Making Martyrs of Our Children: Religious Exemptions in Child Abuse and Neglect Cases

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Devan Stahl, PhD

On August 2, 2018, Seth Welch called 911 after finding his 10-month-old daughter, Mary Anne Welch, unresponsive in her crib. Mary was pronounced dead at the scene and the medical examiner determined Mary’s death was the result of malnutrition and dehydration. During interviews, Seth Welch and his wife Tatiana Fusari admitted they were aware of Mary’s skinny appearance for at least a month prior to her death, but claimed that they had fed her appropriately and did not believe her to be ill. The parents are now awaiting trial for felony murder and first-degree child abuse.

The case has made national headlines, because the parents claim their decision not to take Mary to a doctor was based, in part, on their religious beliefs. Mrs. Fusari said she failed to reach out for medical help for her daughter because she feared having her children removed by Child Protective Services, a lack of faith in the medical system, and “religious reasons.” Further, Mr. Welch claims he is being unfairly charged in Mary’s death because of his “very strong faith.” Neither Mr. Welch nor Mrs. Fusari have explained their religious beliefs, but in Facebook videos, Mr. Welch claims he is “not opposed to medicine or doctors,” but he believes some doctors are part of a “priesthood of the medical cult.” He also claims not to believe in vaccines, and expressed a desire to live in a “commune of Christian disciples living off the grid somewhere.” The reasons Mary’s parents did not take her to see a physician appear to be multifaceted, but their claims to religious liberty are a hot button issue in bioethics and politics today.

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Image description: a baby is photographed lying down, a hand is holding a stethoscope to the baby’s chest. Image source: Bread for the World/Flickr Creative Commons

The case of Mary Anne Welch is yet another in a long line of child neglect and abuse cases where a religious exemption defense is likely to be mounted. All U.S. states have laws prohibiting child abuse and neglect, but 39 states also have laws protecting parents from abuse and neglect charges (though not murder charges) when they fail to provide medical assistance to their children because of their religious beliefs. Religious exemption laws are meant to protect the religious liberty of individuals who use faith-based practices in place of medical science; although in many states the religious exemption only applies to people who are part of “recognized” religious denominations. These exemptions grew out of a Department of Health, Education, and Welfare (HEW) ruling after the 1974 passage of the Child Abuse Prevention and Treatment Act, which specified that religious exemptions be added to states’ child protection laws. In 1983, HEW adopted new regulations that removed the requirement for religious exemption, however, few states have repealed their religious exemption laws. In many states with exemptions, including Michigan where Mr. Welch and Mrs. Fusari reside, courts can order medical services to be provided to a child whose health or life are at risk without medical care.

In nearly all cases, competent adults are free to make medical decisions according to their religious beliefs, and cannot have treatment forced on them for any reason. At the same time, parents have certain obligations toward their children, which restrict their right to exercise their religious beliefs on behalf of their children. In the famous U.S. Supreme Court case Prince v. Massachusetts (1944), the court ruled that “Parents may be free to become martyrs themselves,” but they are not free “to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves.”

The case of Mary Anne Welch is a microcosm of a larger debate happening in health care around religious liberty and the rights of children. The American Academy of Pediatrics (AAP) has stated that parental desires regarding their child’s medical treatment should be followed, unless these decisions clearly go against the child’s best interests. At the same time, for decades the AAP has been opposed to religious exemption laws. In cases where parents are acting maliciously or with gross indifference to the well-being of their child, it is easy to see why overriding parental decision-making would be appropriate. Prosecuting parents for neglect and abuse if their child suffers as a result of their decisions feels appropriate as well. Knowing very little about Mr. Welch and Mrs. Fusari, however, it would be presumptuous to make any judgments about their fitness as parents, or about their care for Mary. At this point it is not clear that given Mary’s weight loss, other reasonable parents in a comparable situation would have taken their child to the doctor regardless of their religious beliefs. Time will tell if Mary’s death should have been foreseeable or if it would have been preventable with proper medical care.

