- Email: [email protected]
A code of ethics for nurse-midwives
A CODE OF ETHICS FOR NURSE-MIDWIVES A Second Proposal Terri Clark-Coller, CNM, MSN
ABSTRACT This paper critically analyzes the proposed Code of Ethics for nurse-midwives that was published in the March/April 1986 issue of this journal by drawing upon the literatures of medical ethics, political economy, cognitive psychology, and the sociology of professions. Examples of practical ethical issues in nurse-midwifery are provided and an alternative Code of Ethics based on the ACNM Philosophy is offered.
In the “Issues and Opinions” column of the March-April 1986 Journal of NurseMidwifery, Henry and Joyce Thompson’ offered a draft code of ethics and invited response from nurse-midwives. This paper represents my thoughts on the proposed code and offers a different perspective to the discussion of ethical issues in nurse-midwifery. The Thompsons are to be congratulated for recognizing the need for a code of ethics for nurse-midwives and for their leadership in mobilizing the College to adopt such a code. However, it does not seem that the proposed code is adequate yet. In formal terms, the code is internally inconsistent, not complete, and not necessarily grounded in the rationale offered. It proposes to provide answers to practical moral dilemmas, but the answers which are consistent with one portion of the code are contradictoy to another. If the code were implemented as it stands, in some cases it would lead nurse-midwives to commit acts that are illegal and could only be considered ethical under one narrow definition of the term. To remedy these difficulties, I will propose a different structure for the code of
Address correspondence to: Terri ClarkCaller, versity
90293.
Deparbnent
of Sociology
C-002,
Uni-
of California, San Diego, La Jolla, CA
ethics for nurse-midwives. Rather than attempting to formulate prescriptions for ethical behavior for nurse-midwives in any conceivable situation, we should have a more modest goal. I suggest that the Code should raise content areas of concern that the CNM should have when she or he confronts an ethical problem, rather than attempting to provide an answer to questions we can’t even begin to imagine. From what foundation should the ethical considerations of the Code originate? The arguments of the philosophers lend a sense of authority and immutability to the proposed Code; however, there is a disadvantage to relying on them. Most nurse-midwives are not sufficiently prepared in philosophy to critically evaluate the validity and relevance of basing our professional code of ethics upon the esoteric reasoning of Kant, Gilligan, and Kohlberg. It ought to be seen as a problem that the proposed philosophical rationale would have to be taken on faith by most nurse-midwives. Rather, I would suggest that we use the Documents of the American College of Nurse-Midwives in the formulation of a code of ethics. The documents are the appropriate base of departure because they clearly identify the goals and purposes of nurse-midwifey-what we consider to be goodand certified nurse-midwives understand the documents and are already committed to them.
274 Copyright0 1988 by the American College of Nurse-Midwives
Journal of Nurse-Midwifery
“MATERNAL-FETAL OF INTEREST”
CONFLICT
If one purpose of a Code of Ethics would be to alert nurse-midwives to the content areas of ethical concern in hard cases, it makes sense to begin by asking how the proposed Code would help the practitioner with the hardest cases of all: the seeming conflict between the interest of the mother and the fetus. It seems to me that, in this regard, the proposed Code uses as a resource precisely that which should be the topic of the discussion. For example, the present draft of the Code’ asserts that “in an emergency, the patient’s autonomy may be set aside to saue a life . patient’s rights are not absolute in all circumstances but are rather to be honored in relation to othersfamily, society, health care providers, etc.” The resolution of the problem of competing interests is precisely what is at issue; but, rather than addressing it as a dilemma with two reasonable sets of concerns competing for our attention, the draft considers the solution settled. Furthermore, the specifics of this solution could be extremely troublesome, for example, when a mother refuses a cesarean section despite fetal indications. If a health professional “sets aside” the right of a competent woman to control her own body, that professional may find herself or himself charged with assault
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an&or battery. Is this what we want included in the Code? If we look closely at the problem of maternal-fetal conflict of interest, we will notice that the resolution is not at all obvious. There are some very good reasons why professionals may not be entitled to “set aside” a woman’s right to control her own body, and, in fact, may be morally bound to respect a woman’s wishes, even if we find them distasteful. What are we saying when we “set aside” a woman’s rights? “Professionals know best?’ Are we saying to the mother that she can’t make an objective decision about her situation and that we can? As a profession, we have to be way of the potential for being used as instruments of social control. We ought not write off a woman’s autonomy easily. It ought to at least count as a problem, even when weighed against the presumption that there is a life at stake.
Terri Clark-Caller receiued a B.A. in Philosophy from Yale College and an M.S.N. from Yale School of Nursing. She gmduated from the Yale Maternal-Newborn, Nurse-Midwifey Program in 1979 and was an instructor there for four years. In 1983, she began work on a Ph.D. at the University of California, San Diego. She has done
graduate work in sociology, philosophy, and psychology while at UCSD, and has been a gmduate student teaching assistant in sociology, philosophy, and in the writing programs. Her dissertation will study biomedical ethical problems related to perinatal care. Teni also works as a staff nursemidwife with the Comprehensive Perinatal Progmm in San Diego and is a uolunteer midwife at the Casa de Salud in Tijuana. She has an appointment as a clinical instructor with the UCSD Depatiment of Reproductive Medicine where she attends deliveries at Cl&e&y Hospital at night and on weekends and functions as a clinical preceptor for UCSDIUCSF nursemidwifery students and UCSD medical students. Her publications include chapters on abortion and menstrual concerns in Helen Vamey Burst’s forthcoming text on women’s health, and an article on “The Nurse as Rape
Counselor” Nursing.
