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Ante Natal diagnosis
  Ante-natal diagnosis: legal and ethical aspects
By Professor Theresa Marteau, John Gillott and Jonathan Montgomery


What follows is a transcript of papers given at a seminar held at Kent University Law School in the Autumn Term 1997. The seminar was organised by Ellie Lee, a student at Kent University and Co-Ordinator of Pro-Choice Forum, to give staff and students the opportunity to discuss issues surrounding fertility, ethics and the law.

Jonathan Montgomery

What I want to do is reflect first on issues that create problems with the concepts of consent and confidentiality. These are concepts that are used widely as key concepts in the regulation of medical ethics, and I want to raise some questions that come up in relation to ante-natal diagnosis, that make me wonder whether these are more complex concepts that some lawyers like to argue. Secondly I want to raise some issues about the NHS in relation to ante-natal diagnosis and the provision of services. These questions seem to me to be pressing and interesting in this area. I want to end up discussing what this area can tell us about the proper role of law and what sort of things we should expect the law to be able to deal with and where the limitations might be.

Dealing first then with the concept of consent, one of the things that it seems to me to be difficult for the law to grapple with in this area is problems about ranges of the understanding people have about what is going on. I am married to a midwife and one of the things midwives come into contact with routinely is ultrasound scans. When my wife was pregnant and we went for an ultrasound scan, our view was 'we hope this doesn't turn up anything unusual'. Our understanding of it, because of my wife's professional background was that the purpose of the ultrasound was to find out if something was wrong and detect anomalies. In my household it was therefore about going for a scan for anomaly. Our friends who are having babies saw going for an ultrasound as the first chance to get the first glimpse of the baby, and found it very exciting. The idea that something might come up which was very negative really was not part of their contemplation when they were going for that procedure.

This raises an important question to reflect on about getting consent. It is easy to talk generally about the need to enable women who are pregnant to have a choice about what goes on, and to gain informed consent. Whether it is because women do not hear what professionals think they are saying (and I am being quite careful there, because what professionals actually say may be different from what we think they have said); or whether professionals are not coming clean about why they are involved in ante-natal diagnosis; or whether professional think it is a nice chance to see the baby too, issues are raised here about informed consent.

Should you make it clear when you offer some sort of screening procedure, not only what is going to happen, that is the physical intervention (we are going to have a look at the baby, to see what it looks like; we are going to do a test to see if there is protein in the blood), but also explain why it is being done? If this is the case, should it be explained in general terms like: 'We are looking to see if the baby is allright'? Or should it be done in such a way that we look for problems where people are concerned that things are not going smoothly? This would mean that the only consent would be where women understand all the things that might be going wrong, and agree to have a test in order to find out whether their baby is suffering from a genetic defect, if there is retardation, or if the baby is missing a vital organ. Should we go through a whole catalogue of possible problems, before we say that there is informed consent?

That seems to me to raise legal issues prefigured in discussion of HIV testing. A line has been taken by some lawyers, most notably Ian Kennedy and Andrew Grubb. They say that you are not giving valid consent to be tested for HIV unless you are clear that what you are having is an HIV test and you have had counselling about the implications, and what the consequences might be if the test proves to be positive. Their argument is that English law requires us to consent to the nature of the procedure being done, and part of the nature of an HIV test is the consequences of the results. It is not just about giving blood, it is about knowing why you are doing it.

If we think that is right, it raises for me some disturbing questions about how to go about checking the right sort of information has been given to women about quite a wide range of tests that are happening during pregnancy and shortly after birth. How do we define what the appropriate level of informed consent is? If we define it in terms of the information being pushed upon women, can that undermine their right to not know about things that might happen during pregnancy and leave things to chance? Should we do what I think most professionals do, at least during ultrasound, and that is give women the opportunity to ask, but not actually regarding that as a necessary condition of valid consent? That leads to all sorts of important questions for lawyers about how to balance the obligations of professionals against the rights of women. I happen to think we have not done too badly with the law in that respect, by recognising that there are two sets of questions that need to be asked. There is a set of questions about the minimum standards for valid consent, which lawyers deal with as whether the consent is real or not.

