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Ethical Principles: Application to an Obstetric Case
principles and practice Ethical Principles: Application to an Obstetric Case ANCELINE BUSHY, RN, PHD, J. RANDALL RAUH, MD, AND BERNARD F. MATT PHD This article focuses on the application of the ethical principles of double effect versus consequentialism, autonomy, beneficence, utility, and justice. An obstetrical case study is presented and discussion of each ethical principle is used to resolve the conflict. The intents of the article are to promote ethical awareness; provide topic areas to facilitate ethical discussion; enhance nurses’ knowledge of the discipline of ethics; and support the necessity of interdisciplinary ethics committees.
PRINCIPLES AND ETHICS
Background When a pregnant woman’s decisions about her medical treatment or her behavior appear to endanger the health of her unborn child, who then has the authority to make a treatment decision-the woman, the physician, o r the courts? With the advent of sophisticated technology, more information about fetal intrauterine life has become available. New treatment modalities facilitate medical interventions, both prenatally (in utero) and neonatally (in high-risk nurseries). However, biotechnology has imposed some unforseen societal ethical problems.
Accepted: October 1988
May/June 1989 JOCNN
Biotechnology, however, is not the sole contributor to ethical problems. Other influences that affect these ethical issues include, advocates of women’s health and advocates of children’s rights, who tend to view any interference with a mother’s treatment decision as inappropriate and dangerous. This interference is interpreted as tampering with an individual’s right to make choices regarding her body. On the other hand, advocates of children’s rights tend to condemn mothers quickly and favor increased state power over the pregnant woman to protect fetal rights. The legal rights of the biological father are even more nebulous, and both groups a r e reluctant to address the father’s Ethical conflicts a r e complicated further by the involvement of the legal system (the state). For
instance, consider the case of Pamela Rae Stewart who, in 1986, was arrested on criminal charges of failure to provide medical treatment to her unborn son. The child was born with severe brain damage.and later died as a result of complications. Since then, many ethical and legal debates have occurred on the subject of the pregnant woman’s duty to her unborn child. Thus, with advanced biotechnology, a potential battle has been staged between a pregnant woman and her fetus. Because of the complexities of human systems, one can safely predict that the debate of mother versus her fetus will ~ o n t i n u e . ~ - ~ To make meaningful contributions to ethical discussions, nurses must become knowledgeable in the fundamental terminologies, concepts, and principles of ethics.*-I2 207
IAdvocates of women’s
I I
health tend to view any interference with a mother’s treatment decision as inappropriate.
OBSTETRICAL CASE STUDY A.O. is a 23-year-old female admitted to the emergency room with vaginal bleeding. The patient states that she is 22 weeks pregnant but has put off visiting her obstetrician because of financial hardship. Her social history reveals that her husband is employed as a farm laborer and that the patient is a homemaker. The couple volunteered that they “both were born and raised Catholic in this small midwest town.” A.O.’s obstetric history revealed she had six previous pregnancies, four of which ended in spontaneous abortions and two that resulted in live births. Of the two live births, one resulted in premature delivery of a son at 28 gestational weeks. Because of sequelae related to his premature birth, Jimmy (3 years old) was neurologically impaired and prone to pulmonary problems. Thus, the couple has incurred additional expenses of medication, physician visits, rehabilitation therapy, and special education. The couple has full responsibility for Jimmy’s care and are quick to point out that their son has brought many insights to them. Another pregnancy resulted in a term delivery of another son Steven, who at 8 months of age is developing at a normal rate. The obstetrician completed the physical examination and confirmed the diagnosis of an incompetent cervix, with delivery of a preterm fetus highly probable. The obstetrician then advised the courses of treatment available for
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the duration of A.O.’s pregnancy: continue with her usual activities and let nature take its course; bedrest restriction, which probably is not realistic because she has two small children, so hospitalization may be necessary; or perform a cerclage with the intent of increasing her chance for a term delivery. The couple understood the situation and consented in writing to the cerclage. The procedure was performed without difficulty and A.O. returned home. However, two weeks later A.O. was admitted to the hospital with uterine contractions. The patient’s physician thought that labor was imminent and that for the fetus to have any chance of survival A.O. could no longer be treated at a small hospital. The physician explained that at 25 gestational weeks, a fetus would have a 10% chance of survival in a highly specialized neonatal care unit, such as the one at a facility 800 miles away, and that an associated risk of abnormalities would be present for such a child. Based on this information, t h e couple was presented with these options. 1) Remove the cerclage and “let nature take its course,” a decision that probably would result in delivery of an immature infant in this small rural hospital. However, an added complication was the absence of the only pediatrician on staff and the assumption of pediatric duties by a general practitioner. In this case study, the general practitioner had limited neonatal experience and, even with the use of all the available resources, the infant probably would die before being transferred to the tertiary center. 2) Transfer A.O. to the tertiary neonatal care center via chartered emergency air transportation. (The couple’s insurance did not reimburse the small hospital for emergency transport services.)
