Access Is Not Care: Perinatal Failure and the Obligation Nobody Held

The distinction that would not leave me

There is a distinction I return to constantly in supervision, and it has been sitting on my chest for several weeks now: the difference between a system that provides access and a system that provides care.

Access is countable. We can measure practitioners per capita, wait times, appointments attended, referrals completed, screens administered. It photographs well in a funding report. Care is relational and cumulative, and it requires that somebody, somewhere, is holding the whole picture of a person over time. For roughly three decades our field has measured the first and reported it as though it were the second.

Consider what it looks like when access is abundant and care is absent.

A mother deteriorates over four months following the birth of her third child. She is not passive in this. She consults a psychiatrist, nurse practitioners, and a therapist. She contacts a crisis line. She attends an emergency department. She is admitted to a psychiatric hospital and discharged. She applies to a specialised perinatal day programme and is not accepted into it. She asks, repeatedly, for her medications to be changed. She is, by profession, a labour and delivery nurse, which means she understands this system from the inside about as well as anyone entering it could.

By any metric a health authority collects, that is a well-served patient.

And then the worst outcome imaginable occurs.

In the aftermath, the analytical instinct is to find the person who missed it. I have watched clinicians pursue that instinct in real time over the past several weeks, on social media and in professional forums, and I want to argue that the instinct is not merely uncharitable. It is descriptively wrong. When many competent practitioners, working separately and largely without contact, converge on compatible conclusions, the most parsimonious explanation is not many separate failures of attention. It is that the structure within which they worked made a particular kind of knowing improbable.

That conclusion leaves us somewhere uncomfortable. If no individual is uniquely culpable, is anyone accountable at all? Western clinical ethics has no satisfying answer here, because its moral vocabulary was built for individual agents making individual decisions. Distributed failure dissolves into the passive voice: mistakes were made, gaps existed, the system fell short. Nobody is named because nobody can be, and the sentence ends.

I posit that the Shia juridical tradition possesses a category built precisely for this problem, and that this category performs work the secular framework cannot. It holds that an obligation can bind a community collectively, such that failure by all constitutes a genuine failure: attributable, accountable, and not dissolved into abstraction. Further, and this is the part I did not expect when I began looking, the jurists worked out centuries ago what happens to that obligation when it becomes clear that nobody else is going to discharge it.

The epistemic direction matters and is easy to get backwards. This is corroboration, not validation. The clinical literature describes a mechanism of failure with considerable precision and then falls silent on the question of who owed what to whom. Revelation supplies the moral architecture the data cannot generate. I write as a clinician and a student of these texts, not as a jurist; where a source is contested or my reading is an application rather than a ruling, I will say so plainly rather than dress it up.

What actually happened in Duxbury

On 24 January 2023, in Duxbury, Massachusetts, Lindsay Clancy killed her three children: Cora, aged five, Dawson, aged three, and Callan, aged eight months. She then attempted to take her own life, surviving with paralysis. Her murder trial began at Plymouth Superior Court in July 2026 and is in evidence as I write this in August 2026. She has pleaded not guilty to three counts of murder.

Her defence argues that she is not criminally responsible, having been in a psychotic episode arising from postpartum illness. The prosecution does not dispute that she was mentally ill; it argues that she acted intentionally and rationally and retained the capacity to appreciate what she was doing. Separately, both Clancy and her former husband have filed medical malpractice suits alleging that her providers failed to diagnose bipolar disorder with postpartum onset and instead subjected her to what the pleadings describe as a disorganised, uncoordinated course of polypharmacy that worsened her condition. The named providers deny the allegations, and none of these claims has been adjudicated.

The clinical picture that has emerged in evidence is this. Between October 2022 and January 2023, roughly four months, Clancy was prescribed thirteen different medications for symptoms including depression, anxiety, insomnia, and psychosis, by multiple clinicians across several institutions. Dosages were adjusted, medications were started and stopped, and at points she received overlapping prescriptions for the same agent days apart.