in The American Journal of
Journal of Nurse-Midwifery
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In a recent review of cases2 in which obstetricians sought court orders to deprive pregnant women of their autonomy in order “to save the baby,” the investigators found that the label of “matemalfetal conflict” tended to be applied primarily to women of color and in cases where the pregnant woman did not speak English. Are nurse-midwives to join the ranks of those who would deny these women self-determination? In our society, every competent adult is supposed to have inalienable rights. Do we want to exclude these pregnant women? What would be consistent with the Philosophy of the College? Along the same lines, we ought to ask ourselves whether nurse-midwives should perform random drug testing in an effort to identify maternal substance abusers. This issue ought to count as a moral dilemma. If women think nursemidwives function as agents of the state they will not seek care. Should a nurse-midwife hold a woman in the hospital against her will to ensure that she takes care of herself in the way we think best? Would we hold a woman in secure detention because we think she is not taking proper care of her fetus? Who must live with the long-term consequences of such decisions? Think about the people who argue that home birth is child abuse. They, too, believe that the woman’s right to autonomy and self-determination may be justifiably “set aside.” These questions should be problematic, and I think the Code begs the issue in its current form. The Code, in its current form, speaks too of the “rights of society”-some claim that the wishes of the collectivity may override the autonomy of the individual childbearing woman. To me this is very troubling. We speak of “society” but, the use of the power of the state is really the issue. The women upon whom the state would exercise its supposed “rights” are the poor.* Women who are economically secure have private sources of care and lawyers to protect their civil liberties. Let us take our assumptions about what is ethical out of the background of the proposed Code and expose them to scrutiny. I do not think that nurse-midwives would want to contribute to the oppression of the childbearing woman. On the contrary, we should be supporting her. Yet, in a disconcertingly high portion of legal cases where physicians
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argued that surgery was necessary to “save the baby,” if the court denied the physician’s requests to proceed, the baby was fine without “lifesaving” surgey.2 Does this finding make us uncomfortable as nurse-midwives? It should make us happy. There is a limit to what we can know as professionals. If we use the power of the state to enforce clinicians’ recommendations, we possibly could do real harm, systematically, and on a grand scale. If mothers make mistakes, they do so on the small scale of their own individual case. Of course, mistakes will be made; but, I would still prefer that mothers receive the benefit of the doubt.
ACCESSTOCARE Although concern is expressed about the problem of access to health care in the proposed Code, a more explicit statement would be beneficial. Access to care is the crucial health care problem confronting the United States in the future. Medical resources for the poor are becoming more scarce as profits on the dollar invested in the health care industry are diminishing. We are seeing sources of prenatal care disappear and women “without funding” are being turned away from hospitals even when they are in labor. In many communities, there are no county hospitals and no “safety net” for women without money. The ACNM can and must take a strong stand on this issue. I assert that a health professional should treat anyone in need of care who has no access to an alternative source of necessay services. To support my claim, I would argue that professional educations are made possible through a complex and highly organized social process. As such, professional skills and judgment are a social product and a social resource. The members of society should have some claim on those social resources. The health services which the professionals provide should be equitably distributed with regard to need. Health services are a public good, not private property. This variation of a “social contract” argument suggests that there are no valid grounds for excluding any member of society from care. The fact that some people may not themselves make a contribution to society is irrelevant. The quality of a society is rightly judged on 275
how well it treats its weakest and least able members. A refusal to provide needed maternity care is particularly objectionable given the history of the problem. In the United States, traditional childbirth attendants have been systematically driven out of practice by the organized professions and through legal statute; thus, alternate sources of care barely exist todayespecially for the poor. Women have been virtually forced into hospitals to have their babies. Now we find businessmen who claim that the hospitals cannot afford to take women “without funding.” Nurse-midwives cannot be party to this violation of trust. I should think that every nurse-midwife would want to have a professional document which states unequivocally that denying the indigent access to health care is unprofessional and unethical. This is consistent with our philosophy. The reason why nurse-midwives practice is to provide service to childbearing women, not to generate profit for any third party. Such a document could only be an aid to us in achieving our goals as a profession; and, in the future, it will ensure that we continue to guarantee access to maternity care for the poor. Historically, the poor have received care through a combination of professional voluntarism and legally mandated hospital fiduciary obligations. This is changing.3 Health care professionals are less apt to be independent operators than they used to be; instead, they tend to be employed today by institutions. As employees, if professionals do only what they are told by administrators of those institutions, and if the institution operates with the final attention given to the “bottom line” of profit, then the care of the poor must inevitably suffer.4 I predict that we are going to hear more and more arguments about why some people are not entitled to access to health care. It is not uncommon to hear the attitude voiced that noncitizens are not entitled to access to care, as if they had never contributed to the same economy that turns its back on them.5 Child-bearing women without funding are going to need more and more protection within the health care system. Certified nurse-midwives should set an example for the other professions by mandating access to maternity care for all in its code of ethics. I don’t want to argue that CNMs in private practice have an obligation to ab276
sorb all patients without funding, because obviously soon they could not practice at all. But as a CNM who works in a large practice in a public institution, 1 would like to argue that nurse-midwives in my position are moml~y obliged to care for women who need midwifery care and have no alternative source of care. Our purpose as a profession is to improve maternal-child health. We can’t do that if we can’t see women who can’t pay: they are the ones who need us most. POLITICAL ECONOMY OF HEALTH CARE Health providers in the United States seemingly fail to notice how peculiar the orientation to profit is in health care and how it distorts the range and availability of possible services. The effect of the profit motive on health care only becomes apparent to us when U.S. perinatal outcomes are contrasted with those of countries which emphasize preventative health care and ensure access to health services for all. Capitalist health care economics assume that people will pursue their rational self-interest.6 However, it is naive to believe that the result of each individual’s pursuing his own self-interest will be consistent with the best interest of society as a whole. Paradoxically, the marketplace that determines the value of all things, is itself irrational. In health care, the irrationality of distribution mechanisms is obvious to the providers. But, notice that the irrational distribution of health care resources can only continue with the tacit consent of professionals. Are we willing to consent to the exclusion of the most needy? Health professionals are currently functioning to buffer the irrationality of market decisions as they impact on individual patient’s lives. Until fundamental changes are made in the economics of health care in this county, the Professional Code has the potential to provide leverage for nurse-midwives who want to use their services to promote the health and well-being of childbearing womennot just to promote the financial wellbeing of health care institutions. People who advocate health care for profit want to believe that they are ethical. They want to believe that their personal gain contributes to the greater good of society. But, if providers of care for-profit skim the group of patients who Journal of Nurse-Midwifery
can pay off the top, who is going to underwrite the cost of the care of the medically indigent? What is the role of society in this regard? Do people have only obligations to their society, and no tights to access public goods such as health care? This is a professional issue about which nurse-midwives need to be concerned. A clear statement about accessto health care in our nurse-midwifery professional code of ethics wiIl assist us in dealing with profit-minded administrators. As a profession, we can challenge those who deny pregnant women access to health care for “business” reasons. It is not a necessary feature of health care systems that some must be excluded in order that the greatest good for the greatest number may be achieved. As nurse-midwives, we do not believe it on public health grounds; and, it is not true on economic grounds either. Arguments to exclude the poor are based on nothing more than a contingent feature of health care in a profit-driven economy. We know this is very short-sighted. Ironically, health care costs everyone more in the long run when some do not have access to preventative services. PROFESSIONAL PRACTICE AND CONTROL-ANOTHER CONFLICT OF INTEREST If “concern for others” is to be a centerpiece of the Code, I would delete the section entitled, “The Profession,“’ from the proposed Code. This looks decidedly like concern for ourselves. I fail to see how the question of “Who decides the standards for the profession” is a uniquely ethical question. I also find the ideas that “competence is an ethical principle in itself ‘l to be unfounded. What would be the implications of this claim? Is incompetence morally bad? Is the incompetent practitioner evil? I don’t believe so. Deriving good or bad out from this sort of factual matter is an example of what the philosophers call the Naturalistic Fallacy.7*8 This is simply the idea that you cannot “derive ought from is. “9 It is an error to think that we may derive an evaluative claim from a descriptive claim without using at least one evaluative premise. We cannot remedy the lack of an evaluative premise in this case by committing the further error of making one up to suit our current needs. I do not think it is adequate to provide such a claim by decree.