This second option was the physician’s recommendation. A dilemma resulted because the couple was adamant about having A.O.’s obstetrician deliver A.O. in the local hospital. The couple believed that they could not absorb the anticipated costs (financial and emotional) associated with another “defective baby.” Moreover, the obstetrician perceived the parents’ request to be tantamount to a (late) second trimester abortion because the inevitable consequence of removing the cerclage without the availability of high-risk neonatal services would result in the death of the fetus. The physician’s reluctance was reinforced by this situation occurring in a Catholic hospital and the conflicting and unresolved legal issues surrounding this
DEFINING ETHICAL PRINCIPLES
Different philosophical principles can be employed to approach this quandary. A s evidenced by the subsequent discussion, medical interventions for the case may be contradictory in nature, depending on the ethical principle used to approach the issue. Double Effect
The principle of double effect states that some actions have both good and evil consequences. Four conditions are subsumed by the principle: The immediate action performed must be good or indifferent; The unforeseen evil consequence must not be intended; The foreseen good consequence must not be an effect of the evil consequence; and The foreseen good consequence must be proportionate to the foreseen evil c o n ~ e q u e n c e . ~ ~ ’ ~
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A classic example of double effect is that of a pregnant woman who is diagnosed with uterine cancer. In this case, the immediate action (intent) is removal of the cancer to save the woman’s life, not to abort the fetus. The subsequent effects on the fetus are unintended consequences.
In this case study, the intended action was to remove the cerclage at the family’s request, not to deliver an immature fetus.
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In the case study, the intended action was to remove the cerclage at the pregnant family’s request. The intent was not the delivery of an immature fetus. Therefore, this principle requires that the physician ascertain whether or not the mother’s life is in imminent danger. When the answer is yes, the principle of double effect allows for the intended action (removal of suture). However, when the mother’s life is not in imminent danger, the physician cannot intervene until at such time as the mother’s life is at risk.
Consequentialism
Consequentialists take a n opposing view; their philosophical approach is to not consider the intended action by itself. Instead, the focus is on the consequences of an action. When the outcome (consequence) is good, the action is viewed as appropriate. Conversely, when an outcome is bad, the action is viewed as evil.”.’* Essentially, the ethical principles of double effect versus consequentialism establish the framework for discussion of this case. However, other dimensions are considered in the principles of utility and justice.
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In the case study, the mother’s physical health may not be overtly improved by the removal of the cerclage. Yet, how does one measure the financial distress, emotional pain, and psychological trauma to a family that has another mentally retarded child? Therefore, should one infer that the benefit of the procedure is the psychological health of the pregnant family, or should one infer that the procedure must have a physical therapeutic effect on the mother (family)? Whichever option is perceived as the benefit, the anticipated consequence is the delivery of an immature fetus. Autonomy
The principle of autonomy states that individuals act autonomously when they, and not others, make decisions that affect their lives. As a result, each individual acts on the basis of his/her decision. Autonomy directs that a patient’s values are of the highest priority and should guide a physician’s treatment regimen for that person. Inherent in the principle of autonomy is the concept of the right of competent adults to accept or refuse medical treatment on the basis of full information from the health-care provider, known as informed consent.6s’2To assure the autonomy of a mentally incompetent person, a responsible individual makes decisions for that individual before medical intervention can be initiated. With the principle of autonomy, a patient’s self-determination takes precedence over the values of medicine. In strict adherence to this principle, when a mentally competent pregnant woman requests a medical intervention or procedure, the physician is obligated to comply. On t h e other hand, the fetus could be viewed as the incompetent patient and the parents are viewed as the responsible individ-
In consequentialism the focus is on the consequences of an action. uals. In such an instance, the parents are making a quality of life decision for the fetus (due to the high risk of abnormality associated with immaturity at birth). Furthermore, should the parent decide to provide all of the medical treatment necessary, the physician is obligated to provide all of the “available treatment” within that health-care agency to the pregnant woman’s fetus before and after delivery. In the case study, this would have allowed for a general practitioner in the small rural hospital to care for the premature infant because the pediatrician was not available. Applying the principle of autonomy, the dilemma can be framed in many ways. For example, should the autonomy of the pregnant woman be interfered with for the benefit of the fetus? Furthermore, can society legally require a pregnant woman to undergo treatment against her will, when the same sacrifice is not required to save the life of a person in other situations?’ These questions are complicated by the scientific community continuing to learn more about intrauterine life, which has resulted in the fetus being viewed as a separate person before birth, both physiologically and legally. Thus, the problems generated by the principle of autonomy for the case study can be summarized as a threefold conflict between the physician and the patient’s right of autonomy; between the physician-patient right to privacy and the state’s interests (legal issues); and between the doctor-patient relationship and the responsibilities of the medical profession. The conflict over autonomy becomes more complex when multi209
ple individuals a r e involved; whose autonomy takes precedence? The case study illustrated that the autonomy of any number of individuals can be identified, including the direct identification of the fetus and the mentally competent mother and the indirect identification of t h e family (father/mother and two siblings). Indirect identification of the physician, hospital, state and society is possible. Furthermore, in reference to the present study, what impact did the initial informed consent by the mother to have the cerclage have on the autonomy of each of the individuals involved? For situations involving only one individual, the principle of autonomy may take precedence in the medical treatment regimen. However, in situations involving two o r more patients, as is t h e case with a pregnant woman, the principle of autonomy may not be appropriate. Therefore, considering the numerous individuals involved in the case, autonomy may not be practical because everyone’s autonomy cannot be fulfilled.