One detail cuts against the simple version of this story. Bipolar disorder was not entirely missed. At least one nurse practitioner considered it and prescribed an antipsychotic. The hypothesis surfaced. What appears not to have happened is that anyone carried it forward: no mood stabiliser was added, and the diagnostic question raised in one room did not become the organising question of her care in the next one. That is a more disturbing finding than a simple miss, and it is why I am writing this. The problem was not only that nobody saw it. The problem was that seeing it did not stick to anything.

What a case like this can and cannot establish

I raise this case because it is the reason the conversation is happening at all. But I want to be exact about what it can carry.

It cannot establish prevalence. How often the mood differential is missed, how often uncoordinated polypharmacy destabilises a perinatal patient, how often collateral history goes ungathered: none of these can be estimated from a case selected for catastrophe and for resources. A civil complaint running to hundreds of pages, supported by retained forensic psychiatry, represents a tier of legal resourcing that almost no family reaches.

It can establish mechanism. A sentinel case functions much as a case report functions in the clinical literature. It demonstrates that a pathway exists and displays its anatomy. Multiple prescribers, no shared formulation, a mood diagnosis raised and then dropped, antidepressants and sedatives continued through visible deterioration: that is a describable failure mode. Whether it is common remains an empirical question this case cannot answer. It is now, however, a question we know to ask.

And it distorts. On 6 August 2026, two days before the Clancy trial’s clinical testimony began drawing national coverage, the Massachusetts Supreme Judicial Court unanimously vacated the first-degree murder convictions of Latarsha Sanders, a Brockton mother found guilty in 2022 of killing her two sons, Edson and La’son Brito, in 2018. The court held that she had been denied a fair trial because the jury was improperly prevented from hearing her full psychiatric history, which went directly to her defence of lack of criminal responsibility. Her case was tried in the same courthouse. It turned on the same question of maternal mental state. Eight years passed between the deaths and that ruling, nearly four of them after her conviction, with a fraction of the attention and none of the parallel civil apparatus.

That asymmetry is the more honest datum. The cases that generate professional reflection are selected by litigability, litigability tracks resources, and resources are very often the inverse of need. Interestingly, our field treats this selection effect as background noise rather than as findings. This begs the question of whether the reforms we are currently proposing are aimed at the failures that are most common in our communities, or merely at the failures that were most visible to us this month.

Why this diagnosis is structurally hard

Postpartum psychosis affects approximately one to two of every thousand birth mothers.¹ It constitutes a psychiatric emergency. It is also, and this is consistently lost in public discussion, highly responsive to treatment when it is recognised.

The best available outcome data come from Bergink and colleagues, who followed sixty-four women consecutively admitted with first-onset postpartum psychosis or mania through a structured four-step algorithm of benzodiazepines, then antipsychotics, then lithium. Nearly all patients, 98.4 per cent, achieved complete remission within the first three steps. None required electroconvulsive therapy. At nine months postpartum, sustained remission was observed in 79.7 per cent.²

Hold those two facts together. This is among the most treatable conditions in psychiatry and among the most catastrophic when it is not treated. The difficulty is therefore not that the illness resists treatment. The difficulty is that it must first be seen, and its early presentation frequently does not resemble psychosis at all.

Three features make this structurally hard rather than carelessly hard.

First, the earliest signs look exactly like ordinary new motherhood. The first things to appear are anxiety, sleeplessness, exhaustion, and intrusive thoughts, meaning unwanted thoughts that arrive on their own and horrify the person having them. Those same four things also describe a very large number of new mothers who are not becoming unwell and never will. Thoughts about harm coming to the baby are common after birth, and in most cases the mother is frightened by the thought rather than drawn to it, which is exactly why it is usually a low-risk sign rather than a dangerous one.

So a clinician cannot treat every one of these as an early warning of psychosis. If we did, we would alarm an enormous number of well mothers, and we would teach them that saying the frightening thing out loud gets you treated as a danger to your own child. They would stop telling us. That silence would cost more than it saved. The real signs are hiding inside a crowd of ordinary ones, and no rule of thumb reliably separates them.

Second, the mood diagnosis is longitudinal, not cross-sectional. Bipolar disorder with postpartum onset is established from a history of elevation, not from an examination of a woman who presents depressed. A clinician who looks for pressured speech, grandiosity, and risk-taking in a patient currently in a depressive phase will find none of them, and may reasonably conclude the criteria are unmet.