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I also question the tenet that exhorts CNMs to “accept responsibility for decision making and actions related to direct practice which may include consultation and referral.“’ Whereas I would agree that it probably is unethical not to accept responsibility for one’s actions as a competent adult, this duty to be responsible is probably a feature of some larger system of rights, entitlements and obligations, rather than being a self-evident “principle in itself’ where all questioning can stop. If we agree with the draft Code that “while respecting authority, professional midwives accept responsibility for their decisions,“’ then we given CNMs the worst of both worlds. We have put nurse-midwives in the classical middlemanager’s situation of having little power and alot of responsibility for outcomes. Do we really want to do this to ourselves? I think that the whole section on control of the profession ought to be dropped from the Code. Properly speaking, this is not an ethical issue and I don’t see how we can bring moral force to bear on it, as much as we might like to. Finally, the preoccupation with power and control-giving it to ourselves especially-could look downright selfserving. PROFESSIONALS’ KNOWLEDGE: SPEAKING LOUDLY AND CARRYING A SMALL STICK It might be objected that in the section of the code on “Professional Relationships” the Thompsonsl specifically mandate “shared professional knowledge leading to informed consent.” That isn’t selfserving, one might argue, that is “empowering the patient.” The reasoning here is that professional-patient relationships are inherently unequal by virtue of the greater knowledge and skill possessed by the professional. Professional ethics require a lessening of that inequality through a sharing or teaching of professional knowledge and the patient’s willingness to learn. While absolute equality is seldom attained, the patient needs as much knowledge as possible to be truly informed, to be autonomous. (emphasis mine) I agree that professional-patient relationships are unequal; but, I have to disagree Journal of Nurse-Midwifery
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with the assumptions being made about the nature of knowledge and who has it. On this point, I draw upon the reasoning of Vera Keane,‘O CNM, a past-president and founding member of the ACNM. She reminds the nurse-midwife that the knowledge is in the woman. “It is a snare and a delusion to think that you control labor-the labor controls you.” I know that she would remind us that the accoucheur is the helper. The woman’s body that knows what to do. If we didn’t believe that, we would not be midwives. In the proposed Code, it is asserted that by sharing information with a childbearing woman we are making her “autonomous.“’ Let us keep this in perspective! In providing her information so that she may make an informed choice, we are discharging our responsibility for an untoward outcome. We are covering ourselves. Is this giving her autonomy? The woman who receives nurse-midwifery care is on the inside of our health care system; but, she is still not in control. The forces of the marketplace create a very circumscribed set of options and we give her information on these. Do we tell her this honestly? Do we say: “You have two undesirable options?” Often that is the truth. The code proposes that “Honesty is the best policy.“’ How can we be honest with a woman if we cannot be honest with ourselves about what we know and don’t know-about what we control and don’t control? THE IDEA OF “RATIONALE:” A TIME-HONORED PROCRUSTEAN BED The contrast of “action” with “rationale” is a familiar pedagogical device for teaching nursing; but, I am not sure that the contrast of “The Code” with “Rationale” is helpful in this context. The juxtaposition implies that the content of the Code is not arbitrary and that it is supported by philosophical justification. I think this may be misleading. First, cognitive psychologists tell us that we do not think in syllogisms. With respect to moral decision-making, I would argue that we do not actually derive a conclusion about what is moral from a set of moral premises. In our daily moral problem-solving as well as in the development of a professional ethic, I would argue that we induce the supposed general ethical principle from the action which, in turn, was put forward as
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the right thing to do by some anterior cognitive process. The verbal reports on this supposed anterior mental process are properly viewed with a large degree of skepticism.” It is a problem that in the draft the type of connection between the Code and the Rationale is not specified. Indeed, it is not clear which came first. If we are not deducing a conclusion about what is moral from the “rationale,” how can the latter be considered to justify the former in any way? As an illustration of the problem, I submit that the problem-solving behavior demonstrated by the Ad Hoc Committee on Developing a Professional Code at a meeting during the 1986 ACNM Convention was consistent with what the psychological literature predicts. We members had the proposed Code; so, the task became one of justifying the contents of the code by drawing on lofty philosophical precepts and principles ex post facto. But, the difficulty here is obvious. How could we be “deriving” moral conclusions from principles when we did not yet know which principles they were? The order of the argument is wrong. How could these principles be used to ground the Code when they were only marshalled later? Anything could be used to justify anything unless there is some relationship specified between the Code and the supposed source of its claim to make actions legitimate. PHILOSOPHICAL ANALYSIS IN YOUR SPARE TIME The proposed Code introduces many concepts from academic philosophy and developmental psychology despite the fact that all nurse-midwives may not be familiar with the works of the utilitarians, Kant, Kohlberg and Gilligan. Therefore, if we are going to consider grounding a professional code in these works we must discuss the ideas critically in our literature. To me, it is a liability of the proposed Code that it draws on ideas that nurse-midwives may not be able to discuss easily. If we can’t discuss them, or write about them, and we can’t understand the strengths and weaknesses of the various positions, then how can we use them as a foundation for our Code of Ethics? Since these philosophical and psychological concepts are on the table, nursemidwives will rise to the occasion. The 277
philosophical question about the proposed Code is: why do we pull Kant’s Categorical Imperative12 out of the hat and not some other thing? It is not obvious to me why we are privileging Kant’s arguments. We could just as well rely on social contract theoy,*3-15 for example. Because there is no reason given for this choice, the reliance on Kant looks arbitrary. The second problem is that actions which are compatible with one “rationale” in the proposed code are inconsistent and incompatible with other “rationale.” For example, in the section on Kant’s Categorical Imperative (which is defined as “unquestioned command to do good,“) there is a claim that his “view of persons negates the common utilitarian concept, the end (purpose) justifies the means.“’ But, the proposed code further notes that “giving and receiving support provides for both the client’s and the health care provider’s well-being.” This is a utilitarian concern. By Kant’s reasoning-as I understand it-providing for well-being would be an illegitimate end! In the parlance of the ethicists, this is a consequentalist claim, not a deontological claim. The means would be “giving and receiving support.” The end would be “client and provider wellbeing.” If this is set out as “good,” then we have the classic utilitarian argument! Kant would say that one does one’s duty and the consequences are morally irrelevant. Because utilitarian concerns16J7 for consequences probably do inform a great deal of nurse-midwifery practice and day-to-day ethical decision making, we have two problems here. There are internal inconsistencies in philosophical argumentation, and the draft code turns out to be incompatible with the ordinary methods of day-to-day ethical reasoning used by many nurse-midwives. Is this what we want? Rather than providing answers for practitioners faced with moral dilemmas, I suggest again that the form the code ought to take is to raise the questions that nurse-midwives ought to be asking themselves in their practice. The code could provide guidance for identijying claims on our attention as ethical actors, in accordance with the Philosophy of the College. We have to make certain concessions and compromises in a complex health care system to be able to help the most 278