Beneficence The principle of beneficence refers to doing or promoting good. Beneficence implies that a physician knows what is in the best interest of the patient (paternalism). Thus, a medical treatment regimen can be implemented based on the physician’s expertise and values, regardless of a patient’s wishes. Paternalism has been used to justify limiting an individual’s liberty in instances in which a person’s actions produce serious harm or fail to produce an important benefit to that person. The question as to whether or not a patient should be told the truth about a poor medical prognosis often is paternalistic in nature. In this situation, others decide how
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much information is t o be divulged t o a sick individual, thereby, limiting that person’s freedom of choice. Logically, the principle of beneficence may be in direct conflict with the principle of auton~my.~J~J~
Applying the principles of autonomy can allow this dilemma to be solved in many ways. An inferred concept within beneficence is the principle of nonmaleficence, which is defined as the duty to avoid intending, causing, permitting, or imposing harm or risk of harm to any person (primum non noncere). However, in some cases pain and suffering conceivably may be more cruel than death.4-6 In the case study, one can argue that the emotional pain associated with having a child who is mentally retarded is a situation that may result in extreme pain to the family. Therefore, if a physician’s primary purpose is to do no harm and to relieve pain and suffering, beneficence would allow a local delivery because this option has the potential of reducing a family’s emotional pain. The intent of the medical intervention in the case study was not abortion, yet the limited perinatal high-risk resources promoted an unfavorable fetal outcome. Beneficence supports the notion that, a t times, abortion may be in the mother’s best interest, which also may be true for the family in this case. Conversely, if the principle of beneficence is focused on the fetus, additional high-risk neonatal medical interventions must be made available. Extraordinary measures a r e required for t h e high-risk newborn; despite that in
the case of A.O., such measures would be available only at a distant medical center and would result in excessive costs to the family, third-party payers, and the local social service agency. Even considering poor fetal prognosis, applying the principle of beneficence in such situations would not be morally wrong. Utility
The principle of utility expands on the consequentialists’ perspective and supports the notion of the greatest good and greatest happiness for the greatest number. The principle of utility is pragmatic in nature, focusing on balancing the good that is possible to do with the harm that might result from doing or not doing a deed.4-6 Based on arguments regarding the principle of utility, ethicists have developed a hierarchical structure of happiness values. Among others, psychological happiness has the highest priority, followed by financial happiness.11”2These raise additional questions relative to the principle of utility. For example, does one consider short-term or long-term happiness? Who determines the greatest number(s) of benefits and costs and how are these effects measured? For example, if psychological happiness has priority over financial happiness, how are the costs and benefits compared for a family of five versus society? When numbers are of paramount consideration, as in this case, obviously the family loses, and society is the only issue. On the one hand, the short-term psychological effects on the family and the fetus seem obvious, but on the other hand, the long-term effects are uncertain for the family o r society in general. Furthermore, one can assume that both long- and short-term costs (psychological and financial) will
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occur if the neonate is abnormal. Conversely, should the infant be normal, how does one determine the contributions this person will make over a lifetime to the family and to society? Hence, a qualityof-life question becomes involved in the decision-making process. Applying the principle of utility to the physician in the case study might indicate that short-term happiness may result from personal satisfaction due to the physician's contributing to a family's happiness or sanity. On the other hand, a short-term cost might be a guilty conscience, increased stress, and personal grief resulting from the selected treatment regimen. An unpredictable long-term cost might be a legal conviction with loss of employment caused by revocation of licensure. Therefore, the principle of utility, applied in the case study, can support the decision to have either a local delivery or to transfer the mother to a tertiary center. The ethical complications vary, depending on who is identified a s the patient (i.e., the mother or the fetus). Justice
The principle of justice implies that equals should be treated equally and those who are unequal should be treated differently according to their differences. Equal treatment is not necessarily identical. Equality means making the same relative contribution to the goodness of individuals' lives, such as having equal opportunity to achieve a virtue or benefit. This may be viewed as an outcome by consequentialists.6J'Jz Justice further infers that medical resources be fairly allocated. Therefore, the principle of distributive justice applies to both scarcity of resources and competition for the benefits. Just distribution can be according to equal shares,
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individual need, individual effort or merit, or societal contribution. Contemporary philosophers are considering another aspect of the allocation of resources, that of the principle of preferential treatment, or the investigation of who is most prone to unjust treatment. Preferential treatment promotes the value that the least advantaged get the most resources from society."
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Nurses have important roles in formal ethics committees as potential members and as contributors to the formal data base.