Third, the elevation is culturally invisible. When hypomania occurs postpartum, families frequently do not report it, because our cultural script reads it as coping well. A mother exercising vigorously five weeks after delivery, sleeping little, and accomplishing a great deal is not described by those around her as unwell. She is described as impressive. As such, the single most diagnostically valuable observation available is filtered out before it reaches a clinician, by people who love her and believe they are praising her.

Where the secular frame stops

The secular frame reaches its limit here in two distinct places.

The first limit is epistemic. Our perinatal screening instruments are built almost entirely around mood in the depressive direction. The Edinburgh Postnatal Depression Scale asks about sadness, anhedonia, self-blame, and hopelessness. It does not reliably ask about reduced need for sleep, elevated activity, or unusual productivity in the early weeks. Clark and colleagues examined precisely this gap and noted that although validated screening tools exist for postpartum unipolar depression, few screening tools for hypomania or mania exist at all.⁴ The instrument cannot detect the very history the correct diagnosis depends on. Clinicians are not misreading the result. The result does not contain the information.

The second limit is normative, and it is the more serious one. Even where the mechanism of failure is completely described, secular clinical ethics offers no account of who bore the obligation when the obligation was distributed across many people and no one held it. It can describe. It cannot assign. Every professional code I have worked under, including my own, defines duty by scope of practice: I am responsible for what I did within my role. None of them tells me what I owe when I can see that a necessary thing is going undone and it is not my job.

What Letter 53 actually says

Before I can make the argument, I have to do the verification honestly, because how we handle these texts determines whether we are doing taḥqīq (تحقيق, verification) or decorating a conviction we already hold.

The instrument of appointment that Imām ʿAlī (ʿa) wrote for Mālik al-Ashtar upon making him governor of Egypt is the longest document in Nahj al-Balāgha, compiled by ash-Sharīf ar-Raḍī. It functions as a constitution for the exercise of delegated authority over people who cannot easily reach the one exercising it. I am quoting throughout from Tahera Qutbuddin’s 2024 translation, and citing by her section numbering so that any reader can check me. Three passages bear on our question, and a fourth resolves it.

On the expectation of error

Imām ʿAlī (ʿa) instructs Mālik that those under his authority are of two kinds:

“People are of two kinds: they are either your brothers in faith or your peers in creation. They make mistakes, they are exposed to temptations, and their hands do wrong, be it deliberately or in error. Grant them your forgiveness and pardon, just as you wish for God to forgive and pardon you.”

Nahj al-Balāgha, Letter 53, §2.53.3⁵

This is a governance principle that treats error as structural rather than aberrant. It does not exempt the one in authority from anything. It reorients him away from the search for a culpable individual and toward the provision of conditions.

Whose approval he should be measuring

In the second passage, Imām ʿAlī (ʿa) tells Mālik which group he should treat as the real test of his governing. It is not the influential few. It is everybody else:

“The people’s dissatisfaction washes away the satisfaction of the elite, while the elites’ dissatisfaction is not significant when the people are satisfied. … The support of religion, the majority of Muslims, and the armies with which to combat enemies come from the common people of the community. Let your attention be focused on them, let your inclination be toward them.”

Nahj al-Balāgha, Letter 53, §2.53.4⁶

On those who cannot reach you

Letter 53 then devotes a dedicated section to what Qutbuddin renders as the lowest strata: a category defined by structural distance from the decision-maker rather than by how well the petitioner can speak. I want to quote this at some length, because the operational specificity of it is the point:

“Beware God’s wrath, and never, ever forsake the people of the lowest strata who have no means … Do not let any kind of pomp and ceremony distract you from attending to the needy. You will not be excused for neglecting small petitions, even if you attend assiduously to the large and important ones. … Keep a check on the welfare of those who do not have direct access to you, people whom eyes disdain and men scorn. Appoint a trusted agent, a man who is godfearing and humble, to care for their needs particularly. … Of all your subjects, these are most in need of your justice.”