people the best way we can. We have to allow for exceptions to moral rules-ofthumb. Not being able to make an exception on utilitarian grounds could be very costly to innocent people. For example, there can be little justification for making a difficult situation worse by destroying a person’s hope or by depriving a woman of her coping mechanisms and defenses when she needs them most. These situations give rise to moral dilemmas and we cannot begin to do them justice by appealing to rigid precepts. The features of actual clinical practice need to be taken into consideration. The individual nurse-midwife’s appreciation of the ethical nuances of each situation ought to be giuen great weight. I, for one, do not want to see clinicians’ hands tied in ordinary practice by the code of ethics which we choose for ourselves. The function of the Code should be to alert the practitioner to the range of ethical concerns-not constrain it. Utilitarianism-and whatever other resources for ethical thinking which a person can bring to bear on a problem -should not be rejected out of hand in our Code. We should acknowledge the complexity of moral dilemmas in clinical practice. We should not underestimate the capacity for moral problem-solving by practitioners in the course of their ordinary work. Finally, I would also argue that ethical questioning does not stop with Kohlberg or Gilligan either. This work is not without controversy. My concern is with cognitive developmental hierarchies in general. What are defined at the outset by the researchers as indicators of increasing sophistication in cognitive function? Thinking more and more like the researcher thinks, it could be argued that the research designs from which these results are obtained are insensitive to cultural variation in subjects and to the pressures of social context in the research setting. Do we want to base our code in categorical hierarchies of moral reasoning that are self-serving and possibly ethnocentric? I would think not. By the same token, I would not include any speculation such as “Sociobiologists refer to an altruistic gene as compared to a selfish gene.“’ If ethical behavior were a function of a biologically determined trait, then developing an ethical code for professionals would be a waste of time. The task of the ethicist would be to discover an “ethical litmus Journal of Nurse-Midwifery
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test” and then to apply it to an individual’s genetic material. As long as we think such an effort would be silly, then, we are better not to deploy speculation about “altruiitic and selfish genes” in our code. Compared to the Thompsons who conceived of and developed the proposed Code, I realized that I was going to have it easy. It is obviously much more difficult to take the first steps in formulating a code than it is to come along afterward and make suggestions about those steps. A negative program is always easier to formulate than a positive program. So, I will offer a positive program for further analysis. Having specified what I would delete from the Code, I will now indicate what I would include in a code such as this. I hope my suggestions advance the discussion and stimulate other nurse-midwives to comment on the proposals regarding the Code of Ethics. A CODE OF ETHICS FOR NURSE-MIDWIVES: ANOTHER PROPOSAL If certified nurse-midwives are to act in ethical ways as professionals, they are obliged to make their actions consistent with the philosophy of the ACNM. In cases involving moral dilemmas or in situations which pose potentials for conflicts of interest, they should consider the following tenets. Respect for human dignity and worth makes it incumbent on the CNM to respect the childbearing woman’s and the childbearing family’s, right to self-determination and autonomy. The right to a safe, satisfying maternity experience obliges the CNM to always to keep safety a primay concern in providing care. If the woman’s or baby’s health status is not reassuring, the nurse-midwife is obliged to implement the appropriate investigation and/or intervention with the patient’s consent and cooperation. Comprehensive care and patient satisfaction are to be goals of care to the extent that they are reasonable and possible. The certified nurse-midwife has received an education which is a public good. The CNM is prepared to manage physical care in an interdependent health care system. As that system and a highly organized society have enabled the CNM to have access to a nurse-midwifery professional education in the first place, society can make reciprocal claims on those 33, No. 6, November/December 1988
skills. If the health resources which are inherent in the CNM are to be used as a major means for intercession into, and improvement and maintenance of, the health of the nation’s families, as asserted by the philosophy of ACNM, those families should have access to CNM services. Health care institution should not put the CNM in the position of having to refuse to provide care to anyone who has no financial resources and no alternative source of care.
2. Kolder V, Gallagher J, Parsons M: Court ordered obstetrical interventions. N Engl J Med 316(19):1192-1196, 1987. 3. Starr P: The Social Transformation of American Medicine. New York, Basic Books, 1982. 4. Blessed Events and the Bottom Line: Financing Maternity Care in the United States. New York, The Alan Guttmacher Institute, 1987. 5. Nickle J: Should undocumented aliens be entitled to health care? Hastings Center Report: 19-23, December, 1986.
The author would like to thank Hugh Mehan, PhD, Jeanne Raisler, CNM, MS, MPH, and Joyce Beebe Thompson, CNM, DrPH,FAAN, for their comments, suggestions, and criticisms.
6. Smith A: An Inquiry Into the Nature and Causes of the Wealth of Nations, Volume 1. Indianapolis, Liberty Classics, 1981.
REFERENCES
7. Searle J: How to derive ‘ought’ from ‘is.’ Foote P (ed), Theories of Ethics. Oxford, Oxford University Press, 1971.
1. Thompson H, Thompson J: Code of ethics for nurse-midwives. J NursMidwif 31(2):99-102, 1986.
8. Hare R: The promising game. Foote P (ed), Theories of Ethics. Oxford, Oxford University Press, 1971.
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9. Hume D: A Treatise of Human Nature. Oxford, Oxford University Press, 1983. 10. Personal communication with Vera Keane in preparation of a seminar paper, July 1986. 11. Nisbett R, Wilson T: Telling more than we can know: Verbal reports on mental processes. Psych Review; 84(3):231-257, 1977. 12. Kant I: Foundations of the Metaphysics of Morals. Indianapolis, BobbsMerrill, 1959. 13. Hobbes T: Leviathan. New York, Penguin Books, 1983. 14. Locke J: Second Treatise of Government. Indianapolis, Hackett, 1980. 15. Rousseau J: The Social Contract. New York, Simon and Schuster, Inc, 1974. 16. Sen A, Williams G: Utilitarianism and Beyond. New York, Cambridge University Press, 1983. 17. Mill J: Utilitarianism and Other Writings. New York, New American Library, 1962.
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ABSTRACT This paper critically analyzes the proposed Code of Ethics for nurse-midwives that was published in the March/April 1986 issue of this journal by drawing upon the literatures of medical ethics, political economy, cognitive psychology, and the sociology of professions. Examples of practical ethical issues in nurse-midwifery are provided and an alternative Code of Ethics based on the ACNM Philosophy is offered.
In the “Issues and Opinions” column of the March-April 1986 Journal of NurseMidwifery, Henry and Joyce Thompson’ offered a draft code of ethics and invited response from nurse-midwives. This paper represents my thoughts on the proposed code and offers a different perspective to the discussion of ethical issues in nurse-midwifery. The Thompsons are to be congratulated for recognizing the need for a code of ethics for nurse-midwives and for their leadership in mobilizing the College to adopt such a code. However, it does not seem that the proposed code is adequate yet. In formal terms, the code is internally inconsistent, not complete, and not necessarily grounded in the rationale offered. It proposes to provide answers to practical moral dilemmas, but the answers which are consistent with one portion of the code are contradictoy to another. If the code were implemented as it stands, in some cases it would lead nurse-midwives to commit acts that are illegal and could only be considered ethical under one narrow definition of the term. To remedy these difficulties, I will propose a different structure for the code of
Address correspondence to: Terri ClarkCaller, versity
90293.
Deparbnent
of Sociology
C-002,
Uni-
of California, San Diego, La Jolla, CA
ethics for nurse-midwives. Rather than attempting to formulate prescriptions for ethical behavior for nurse-midwives in any conceivable situation, we should have a more modest goal. I suggest that the Code should raise content areas of concern that the CNM should have when she or he confronts an ethical problem, rather than attempting to provide an answer to questions we can’t even begin to imagine. From what foundation should the ethical considerations of the Code originate? The arguments of the philosophers lend a sense of authority and immutability to the proposed Code; however, there is a disadvantage to relying on them. Most nurse-midwives are not sufficiently prepared in philosophy to critically evaluate the validity and relevance of basing our professional code of ethics upon the esoteric reasoning of Kant, Gilligan, and Kohlberg. It ought to be seen as a problem that the proposed philosophical rationale would have to be taken on faith by most nurse-midwives. Rather, I would suggest that we use the Documents of the American College of Nurse-Midwives in the formulation of a code of ethics. The documents are the appropriate base of departure because they clearly identify the goals and purposes of nurse-midwifey-what we consider to be goodand certified nurse-midwives understand the documents and are already committed to them.
274 Copyright0 1988 by the American College of Nurse-Midwives
Journal of Nurse-Midwifery
“MATERNAL-FETAL OF INTEREST”
CONFLICT
If one purpose of a Code of Ethics would be to alert nurse-midwives to the content areas of ethical concern in hard cases, it makes sense to begin by asking how the proposed Code would help the practitioner with the hardest cases of all: the seeming conflict between the interest of the mother and the fetus. It seems to me that, in this regard, the proposed Code uses as a resource precisely that which should be the topic of the discussion. For example, the present draft of the Code’ asserts that “in an emergency, the patient’s autonomy may be set aside to saue a life . patient’s rights are not absolute in all circumstances but are rather to be honored in relation to othersfamily, society, health care providers, etc.” The resolution of the problem of competing interests is precisely what is at issue; but, rather than addressing it as a dilemma with two reasonable sets of concerns competing for our attention, the draft considers the solution settled. Furthermore, the specifics of this solution could be extremely troublesome, for example, when a mother refuses a cesarean section despite fetal indications. If a health professional “sets aside” the right of a competent woman to control her own body, that professional may find herself or himself charged with assault
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an&or battery. Is this what we want included in the Code? If we look closely at the problem of maternal-fetal conflict of interest, we will notice that the resolution is not at all obvious. There are some very good reasons why professionals may not be entitled to “set aside” a woman’s right to control her own body, and, in fact, may be morally bound to respect a woman’s wishes, even if we find them distasteful. What are we saying when we “set aside” a woman’s rights? “Professionals know best?’ Are we saying to the mother that she can’t make an objective decision about her situation and that we can? As a profession, we have to be way of the potential for being used as instruments of social control. We ought not write off a woman’s autonomy easily. It ought to at least count as a problem, even when weighed against the presumption that there is a life at stake.
Terri Clark-Caller receiued a B.A. in Philosophy from Yale College and an M.S.N. from Yale School of Nursing. She gmduated from the Yale Maternal-Newborn, Nurse-Midwifey Program in 1979 and was an instructor there for four years. In 1983, she began work on a Ph.D. at the University of California, San Diego. She has done
graduate work in sociology, philosophy, and psychology while at UCSD, and has been a gmduate student teaching assistant in sociology, philosophy, and in the writing programs. Her dissertation will study biomedical ethical problems related to perinatal care. Teni also works as a staff nursemidwife with the Comprehensive Perinatal Progmm in San Diego and is a uolunteer midwife at the Casa de Salud in Tijuana. She has an appointment as a clinical instructor with the UCSD Depatiment of Reproductive Medicine where she attends deliveries at Cl&e&y Hospital at night and on weekends and functions as a clinical preceptor for UCSDIUCSF nursemidwifery students and UCSD medical students. Her publications include chapters on abortion and menstrual concerns in Helen Vamey Burst’s forthcoming text on women’s health, and an article on “The Nurse as Rape
Counselor” Nursing.
in The American Journal of
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In a recent review of cases2 in which obstetricians sought court orders to deprive pregnant women of their autonomy in order “to save the baby,” the investigators found that the label of “matemalfetal conflict” tended to be applied primarily to women of color and in cases where the pregnant woman did not speak English. Are nurse-midwives to join the ranks of those who would deny these women self-determination? In our society, every competent adult is supposed to have inalienable rights. Do we want to exclude these pregnant women? What would be consistent with the Philosophy of the College? Along the same lines, we ought to ask ourselves whether nurse-midwives should perform random drug testing in an effort to identify maternal substance abusers. This issue ought to count as a moral dilemma. If women think nursemidwives function as agents of the state they will not seek care. Should a nurse-midwife hold a woman in the hospital against her will to ensure that she takes care of herself in the way we think best? Would we hold a woman in secure detention because we think she is not taking proper care of her fetus? Who must live with the long-term consequences of such decisions? Think about the people who argue that home birth is child abuse. They, too, believe that the woman’s right to autonomy and self-determination may be justifiably “set aside.” These questions should be problematic, and I think the Code begs the issue in its current form. The Code, in its current form, speaks too of the “rights of society”-some claim that the wishes of the collectivity may override the autonomy of the individual childbearing woman. To me this is very troubling. We speak of “society” but, the use of the power of the state is really the issue. The women upon whom the state would exercise its supposed “rights” are the poor.* Women who are economically secure have private sources of care and lawyers to protect their civil liberties. Let us take our assumptions about what is ethical out of the background of the proposed Code and expose them to scrutiny. I do not think that nurse-midwives would want to contribute to the oppression of the childbearing woman. On the contrary, we should be supporting her. Yet, in a disconcertingly high portion of legal cases where physicians
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argued that surgery was necessary to “save the baby,” if the court denied the physician’s requests to proceed, the baby was fine without “lifesaving” surgey.2 Does this finding make us uncomfortable as nurse-midwives? It should make us happy. There is a limit to what we can know as professionals. If we use the power of the state to enforce clinicians’ recommendations, we possibly could do real harm, systematically, and on a grand scale. If mothers make mistakes, they do so on the small scale of their own individual case. Of course, mistakes will be made; but, I would still prefer that mothers receive the benefit of the doubt.
ACCESSTOCARE Although concern is expressed about the problem of access to health care in the proposed Code, a more explicit statement would be beneficial. Access to care is the crucial health care problem confronting the United States in the future. Medical resources for the poor are becoming more scarce as profits on the dollar invested in the health care industry are diminishing. We are seeing sources of prenatal care disappear and women “without funding” are being turned away from hospitals even when they are in labor. In many communities, there are no county hospitals and no “safety net” for women without money. The ACNM can and must take a strong stand on this issue. I assert that a health professional should treat anyone in need of care who has no access to an alternative source of necessay services. To support my claim, I would argue that professional educations are made possible through a complex and highly organized social process. As such, professional skills and judgment are a social product and a social resource. The members of society should have some claim on those social resources. The health services which the professionals provide should be equitably distributed with regard to need. Health services are a public good, not private property. This variation of a “social contract” argument suggests that there are no valid grounds for excluding any member of society from care. The fact that some people may not themselves make a contribution to society is irrelevant. The quality of a society is rightly judged on 275
how well it treats its weakest and least able members. A refusal to provide needed maternity care is particularly objectionable given the history of the problem. In the United States, traditional childbirth attendants have been systematically driven out of practice by the organized professions and through legal statute; thus, alternate sources of care barely exist todayespecially for the poor. Women have been virtually forced into hospitals to have their babies. Now we find businessmen who claim that the hospitals cannot afford to take women “without funding.” Nurse-midwives cannot be party to this violation of trust. I should think that every nurse-midwife would want to have a professional document which states unequivocally that denying the indigent access to health care is unprofessional and unethical. This is consistent with our philosophy. The reason why nurse-midwives practice is to provide service to childbearing women, not to generate profit for any third party. Such a document could only be an aid to us in achieving our goals as a profession; and, in the future, it will ensure that we continue to guarantee access to maternity care for the poor. Historically, the poor have received care through a combination of professional voluntarism and legally mandated hospital fiduciary obligations. This is changing.3 Health care professionals are less apt to be independent operators than they used to be; instead, they tend to be employed today by institutions. As employees, if professionals do only what they are told by administrators of those institutions, and if the institution operates with the final attention given to the “bottom line” of profit, then the care of the poor must inevitably suffer.4 I predict that we are going to hear more and more arguments about why some people are not entitled to access to health care. It is not uncommon to hear the attitude voiced that noncitizens are not entitled to access to care, as if they had never contributed to the same economy that turns its back on them.5 Child-bearing women without funding are going to need more and more protection within the health care system. Certified nurse-midwives should set an example for the other professions by mandating access to maternity care for all in its code of ethics. I don’t want to argue that CNMs in private practice have an obligation to ab276
sorb all patients without funding, because obviously soon they could not practice at all. But as a CNM who works in a large practice in a public institution, 1 would like to argue that nurse-midwives in my position are moml~y obliged to care for women who need midwifery care and have no alternative source of care. Our purpose as a profession is to improve maternal-child health. We can’t do that if we can’t see women who can’t pay: they are the ones who need us most. POLITICAL ECONOMY OF HEALTH CARE Health providers in the United States seemingly fail to notice how peculiar the orientation to profit is in health care and how it distorts the range and availability of possible services. The effect of the profit motive on health care only becomes apparent to us when U.S. perinatal outcomes are contrasted with those of countries which emphasize preventative health care and ensure access to health services for all. Capitalist health care economics assume that people will pursue their rational self-interest.6 However, it is naive to believe that the result of each individual’s pursuing his own self-interest will be consistent with the best interest of society as a whole. Paradoxically, the marketplace that determines the value of all things, is itself irrational. In health care, the irrationality of distribution mechanisms is obvious to the providers. But, notice that the irrational distribution of health care resources can only continue with the tacit consent of professionals. Are we willing to consent to the exclusion of the most needy? Health professionals are currently functioning to buffer the irrationality of market decisions as they impact on individual patient’s lives. Until fundamental changes are made in the economics of health care in this county, the Professional Code has the potential to provide leverage for nurse-midwives who want to use their services to promote the health and well-being of childbearing womennot just to promote the financial wellbeing of health care institutions. People who advocate health care for profit want to believe that they are ethical. They want to believe that their personal gain contributes to the greater good of society. But, if providers of care for-profit skim the group of patients who Journal of Nurse-Midwifery
can pay off the top, who is going to underwrite the cost of the care of the medically indigent? What is the role of society in this regard? Do people have only obligations to their society, and no tights to access public goods such as health care? This is a professional issue about which nurse-midwives need to be concerned. A clear statement about accessto health care in our nurse-midwifery professional code of ethics wiIl assist us in dealing with profit-minded administrators. As a profession, we can challenge those who deny pregnant women access to health care for “business” reasons. It is not a necessary feature of health care systems that some must be excluded in order that the greatest good for the greatest number may be achieved. As nurse-midwives, we do not believe it on public health grounds; and, it is not true on economic grounds either. Arguments to exclude the poor are based on nothing more than a contingent feature of health care in a profit-driven economy. We know this is very short-sighted. Ironically, health care costs everyone more in the long run when some do not have access to preventative services. PROFESSIONAL PRACTICE AND CONTROL-ANOTHER CONFLICT OF INTEREST If “concern for others” is to be a centerpiece of the Code, I would delete the section entitled, “The Profession,“’ from the proposed Code. This looks decidedly like concern for ourselves. I fail to see how the question of “Who decides the standards for the profession” is a uniquely ethical question. I also find the ideas that “competence is an ethical principle in itself ‘l to be unfounded. What would be the implications of this claim? Is incompetence morally bad? Is the incompetent practitioner evil? I don’t believe so. Deriving good or bad out from this sort of factual matter is an example of what the philosophers call the Naturalistic Fallacy.7*8 This is simply the idea that you cannot “derive ought from is. “9 It is an error to think that we may derive an evaluative claim from a descriptive claim without using at least one evaluative premise. We cannot remedy the lack of an evaluative premise in this case by committing the further error of making one up to suit our current needs. I do not think it is adequate to provide such a claim by decree.
