion about decision-making behavior. It is always to our advantage to be open to new information that leads to new ways of thinking. New information will affect the way we see ourselves, the consumers with whom we work, and the responsibilities of our profession. New strategies will emerge and will be implemented in new ways. New problems will certainly appear. We cannot afford to remain motionless; we must be open to the flow of change.
The next decade will bring new challenges to professional interpreters and students. As we try to reconcile the need to apply an ethical code to more and more complex situations, we will need everyone’s perspective. Our judgments might not always be perfect, and our efforts might not always meet success, but our participation will surely be appreciated.
As educators, it is up to us to help students enjoy the prospect of building their futures. We can help them to understand that when we behave according to our personal ethics, we enjoy an internal feeling of harmony. As consumers and colleagues recognize us as ethical professionals, we feel the rewards of validation and support. We all have a great deal at stake in the application of ethical behavior to our professional lives. May this manual help students understand that our goal is to be ethical human beings; that it is the healthiest way to live as individuals, and that it is the way in which we can all make a contribution to our profession and to our society.
Special thanks to the following people for their contributions to the manual and to this paper: Pauline Annarino, Marty Barnum, MJ Bienvenu, Betty Colonomos, Carol Fay, Jan Fried, Dr. Jan Kanda, Dr. Marina McIntire, Diane Currie Richardson, Jill Roerich, Risa Shaw, Elizabeth Sizemore Siebert, and the students of The College of St. Catherine, St. Mary’s Campus.
 

Resource Bibliography

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Baker, C. and D. Cokely. 1980. American Sign Language: A Teacher’s Resource Text on Grammar and Culture. Silver Spring, MD: T. J. Publications.
Baker-Shenk, C. 1986. “Characteristics of oppressed and oppressor peoples: Their effect on the interpreting context”. In M. McIntire, (Ed.), Interpreting: The Art of Cross-Cultural Mediation. Silver Spring, MD: RID Publications.
Baker-Shenk, C. 1986. “The road to liberation is bumpy – Ouch!” Paper presented at the International Catholic Deaf Association Convention.
Beattie, M. 1987. Codependent No More. San Francisco: Harper & Row.
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Brislin, R. W. 1981. Cross-Cultural Encounters: Face to Face Interaction. Elmsford, NY: Pergamon Press.
Cassell, J. 1983. “Innovative strategies for enhancing professional attitudes and behavior in students of interpreting”. In M. McIntire, (Ed.), (Proceedings of the Fourth National Conference of Interpreter Trainers Convention). Silver Spring, MD: RID Publications.
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Davis, A. J. 1984. Listening and Responding. The C.V. Mosby Company.
Duffy, T. 1986. “Attitudes of hearing impaired consumers of sign language interpreting services”. Masters Thesis, San Jose State University.
Fenner, K. M. 1980. Ethics and Law in Nursing; Professional Perspectives. New York: D. Van Nostrand Company.
Freire, P. 1970. Pedagogy of the Oppressed. New York: Seabury Press.
Frishberg, N. 1986. Interpreting: An Introduction. Silver Spring, MD: RID Publications.
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Gish, S. 1988. “Language and power: The impact of status”. TBC Newsletter, 5: 6-7.
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Johnson, D. W. 1972. Reaching Out: Interpersonal Effectiveness and Self-Actualization. New York: Prentice-Hall.
Johnson, D. W. 1978. Human Relations and Your Career: A Guide to Interpersonal Skills. Englewood Cliffs, NJ: Prentice-Hall.
Johnson, D. W. and F. P. 1987. Joining Together: Group Theory and Group Skills. Prentice-Hall.
Johnson, D. W. and R. T. Johnson. 1987. Learning Together and Alone: Cooperative, Competitive and Individualistic Learning. Englewood Cliffs, NJ: Prentice-Hall.
Johnson, D. W., R. T. Johnson, and E. Johnson-Holubec. 1986. Circles of Learning: Cooperation in the Classroom. Alexandria, VA: Interaction Book Co.
Kober, Don and J. Bagnall. 1972. The Universal Traveler: Creative Problem-Solving and the Process of Reaching Goals. Los Altos, CA: William Kaufman, Inc.
Kraft, B. S. 1984. “Ethics and Role in a Cultural Context”. In M. McIntire, (Ed.), (Proceedings of the Eighth National Convention of Registry of Interpreters for the Deaf). Silver Spring, MD: RID Publications.
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Lane, H. 1984. When the Mind Hears: A History of the Deaf. New York: Random House.
Lane, H. 1985. “On Language, Power ad the Deaf’. In M. McIntire, (Ed.), (Proceedings of the Ninth National Convention of Registry of Interpreters for the Deaf). Silver Spring, MD: RID Publications.
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APPENDIX A

Activity: Forced Choices

Because our values are so important to us, we sometimes make the mistake of believing that other people’s value systems are the same as ours. The first part of this activity forces you to choose among your own values and assign priorities to them. In the second part, you compare your choices with those of your classmates.