What is likely to happen in the meantime, and seems to be happening already in the media, is that Mr. Welch and Mrs. Fusari’s religious beliefs will be scrutinized. (Their concerns about the dangers of hospitalization are supported by recent studies about medical errors.) Religious exemption laws regarding parental neglect are controversial, and critics are right to question the legitimacy of such laws when children die as a result of their parent’s religious beliefs. Despite their religious beliefs, we ought to hold parents to a standard where they are expected to prevent injuries to their children. At the same time, we ought not to hold parents such as Mr. Welch to a higher standard for parental care, simply because he has particular religious beliefs that are not widely held by other parents. Plenty of parents choose to opt out of certain medical treatments for religious and non-religious reasons alike, and it is not clear that medical orthodoxy should always be determinative of a child’s best interest. Time will tell if other prudent parents would have taken a child in Mary’s condition to the doctor. If that is found to be the case, then Mary’s parents should be held accountable for their decisions.

Devan Stahl photoDevan Stahl, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 4, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More Bioethics in the News from Dr. Stahl: Mass Shootings, Mental Illness and Stigma; Disability and the Decisional Capacity to Vote

References

  1. John Agar. “Couple ‘grief stricken’ after daughter’s alleged malnutrition death, attorney says,” MLive 20, 2018. https://www.mlive.com/news/grand-rapids/index.ssf/2018/08/couple_grief_stricken_after_da.html.
  2. Ken Kolker. “Records outlive why parents didn’t get help for starving baby,” Woodtv 9, 2018. https://www.woodtv.com/news/kent-county/records-outline-why-parents-didn-t-get-help-for-starving-baby/1349369491.
  3. Michaela Broyles. “Parents didn’t trust doctors, court documents show. Now they face murder charges,” The State 14, 2018 https://www.thestate.com/news/nation-world/national/article216654390.html.
  4. Lindsey Bever. “A 10-month-old died after her parents refused to get help for religious reasons, police say,” The Washington Post 8, 2018 https://www.washingtonpost.com/news/acts-of-faith/wp/2018/08/08/a-10-month-old-died-after-her-parents-refused-to-get-help-for-religious-reasons-police-say/?utm_term=.20c48845d5d1.
  5. National Center for Prosecution of Child Abuse National District Attorney Association, “Religious exemptions to child neglect” Feb. 2015 https://ndaa.org/wp-content/uploads/2-11-2015-Religious-Exemptions-to-Child-Neglect.pdf.
  6. National Child Abuse and Neglect Training and Publications Project (2014). The Child Abuse Prevention and Treatment Act: 40 years of safeguarding America’s children. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. https://www.acf.hhs.gov/sites/default/files/cb/capta_40yrs.pdf.
  7. Michigan Legislature MCL 722.634. “Child protection law” https://www.legislature.mi.gov/(S(ctyef0ed5imcuvwc4m4jgtsl))/mileg.aspx?page=getObject&objectName=mcl-722-634.
  8. Prince v. Massachusetts, 321 U.S. 158. 1944. https://www.courtlistener.com/opinion/103933/prince-v-massachusetts/.
  9. Mark R. Mercurio, Marilyn A. Maxwell, Brenda J. Mears, et al. (2008) “American Academy of Pediatrics, policy statements on bioethics: Summaries and commentaries: Part 2.” Pediatrics in Review 29(3): e 15-22. http://pedsinreview.aappublications.org/content/pedsinreview/29/3/e15.full.pdf.
  10. American Academy of Pediatrics. (2013) “Conflicts between religious or spiritual beliefs and pediatric care: informed refusal, exemptions, and public funding” Pediatrics 132(5):962-965. http://pediatrics.aappublications.org/content/pediatrics/132/5/962.full.pdf.
  11. Martin A. Makary and Michael Daniel. (2016) “Medical errors—the third leading cause of death in the U.S,” British Medical Journal 353: i2139.
  12. Vanessa McMains. “Johns Hopkins study suggests medical errors are third-leading cause of death in U.S.” Hub May 3, 3016. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/.