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Considering the case study, the primary question in applying the principle of justice is to identify who is most disadvantaged and/or at the highest risk. One can accept the stance that this may be the pregnant woman, the family, o r the fetus. The pregnant woman might be considered the most disadvantaged when one considers her role as the primary caretaker of three preschool children, two of whom may be abnormal. When the family is defined as the most disadvantaged, the focus could be on psychological pain and financial distress which often result in additional social problems for society and the family. Some may view the fetus as being the most disadvantaged-a notion that seems to be supported by some current legal cases that assign a fetus legal rights. In a more global perspective, society could be identified as the most disadvantaged, considering the current global economic crises and the high rate of poverty.'* Accordingly, t h e principle of utility and preferential treatment
often has been summarized as a Christian utopian ideal; however, is this ideal impractical and unrealistic to achieve? For the case, the decision maker would need to identify clearly the patient. Consequently, this principle probably would be impossible to implement in this instance. IMPLICATIONS FOR NURSING
Recent medical research has resulted in concerns about the lifestyle of a pregnant woman and the safety of her fetus. Consequently, health professionals may find themselves as middle-persons because they recognize the unique relationship between mother and fetus. Health professionals also feel distinct discomfort in attempting to balance the needs of the two when providing medical interventions. Thus, numerous questions arise, and before deciding on an intervention, one must consider the legal and ethical dimensions. One consideration is identification of the patient, i.e., the mother, father, entire family, or fetus. Also to be considered are how abortion is defined, and by whom-the mother, family, physician, or the state-and whose definition carries the greatest weight? Another question is what weight is carried by the decision of the marital bond between the mother and father in the treatment selection of the pregnant woman? Finally, one must question how society ascertains the short- and long-term effects of the selected option on the mother, family, physician, community, and on society a s a whole?3 The conflict in this instance supports the need for interdisciplinary discussion to address multifaceted ethical quandaries. As part of a health team, nurses play a significant role in the ethical decision-making process.
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Nurses often are the first to become aware of an impending conflict because they provide direct patient care. A patient is part of a family system and nurses, because of their roles, encounter family members on a more regular basis than do other health-care professionals. Nurses also are instrumental in obtaining the informed consent signatures for the selected biomedical options, so nurses may be involved in patient teaching and counseling. As a result, nurses are in positions to observe the responses of families, and these observations may include early indications of an impending c o n f l i ~ t . ~ . ~ Nurses also must participate in and implement the decisions of others. For example, after the client and physician have selected an option, the nurse may be responsible for implementing the selected medical alternative. In some instances, these interventions may be in conflict with a nurse’s personal value system. Nurses must, therefore, separate personal from professional values. Whatever a nurse’s values, the nurse often is involved in an advocacy role to one or more of those individuals involved in the decision making.6s7 As one considers these complex dimensions, evidence mounts that one individual is not in a position to ascertain the full implications of an ethical issue. This is one rationale for the necessity of interdisciplinary bioethics committees. Nurses also have important roles on formal ethics committees, as
potential members and as contributors to the formal data base required by the group to make sound ethical decisions. In summary, a number of guiding principles delineate an ethical situation. In this manuscript, several are described in detail and applied to an obstetrical situation. By becoming familiar with the basic principles of ethics, nurses will .have a greater awareness of ethical principles and thereby provide greater substance to interdisciplinary biomedical ethics discussions. REFERENCES 1. Lagerlof, J. 1988. Maternal fetal conflict. California Nursing Review. (Jan.-Feb):34-36. 2. Guido, G. 1988. Legal issues in nursing: Source book for practice. Norwalk, Connecticut: Appleton & Lange. 3. Dan, J., and J. Peterman. 1985. Abortion and women’s health: Responsibility of nurses. In Current Issues in Nursing, eds. J. Mclosky and H. Grace, 1071-81. Boston: Blackwell Scientific Publications. 4. Comi, J., J. Mclosky, and H. Grace. 1985. Nursing’s ethical dilemma. In Current Issues in Nursing, eds. J. Mclosky and H. Grace, 1005-7. Boston: Blackwell Scientific Publications. 5. Gaffney, J. 1979.Newness oflife.St. Louis: Paulist Press. 6. Mclosky, J., and H. Grace, eds. 1985. Current Issues in Nursing. Boston: Blackwell Scientific Publications. 7. Cushing, M. 1985. Euthanasia: A legal perspective. In Current Issues in Nursing, eds. J. Mclosky, and H. Grace. 1044-71.Boston: Blackwell Scientific Publications.
8. Aroskar, M. 1984. Considerations in establishing an ethics committee. AORN J. 40:88-92. 9. May, W. 1975. The composition and function of ethics committee. J Med Ethics. 1:23-29. 10. Thomasma, D. 1985. Hospital ethics committee and hospital policy. QRB. 11:204-9. 11. Gannon, T., ed. 1987. Catholic Challenge to the American Economy: Reflections on the US. Bishops’ Pastoral Letter on Catholic Social Teachings in the US.Economy. New York: McMillan and Sons. 12. Ashley, B., and K. Rourke. 1982. Health care ethics: A theological analysis, 218-327. St. Louis: The Catholic Association of the United States. 13. Rauh, J. 1988.Big time ethical decision-making in small health care facilities. Conference on Rural Health-N.D. presentation. 14. Freel, M. 1985. Truth telling. In Current Issues in Nursing, eds., J. Mclosky, and H. Grace, 1008-24. Boston: Blackwell Scientific Publications.
Address for correspondence: Dr. Angeline Bushy, 1914 North 2d Street, Bismarck, ND 58501.
Angeline Bushy is associate professor at Medcenter One, in Bismarck, North Dakota. Dr. Bushy is a member of NAACOG, the American Nurses’ Association, and the International Congress of Women. J. Randall Rauh is an obstetrician and gynecologist in private practice in Miles City, Montana. Dr. Rauh is a Fellow of the American College of Obstetricians and Gynecologists, Fellow of the American College of Surgeons, and a member of the American Fertility Society.