Here we should not expect all the ramifications of tests to be rammed down women's throats. We should expect that women are clear about what is going to happen to them physically, and that they have the opportunity to ask questions about things that concern them. We should separate that from the question of what appropriate professional care is in opening up possibilities for asking those questions, and indeed in some contexts making it clear to people that the purpose of the particular test is 'x' or 'y'. I think that is particularly important where the uses to which certain information may be put are very limited. This is the case where really the only thing you are likely to do with a piece of information is consider a termination of pregnancy.

I think if this is the case, if the only question is: 'Would the person terminate the pregnancy if this diagnosis was made?' Is it right to create a legal framework which confronts women with that decision when they would be very clear about what they will do, and therefore there is no need to raise the stakes and levels of anxiety? Or is it that the better mechanism is to look at some way of structuring the obligations of professionals, which is not about is the consent valid or not, but rather what appropriate practice is. This raises questions not unique to ante-natal diagnosis, but more pressing to grapple with because I can see how things could go wrong it that area rather more clearly than I can say, in consent to curative surgery.

The second area is confidentiality. It seems to me this area throws into question the whole idea of what it is we are actually doing in our rules on confidentiality. Is it that what we are trying to protect is an individual's privacy, and their right to information about them to remain private and not be broadcast? Or actually are we trying to deal with the regulation of information itself, not necessarily about the person from whom it is generated. That interests me particularly in relation to genetics, because if you are going to do some sort of ante-natal diagnosis that will reveal genetic information, that information is not only going to be information about the woman who is pregnant. It is going to be information about the child, it may be information about the father of the child, or information that more broadly still may be of interest to other members of the family. So the question of confidentiality is not so easy as the question of is it right that the person who is the source of this information is entitled to tell health professionals who and who cannot be told about the information.

Now I am not sure that this way of characterising things as problematic, necessarily leads to different conclusions about how to decide who can and who can not be told information. However it does call into question the model of the professional's relationship with a client that assumes it is a one-to-one relationship. At the very least there is in the context of abortion discussions, issues of responsibilities of professionals to potential children. There are also questions about the role of professionals in relation to families, which our models of confidentiality which remain intensely individualistic in most of the medical/legal literature, strike me as not necessarily providing the smoothest of answers. It is not that one would want to necessarily reject the outcomes, but we do need to recognise a more difficult dimension and that what might be crucial is the proper approach to handling a regulating knowledge, which may involve more than the individual immediately concerned.

The third area is the role of the NHS. I have no difficulties at all in recognising the importance of ante-natal diagnosis, and the ways in which people use this information to make choices. It is therefore easy to say this is centrally part of NHS services. It clearly provides information that enables people to make decisions about their own health. It clearly provides information that enables them if they choose to avoid problems of ill health for a child that might otherwise be born with a serious abnormality. There is no doubt that with this service we are carrying on with what is at the heart of the NHS, improving the health of the population. Remember that what is set down legally as the obligation of the NHS is to provide services for the population, rather than individuals.

Equally it seems to me we are dealing with issues where provision of these services is going to enhance people's ability to make choices about a very major part of their future lives, and those choices might include issues about access to health services now or later. So I have no trouble that this is part of the National Health Service.

Where I think it becomes more difficult is in relation to rationing and the setting of priorities. It seems to me very difficult in the abstract to take the view that ante-natal diagnosis is a higher priority than other services. I would think we should be looking at questions of what sort of ante-natal diagnostic services we are taking about. We may need to make very hard choices about whether there are certain bits of information which generally as a society we are not prepared to pay for. We might consider whether there is a difference between information where the impact of that information on women and their families would be so great that we find it difficult to justify not providing it.

What is very interesting about this issue is that it leads us to a discussion about the rationality of drawing lines. I sat on a working party in Southampton looking at this recently, and one of the issues was age restrictions for diagnostic services for screening for Down's. The discussion was whether it was right to have an age restriction, where if you are in your thirties you will get the service, but if not you will have to push for it. The difficulty is in taking a decision at a very abstract level on the basis of statistics, where on one level you can say that difference in the rate of problems for a woman who is 29 and a woman who is 30 is very small. Yet one woman gets the service and the other does not. However we are always having to draw these sorts of lines. One of the things the working party discussed was whether we could create a system where there was a core of services that the NHS region should make available everywhere, where you could identify and make room for local discretion, or whether some extra services should be available if people are prepared to pay for them.