20 thoughts on “Making Martyrs of Our Children: Religious Exemptions in Child Abuse and Neglect Cases”

  1. Hi Devan,
    Thanks for this thoughtful write-up about such an important issue.

    I think I agree with all of your major points, but it might be helpful to look at the updated AAP Committee on Bioethics guidance on permissible physician interference with suboptimal parent decisions about their children’s health care. In 2016’s “Informed Consent in Decision-Making in Pediatric Practice” (Pediatrics 138 (2): e20161484. https://doi.org/10.1542/peds.2016-1484), the AAP Committee on Bioethics moves away from the claim (present or implicit in earlier guidance) that deviation from best interests could suffice for interference. Instead, this document embraces Diekema’s conception of “significant risk of serious harm” as the threshold for permissible interference.

    Perhaps the new AAP guidance is closer to your own views—that parents should be “expected to prevent injuries to their children”—than the previous guidelines were. In particular, I share with you the sense that a harm threshold (understood in terms of the violation of children’s basic interests) provides more appropriate guidance for interference than does talk about best interests.

    On a related note, I recommend Johan Bester’s recent (August 2018) AJOB piece on the Best Interests Standard and the Harm Threshold—not because I agree with him, but because I think his argument (and his critics’ arguments) do a good job illuminating some of the issues in play in the sort of case you’ve discussed.

    And, for anyone interested, there will be a session at this year’s ASBH meeting on “Harm and Parental Permission,” with Doug Diekema, Lainie Ross, Johan Bester, and me. You can find it in the Wilderness Room at 10:45 AM on 10/19.

    Best,
    Mark

    1. Thanks Mark, you are right to point out that the AAP’s newer guidelines do appear to shift the conversation about parental decision making from ‘best interests’ to a ‘harm threshold’. I believe this was an appropriate move, since it is quite difficult to tease apart child’s interests from those of their families and caretakers. It also allows us to bypass more complicated questions about what is in the child’s best interest spiritually, which is something I don’t think we want the State to judge.
      I hope all of those who attend ASBH and are interested in this topic will attend your panel! It should make for and interesting discussion.

    1. Thanks for this Meghan. This blog gets at some even thornier questions about when the religious exemption statute applies. In cases like the one I have described and the case mentioned in the blog you cite, parents refused to take their children to a physician in the first place, making it impossible for a physician to have tried to get a court injunction to treat the child over the parent’s objections (which is also permissible under the statute.) The judges opinion (in the case you have cited) that MCL 722.634 only provides a defense of parents who “neglected to seek medical treatment—not situations where the parents refused to seek medical treatment” is a distinction I have not heard before and I am not entirely sure I understand. We will have to see how the judge handles a religious exemption defense in the case I have presented.

  3. Hi Devan,

    I found the information in this post to be heart wrenching to know another young life has ended so soon. However, it is post like yours that continues to open my eyes to ethical dilemmas and ethics in general while pursuing another degree. Your article has definitely encouraged me to look more into the AAP guidelines and research the religious exemptions. Though the content is hard to digest, especially for those with religious backgrounds, I think this topic should be discussed more often. So thank you for the information Devan.

    1. Thank you for your comment Alexis. I would recommend Mark Navin and Jason Wasserman’s article, “Reasons to Amplify the Role of Parental Permission in Pediatric Treatment,” AJOB 17(11) 2017. In it they discuss the newest AAP guidelines on the best interests of children and the harm threshold. As you can see in my comments to Caitlin below there is considerable dispute and uncertainty regarding religious exemptions moving forward and all those interested in bioethics, patient care, and public health need to be aware of what is going on legislatively.

  4. Hi Devan,
    I thought this was extremely interesting and agreed with many of your points. Something that stood out to me was mentioning parents “are expected to prevent injuries to their children”. You mentioned how the parents were worried about Child protective services, however, if they went in before the child became extremely ill would there have been such repercussions such as CPS being called? Do you think there is a misconception of when CPS is utilized and when it is not?

    I also think that even though there are religious exemption laws that there must be some way that the parents must prove that their religion was the reason why they did not receive medical help. It sounds like the parents do not have a reason or clear explanation of why it went against their faith. I lack knowledge about these exemption laws and will have to do further research. However, do you know if these exemption laws have specific requirements to prove it was based on their faith to not pursue medical treatment?