Bernard F. Matt is an associate professor at Mary College, Division of Theology and Philosophy, in Bismarck, North Dakota.
What are your reactions to the articles in this issue of JOCNN? Express those thoughts and feelings. Write a letter t o the editor.
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PRINCIPLES AND ETHICS
Background When a pregnant woman’s decisions about her medical treatment or her behavior appear to endanger the health of her unborn child, who then has the authority to make a treatment decision-the woman, the physician, o r the courts? With the advent of sophisticated technology, more information about fetal intrauterine life has become available. New treatment modalities facilitate medical interventions, both prenatally (in utero) and neonatally (in high-risk nurseries). However, biotechnology has imposed some unforseen societal ethical problems.
Accepted: October 1988
May/June 1989 JOCNN
Biotechnology, however, is not the sole contributor to ethical problems. Other influences that affect these ethical issues include, advocates of women’s health and advocates of children’s rights, who tend to view any interference with a mother’s treatment decision as inappropriate and dangerous. This interference is interpreted as tampering with an individual’s right to make choices regarding her body. On the other hand, advocates of children’s rights tend to condemn mothers quickly and favor increased state power over the pregnant woman to protect fetal rights. The legal rights of the biological father are even more nebulous, and both groups a r e reluctant to address the father’s Ethical conflicts a r e complicated further by the involvement of the legal system (the state). For
instance, consider the case of Pamela Rae Stewart who, in 1986, was arrested on criminal charges of failure to provide medical treatment to her unborn son. The child was born with severe brain damage.and later died as a result of complications. Since then, many ethical and legal debates have occurred on the subject of the pregnant woman’s duty to her unborn child. Thus, with advanced biotechnology, a potential battle has been staged between a pregnant woman and her fetus. Because of the complexities of human systems, one can safely predict that the debate of mother versus her fetus will ~ o n t i n u e . ~ - ~ To make meaningful contributions to ethical discussions, nurses must become knowledgeable in the fundamental terminologies, concepts, and principles of ethics.*-I2 207
IAdvocates of women’s
I I
health tend to view any interference with a mother’s treatment decision as inappropriate.
OBSTETRICAL CASE STUDY A.O. is a 23-year-old female admitted to the emergency room with vaginal bleeding. The patient states that she is 22 weeks pregnant but has put off visiting her obstetrician because of financial hardship. Her social history reveals that her husband is employed as a farm laborer and that the patient is a homemaker. The couple volunteered that they “both were born and raised Catholic in this small midwest town.” A.O.’s obstetric history revealed she had six previous pregnancies, four of which ended in spontaneous abortions and two that resulted in live births. Of the two live births, one resulted in premature delivery of a son at 28 gestational weeks. Because of sequelae related to his premature birth, Jimmy (3 years old) was neurologically impaired and prone to pulmonary problems. Thus, the couple has incurred additional expenses of medication, physician visits, rehabilitation therapy, and special education. The couple has full responsibility for Jimmy’s care and are quick to point out that their son has brought many insights to them. Another pregnancy resulted in a term delivery of another son Steven, who at 8 months of age is developing at a normal rate. The obstetrician completed the physical examination and confirmed the diagnosis of an incompetent cervix, with delivery of a preterm fetus highly probable. The obstetrician then advised the courses of treatment available for
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the duration of A.O.’s pregnancy: continue with her usual activities and let nature take its course; bedrest restriction, which probably is not realistic because she has two small children, so hospitalization may be necessary; or perform a cerclage with the intent of increasing her chance for a term delivery. The couple understood the situation and consented in writing to the cerclage. The procedure was performed without difficulty and A.O. returned home. However, two weeks later A.O. was admitted to the hospital with uterine contractions. The patient’s physician thought that labor was imminent and that for the fetus to have any chance of survival A.O. could no longer be treated at a small hospital. The physician explained that at 25 gestational weeks, a fetus would have a 10% chance of survival in a highly specialized neonatal care unit, such as the one at a facility 800 miles away, and that an associated risk of abnormalities would be present for such a child. Based on this information, t h e couple was presented with these options. 1) Remove the cerclage and “let nature take its course,” a decision that probably would result in delivery of an immature infant in this small rural hospital. However, an added complication was the absence of the only pediatrician on staff and the assumption of pediatric duties by a general practitioner. In this case study, the general practitioner had limited neonatal experience and, even with the use of all the available resources, the infant probably would die before being transferred to the tertiary center. 2) Transfer A.O. to the tertiary neonatal care center via chartered emergency air transportation. (The couple’s insurance did not reimburse the small hospital for emergency transport services.)