Nahj al-Balāgha, Letter 53, §2.53.14⁷

And then the anchor

In that same section on the lowest strata, Imām ʿAlī (ʿa) quotes the Noble Prophet (ṣ) directly:

“I have heard the Messenger say on more than one occasion: A nation in which the weak are not given justice against the strong except by anxiously stammering will never be made holy.”

Nahj al-Balāgha, Letter 53, §2.53.14⁸

I want to note the transmission honestly. This prophetic report is widely transmitted, and it appears in collections outside our own. What I am citing is Nahj al-Balāgha, where it comes to us as speech of Imām ʿAlī (ʿa) reporting the Prophet (ṣ), inside the letter itself, in the section on precisely the population it concerns. That is the citation, and it stands on its own.

Read it slowly, because it is doing something unusual. It does not say that a nation which denies justice to the weak will be judged. It says that a nation in which the weak can obtain justice only by stammering their way toward it will never be sanctified. The standard is not whether the remedy exists somewhere in the system. The standard is what it costs the weakest person to reach it.

That is a health-systems standard. A perinatal programme with the capacity to decline an applicant, a screening instrument that cannot see the relevant history, a referral pathway that requires a frightened and exhausted woman to advocate for herself across multiple institutions: each of these can be entirely defensible on its own terms and still constitute a system in which justice is available only to those with the composure to stammer for it. Thus the tradition supplies not merely a moral sentiment but an evaluative criterion, and it is one that our own quality metrics do not currently contain.

The category built for distributed failure

Having established the clinical picture and the governance ethic, I now turn to the juridical machinery, because it is here that the tradition does the work secular ethics cannot.

Islamic legal theory distinguishes two kinds of binding obligation. Sayyid Hāshim al-Mūsawī sets them out in Manhaj al-Fiqh al-Islāmī:

“The Individual Wājib, or al-Wājib al-ʿAynī, is to be performed by every individual who has reached the age of consent, and nobody else may do it for him. Such as the daily Ṣalāt and the Ṣawm … The Collective Wājib, al-Wājib al-Kifāʾī: it is a duty which Allah wants to be performed by any grown up person, not a particular one, as the important thing is to have the Wājib carried out, such as washing the body of the dead, performing the Ṣalāt over it, rescuing the drowned.”

al-Mūsawī, Manhaj al-Fiqh al-Islāmī⁹

The canonical examples are not incidental to my argument. Washing and praying over the dead is established in our primary sources as an obligation of sufficiency; Shaykh al-Ḥurr al-ʿĀmilī collects the narrations in Wasāʾil ash-Shīʿa under a chapter heading rendered as the funeral prayer being obligatory based on sufficiency, permitting one or two people to discharge it on behalf of everyone.¹⁰ And rescuing the drowned sits in that same category. The jurists placed the emergency rescue of a stranger and the ritual dignity of the dead under one legal heading, because both are things that must simply get done, by someone, and the identity of that someone is not what is at stake.

Now the part that matters. What happens when nobody does it?

“If nobody offers to take these responsibilities or does not complete them, every mature member of the Islamic society would be committing a sin, and would deserve punishment, whereas the one who performs this Wājib will be rewarded.”

al-Mūsawī, Manhaj al-Fiqh al-Islāmī¹¹

Wājib kifāʾī is, so far as I am aware, the only moral structure available to us in which “everyone assumed somebody else would handle it” is not an excuse but a precise description of the offence. Note also the clause about incomplete performance: the obligation is discharged by accomplishment, not by effort.

Apply that to our case. Every clinician in that chain did something. Assessments were conducted, medications prescribed and adjusted, an admission occurred, a diagnostic hypothesis was even raised. Under a scope-of-practice ethic, each of those actions may have been locally defensible. Under a sufficiency ethic the question is harder: was the thing that needed doing done? A held formulation, carried across institutions and tested against collateral history, is what needed doing. It was not. As such, on this reading, effort by several does not lift the obligation from the rest.

The rule I did not expect to find

There is a further move in the fiqh, and when I found it I stopped writing for a day.