Part I

For each set of two circumstances described below, check the situation which most strongly conflicts (if at all) with your own values system. Briefly describe the reasons for your choice.

  1. The much-admired girls’ basketball coach at a well-known high school privately gives birth control information to students at the students’ request.

A much-admired boys’ football coach, known for his outstanding win-loss record, teaches boys how to cheat in order to win games.
Reasons for your choice:

  1. A business person habitually drives recklessly during rush hour traffic in order to have more time with hislher family.

 
Divorced parents fight an extended custody battle for their children, each thinking the other parent is unfit.
Reasons for your choice:
 

  1. A religious leader is charged with sexually abusing children enrolled in religious education.

 
A teenage father is charged with murder for smothering his infant when the baby wouldn’t stop crying.
Reasons for your choice:
 

  1. A college gives passing grades to athletes, despite their poor classroom performance, in order to build its athletic program.

A prestigious employment firm consistently turns down job applications from minority applicants.
Reasons for your choice:

  1. An interpreter calls a family in which a loved one has died and offers to interpret for the funeral. The family thinks this service is a gift, but later the interpreter bills the family for her full fee.

 
A less-experienced interpreter charges the same hourly freelance rate as more experienced interpreters because she needs the money and feels that interpreters should be paid more.
Reasons for your choice:
 

  1. An interpreter refuses to interpret for an emergency medical abortion because of personal feelings regarding abortion.

 
An interpreter refuses to interpret for a last-minute court appearance of an alleged sexual abuser because the defendant is known to make sexually-explicit remarks to previous interpreters.
Reasons for your choice:
 
 
Part II
Compare your decisions with those of your classmates.
1.         What are the different values-based reasons for your and your classmates’ choices?
 
2.         What are the similarities in value systems among you and your classmates?
 
3.         What are the differences in value systems among you and your classmates?
 
4.         With what other classmate’s decision did you most strongly agree? Why?
 
5.         With what other classmate’s decision did you most strongly disagree? Why?
 
6.         Were you surprised by any of your decisions? Were you surprised by any of the decisions of your classmates?
 
7.         Did class discussion cause you to change any of your decisions? Why or why not?
 
 

APPENDIX B

Activity: Health Care in History

Divide into three groups. One group lives in the year 1900, the second group lives in the year 1940, and the third group lives in the year 1990.
Imagine that you (or your partner) give birth to a child with severe medical and physical complications. Depending upon the era in which you live, describe what happens to you and your family by answering the following questions.
1.         What do you do first in reaction to this event?
2.         Who do you contact first?
3.         Who are your contacts within the health care system?
4.         Who else do you contact for support and guidance?
5.         What happens to your child?
6.         What future contacts do you make for support and guidance?
 

APPENDIX C

Activity: Course Project

  1. Divide into small groups.
  2. Identify a group topic (or an aspect of a particular topic) for research study.
  3. Deliver a final report which addresses the following questions:

a.             What is the position in favor of the ethical issue?
b.             What is the position in opposition to the ethical issue?
c.             What impact does this issue have on the health care interpreter?

4. Students may use the following list to stimulate their choices of ethical issues. Students are welcome to identify additional issues not presented on this list.
 

Potential Topics

  1. Euthanasia
  • Older people
  • People in comas or vegetative states
  • People who have terminal illnesses or painful injuries
  • People who have survived terrible injuries
  • Infants born with severe medical complications
  • Other
  1. The Right to Die
  • Older people
  • People who have terminal illnesses or painful injuries
  • People who have survived terrible injuries
  • People who have permanent disabilities
  • As a decision made by a family member or designated person
  • Other
  1. The Distribution of Scarce Medical Resources
  • Transplants
  • Kidney dialysis
  • Scarce or expensive drugs or treatment
  • Experimental drugs or treatment
  • Other
  1. Birth Control
  • Availability to minors with or without parental consent
  • Distribution in high schools. community centers, youth centers, etc.
  • Experimental methods
  • Experimentation on women (all women, minority culture women)
  • For men
  • Other
  1. Abortion
  • On demand or under specifically defined circumstances
  • For minors with or without parental consent
  • As a form of birth control
  • Federal assistance for poor women and families
  • As it relates to the viable fetus issue
  • Other
  1. AIDS
  • Mandatory testing
  • Mandatory disclosure
  • The right to privacy
  • The right to treatment
  • Availability of treatment and services
  • Experimental treatment
  • Potential dangers to health care workers
  • Insurance issues
  • Other
  1. Genetic Engineering
  • Genetic screening for women or couples who want to have children
  • Genetic counseling
  • Amniocentesis
  •  Artificial insemination
  • Surrogate parenting –
  • Other
  1. Controlled substances
  • Legalization of drugs or “safe” drugs
  • Illegalization of alcohol
  • Mandatory drug testing -Sentencing for possession, sale, and distribution – Other
  1. Other: