New reproductive and birthing technologies can also pose ethical issues for midwives (Frith 2004). The rise of genetics and particularly prenatal genetic screening may stir ethical unease in many midwives, especially if abortion is involved (Jones 2000). Because women now have fewer children, the pressure exists for each child to be the ‘perfect’ child, and the idea that there are now ways of ensuring that each child is ‘perfect’ can be enormously attractive to some people. Involving women in research also raises ethical concerns.

There is little doubt that these and many other contentious issues make midwifery an ethically interesting and sometimes challenging occupation. On reading a list of potential ethical concerns such as those listed above, many people will have a ‘gut’ response to some issues. And while this kind of response might be a good indicator that there is indeed an important issue involved, gut instincts may be based more on our distaste for, or level of discomfort with, a situation. Being able to recognise an ethical issue in clinical practice is a good start, but getting to the heart of why these might be troubling, and beginning to unravel the issues, requires a more systematic response. For that we begin by turning to the academic discipline of bioethics.

Bioethics is commonly described as a branch of applied moral philosophy.¹ In the midwifery context, bioethical approaches can be used to provide reasoned analysis of the array of ethical concerns. Ethical analysis can assist a midwife to untangle the issues involved in a particular situation, helping to identify and clarify the moral concerns and at times helping her to find a resolution to the problem. We can explore an ethical problem using a variety of approaches. Each approach acts to highlight a different aspect of the particular problem.

Moral ideas from everyday life

All of us are familiar with moral concepts (although they might not have been identified as such) from our upbringing. As young children we are taught a range of important moral ideas. We learn, for example, the importance of telling the truth and of not hurting others, the significance of keeping our promises and respecting the views of others, and about sharing, to name a few. These concepts are reinforced by our own experiences of what it feels like to be caught telling lies or to be hurt by others (Brenner et al 2004).

Much of the time these ideas work well—we keep our promises and others keep their promises to us, or we are kind to others, and so on. However, problems soon arise when we discover that in order to follow one concept, we can no longer comply with another. For example, if we are asked by a friend who is trying on clothes, ‘Do I look fat in this?’ we might begin to question whether honesty is indeed the best policy. So while honesty is an important concept for a young child to learn, later we might learn that complete honesty might cause harm to the feelings of others and that it may be better to say nothing or modify our statements than to tell the complete truth. However, as an individual moves into professional practice it is important to know when to apply which moral idea. For example, honesty may not be best when giving clothing advice to overweight friends, but for a woman in labour who has decisions to make, honesty will be required from her caregivers in order for her to make an informed decision.

Moral concepts in professional practice

As a student trains to become a midwife, moral ideas become increasingly important. Many of these are written into professional codes of practice that establish particular ethical standards of behaviour that midwives are expected to meet. These will be discussed later in the chapter.

Law and ethics

Expectations about the quality and standards of all healthcare professionals in their dealings with those in their care may also be expressed in legislation. For example, getting informed consent from a woman prior to undertaking any treatment or care is now an expectation under New Zealand law. For a woman to be able to make a decision about her care, she must receive information about why something is being suggested and what it might mean to make each choice, as well as the risks and benefits, and so on. And so honesty is an example of a moral idea from early life that develops new meaning and legal expectations in professional midwifery care.

However, ethical reasoning is not simply an application of legal expectations in professional life. Law and ethics have much common ground, and yet they are distinct disciplines. What is ethically acceptable might differ significantly from what is legally acceptable. For example, some laws might be ethically unacceptable. There may also be times when an activity is not illegal but could certainly be considered ethically dubious. For example, imagine a woman who says she will take her lonely friend out to the movies, but later gets invited to a party with some people she has been trying for some time to impress. The woman then calls her friend to say she is sick, in order to break their arrangement so she can go to the party. Although she hasn’t done anything illegal, we could question her standard of ethics.

A reason sometimes given by healthcare professionals for complying with legislation put in place to protect those they care for is fear of legal reprisals for failure to do so. An example of this might be when getting informed consent from a woman. It is often heard that this is only done to avoid getting into trouble with the law. However, such a motivation—fear of legal punishment—fails to comprehend the ethical value in informing women, including acknowledging and respecting a woman’s right to make decisions for herself.

The history and development of bioethics

Bioethics emerged during the last half of the 20th century, partly in response to the revelation of unethical and unchecked action by doctors and scientists, but also in response to the exceptional clinical developments in healthcare at around that time, as well as the social changes already outlined at the beginning of this chapter. At the end of the Second World War, Nazi doctors being tried at Nuremberg revealed that horrific experiments had been carried out on prisoners of war and others. While many attributed these actions to the horrors of war and the monstrous Nazi regime, that doctors could be involved in such atrocities in the name of research was of major concern. Protection of research participants from unethical research was an important development resulting from the Nuremberg Trials.

Unethical research was found not to be limited to war when, in 1966, Henry Beecher wrote his famous article entitled, ‘Ethics and clinical research’. This article uncovered 22 research studies he claimed were unethical, being carried out in US hospitals. The desire to improve clinical care had led many researchers to disregard the health and wellbeing of the research subject, many of who were vulnerable or considered to be of lower social class.² The Beecher article demonstrated that all was not well with medicine and science, particularly in the world of research. The need to protect the participants in research became paramount.

Developments in clinical medicine were burgeoning around this time and these also contributed to the development of ethical reflection on their use. One such clinical example of this kind of development was that of regular kidney dialysis in 1961—this provided an opportunity for lives to be extended where they previously would have ended. However, a shortage of dialysis machines meant that decisions had to be made about who should get this precious resource.