“The collective duties are considered individual duties, if they are confined to some of the people. For example, if somebody saw a man drowning, or exposed to a destructive danger, and there was no one else capable of saving the endangered man, it would be his individual duty to save him, and he would not be excused. … In this way, a Wājib Kifāʾī turns into a Wājib ʿAynī on the people, if it is confined only to them, and there is nobody else to do it.”

al-Mūsawī, Manhaj al-Fiqh al-Islāmī¹²

The collective obligation does not stay collective. When the circle of people actually capable of discharging it narrows to you, it collapses onto you personally, and your ordinary exemption evaporates. You do not get to point at the community any more, because in that moment you are what the community amounts to.

I had intended to propose a practical rule of my own for clinicians, derived by analogy. I no longer think it is an analogy. It is a direct application of an established juridical principle to a fact pattern the jurists did not anticipate but plainly covered: rescuing the drowned was always the example.

Underneath all of this sits ghaflah (الغفلة, heedlessness), which is not malice but the state of not attending, of the obvious passing unregistered. Our tradition treats it as a spiritual condition requiring active remedy rather than a neutral absence, which is precisely why it can be held against a person who meant no harm. I argue that institutions are capable of ghaflah in exactly this sense, and that institutional heedlessness is a more accurate diagnosis of what happened here than individual incompetence.

Five places the holding failed

What follows are five dimensions along which the obligation went unmet, each with its clinical parallel.

1. Formulation: nobody held the whole

A diagnostic formulation is not a diagnosis. It is a running account of who this person is, what has changed, and what explains the change, and it requires continuity to construct and someone willing to own it.

Multiple prescribers each held a fragment. No mechanism existed to assemble the fragments, and no role was defined as the one that assembles them. Each decision was locally reasonable; the sequence was incoherent. This is the failure that case management exists to prevent, and it is the function most reliably cut first when funding contracts. Under a sufficiency ethic, if no one is holding the formulation, it becomes my obligation to hold it or to ensure somebody does. Referral is not discharge.

2. Collateral: the history was never requested

The history that establishes bipolarity lived with the family, not with a patient in a depressive phase who has no reason to recall a period of high energy as pathological.

Families are rarely told that collateral information is welcome. Privacy norms are widely misread, by clinicians as well as by families, as prohibiting clinicians from receiving information, which they do not; confidentiality constrains what I may disclose, not what I may be told. Remote appointments then remove the ambient friction, the waiting room and the partner in the car, that used to produce collateral incidentally. Collateral gathering is standard in child, geriatric, and forensic work and treated as optional in adult outpatient psychiatry. There is no clinical justification for that inconsistency, only a historical one.

3. Convalescence: the postnatal state was not recognised as a state

Islamic law recognises nifās (النفاس), the postnatal bleeding period, as a distinct legal condition with its own rulings. Shaykh aṣ-Ṣadūq treats it at length in Man Lā Yaḥḍuruhu al-Faqīh: the ritual prayer is set aside for its duration, and the boundaries of that duration are debated and fixed.¹³

I want to be careful here, and more careful than my first draft was. The fiqh of nifās governs ritual obligation. It is not a prescription for convalescence, and it would be a conflation to present it as clinical guidance about rest. My claim is narrower and epistemic: the tradition encodes the postpartum period as a recognised state rather than as a return to baseline. The law itself pauses. A culture that must determine when the postnatal period ends is a culture that has agreed it exists.

The dominant North American script inverts this, treating rapid return to full capacity as the marker of a good recovery. This inversion is not merely a cultural preference; it exists as an epistemic liability, because it conceals the very prodrome the diagnosis depends upon. Our instruments inherit the script. They ask about incapacity and are blind to inappropriate capacity.

4. Threshold: base rates were applied past their usefulness

Predicting a rare catastrophic outcome is not a realistic clinical demand, and any framework that requires it will produce defensive practice rather than care.

It is also true that a patient stops being a base-rate case once she has accumulated months of insomnia, an emergency department visit, a crisis line contact, an inpatient admission, thirteen medications from multiple prescribers, repeated requests to change them, and a rejected application to a specialised programme. The relevant question is not “what is the probability of catastrophe?” It is “does this presentation still belong to the population my ordinary heuristics were built for?” Once the answer is no, continuing to use them is a decision rather than a default.