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I also question the tenet that exhorts CNMs to “accept responsibility for decision making and actions related to direct practice which may include consultation and referral.“’ Whereas I would agree that it probably is unethical not to accept responsibility for one’s actions as a competent adult, this duty to be responsible is probably a feature of some larger system of rights, entitlements and obligations, rather than being a self-evident “principle in itself’ where all questioning can stop. If we agree with the draft Code that “while respecting authority, professional midwives accept responsibility for their decisions,“’ then we given CNMs the worst of both worlds. We have put nurse-midwives in the classical middlemanager’s situation of having little power and alot of responsibility for outcomes. Do we really want to do this to ourselves? I think that the whole section on control of the profession ought to be dropped from the Code. Properly speaking, this is not an ethical issue and I don’t see how we can bring moral force to bear on it, as much as we might like to. Finally, the preoccupation with power and control-giving it to ourselves especially-could look downright selfserving. PROFESSIONALS’ KNOWLEDGE: SPEAKING LOUDLY AND CARRYING A SMALL STICK It might be objected that in the section of the code on “Professional Relationships” the Thompsonsl specifically mandate “shared professional knowledge leading to informed consent.” That isn’t selfserving, one might argue, that is “empowering the patient.” The reasoning here is that professional-patient relationships are inherently unequal by virtue of the greater knowledge and skill possessed by the professional. Professional ethics require a lessening of that inequality through a sharing or teaching of professional knowledge and the patient’s willingness to learn. While absolute equality is seldom attained, the patient needs as much knowledge as possible to be truly informed, to be autonomous. (emphasis mine) I agree that professional-patient relationships are unequal; but, I have to disagree Journal of Nurse-Midwifery
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with the assumptions being made about the nature of knowledge and who has it. On this point, I draw upon the reasoning of Vera Keane,‘O CNM, a past-president and founding member of the ACNM. She reminds the nurse-midwife that the knowledge is in the woman. “It is a snare and a delusion to think that you control labor-the labor controls you.” I know that she would remind us that the accoucheur is the helper. The woman’s body that knows what to do. If we didn’t believe that, we would not be midwives. In the proposed Code, it is asserted that by sharing information with a childbearing woman we are making her “autonomous.“’ Let us keep this in perspective! In providing her information so that she may make an informed choice, we are discharging our responsibility for an untoward outcome. We are covering ourselves. Is this giving her autonomy? The woman who receives nurse-midwifery care is on the inside of our health care system; but, she is still not in control. The forces of the marketplace create a very circumscribed set of options and we give her information on these. Do we tell her this honestly? Do we say: “You have two undesirable options?” Often that is the truth. The code proposes that “Honesty is the best policy.“’ How can we be honest with a woman if we cannot be honest with ourselves about what we know and don’t know-about what we control and don’t control? THE IDEA OF “RATIONALE:” A TIME-HONORED PROCRUSTEAN BED The contrast of “action” with “rationale” is a familiar pedagogical device for teaching nursing; but, I am not sure that the contrast of “The Code” with “Rationale” is helpful in this context. The juxtaposition implies that the content of the Code is not arbitrary and that it is supported by philosophical justification. I think this may be misleading. First, cognitive psychologists tell us that we do not think in syllogisms. With respect to moral decision-making, I would argue that we do not actually derive a conclusion about what is moral from a set of moral premises. In our daily moral problem-solving as well as in the development of a professional ethic, I would argue that we induce the supposed general ethical principle from the action which, in turn, was put forward as
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the right thing to do by some anterior cognitive process. The verbal reports on this supposed anterior mental process are properly viewed with a large degree of skepticism.” It is a problem that in the draft the type of connection between the Code and the Rationale is not specified. Indeed, it is not clear which came first. If we are not deducing a conclusion about what is moral from the “rationale,” how can the latter be considered to justify the former in any way? As an illustration of the problem, I submit that the problem-solving behavior demonstrated by the Ad Hoc Committee on Developing a Professional Code at a meeting during the 1986 ACNM Convention was consistent with what the psychological literature predicts. We members had the proposed Code; so, the task became one of justifying the contents of the code by drawing on lofty philosophical precepts and principles ex post facto. But, the difficulty here is obvious. How could we be “deriving” moral conclusions from principles when we did not yet know which principles they were? The order of the argument is wrong. How could these principles be used to ground the Code when they were only marshalled later? Anything could be used to justify anything unless there is some relationship specified between the Code and the supposed source of its claim to make actions legitimate. PHILOSOPHICAL ANALYSIS IN YOUR SPARE TIME The proposed Code introduces many concepts from academic philosophy and developmental psychology despite the fact that all nurse-midwives may not be familiar with the works of the utilitarians, Kant, Kohlberg and Gilligan. Therefore, if we are going to consider grounding a professional code in these works we must discuss the ideas critically in our literature. To me, it is a liability of the proposed Code that it draws on ideas that nurse-midwives may not be able to discuss easily. If we can’t discuss them, or write about them, and we can’t understand the strengths and weaknesses of the various positions, then how can we use them as a foundation for our Code of Ethics? Since these philosophical and psychological concepts are on the table, nursemidwives will rise to the occasion. The 277
philosophical question about the proposed Code is: why do we pull Kant’s Categorical Imperative12 out of the hat and not some other thing? It is not obvious to me why we are privileging Kant’s arguments. We could just as well rely on social contract theoy,*3-15 for example. Because there is no reason given for this choice, the reliance on Kant looks arbitrary. The second problem is that actions which are compatible with one “rationale” in the proposed code are inconsistent and incompatible with other “rationale.” For example, in the section on Kant’s Categorical Imperative (which is defined as “unquestioned command to do good,“) there is a claim that his “view of persons negates the common utilitarian concept, the end (purpose) justifies the means.“’ But, the proposed code further notes that “giving and receiving support provides for both the client’s and the health care provider’s well-being.” This is a utilitarian concern. By Kant’s reasoning-as I understand it-providing for well-being would be an illegitimate end! In the parlance of the ethicists, this is a consequentalist claim, not a deontological claim. The means would be “giving and receiving support.” The end would be “client and provider wellbeing.” If this is set out as “good,” then we have the classic utilitarian argument! Kant would say that one does one’s duty and the consequences are morally irrelevant. Because utilitarian concerns16J7 for consequences probably do inform a great deal of nurse-midwifery practice and day-to-day ethical decision making, we have two problems here. There are internal inconsistencies in philosophical argumentation, and the draft code turns out to be incompatible with the ordinary methods of day-to-day ethical reasoning used by many nurse-midwives. Is this what we want? Rather than providing answers for practitioners faced with moral dilemmas, I suggest again that the form the code ought to take is to raise the questions that nurse-midwives ought to be asking themselves in their practice. The code could provide guidance for identijying claims on our attention as ethical actors, in accordance with the Philosophy of the College. We have to make certain concessions and compromises in a complex health care system to be able to help the most 278