This second option was the physician’s recommendation. A dilemma resulted because the couple was adamant about having A.O.’s obstetrician deliver A.O. in the local hospital. The couple believed that they could not absorb the anticipated costs (financial and emotional) associated with another “defective baby.” Moreover, the obstetrician perceived the parents’ request to be tantamount to a (late) second trimester abortion because the inevitable consequence of removing the cerclage without the availability of high-risk neonatal services would result in the death of the fetus. The physician’s reluctance was reinforced by this situation occurring in a Catholic hospital and the conflicting and unresolved legal issues surrounding this
DEFINING ETHICAL PRINCIPLES
Different philosophical principles can be employed to approach this quandary. A s evidenced by the subsequent discussion, medical interventions for the case may be contradictory in nature, depending on the ethical principle used to approach the issue. Double Effect
The principle of double effect states that some actions have both good and evil consequences. Four conditions are subsumed by the principle: The immediate action performed must be good or indifferent; The unforeseen evil consequence must not be intended; The foreseen good consequence must not be an effect of the evil consequence; and The foreseen good consequence must be proportionate to the foreseen evil c o n ~ e q u e n c e . ~ ~ ’ ~
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A classic example of double effect is that of a pregnant woman who is diagnosed with uterine cancer. In this case, the immediate action (intent) is removal of the cancer to save the woman’s life, not to abort the fetus. The subsequent effects on the fetus are unintended consequences.
In this case study, the intended action was to remove the cerclage at the family’s request, not to deliver an immature fetus.
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In the case study, the intended action was to remove the cerclage at the pregnant family’s request. The intent was not the delivery of an immature fetus. Therefore, this principle requires that the physician ascertain whether or not the mother’s life is in imminent danger. When the answer is yes, the principle of double effect allows for the intended action (removal of suture). However, when the mother’s life is not in imminent danger, the physician cannot intervene until at such time as the mother’s life is at risk.
Consequentialism
Consequentialists take a n opposing view; their philosophical approach is to not consider the intended action by itself. Instead, the focus is on the consequences of an action. When the outcome (consequence) is good, the action is viewed as appropriate. Conversely, when an outcome is bad, the action is viewed as evil.”.’* Essentially, the ethical principles of double effect versus consequentialism establish the framework for discussion of this case. However, other dimensions are considered in the principles of utility and justice.
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In the case study, the mother’s physical health may not be overtly improved by the removal of the cerclage. Yet, how does one measure the financial distress, emotional pain, and psychological trauma to a family that has another mentally retarded child? Therefore, should one infer that the benefit of the procedure is the psychological health of the pregnant family, or should one infer that the procedure must have a physical therapeutic effect on the mother (family)? Whichever option is perceived as the benefit, the anticipated consequence is the delivery of an immature fetus. Autonomy
The principle of autonomy states that individuals act autonomously when they, and not others, make decisions that affect their lives. As a result, each individual acts on the basis of his/her decision. Autonomy directs that a patient’s values are of the highest priority and should guide a physician’s treatment regimen for that person. Inherent in the principle of autonomy is the concept of the right of competent adults to accept or refuse medical treatment on the basis of full information from the health-care provider, known as informed consent.6s’2To assure the autonomy of a mentally incompetent person, a responsible individual makes decisions for that individual before medical intervention can be initiated. With the principle of autonomy, a patient’s self-determination takes precedence over the values of medicine. In strict adherence to this principle, when a mentally competent pregnant woman requests a medical intervention or procedure, the physician is obligated to comply. On t h e other hand, the fetus could be viewed as the incompetent patient and the parents are viewed as the responsible individ-
In consequentialism the focus is on the consequences of an action. uals. In such an instance, the parents are making a quality of life decision for the fetus (due to the high risk of abnormality associated with immaturity at birth). Furthermore, should the parent decide to provide all of the medical treatment necessary, the physician is obligated to provide all of the “available treatment” within that health-care agency to the pregnant woman’s fetus before and after delivery. In the case study, this would have allowed for a general practitioner in the small rural hospital to care for the premature infant because the pediatrician was not available. Applying the principle of autonomy, the dilemma can be framed in many ways. For example, should the autonomy of the pregnant woman be interfered with for the benefit of the fetus? Furthermore, can society legally require a pregnant woman to undergo treatment against her will, when the same sacrifice is not required to save the life of a person in other situations?’ These questions are complicated by the scientific community continuing to learn more about intrauterine life, which has resulted in the fetus being viewed as a separate person before birth, both physiologically and legally. Thus, the problems generated by the principle of autonomy for the case study can be summarized as a threefold conflict between the physician and the patient’s right of autonomy; between the physician-patient right to privacy and the state’s interests (legal issues); and between the doctor-patient relationship and the responsibilities of the medical profession. The conflict over autonomy becomes more complex when multi209
ple individuals a r e involved; whose autonomy takes precedence? The case study illustrated that the autonomy of any number of individuals can be identified, including the direct identification of the fetus and the mentally competent mother and the indirect identification of t h e family (father/mother and two siblings). Indirect identification of the physician, hospital, state and society is possible. Furthermore, in reference to the present study, what impact did the initial informed consent by the mother to have the cerclage have on the autonomy of each of the individuals involved? For situations involving only one individual, the principle of autonomy may take precedence in the medical treatment regimen. However, in situations involving two o r more patients, as is t h e case with a pregnant woman, the principle of autonomy may not be appropriate. Therefore, considering the numerous individuals involved in the case, autonomy may not be practical because everyone’s autonomy cannot be fulfilled.