Of course this makes it very difficult for our legal structure, because we have a system where it is very difficult to mix and match private sector care and NHS care. This struck me however as an area where it might be quite reasonable for professionals say that a patient is not at sufficiently high a risk to justify spending money on this diagnosis, but of course access can provided to the services if the patient will pay. One of the issues that it is interesting to explore, but where the law places constraints, is whether it is right to make sure that a local health authority can go beyond the minimum standards that the NHS will provide.

The final issue is about the role of the law in regulating ante-natal diagnosis, and I want to draw a distinction between two types of concerns that the law might have. One is a focus on the substantive decisions that are made by individual women in relation to their pregnancies. It could be that the proper function for the law is to find of way of deciding if the decision taken by the woman is one that we regard as acceptable or unacceptable. That will take us, if we go down that track, into the motivation for decisions.

Let us say we take the view that the commitment to an egalitarian society, that doesn't discriminate on the basis of disability, is the society we now are. Therefore we think it improper to terminate pregnancy on the basis of at least some degrees of disability. The sort of legal system that would follow from that would not be the kind of legal system we have currently. Our current regime on termination for abnormality has a very loosely defined disability ground. It is filtered through the views of two doctors; it is filtered through an undefined concept of substantial risk and serious handicap. If we really wanted to identify motive as what the law is about, we would really have to tighten up those grounds, and also need to think about whether it was desirable to place limits on termination early in pregnancy, where we don't require women to go through those hoops at the moment.

Is it possible, or desirable for the law to regulate individual decisions, where we believe those decisions are highly charged. Is it right to expect the law to deal with that? The contrasting scenario, which I think loosely describes the situation I think we do have is a system that doesn't concern itself with the motivation behind decisions, but concerns itself with allocating the power to decide. It doesn't allocate that power just to women. If we were to do that, and just concern ourselves with women's choice, we would not have any restrictions on termination, we would just have the law of consent. We do not do this, and instead we create a series of legal hurdles that women have to get through, and we do begin to decide on certain limits which create a space for a choice to be made by the interested parties. We do set limits on time, and we do go some way to defining the sorts of circumstances in which we think termination is justified, although we don't do that very precisely.

The image I would leave you with is one that will be familiar certainly to lawyers who work on mediation. One of my other interests is family law, and a lot of the literature on how people negotiate in the shadow of family law. Some writers suggest that assumptions that the way in which the law regulates decisions provides incentives to reach certain settlements. So if we are considering law relating to settlement of financial provision on divorce, one argument is that because of what is likely to happen in the courts, people come to decisions that they think are in line with what the law will do. This is what is called bargaining in the shadow of the law.

This assumes the law can do things. It can provide a mechanism for settling disputes, but can also have an influence on negotiation. Now this seems to me to raise a contrast. Is it that the law is trying to create a framework that would only come into play when there is a dispute to be resolved, that is in extreme cases, but would still have something to say to people when they are deciding what they want to do, and would influence their decision? That would push us towards the motive model. Or are we saying that all the law should do is to identify those things where we are sufficiently clear about the right outcome. Here we should make people do what we think they should so. We should leave all the rest, hoping that they act appropriately and rely on professionals to act appropriately within a space that the law has marked off for them to work with as best they can.

Theresa Marteau

I am a health psychologist, and I do not practice clinically. The work that I do is to look at the psychological implications of some of the technologies that Jonathan has been talking about. For the last ten or more years I have been interested in how doctors and midwives talk to pregnant women about pre-natal tests. I am concerned with how they are actually talking to women and what the consequences are for the women of undergoing or not undergoing particular pre-natal tests.

I would say that in terms of what guides practice, my impression is that the practice of health professionals is guided more by policy in this area than the law. Central to all policy is the idea that women, for most often it is women that are spoken about, are making a choice that is theirs alone. Words like autonomy are used frequently, in phrases such as 'there must be respect shown for individual autonomy in this area', and the issue of consent, which is the term that lawyers use, comes up too. There is a particular reason for this because of the history of eugenics in the last hundred years in the Western World, which so horribly went wrong in Nazi Germany, but there are many other examples too, not just that one. For many people one of the central defining points of eugenics is imposition from a State, to try to effect people with a particular genetic state in a population.

It is felt to be very important that one way to disentangle past abuses of genetics from the current use of genetics is to make decisions individually based. The idea is that people should have the choice, and it is not expected that people will undergo terminations or that people will not undergo terminations. It is seen as a private area that needs to be protected.