5. Attention: reform followed visibility

The professional response has largely framed the problem as clinician behaviour, solvable by individual practitioners resolving to do better. That framing is comfortable, it is cheap, and it leaves the determinants untouched: that a specialised perinatal programme had the capacity to decline an applicant, that generalists receive minimal perinatal training, that nothing funds coordination across multiple prescribers, and that postpartum psychosis is not a distinct diagnosis in the DSM at all.

This is the pattern Letter 53 names directly, and it deserves its own treatment.

When the system becomes a face

While drafting this post I was shown a widely circulated social media image: a photograph of one of the clinicians who testified at the trial, captioned with the claim that this person’s face is what is wrong with the medical system today, alongside the observation that she will never be hired again.

I am not naming the poster, and I am not reproducing the caption, because the pattern is what matters and amplification is exactly the harm. But I want to sit with the grammar of it, because the grammar gives it away. The predicate is a systemic claim. The subject is one person’s face. It performs structural critique while doing the precise opposite of it, and the systemic language functions as cover for what is otherwise simply a career-destruction post.

Three things are worth naming.

It punishes testimony. The clinician in that photograph was a witness, not a defendant, in the proceeding where the image was captured. Testifying was almost certainly compelled. Punishing a clinician for the content of sworn testimony has an entirely predictable effect: it teaches every clinician watching to say as little as possible in inquests, incident reviews, root-cause analyses, and coroner’s proceedings. Those forums are how a system learns what happened inside itself. Degrade them and you degrade the exact information environment that systemic reform depends upon. The post makes the system measurably harder to fix while claiming to indict it. In the vocabulary of this post, that is ghaflah reproducing itself: an act of heedlessness performed in the confident belief that it is an act of attention.

It selects the least protected person in the chain. The clinical chain here included an inpatient team, an emergency department, a crisis line, a specialised programme that declined an application, and multiple prescribers across several institutions. Public attention landed on one of the individual clinicians in it, and specifically on one whose face had been placed in front of a camera. That selection is not a coincidence and it is not incidental. It is the systemic pattern operating unnoticed inside a post about systemic patterns: attention allocated by exposure rather than by structural position. Interestingly, the more senior and more institutional a decision was in this case, the less discourse it has attracted. This begs the question of whether our profession’s appetite for accountability reliably stops at the point where accountability would become expensive.

It is Letter 53 read in reverse. Imām ʿAlī (ʿa) instructs Mālik to direct his attention toward those with no access and to refuse to let the prominent case crowd out the small petition. Our default configuration does the opposite at both ends. The cases that receive forensic reconstruction and national reflection are the ones attached to resources, and within those cases, the individuals who absorb the consequences are the ones with the least institutional protection. The configuration Letter 53 explicitly forbids is not a hypothetical failure mode for us. It is the setting we ship with.

This is also the strongest argument I can make for why this post does not name the clinicians involved. Whatever my analysis concludes, publishing it with their names attached would put me in the same feed performing a more literate version of the same act. The systems argument does not need the individuals. Nothing is lost by leaving them out, and the argument’s authority comes precisely from declining to do this. I would keep it this way even after a verdict lands.

What changes on Monday

Having laid out the framework, I now turn to what any of it means for a caseload.

The sufficiency principle

I offer the following not as an invention but as an application of the collapse rule set out above:

Where you can identify no clinician who is holding the whole picture, the obligation to hold it has narrowed to you, regardless of your role, discipline, or seniority. You are not excused by the existence of other people who could have done it and did not.

This will sometimes mean doing work that is not funded, not billable, and not strictly yours. That is precisely what a sufficiency obligation entails, and the jurists were unsentimental about it: the man on the riverbank does not get to observe that lifeguarding is not his profession.

The thirty-second question

Screening asks new mothers about low mood. It does not reliably ask families this:

“In the first two months after the birth, was there a stretch where she seemed to need very little sleep and was getting a great deal done?”