Beneficence The principle of beneficence refers to doing or promoting good. Beneficence implies that a physician knows what is in the best interest of the patient (paternalism). Thus, a medical treatment regimen can be implemented based on the physician’s expertise and values, regardless of a patient’s wishes. Paternalism has been used to justify limiting an individual’s liberty in instances in which a person’s actions produce serious harm or fail to produce an important benefit to that person. The question as to whether or not a patient should be told the truth about a poor medical prognosis often is paternalistic in nature. In this situation, others decide how
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much information is t o be divulged t o a sick individual, thereby, limiting that person’s freedom of choice. Logically, the principle of beneficence may be in direct conflict with the principle of auton~my.~J~J~
Applying the principles of autonomy can allow this dilemma to be solved in many ways. An inferred concept within beneficence is the principle of nonmaleficence, which is defined as the duty to avoid intending, causing, permitting, or imposing harm or risk of harm to any person (primum non noncere). However, in some cases pain and suffering conceivably may be more cruel than death.4-6 In the case study, one can argue that the emotional pain associated with having a child who is mentally retarded is a situation that may result in extreme pain to the family. Therefore, if a physician’s primary purpose is to do no harm and to relieve pain and suffering, beneficence would allow a local delivery because this option has the potential of reducing a family’s emotional pain. The intent of the medical intervention in the case study was not abortion, yet the limited perinatal high-risk resources promoted an unfavorable fetal outcome. Beneficence supports the notion that, a t times, abortion may be in the mother’s best interest, which also may be true for the family in this case. Conversely, if the principle of beneficence is focused on the fetus, additional high-risk neonatal medical interventions must be made available. Extraordinary measures a r e required for t h e high-risk newborn; despite that in
the case of A.O., such measures would be available only at a distant medical center and would result in excessive costs to the family, third-party payers, and the local social service agency. Even considering poor fetal prognosis, applying the principle of beneficence in such situations would not be morally wrong. Utility
The principle of utility expands on the consequentialists’ perspective and supports the notion of the greatest good and greatest happiness for the greatest number. The principle of utility is pragmatic in nature, focusing on balancing the good that is possible to do with the harm that might result from doing or not doing a deed.4-6 Based on arguments regarding the principle of utility, ethicists have developed a hierarchical structure of happiness values. Among others, psychological happiness has the highest priority, followed by financial happiness.11”2These raise additional questions relative to the principle of utility. For example, does one consider short-term or long-term happiness? Who determines the greatest number(s) of benefits and costs and how are these effects measured? For example, if psychological happiness has priority over financial happiness, how are the costs and benefits compared for a family of five versus society? When numbers are of paramount consideration, as in this case, obviously the family loses, and society is the only issue. On the one hand, the short-term psychological effects on the family and the fetus seem obvious, but on the other hand, the long-term effects are uncertain for the family o r society in general. Furthermore, one can assume that both long- and short-term costs (psychological and financial) will
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occur if the neonate is abnormal. Conversely, should the infant be normal, how does one determine the contributions this person will make over a lifetime to the family and to society? Hence, a qualityof-life question becomes involved in the decision-making process. Applying the principle of utility to the physician in the case study might indicate that short-term happiness may result from personal satisfaction due to the physician's contributing to a family's happiness or sanity. On the other hand, a short-term cost might be a guilty conscience, increased stress, and personal grief resulting from the selected treatment regimen. An unpredictable long-term cost might be a legal conviction with loss of employment caused by revocation of licensure. Therefore, the principle of utility, applied in the case study, can support the decision to have either a local delivery or to transfer the mother to a tertiary center. The ethical complications vary, depending on who is identified a s the patient (i.e., the mother or the fetus). Justice
The principle of justice implies that equals should be treated equally and those who are unequal should be treated differently according to their differences. Equal treatment is not necessarily identical. Equality means making the same relative contribution to the goodness of individuals' lives, such as having equal opportunity to achieve a virtue or benefit. This may be viewed as an outcome by consequentialists.6J'Jz Justice further infers that medical resources be fairly allocated. Therefore, the principle of distributive justice applies to both scarcity of resources and competition for the benefits. Just distribution can be according to equal shares,
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individual need, individual effort or merit, or societal contribution. Contemporary philosophers are considering another aspect of the allocation of resources, that of the principle of preferential treatment, or the investigation of who is most prone to unjust treatment. Preferential treatment promotes the value that the least advantaged get the most resources from society."
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Nurses have important roles in formal ethics committees as potential members and as contributors to the formal data base.
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Considering the case study, the primary question in applying the principle of justice is to identify who is most disadvantaged and/or at the highest risk. One can accept the stance that this may be the pregnant woman, the family, o r the fetus. The pregnant woman might be considered the most disadvantaged when one considers her role as the primary caretaker of three preschool children, two of whom may be abnormal. When the family is defined as the most disadvantaged, the focus could be on psychological pain and financial distress which often result in additional social problems for society and the family. Some may view the fetus as being the most disadvantaged-a notion that seems to be supported by some current legal cases that assign a fetus legal rights. In a more global perspective, society could be identified as the most disadvantaged, considering the current global economic crises and the high rate of poverty.'* Accordingly, t h e principle of utility and preferential treatment
often has been summarized as a Christian utopian ideal; however, is this ideal impractical and unrealistic to achieve? For the case, the decision maker would need to identify clearly the patient. Consequently, this principle probably would be impossible to implement in this instance. IMPLICATIONS FOR NURSING
Recent medical research has resulted in concerns about the lifestyle of a pregnant woman and the safety of her fetus. Consequently, health professionals may find themselves as middle-persons because they recognize the unique relationship between mother and fetus. Health professionals also feel distinct discomfort in attempting to balance the needs of the two when providing medical interventions. Thus, numerous questions arise, and before deciding on an intervention, one must consider the legal and ethical dimensions. One consideration is identification of the patient, i.e., the mother, father, entire family, or fetus. Also to be considered are how abortion is defined, and by whom-the mother, family, physician, or the state-and whose definition carries the greatest weight? Another question is what weight is carried by the decision of the marital bond between the mother and father in the treatment selection of the pregnant woman? Finally, one must question how society ascertains the short- and long-term effects of the selected option on the mother, family, physician, community, and on society a s a whole?3 The conflict in this instance supports the need for interdisciplinary discussion to address multifaceted ethical quandaries. As part of a health team, nurses play a significant role in the ethical decision-making process.