What I want to do is give a couple of examples from research by my own group as well as from others to ask the question: 'What does it actually mean to say that an individuals decision has been autonomous?' I have no answer, but I think that the concept of autonomy is quite problematic, certainly for a psychologist. It is a potentially useful term, certainly for reminding us of past abuses and why we need to be very careful in trying to make the conduct of healthcare in this area better. I think also that it is a bit of a smokescreen, because it stops us going beyond political rhetoric and ideology.

I am going to look at research that illustrates two issues. The first is that people's behaviour or choice is influenced by the situation in which they find themselves. This has happened to you already many times today. If you go shopping in a supermarket, it is estimated that up to 50 per cent of things that end up in our trolley were determined by packaging and where things were put on the shelf. You also know that what you were able to choose depends on what was put on the shelf. All of us are already familiar with that idea. The supermarket manager did not force you to put those things in your trolley, but the situation determined what you actually did. I can give two examples of this in the ante-natal context.

The first is a study that was conducted over ten years ago. This was carried out in the States. It was not an experimental study, but what they did was offer amniocentesis to women who were aged over 35. This is an invasive test to check the chromosomes, to see whether the baby has Down's Syndrome. What this study shows is that if the doctor spoke about the test, and told the woman that the test could be done that day, then 93 per cent of the sample said yes, gave consent and underwent the test. If the woman was told about the procedure on one day, and then had to make a return visit to the hospital, then only 78 per cent came back and underwent the procedure. In both cases consent was obtained, but a different number actually underwent the test.

Another example is from a study conducted in the UK by a group I was working with, and a similar study conducted by colleagues of ours in the States. What we were doing was offering carrier testing for Cystic Fibrosis. What that means is that we were offering adults, aged between 18 and 45, who were all registered with one General Practice, the chance to find out if they carried the gene for Cystic Fibrosis, which is a recessively inherited condition. This means that if you have a child with someone else who is a carrier, there is a one in four chance that your baby might have this condition. 5 000 adults were offered this test, and initially we sent a letter to a thousand of then, in London, giving them the opportunity to come into the centre, to take a mouth-wash to find out if they were a carrier for this condition. We found that ten per cent came for this.

We noticed up the road that there was a group of geneticists carrying out the same test, but getting an uptake rate of 70 per cent, and we wondered what was going on. We found out what they were doing and did the same thing and found that lo and behold the rate changed. The method used was for a very attractive researcher to approach patients when they came in to see the GP and give them information about what the test was about rather than them just receiving a written letter. This way we also found that 70 per cent underwent the test. We varied again, and they were offered the opportunity to undergo this test face-to-face, but had to come back another day to take the test. Here the uptake rate went down to 25 per cent.

The similar study in the States found essentially the same pattern, whether there was a letter or information given face-to-face, but the uptake in both cases is much lower. This may be something to do with insurance concerns in the States and the issue of abortion, where a higher proportion of people do not see this as an option. Nonetheless, the point is that people choose different things depending on how the information is given.

One question is which is better? The answer depends who you are. If you run a CF testing company, then you will say face-to-face same day testing, because you get a higher uptake. Really one needs more information, because it may be that lower uptake happens where the inconvenience factor has overtaken what people want ideally, and compromised their choice. It may be that higher uptake rates reflect social influence because of face-to-face communication, which is not actually to do with undergoing the tests. Although we hear a lot of talk about how relationships with doctors has broken down, in the main relationships between health professionals and the public are very positive. Doctors and nurses are still powerful people in our culture.

This evidence raises questions about what is a choice in this situation. The other issue that I want to touch on is communication between health professionals and their clients. How do doctors and nurses talk to their patients about pre-natal tests? I want to give one example from a study we conducted two years ago where we tape-recorded routine consultations of obstetricians and midwives, although I am just going to give the example about obstetricians now, where they were talking about pre-natal tests. The test is amniocentesis and this is what was said by three obstetricians talking to women.