That question costs thirty seconds. Based on my limited exploration of this literature, it is the single question most likely to surface the history on which the correct diagnosis depends, and it is not on our instruments. It should be asked of the family rather than only of the patient, because a patient in a depressive phase will not recall the elevation as pathological, and because the family has been trained by our culture to remember it as a period when she was doing well.

For clinicians

You are not the person responsible for predicting rare catastrophic outcomes. That expectation is neither achievable nor fair, and holding it produces defensive practice, not care.

You are the person positioned to convert a distributed information problem into a formulation. In most fragmented perinatal presentations, somebody must do this, and frequently nobody has.

Competencies worth developing: the mood differential in the perinatal period, with specific attention to mixed and irritable presentations rather than euphoric ones; collateral gathering as routine practice rather than as escalation; recognition of nifās and analogous convalescence frameworks in your clients’ traditions, and the assessment questions they open; and comfort naming fragmentation to a client and her family as a clinical problem in its own right, rather than treating it as the weather.

Frequently asked questions

Does a systems analysis let individual clinicians off the hook?

No, and this is the central point of the post. Wājib kifāʾī is specifically the category in which every capable person remains accountable when a collective obligation goes unmet, and the jurists are explicit that partial effort does not discharge it. It relocates responsibility. It does not dissolve it.

Does this mean the treating clinicians in this case were negligent?

That is a legal question currently before a court and I take no position on it. My argument is narrower and, I think, more useful: the convergence of multiple independent clinicians on compatible conclusions is better evidence of structural failure than of individual incompetence. Whether it also meets a negligence standard is an entirely separate matter, decided by a different process, on evidence I do not have.

Is postpartum psychosis a spiritual condition?

It is a medical emergency with biological determinants and it must be treated as one. To frame it otherwise is a category error that costs lives. Mental illness is not a deficiency of faith, and a mother in psychosis is not a mother who prayed insufficiently. Nothing in this post should be read as suggesting that spiritual resources substitute for psychiatric treatment; the argument is about who is obligated to arrange that treatment, not about whether it is needed.

Should families be attending appointments?

Yes, and I would put this more strongly than is customary. Where a family member holds a concern serious enough that they are weighing whether to raise it, that deliberation is itself sufficient reason to attend and speak. Clinicians are permitted to receive information from families even where confidentiality limits what they may disclose in return. Most families do not know this, and most of us have never told them.

Why frame a North American clinical failure through Shia jurisprudence?

Because Western clinical ethics lacks a category for collective culpability, and our tradition has one that has been refined across more than a millennium of juristic work, complete with a worked-out rule for what happens when the capable circle narrows to a single person. The clinical literature describes the failure mechanism with precision and then goes silent on obligation. Revelation supplies what the data cannot. A non-Muslim colleague can adopt the sufficiency principle without adopting the theology, and I would consider that a good outcome.

Is therapy allowed in Islam?

The Noble Prophet (ṣ) said: “Seek cure, O servants of Allah, for Allah has not created a disease without creating a cure for it.”¹⁴ This prophetic instruction, known as istishfāʾ, makes seeking treatment not merely permissible but encouraged. Therapy is a form of seeking cure for psychological distress. Our tradition has always recognised that the soul can become ill and that seeking knowledge and treatment for those illnesses is consistent with faith. It is also worth saying plainly, given the subject of this post: the practice of medicine itself sits in the category of wājib kifāʾī. Somebody in the community is obligated to become competent at treating you.

What if I am not sure I need therapy? Can I just try a session?

You do not need to be in crisis to benefit from therapy. Many clients begin because something feels unresolved, not because something is broken. A free consultation at tabeeahservices.janeapp.com is a conversation, not a commitment. It is an opportunity to ask whether faith-integrated psychotherapy might help with what you are carrying, with no obligation to continue.

A closing thought on sufficiency

This blog post has attempted four things: to establish that access and care are distinct goods and that our field has been measuring the wrong one; to recover wājib kifāʾī, its collapse rule, and the governance ethic of Letter 53 as the categories adequate to distributed failure; to read a sentinel case honestly, for mechanism rather than for prevalence; and to translate all of it into something a clinician can do on a Monday.

I have proceeded throughout by parallel ontological integration. The clinical literature supplies the mechanism. Revelation supplies the account of obligation. Neither has been reduced to the other, and neither required the other’s permission.