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Nurses often are the first to become aware of an impending conflict because they provide direct patient care. A patient is part of a family system and nurses, because of their roles, encounter family members on a more regular basis than do other health-care professionals. Nurses also are instrumental in obtaining the informed consent signatures for the selected biomedical options, so nurses may be involved in patient teaching and counseling. As a result, nurses are in positions to observe the responses of families, and these observations may include early indications of an impending c o n f l i ~ t . ~ . ~ Nurses also must participate in and implement the decisions of others. For example, after the client and physician have selected an option, the nurse may be responsible for implementing the selected medical alternative. In some instances, these interventions may be in conflict with a nurse’s personal value system. Nurses must, therefore, separate personal from professional values. Whatever a nurse’s values, the nurse often is involved in an advocacy role to one or more of those individuals involved in the decision making.6s7 As one considers these complex dimensions, evidence mounts that one individual is not in a position to ascertain the full implications of an ethical issue. This is one rationale for the necessity of interdisciplinary bioethics committees. Nurses also have important roles on formal ethics committees, as
potential members and as contributors to the formal data base required by the group to make sound ethical decisions. In summary, a number of guiding principles delineate an ethical situation. In this manuscript, several are described in detail and applied to an obstetrical situation. By becoming familiar with the basic principles of ethics, nurses will .have a greater awareness of ethical principles and thereby provide greater substance to interdisciplinary biomedical ethics discussions. REFERENCES 1. Lagerlof, J. 1988. Maternal fetal conflict. California Nursing Review. (Jan.-Feb):34-36. 2. Guido, G. 1988. Legal issues in nursing: Source book for practice. Norwalk, Connecticut: Appleton & Lange. 3. Dan, J., and J. Peterman. 1985. Abortion and women’s health: Responsibility of nurses. In Current Issues in Nursing, eds. J. Mclosky and H. Grace, 1071-81. Boston: Blackwell Scientific Publications. 4. Comi, J., J. Mclosky, and H. Grace. 1985. Nursing’s ethical dilemma. In Current Issues in Nursing, eds. J. Mclosky and H. Grace, 1005-7. Boston: Blackwell Scientific Publications. 5. Gaffney, J. 1979.Newness oflife.St. Louis: Paulist Press. 6. Mclosky, J., and H. Grace, eds. 1985. Current Issues in Nursing. Boston: Blackwell Scientific Publications. 7. Cushing, M. 1985. Euthanasia: A legal perspective. In Current Issues in Nursing, eds. J. Mclosky, and H. Grace. 1044-71.Boston: Blackwell Scientific Publications.
8. Aroskar, M. 1984. Considerations in establishing an ethics committee. AORN J. 40:88-92. 9. May, W. 1975. The composition and function of ethics committee. J Med Ethics. 1:23-29. 10. Thomasma, D. 1985. Hospital ethics committee and hospital policy. QRB. 11:204-9. 11. Gannon, T., ed. 1987. Catholic Challenge to the American Economy: Reflections on the US. Bishops’ Pastoral Letter on Catholic Social Teachings in the US.Economy. New York: McMillan and Sons. 12. Ashley, B., and K. Rourke. 1982. Health care ethics: A theological analysis, 218-327. St. Louis: The Catholic Association of the United States. 13. Rauh, J. 1988.Big time ethical decision-making in small health care facilities. Conference on Rural Health-N.D. presentation. 14. Freel, M. 1985. Truth telling. In Current Issues in Nursing, eds., J. Mclosky, and H. Grace, 1008-24. Boston: Blackwell Scientific Publications.
Address for correspondence: Dr. Angeline Bushy, 1914 North 2d Street, Bismarck, ND 58501.
Angeline Bushy is associate professor at Medcenter One, in Bismarck, North Dakota. Dr. Bushy is a member of NAACOG, the American Nurses’ Association, and the International Congress of Women. J. Randall Rauh is an obstetrician and gynecologist in private practice in Miles City, Montana. Dr. Rauh is a Fellow of the American College of Obstetricians and Gynecologists, Fellow of the American College of Surgeons, and a member of the American Fertility Society.
Bernard F. Matt is an associate professor at Mary College, Division of Theology and Philosophy, in Bismarck, North Dakota.
What are your reactions to the articles in this issue of JOCNN? Express those thoughts and feelings. Write a letter t o the editor.
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