and midwifery practice

Chapter 8 Ethics and midwifery practice



Shirley R. Jones



Learning Outcomes


At the end of this chapter, the reader should be:


• aware of the difference between morality and ethics

• aware of the three areas of ethics and their applicability to practice

• able to recognize the importance of ethics in midwifery practice

• familiar with the difference between moral conflicts and dilemmas

• able to distinguish between the various normative ethical theories and their tenets

• able to apply certain pluralist duties within the duty of care

• able to recognize the need to uphold the principle of women’s autonomy in practice

• able to reflect on the ethical aspects of their practice

• able to follow up on principles and issues by further reading.

Ethics is now recognized as a major part of both midwifery education and practice; it permeates all professional relationships. Many childbearing women are no longer willing to be passive recipients of care; they expect to be fully informed of all aspects of their care so that they, rather than the professionals, make informed decisions, thereby retaining their autonomy and control. Knowledge of ethics will enable midwives to have a clear understanding of issues related to their practice and, in particular, of their role in empowering women to achieve a pleasurable, fulfilling experience of childbirth.



What is ethics?


Ethics is basically moral philosophy, or at least the vehicle by which we transport moral philosophy into practical, everyday situations. There is a tendency to consider ‘moral’ to be related to matters of sexuality; however, here it relates to the ‘rights and wrongs’ or the ‘oughts and ought nots’ of any situation. There are three levels to ethics:


1 Meta-ethics involves the deeper philosophy of examining everything in abstract; for instance, what we mean by ‘right’ and ‘wrong’. In everyday situations, we do not have time for this level of consideration.

2 Ethical theory aims to create mechanisms for problem solving, much as mathematicians created formulae for solving problems related to their field. Whether such theories are of use to midwives will be discussed later.

3 Practical ethics, as the term suggests, is the active part where the work of the moral philosophers is put into practice. It is also the area on which this chapter will generally concentrate.

In everyday life, morality underpins our actions; particularly those that involve other people and their possessions. It is translated into our thoughts and actions by principles and concepts that we have learned since early childhood, such as truth telling. This clearly should start within the family but there are outside influences: educational and religious institutions, the media and peer groups. This is not to say that all adults will behave within a given moral code. As is all too obvious, there are those who never receive the principles and concepts in the first place and others who choose to take a different path. However, these individuals will still be judged according to the code which is generally accepted by society at the time of the incident, and which underpins our civil law. Everyone has the right to expect that moral principles will be upheld; these, therefore, become ‘moral rights’. As professionals in healthcare, it is important that midwives have a deeper understanding of morality than do members of the public. This depth of understanding is achieved by education regarding relevant moral principles, concepts and theories; by analysing real-life situations and posed dilemmas; by evaluation of the actions of ourselves and others. In this way, we move from morality into ethics.


There are numerous principles, concepts and doctrines, some of which are listed here. Further reading in relation to these principles, concepts and doctrines is suggested, sources for which are included at the end of this chapter, as they cannot all be discussed in depth here. However, autonomy will be discussed later in the chapter.


• Accountability

• Beneficence

• Non-maleficence

• Confidentiality

• Justice

• Autonomy

• Paternalism

• Consent

• Value of life

• Quality of life

• Sanctity of life

• Status of the fetus

• Acts and omissions

• Killing or letting die

• Ordinary or extraordinary means

• Double effect

• Truth telling.


Why is ethics important in midwifery?


Women do not surrender their moral rights once they seek care; these rights have to be observed within their new experience, in any setting. In midwifery, care is very intimate – from the handling of personal information through the spectrum of physical, psychological, social and educational care. Added to this there is another dimension: there is no other field of human care where there is one person at the first point of contact and more than one at the end (obstetrics is considered with midwifery here). This transition itself is the source of great complexity when decisions have to be made. An understanding of ethics not only will assist the carer to make decisions, it will also help with the empowerment of the woman to make informed decisions and assist the carer in understanding the basis of those decisions. There are ethical issues (i.e. debate or concern regarding the right and wrong actions) in all areas of midwifery. It is fairly easy to construct a list of the various areas from preconception care, through fertility and screening issues, to the end of the puerperium. Most people’s lists would consist mainly of the highly emotive areas, which gain media coverage, but there are many issues involved in the care of ‘normal’ pregnancy, labour, puerperium and the neonatal period. Where there are ethical issues, there is the potential for conflicts and dilemmas to occur.