    1. Hi Caitlin, Great questions. I did not get into this too much in the post, but there is actually a big question mark around religious exemptions moving forward as a result of the U.S. Supreme Court Hobby Lobby case. As I mentioned, some states clarify what that the religious belief has to be recognized or authentic, but that requirement may go away in the future. If these parents do indeed use a religious exemption defense under the religious freedom restoration act (RFRA), the SCOTUS decision (Burwell v. Hobby Lobby) precludes the scrutiny of religious beliefs as legitimate or illegitimate and instead demands only a compelling government interest and reasonable accommodation standards are met. The precedent in Hobby Lobby made reasonable accommodation of religious beliefs quite broad in favor of the person seeking the exemption. So far, a child welfare case like the one I have cited in the blog has not made its way to the circuit or SCOTUS court level, but when one does we will see if judges want to use Hobby Lobby as instructive. We will have to wait and see.

  5. Devan,
    Thank you for writing about this important topic. It is a lot to wrap my head around, but I think it is an important topic to consider based on my profession. I find it interesting that the parents claim they were aware of Mary’s skinny appearance, but didn’t believe that she was ill. When they go on to describe that the reasons in which they didn’t reach out for medical help, none of those reasons are that they thought she was fine. It is a gap in their story that I can’t make sense of. It is clear to me that they knew something was wrong, and didn’t reach out for medical help because of an ulterior fear not mentioned, neglect. It leads me to believe that their “religious reasons” and fear of medical practice is a way to turn our heads away from the clear neglect that took place. Regardless of their truth, it does bring awareness to this interesting topic. Prior to reading this, I had never given much thought into religion and the way it can interact with medicine. I know that parents can deny vaccines for religious reasons, but I personally know a family who opted for this reason, with no religious affiliation at all. I have never considered how wrong that can be, and how it ruins the credibility of those who truly believe faith-based practices over medical science. I want to thank you for bringing this topic to my attention, and I plan to look further into these laws and policies in my area.

    1. Thank you for your comments McKenzie. I agree that there seems to be many holes in the story–much of which might be addressed once the trial begins. It will be up to the jury to decide if other reasonable parents would have taken their child to the doctor in Mary’s condition and if they truly were neglectful. An interesting companion case is the Commonwealth v. Twitchell case (1993), which prosecuted Christian Scientists for not taking their child to the doctor. Although they were found guilty, there remains a big question about what other parents would have taken their child to the doctor if they had merely suspected the flu. Here’s a New York Times article that discusses the case: https://www.nytimes.com/1990/07/07/us/christian-scientists-are-given-probation-for-death-of-child.html

  6. Hello Dr. Stahl,

    This whole topic reminds me of my just religious beliefs leading to children at risk for neglect, but also cultural practices. For example, many families do not vaccinate because they do not believe that vaccines benefit their child; for a more extreme example, many other cultures remain suspicious of psychotropic and anti-seizure medications and therefore may not give their child these medications. This can certainly be considered medical neglect and it creates even more murky legal circumstances.

    1. Hi Amelia, of course you are right that these are legally murky and perhaps only getting more complicated as SCOTUS weighs in. We certainly want to allow parents to have the freedom make some choices for their children that might expose them to some minimal risk of harm–playing football for instance. And we wouldn’t want to prosecute most parents for feeding their child a vegetarian diet based on religious beliefs, but where do we draw the line? This is the crucial question for cases like this.

  7. This is such an intriguing and multifaceted problem. In keeping church and state separate, we allow for individuals to have unbiased beliefs protected by a lack of prejudice and outside intervention. This is important to respect within the medical community, but as with other parenting decisions, there are mandates to protect the vulnerable, even from well-intentioned individuals. I am very interested in the idea of a “harm threshold,” as this phrasing does not mention intention or the motivations of the actions, simply displaying that there could always be a harm threshold that needs to be kept in mind. It will be interesting, however heartbreaking, to see the determination of this case and how this could affect future policies or laws in regards to the treatment of children despite religious differences. Could intentions play a part in the trial if the parents truly believed that the child was not ill and that they were following all health recommendations to the best of their understanding?