In New Zealand, the growth of bioethics can, in part, be attributed to the revelation of its own unethical research at National Women’s Hospital in Auckland. In 1987, two journalists published an article in an Auckland magazine.³ This article detailed the research of Associate Professor Herbert Green into carcinoma in situ of the cervix (cervical cancer). A small number of doctors at the hospital collaborated with the authors after their own earlier attempts to call a halt to the study had failed. The authors claimed that Professor Green (a consultant obstetrician and gynaecologist at National Women’s Hospital in Auckland) had conducted a medical experiment in which conventional treatment was withheld without the women’s knowledge and consent over a period of nearly 20 years. Professor Green believed that carcinoma in situ did not lead to invasive cancer, despite this being recognised internationally at the time. The intense public interest generated by the article led to the Minister of Health appointing Judge Silvia Cartwright to head an inquiry. The Inquiry validated the allegations of the article, concluding that ‘for a minority of women, their management resulted in persisting disease, the development of invasive cancer and, in some cases, death’ (Cartwright 1988). The Inquiry did not limit itself solely to the research project but also explored other related issues, such as patients’ rights, medical power and hierarchy, and the problems of effective problem solving in medical institutions. The Cartwright Inquiry can be understood as the first public scrutiny of medical practice, research, education and institutions in New Zealand. One of the most significant outcomes in New Zealand has been the development of the Code of Health and Disability Services Consumers’ Rights, which enshrines a code of patients’ rights under legislation. Another important outcome has been the development of ethical review of research through a system of ethics committees.

The Cartwright Inquiry and the subsequent developments in patient rights and ethical review of research could not simply have occurred at any time; they needed the right sociopolitical conditions in which to emerge. The second wave of feminism and the rise of women’s health issues surrounding women’s reproductive choices were significant issues of this time, creating a climate ripe for the examination of the practices of those in authority. Bioethics therefore has, to some degree, developed out of a social movement that challenges traditionally held authority and has been involved in empowerment of those who are socially marginalised (Nie & Anderson 2003).

APPROACHES TO ETHICS

The four-principle approach to healthcare ethics

The framework most commonly seen within the bioethics literature is that of the four principles developed by Beauchamp and Childress (2008). These include: autonomy, beneficence, non-maleficence and justice. Although originally developed with medicine in mind, many of these concepts are valuable in other healthcare professional contexts and will be discussed here. This framework also has some shortcomings, which will be discussed later in the chapter.

Autonomy

The term ‘autonomy’ literally means self-rule or self-determination. It means having the freedom to make decisions in line with how we want our life to be. Autonomy is based on the idea that we all have our own experiences, identities and significant features in our life; therefore it is thought that we will have the ability to judge what is best for us.

In healthcare, the concept of autonomy involves respecting the ability of a person to make choices about their treatment and for those choices to be respected. It implies that the individual has the competence to make decisions for themselves and also that they should not be coerced or forced into making decisions.

Autonomy in healthcare is a relatively recent development in line with the social changes outlined earlier. It has come about due to a rise in individualism and a growing desire for people to have increasing involvement in their own care. It is also a direct challenge to medical paternalism, where the doctor has traditionally been held to know what is best. The rise in autonomy has meant a shift in the locus of decision-making in healthcare from the healthcare professional to the person himself or herself.

Informed consent

One of the most important ways in which we can commonly see the principle of autonomy in action is through the process of informed consent. In the midwifery context, informed consent involves providing information to the woman and allowing her to either consent to or refuse the suggested course of action (Draper 2004).

Informed consent has two main components—the providing of information, and the giving of consent. These two components can be broken down further to:

• information

• comprehension

• competence

• voluntariness (Beauchamp & Childress 2008).

Take the example of a woman being presented with the option of a vitamin K injection for the baby following delivery. The midwife would need to provide information to the woman, telling her what vitamin K is and what it does, what the procedure entails, what risks and benefits are associated with the injection (including short- and long-term benefits and risks), how much pain the baby would be expected to experience due to the injection, any possible effective alternatives, what if any costs the woman might be expected to incur, and so on. The information needs to be provided in a way that the woman can understand. This does not mean that the woman should be spoken down to, but that the information should be given at a level that is comprehensible to the woman, and is jargon-free.

Midwives sometimes wonder how much information to give about a particular topic. Should they give out information about very rare complications related to some procedures? There are common concerns that this kind of information could frighten some people and put them off a procedure that might be important. In order to answer this we need to return to the concept of autonomy. To be truly respectful of autonomy, midwives are required to give the information. The extent of the information that needs to be given has been a topic under scrutiny in recent times, particularly in the courts.

The ‘consent’ part of informed consent involves considering the competence of the woman to give informed consent and the voluntariness of that decision. Under New Zealand law, every person is presumed competent to consent unless proven otherwise. For some, it may take more explanation, and the use of diagrams and other methods, but the presumption should be that nearly all women are able to give consent. Questioning the competence of a woman simply because she is making a choice that the midwife doesn’t agree with is not acceptable and not in line with a respect for autonomy.

Consent should also be voluntary, meaning that it should not be coerced. An example of coercion would be if a midwife carrying out research tells a woman that she will withdraw some element of care if the woman does not agree to take part in the research. The woman who consents under these circumstances could be said to have been coerced.

Informed consent should be viewed as an ongoing conversation between the midwife and the woman, not a one-off event. In this way the midwife is always checking with the woman that care is proceeding along lines that she is comfortable with.

We are all aware that some people will not be able to be autonomous, including a person with a severe and acute psychiatric illness or severe brain injury. In these situations we might rightly question the competency of this person. There may be times when people who are normally competent temporarily lose such ability, due, for example, to the administration of an anaesthetic or due to unconsciousness. Under these circumstances care can be provided that is perceived to be in that person’s best interests, until such time as they recover their competency.