Moral conflict


A moral conflict could be considered to be a show of strength within a moral principle, for instance the autonomy of the woman versus that of the midwife or, more commonly, the autonomy of two or more professionals. A conflict could also arise between two or more different principles. On closer examination of the conflict, one side becomes a clear winner. Consider the following case.



Reflective activity 8.1


On immediate visual examination, a neonate is thought to have Down syndrome and the mother’s first question is: ‘Is he alright?’ Should the midwife protect the mother (non-maleficence) by answering ‘yes’, on the grounds that the Apgar scores were good and chromosome studies need to be performed for confirmation? Alternatively, should the midwife tell the truth and explain that tests are required to confirm the suspicion?


Ethically, telling the truth wins. The mother has the right to know, especially as a positive test will indicate to her that she was initially deceived and this could affect her ability to trust the midwives, or other healthcare professionals, in future encounters. Added to which, the mother’s permission should be sought regarding tests to be performed on her baby; she cannot consent unless she has the information. It is hoped that the reader can see, from this example, that a conflict is logical in resolution once thought through properly. It is also acknowledged that in some units, in circumstances similar to this example, not all practitioners take this particular action; they obviously find that their clear solution is to protect the mother.



Moral dilemma


When examination of an apparent conflict between principles indicates two or more options, none of which is morally ideal, then this is a dilemma, such as the following case.



image Case scenario 8.1


A primiparous woman is admitted in established labour. She has a birth plan which states that under no circumstances will she give consent to an episiotomy. During the second stage of labour, progress is slow but positive; however, the perineum remains thick and rigid. The situation is explained to the woman but she maintains her position regarding episiotomy. As time progresses, the fetal heart shows signs of slight distress, to the point where most midwives would consider episiotomy to be the action of choice, but still the woman withholds consent. The midwife could either continue, hoping that the fetus will survive (obviously notifying appropriate personnel), or she could perform the procedure without consent, in order to protect the fetus. If she carries out the episiotomy without consent, she could face a claim of battery against her. Neither is the ideal solution. (Jones 2000)


The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC 2008:4) states that you must ‘make the care of [women] your first concern, treating them as individuals and respecting their dignity.’ What the woman feels is in her best interests may not correspond with the midwife’s view; it could be considered detrimental to the woman’s condition, or that of her fetus. However, where at one time paternalism was virtually encouraged, The Code now states: ‘You must respect and support people’s rights to accept or decline treatment and care’ (NMC 2008:4).



How are dilemmas solved?


This is where level two of ethics is required – ethical theory. There are possibly nearly as many theories as there are philosophers, as they will all have their own particular stance, but generally speaking their views fit broadly into major theories. Two such theories of normative ethics, at either end of the spectrum, are utilitarianism and deontology.



Utilitarianism


Utilitarianism is a consequentialist theory, where possible actions are considered in terms of their probable consequences. The original aim was for all actions to create the greatest happiness for the greatest number of people. Current thinking would probably use the term benefit rather than happiness, which would describe the essential outlook of those managing the National Health Service (NHS). It would also describe the intentions of Hitler in the Second World War, with his views of improving the human race, as, unfortunately, a belief within this theory is ‘the end justifies the means’.


There are two forms of the theory: act-utilitarianism and rule-utilitarianism. The first is the purer form, developed in the 18th and 19th centuries by Bentham, Mill and Sidgwick, which expects every potential action to be assessed according to its predicted outcomes in terms of benefit. The second form does not look directly at the actual benefit of each act, rather it considers moral rules which are intended to ensure the greatest benefit, and each act is assessed as to its conformity to the rules.

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Jun 18, 2016 | Posted by in MIDWIFERY | Comments Off on and midwifery practice

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