The first one says: 'Obviously at your age we would strongly advise the amniocentesis test'. Another says: 'I would do the same thing in your position'. The last says: 'If you were my wife I would advise amniocentesis'. There is one school of thought that says this approach is awful. It doesn't understand the ethical sensitivities of ante-natal testing, and doctors are exercising power in pushing their patients in one direction. If you look at geneticists talking to patients, they would not use this language. There is another argument that says maybe the obstetricians are helping the women who are faced with a quite isolated decision, and giving them more of a sense of where they stand, given the majority of women do undergo these tests. So one could approach it from a pragmatic point of view, and do research to look at patterns of communication, to see how patients are feeling following different patterns of communication. It may be that actually women are much happier about the decisions that they make when they have had a health professional giving them some advice. It may be that ethicists feel that women's happiness is not the important thing but it is more important that the right process is stuck to. I have characterised the debate rather crudely, but that is one of the debates that runs through this area.

My sense is that all of us are operating in a social environment. There is social influence going on all the time, and I do not think there is any evidence of people being coerced or forced to undergo these tests. Nevertheless the information is being presented in such a way that is more likely to lead people to undergo tests than not. That leads us to ask what is the optimal way of giving information. One could say that autonomy is being minimised in some of the clinics, but this may not be the case.

John Gillott

To begin on a popular note, I don't know if any of you heard about this story, but some adverts appeared in America in mid-September which said 'Children made to order - there has never been a better way to bring a child into the world. At GATTICA it is now possible to engineer your offspring. Here's a check-list to help you decide which traits you would like to pass on to your new-born'. It begins with ways of making sure most of the hereditary diseases can not be passed on. It moves onto the character and behavioural traits, such as musical ability or athletic prowess and so on. You may know that this was a spoof, put out as a way of drumming up interest for a film called GATTICA. However as an item in Nature pointed out, quite a few people who are involved in medicine thought it was serious and rang up to check, to see if they had missed something.

Perhaps even more intriguingly, the day before the ad appeared, not unrelated themes were on the agenda for the first meeting of the Gene Therapy Policy Conference, sponsored by the National Institutes of Health. At this conference, leading gene therapists like W. French Anderson, were arguing that it was going to be hard very shortly to avoid the possibility of testing for enhancement through genetics, rather then simply the detection of genetic disease. I throw this out because these are the kind of things that fill the media all the time, and we may want to talk about them during the discussion. I am not going to talk about the speculative, futuristic issues myself, but the advances in science to do with genetic disease are perhaps no less rapid than some of the projections we do see in the media.

A lot of the background to this discussion is about rapid scientific advance, but there is great advance in services as well. It is worth bearing in mind that pre-natal testing is now allowing more conditions to be tested for, but there are also safer methods of testing and earlier kinds of testing. Soon we will have non-invasive methods of testing during pregnancy, where it is going to be possible to isolate minute amounts of fetal blood from the mother's blood stream. The testing is soon to become quicker and less invasive, and picking up in Jonathan's argument, perhaps cheaper.

This advance of the service, and the possibility of offering testing more widely, from a public health perspective, have raised a number of concerns. I want to look at three linked objections or concerns in the area. The first is that science and technology are shaping the demand for the service. This is the idea that the advance of science itself is making people opt for testing. Choices are not being freely made, but rather are being constructed or encouraged. The second idea is that the service is directive, even if it is not coercive. People in the past used to fear eugenics, in the sense of a state plan. Now the argument is more that we face eugenics by stealth. The case made is that demands are shaped by science, services will be directive, and this will lead to a context where parents 'choose' their offspring, but without real choice. De facto there is a eugenics policy, without it necessarily being called that. Linked up with this approach is the idea that this kind of push will devalue and discriminate against disabled people.

I want to begin by talking about the issue of choice, but take a slightly different approach to Theresa. I want to argue that people can and do make choices. To look at this it is worth breaking down who actually uses the service. The first thing to bear in mind is that there is a group of people who most obviously are making choices and who most obviously are well informed. This is people with a genetic condition in the family, with an affected child, who know a lot about the condition. They are very well motivated and very aware about the condition, often to a greater degree than a lot of the medics. They are making a choice, on the grounds that they know they are at high risk, and because of this actively want ante-natal testing services.

That set of people also minimises some of the problems of consent and confidentiality, precisely because the condition is already known in the family, so there is just not a question there. The second set of people is couples screening. Here, generally speaking, most people who might have a child with Cystic Fibrosis would not be aware that this could happen, because they are not aware of a family history. What happens it that in some places, for example Scotland, there is a very well organised service offering couples screening during pregnancy, and following that up with ante-natal testing were both partners shown to be carriers of CF. There is a high uptake of this service of around 80 per cent.