    1. Great questions Jessica. Intention is such a hard thing to get at and yet much of our legal system is built on the presumption that intent does matter. Manslaughter is different crime from first degree murder, in part because of the intention of the actor. But how can we every truly know someone’s intent was religiously motivated or not? I imagine in the court hearing, this will come up–were these sincere religious beliefs or are the parents merely trying to set up a defense against their actions? It is unlikely that these parents intentionally caused harm to their child, but they may still be held accountable for harm if their neglect was the cause of their child’s death. We will have to wait for the hearing to see how this plays out.

      1. I agree, there will be much to follow up on in regards to this case. And as you pointed out, what was the “motive” could actually be the defense, such as when a mentally sound individual attempts to use the not guilty by reason of insanity plea. Thank you again for posting such a though-provoking topic!

  8. Hi Devan,
    Thank you for writing this article that opened my eyes to the controversy of religious exemptions in the medical field. I found it interesting that “she feared having her children removed by Child Protective Services, a lack of faith in the medical system, and “religious reasons.” I wonder if there was a past trauma or incident that made the family fear CPS and have distrust in the medical system. I feel that this must be a hard time for the family and especially the couple’s other children. After reading the attached articles and watching the videos, I think there is a lot more to the story. I wonder how the court will decide if the family is truly following a religion and where the line falls between following their religion and neglecting their kids. I feel this is a great time to advocate for the well being of children. I know that I must do more research the Child Abuse Prevention and Treatment Act and similar laws to form my opinion on the case.

    1. Hi Jessica, these are all good points. From what I can gather the parents made some reference to having CPS called on them after their first child was born, one article mentioned a positive drug screen as the source of that call. This has me wondering whether other parents are hesitant to take their children to the doctor after a CPS referral and if this should caution clinicians against called CPS too quickly – these are hard judgments to make, but oftentimes they are legally mandated referrals.

  9. Devan,
    Thank you for such a heart-breaking and fascinating portrayal of issues that are happening in our hospitals every day. This is such a hot-topic issue in today’s society, and in a modern time where social workers need to protect children, yet they are trying to advocate for individual’s religious freedom, we’re at a stalemate of sorts. It’s very interesting that you pointed out the AAP guidelines saying that parental desires should be followed, yet if it goes against the best interest of the child, something needs to be done to protect the child. The parents said that their failure to seek medical attention was due to their religious convictions, but had they mentioned what type of religion they were a part of? You mentioned the religious exemptions in certain states previously, do you think that those should be reinstated in Michigan? How do you think this situation would have gone if the parents had in fact taken their child to the emergency room?

  10. Hi Renee, good questions. Michigan does have a law that attempts to address prosecution of parents who acting in accordance with their religious beliefs (Michigan Legislature MCL 722.634. “Child protection law” https://www.legislature.mi.gov/(S(ctyef0ed5imcuvwc4m4jgtsl))/mileg.aspx?page=getObject&objectName=mcl-722-634) but it is not always clear how to interpret this statute, which is why we still need judges and trials on these cases. We do not yet know what religion these parents practiced, though they do make reference to Christianity. We do not yet know if Mary’s life could have been saved if her parents had taken her to the emergency room (and when they would have needed to do this), though there is some evidence that taking her to a doctor when she first started to appear skinny may have helped. This is all evidence that I imagine will be presented in court, so we will have to wait and see.

  11. Hi Devan,

    I have so many thoughts regarding this case. First, I feel that all parents should have the freedom of choice to decide what is best for their child regarding all medical aspects. However, an individual’s health condition is a direct result of their decisions regarding medical care. Just because they chose to not utilize modern medicine, is not an excuse for leaving a child in poor health. Since they were well aware of her “skinny” appearance for a month prior to her death, did they do anything to try to improve her condition, let’s say, holistically? At what point does the health of a child come before religious beliefs?

    Mary was not free to make her own religious beliefs, her parents imposed theirs upon her, and those beliefs lead to her death.

    In my eyes, you cannot commit a crime, and claim religious freedom. This is a crime.

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