Health policy is defined as – “authoritative decisions made within government…intended to direct or influence the actions, behaviors, or decisions of others pertaining to health and its determinants (Longest, 2010).”
Ethics is defined in various ways around the core concepts of moral rightness and related behaviors and decisions. With respect to public health policy ethics, the Public Health Leadership Society (2002) published Principles of the Ethical Practice of Public Health consisting of “12 Principles of the Ethical Practice of Public Health” and accompanying appendices. In the following, a particularly appropriate principle regarding PAMS and current public position statements of the CDC, FDA, and WHO regarding PAMS is Principle 8 –
“Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.”
Statements Regarding PAMS
The FDA rightly advises parents that there are risks of infectious disease (emphasizing HIV), chemical and pharmaceutical contaminants, and illness resulting from improper handling of milk as well as counsels to seek guidance from a healthcare provider. The next portion of the statement describes the FDA’s belief that it is not possible to safely handle and adequately screen an individual privately to ensure milk safety. The final portion of this statement refers families to HMBANA.
The CDC does not specifically address intentional sharing of milk, but does address the accidental consumption of milk that is not intended for the recipient child, again, focusing exclusively on HIV risks –
“The risk of HIV transmission from expressed breast milk consumed by another child is believed to be low because
* In the United States, women who are HIV positive and aware of that fact are advised NOT to breastfeed their infants
* Chemicals present in breast milk act, together with time and cold temperatures, to destroy the HIV present in expressed breast milk
* Transmission of HIV from single breast milk exposure has never been documented”
discusses several options beyond the closed biological breastfeeding relationship-
“For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.”
Ethics of Statements
The CDC and FDA statements fail to provide families with adequate information regarding health risks associated with PAMS (Gribble & Hausman, 2012). In the case of HIV, transmission rates in breastfeeding dyads where the parent is known to be HIV positive and in resource limited settings is less than 15% (Coovadia & Bland, 2007). Further, these statements fail to acknowledge the cultural and religious factors of milk kinship present in Islam and Orthodox Judaism that make accepting milk from a milk bank or other anonymous source a choice in violation of faith. Many families in the PAMS culture have ethical objections to hierarchy of need placed upon recipient families by HMBANA (Gribble, 2013; HMBANA, 2010). The WHO statement clearly addresses the viability of providing milk from a wet nurse (presumed to mean from the breast or through expression) in situations where resources are appropriate.
Current policy statements from the CDC and FDA are inadequate in meeting the expectations of ethics associated with public health. STI screening and home pasteurization are, in fact, readily available to most families in the United States. Individuals have the right and responsibility to decide where and with whom they share breastmilk. Donors and recipients who do not currently have access to banked milk still have the right to biologically normal nutrition for their infants. Public health agencies have the vested responsibility to provide comprehensive guidance, which has not been met. These agencies have ready access to the necessary information to provide families with this information, as is evident in the provided resources from milk sharing networks.
Coovadia, H. M., & Bland, R. M. (2007). Preserving breastfeeding practice through the HIV pandemic. Tropical Medicine & International Health : TM & IH, 12(9), 1116-1133. doi:10.1111/j.1365-3156.2007.01895.x
Gribble, K. D., & Hausman, B. L. (2012). Milk sharing and formula feeding: Infant feeding risks in comparative perspective? The Australasian Medical Journal, 5(5), 275-283. doi:10.4066/AMJ.2012.1222
Gribble, K. D. (2013). Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN / NAACOG, 42(4), 451-461. doi:10.1111/1552-6909.12220