There are two ways of looking at this. You could argue, following Theresa's point, that the medical profession is making this choice. The medical profession is saying 'Here's this test. You really want to take it'. The other way of putting it is that people are inevitably na´ve to the test being available, because they have no family history, and do not think there is an issue. Once it is made known to them during pregnancy that there is some risk, and testing is available, then they can become quite self-motivated to find out. We do know that pregnant women and families as a whole are quite keen to make sure that everything is done that is possible to ensure a healthy birth. If the science is made known to them, and therefore they are no longer na´ve, it can be argued convincingly that they are making their own choices. You can not make a choice if you do not know what is on offer. But once it is known what is on offer, then people are capable of making choices, and pursuing what is best for them. The vast majority do undergo couple screening and follow on with tests where necessary.

Where there is a question of things cropping up out of the blue is in the area that Jonathan raised. This is about routine screening, where problems are turned up which are not necessarily associated with the screen. To put this in perspective, I still think people can and do make choices. In the event of a problem being detected, they have to be informed of the issues, but then do make choices. I would argue that reasonably strongly.

This is obviously a contentious area. I would slightly disagree with the way Jonathan put this. Even if we did follow the Ian Kennedy line on the law, and said we should impose law which we think is right, I still think it would be possible to have total freedom to terminate pregnancy on the basis of genetic diagnosis, without in any way being discriminatory to people with genetic conditions. Members of GIG for example, who have children with a genetic condition, and choose not to have any more, do not care less for or value less the child they have already as a result of making this choice. It is also possible at a society-wide level to have the same kind of attitude.

It is important to separate out the medical condition from the individual, and recognise people can be granted full human rights, without having to say it is as beneficial to have a genetic disease as to be free from it. In other words, there is no need to link disease to identity. In think it is a feature of the growth of a form of identity politics that the two are often put together now. Respect for human rights is being equated with being non-judgmental about having a medical condition. In contrast I think we can talk about curing disease, and say it is better not to have than to have a genetic disorder, without saying we want to get rid of people with conditions. I think this is an important point.

If you then add to that the status of a fetus and the status of a living individual, however we define the difference between those two, we can have a view which says it is in no way discriminatory to seek to have people making choices to avoid the birth of a child with a genetic condition. I do not think it is even discriminatory for society from a public health point of view to organise on that basis. It would be na´ve to argue that services are not organised in this way, in order to reduce the incidence of genetic conditions, but I think at the same time this is not equal to discrimination against the disabled. Today we have a rise in genetic diagnosis, but it is not the case that society is becoming more intolerant to people with genetic conditions. People say there is less tolerance, but I do not sense it myself in contemporary culture.

So I think people do make choices, and that there is nothing discriminatory about those choices, even if organised and promoted by society. The final point I want to look at is raised by a piece of work that Theresa has co-authored. The article is called 'Non-directiveness in genetic counselling -an empirical study', published in the American Journal of Human Genetics. It is a very interesting piece of work, which documents the attitudes of counsellors, counsellees and uses objective measures of directiveness during genetic counselling. The main thing that came out of the research, was a recognition that regardless of the professed desire to be non-directive, whichever way you look at it, services are directive in one way or another. This raises two important questions. One is whether genetic services could ever be non-directive, and the other is it a problem that they are not at the moment. Is its desirable to even aspire to be.

I would make a few points in response to these issues. One is that I do not see anything wrong in counsellors clarifying likely implications of genetic conditions. If that is what is meant by being directive, then so be it. I think it is a necessary part of the job to do this, and a reasonable part of the job. An interesting fact in the paper is that those being counselled were happiest when the professionals were being most directive. The post positive experience is where they spell out what results mean, explain the implications and say what other people have done in that situation.

We could go a step further and say that coming back to the question of free choice, that there is perhaps an obligation on genetic services to be directive, because people are not initially aware of the choices they can make, and these should be pointed out them. Most people come to services na´ve to the reality of genetic conditions, and it is reasonable that this is pointed out to them. Second time around parents make the choices they do knowing the reality of a genetic condition. It would be quite reasonable for professionals to let people know the first time that are considering a child what the reality is. If that means being directive, we should not worry about it, and in fact services should carry on in this way.
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