What remains is the harder part. Our fiṭrah (الفطرة), the innate disposition with which we are created, orients us toward the recognition of another’s need. Ghaflah is the film that settles over that orientation until the obvious goes unregistered, and it settles over institutions exactly as it settles over individuals. The remedy in both cases is the same: deliberate attention, repeatedly renewed, toward the person who cannot reach us.

The Prophet’s standard, transmitted to us through Imām ʿAlī (ʿa) in a letter about how to govern people you will never meet, is not that the weak eventually receive justice. It is that they should not have to stammer for it. Measured against that, a mother making her way alone across six clinicians in four months was not being served by a system that was merely imperfect. She was being asked to stammer.

For the clinician, the invitation is to treat coordination as an obligation rather than a courtesy. For the believer, the invitation is harder. When we say that the system failed, our tradition does not permit the sentence to end there. Somebody was capable. That is sufficient for accountability, and it is sufficient for repair.

May Allah (swt) protect the mothers among us in the weeks when they are least able to ask, grant ease to those carrying what they cannot yet name, and make of us the sufficient few rather than the absent many.

Notes and references

1. Wesseloo, R., Burgerhout, K. M., Koorengevel, K. M., & Bergink, V. (2015). Postpartum psychosis in clinical practice: diagnostic considerations, treatment and prevention. Nederlands Tijdschrift voor Geneeskunde. Incidence reported as 1–2 per 1,000 deliveries.
2. Bergink, V., Burgerhout, K. M., Koorengevel, K. M., Kamperman, A. M., Hoogendijk, W. J., Lambregtse-van den Berg, M. P., & Kushner, S. A. (2015). Treatment of psychosis and mania in the postpartum period. American Journal of Psychiatry, 172(2), 115–123. doi:10.1176/appi.ajp.2014.13121652
3. Wisner, K. L., Sit, D. K., McShea, M. C., et al. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, 70(5), 490–498. doi:10.1001/jamapsychiatry.2013.87
4. Clark, C. T., Sit, D. K., Driscoll, K., et al. (2015). Does screening with the MDQ and EPDS improve identification of bipolar disorder in an obstetrical sample? Depression and Anxiety, 32(7), 518–526. doi:10.1002/da.22373
5. ash-Sharīf ar-Raḍī, Nahj al-Balāgha, Letter 53 (The Testament for Mālik al-Ashtar), §2.53.3. Translated by Tahera Qutbuddin, Nahj al-Balāghah: The Wisdom and Eloquence of ʿAlī (Library of Arabic Literature, 2024).
6. Ibid., §2.53.4.
7. Ibid., §2.53.14.
8. Ibid., §2.53.14. Prophetic report quoted by Imām ʿAlī (ʿa) within the letter. The same report is transmitted through additional chains outside the Imāmī collections; the citation given here is Nahj al-Balāgha itself.
9. al-Mūsawī, Sayyid Hāshim. A Course in Islamic Jurisprudence (Manhaj al-Fiqh al-Islāmī), “The Individual and Collective Wājibs.”
10. al-Ḥurr al-ʿĀmilī, Wasāʾil ash-Shīʿa, Vol. 3, Abwāb Ṣalāt al-Janāzah, Bāb 28 (“Funeral Prayer Being Obligatory Based on Sufficiency”), Ḥadīth 3187.
11. al-Mūsawī, op. cit.
12. Ibid., section headed “Explanation.”
13. aṣ-Ṣadūq, Man Lā Yaḥḍuruhu al-Faqīh, Vol. 1, Kitāb aṭ-Ṭahārah, ḥadīth 176 and ḥadīth 210, with the accompanying discussion of the ten-day and eighteen-day limits. aṣ-Ṣadūq notes that reports specifying forty days are weak and were transmitted under taqiyya.
14. On istishfāʾ, the prophetic instruction to seek cure; the principle is transmitted across multiple Imāmī collections and is uncontested in our tradition.

This post is educational and reflective. It is not medical advice, a fatwā, a legal opinion, or a substitute for professional care. It contains no determination regarding any pending proceeding.