people the best way we can. We have to allow for exceptions to moral rules-ofthumb. Not being able to make an exception on utilitarian grounds could be very costly to innocent people. For example, there can be little justification for making a difficult situation worse by destroying a person’s hope or by depriving a woman of her coping mechanisms and defenses when she needs them most. These situations give rise to moral dilemmas and we cannot begin to do them justice by appealing to rigid precepts. The features of actual clinical practice need to be taken into consideration. The individual nurse-midwife’s appreciation of the ethical nuances of each situation ought to be giuen great weight. I, for one, do not want to see clinicians’ hands tied in ordinary practice by the code of ethics which we choose for ourselves. The function of the Code should be to alert the practitioner to the range of ethical concerns-not constrain it. Utilitarianism-and whatever other resources for ethical thinking which a person can bring to bear on a problem -should not be rejected out of hand in our Code. We should acknowledge the complexity of moral dilemmas in clinical practice. We should not underestimate the capacity for moral problem-solving by practitioners in the course of their ordinary work. Finally, I would also argue that ethical questioning does not stop with Kohlberg or Gilligan either. This work is not without controversy. My concern is with cognitive developmental hierarchies in general. What are defined at the outset by the researchers as indicators of increasing sophistication in cognitive function? Thinking more and more like the researcher thinks, it could be argued that the research designs from which these results are obtained are insensitive to cultural variation in subjects and to the pressures of social context in the research setting. Do we want to base our code in categorical hierarchies of moral reasoning that are self-serving and possibly ethnocentric? I would think not. By the same token, I would not include any speculation such as “Sociobiologists refer to an altruistic gene as compared to a selfish gene.“’ If ethical behavior were a function of a biologically determined trait, then developing an ethical code for professionals would be a waste of time. The task of the ethicist would be to discover an “ethical litmus Journal of Nurse-Midwifery
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test” and then to apply it to an individual’s genetic material. As long as we think such an effort would be silly, then, we are better not to deploy speculation about “altruiitic and selfish genes” in our code. Compared to the Thompsons who conceived of and developed the proposed Code, I realized that I was going to have it easy. It is obviously much more difficult to take the first steps in formulating a code than it is to come along afterward and make suggestions about those steps. A negative program is always easier to formulate than a positive program. So, I will offer a positive program for further analysis. Having specified what I would delete from the Code, I will now indicate what I would include in a code such as this. I hope my suggestions advance the discussion and stimulate other nurse-midwives to comment on the proposals regarding the Code of Ethics. A CODE OF ETHICS FOR NURSE-MIDWIVES: ANOTHER PROPOSAL If certified nurse-midwives are to act in ethical ways as professionals, they are obliged to make their actions consistent with the philosophy of the ACNM. In cases involving moral dilemmas or in situations which pose potentials for conflicts of interest, they should consider the following tenets. Respect for human dignity and worth makes it incumbent on the CNM to respect the childbearing woman’s and the childbearing family’s, right to self-determination and autonomy. The right to a safe, satisfying maternity experience obliges the CNM to always to keep safety a primay concern in providing care. If the woman’s or baby’s health status is not reassuring, the nurse-midwife is obliged to implement the appropriate investigation and/or intervention with the patient’s consent and cooperation. Comprehensive care and patient satisfaction are to be goals of care to the extent that they are reasonable and possible. The certified nurse-midwife has received an education which is a public good. The CNM is prepared to manage physical care in an interdependent health care system. As that system and a highly organized society have enabled the CNM to have access to a nurse-midwifery professional education in the first place, society can make reciprocal claims on those 33, No. 6, November/December 1988
skills. If the health resources which are inherent in the CNM are to be used as a major means for intercession into, and improvement and maintenance of, the health of the nation’s families, as asserted by the philosophy of ACNM, those families should have access to CNM services. Health care institution should not put the CNM in the position of having to refuse to provide care to anyone who has no financial resources and no alternative source of care.
2. Kolder V, Gallagher J, Parsons M: Court ordered obstetrical interventions. N Engl J Med 316(19):1192-1196, 1987. 3. Starr P: The Social Transformation of American Medicine. New York, Basic Books, 1982. 4. Blessed Events and the Bottom Line: Financing Maternity Care in the United States. New York, The Alan Guttmacher Institute, 1987. 5. Nickle J: Should undocumented aliens be entitled to health care? Hastings Center Report: 19-23, December, 1986.
The author would like to thank Hugh Mehan, PhD, Jeanne Raisler, CNM, MS, MPH, and Joyce Beebe Thompson, CNM, DrPH,FAAN, for their comments, suggestions, and criticisms.
6. Smith A: An Inquiry Into the Nature and Causes of the Wealth of Nations, Volume 1. Indianapolis, Liberty Classics, 1981.
REFERENCES
7. Searle J: How to derive ‘ought’ from ‘is.’ Foote P (ed), Theories of Ethics. Oxford, Oxford University Press, 1971.
1. Thompson H, Thompson J: Code of ethics for nurse-midwives. J NursMidwif 31(2):99-102, 1986.
8. Hare R: The promising game. Foote P (ed), Theories of Ethics. Oxford, Oxford University Press, 1971.
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9. Hume D: A Treatise of Human Nature. Oxford, Oxford University Press, 1983. 10. Personal communication with Vera Keane in preparation of a seminar paper, July 1986. 11. Nisbett R, Wilson T: Telling more than we can know: Verbal reports on mental processes. Psych Review; 84(3):231-257, 1977. 12. Kant I: Foundations of the Metaphysics of Morals. Indianapolis, BobbsMerrill, 1959. 13. Hobbes T: Leviathan. New York, Penguin Books, 1983. 14. Locke J: Second Treatise of Government. Indianapolis, Hackett, 1980. 15. Rousseau J: The Social Contract. New York, Simon and Schuster, Inc, 1974. 16. Sen A, Williams G: Utilitarianism and Beyond. New York, Cambridge University Press, 1983. 17. Mill J: Utilitarianism and Other Writings. New York, New American Library, 1962.
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