Ethics in reproductive health care: a midwifery perspective

ETHICS IN REPRODUCTIVE HEALTH CARE: A MIDWIFERY PERSPECTIVE Elizabeth S. Sharp, CNM, DrPH, FACNM, FAAN ABSTRACT Knowledge and technologic advancements have created a myriad of new screening, diagnostic, and treatment options for women of reproductive age. These new options often raise ethical issues as the women, their health care professionals, and society adapt to the benefits while coping with the pressures and burdens these options create. Threats to accomplishing the good that midwifery strives to contribute to health care for the benefit of women are identified from the perspective of the midwife’s instrumental and expressive roles. Suggestions are presented for resolving ethical dilemmas that may occur in the selection and implementation of health care options. A distinction is made between midwifery practice at the microlevel, which achieves the good through direct interaction with the woman, and the institutional macrolevel that promotes accomplishing the good in reproductive health care through policy development and management decisions. q 1998 by the American College of Nurse-Midwives.

The concept of reproductive health care has vastly changed from the 1920s when nurse-midwifery was first established in this country. At that time, the concept of reproductive health care focused primarily on the care of women and their infants throughout the maternity cycle. By the 1970s, high-risk obstetrics and preconception care, family planning and abortion services, infertility treatment, and genetics were emerging as subspecialties within obstetrics and gynecology. This resulted in expanded nurse-midwifery functions and influenced the ways in which nurse-midwives interface with both the medical and nursing professions. Although midwifery* has retained its distinctive focus on the care of childbearing women and their newborns, certified nurse-midwives (CNMs) and certified midwives (CMs)* work today in complex health care systems in which their practices may transcend the reproductive years of women. Along with many other health care providers, CNMs and CMs must take into account the numerous options for care that their patients have been

Address correspondence to Elizabeth S. Sharp, CNM, DrPH, 4825 Lake Forrest Drive NE, Atlanta, GA 30342.

FACNM,

FAAN,

*CNMs/CMs and midwives as used herein refer to those midwifery practitioners who are certified by the American College of NurseMidwives (ACNM) or the ACNM Certification Council, Inc.; midwifery refers to the profession as practiced in accordance with the standards promulgated by the ACNM.

Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998 q 1998 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.

afforded by expanding knowledge and technologic advancements. In doing so, they find themselves engaged in decision making that has become more complex than in the past. As Jonsen (1) observed, “modern medicine must find the proper apportionment of rights among its own practitioners, its patients, and those who pay for their services, the government and the citizenry.” It is within this context that the field of bioethics has emerged. The vastness of reproductive health care raises a myriad of ethical issues that demand attention in detail from a multidisciplinary approach. This article, however, focuses on reproductive health care solely from a midwifery perspective. The reader is oriented first to the good that the midwifery profession claims to contribute to health care. Then, the impact of new knowledge and technology on the lives of women, society, and the midwifery profession is discussed in relation to reproductive health care. Finally, suggestions for resolving ethical dilemmas will be presented at two levels: the microlevel in the provision of direct patient care and the macrolevel in the promotion of policies that protect the interests of women and their newborns. Approaches for the resolution of ethical dilemmas in practice that are consonant with the promotion of the good practiced by midwives will be considered in two parts: 1) ethical issues related to the selection of health care options that are offered to patients and 2) the resolution of ethical dilemmas as illustrated through clinical examples. In keeping with the primary emphasis of midwives, most illustrations will be related to maternity care. DEFINITION OF THE GOOD

H. R. Niebuhr (2) describes humans as moral agents who have the choice to form images or visions of the good toward which they direct their actions; specifically within their professional role, the good is defined mutually by the professional reference group. In the United States, a professional group defines its practice based on the needs of society and informs the public of that practice for which it will be responsible. Likewise, one choosing to enter the profession should be held accountable for knowing the obligations that will be assumed in the chosen profession (3). Health care professions have not evolved completely

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distinct from one another; in the case of medicine and nursing, some overlap clearly exists. Medicine has been predominantly concerned with the instrumental role of cure: diagnosis and treatment. Nursing, on the other hand, has been traditionally concerned with the expressive role of caring that includes helping, comforting, and guiding (4). The overlap of the instrumental role has become more extensive in recent years as the roles of the nursemidwife and nurse practitioner have incorporated more instrumental functions of medicine into their practices. This overlap has become especially apparent in reproductive health care as nursing has expanded nurse practitioner specialties and medicine has established the role of the physician assistant. Except for management of care during the intrapartal period, nurse-midwifery practice overlaps with the functions of nurse practitioners and physician assistants employed in some reproductive health care settings. The expressive role in midwifery in the United States had its roots in professional nursing. In the early 1960s, Ernestine Wiedenbach, a nurse-midwife, described the nursing component of nurse-midwifery as “to facilitate the efforts of the expectant mother (and father) to utilize measures prescribed or designed for attainment and maintenance of her own and her unborn baby’s health throughout the childbearing cycle” (5). Wiedenbach also was influential in the writing of the first ACNM philosophy in which respect for each person encompassed dignity, worth, autonomy, and individuality (6). These beliefs continue to guide midwifery practice as reflected in current ACNM documents (7–10). In the complex health care system today, however, achieving respect for autonomy with competing principles is more difficult because of the increasing number of options for screening, diagnosis, and treatment. THE GOOD AS PROFESSED BY MIDWIFERY

It is customary for each profession to define its own contribution of the good. The good in reproductive health care depends on the blend of each discipline contributing to the collective good. The ACNM’s official documents clearly communicate the notions of the good encompassed in midwifery

Elizabeth S. Sharp is a BSN graduate of the University of Michigan and the Yale University School of Nursing, Maternal and Newborn Nursing Program. She earned her doctorate in Public Health at the School of Hygiene and Public Health, The Johns Hopkins University. Dr. Sharp is an associate professor in the Department of Gynecology and Obstetrics, School of Medicine; professor in the Nell Hodgson Woodruff School of Nursing; and adjunct professor in the School of Public Health, Emory University, Atlanta, Georgia.

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(7–10) as does the Code of Ethics of the International Confederation of Midwives (11). Midwives believe that reproduction represents normal and developmental processes (menstruation, pregnancy, birth, and menopause) that are to be protected and enhanced, with intervention applied for specific indications only. They also believe in safe and comprehensive care achieved through independent midwifery management or through medical consultation, collaborative management, or referral. The blend of the instrumental and expressive roles for the care of childbearing women and their newborns who are essentially healthy constitutes the distinctiveness of midwifery. Recently, the instrumental role of nursemidwifery in the United States has been expanded formally into primary care to reflect the reconfiguration of health care services within managed care systems. The expressive role embraces all aspects of midwifery care that assist women to engage in the actions that are necessary for promotion of their health and that of their newborns within the context of their defined family and interpersonal relationships. The expressive role incorporates education, support, problem-solving, and advocacy in a manner that promotes the woman as a partner in her care and respects her beliefs, values, capabilities, and resources. Both the instrumental and expressive roles are enhanced through the promotion of continuity of care and the therapeutic value of human presence (10). THE IMPACT OF NEW KNOWLEDGE AND TECHNOLOGY

With the increasing complexity of reproductive health care that has resulted from the proliferation of new knowledge and technology, midwifery practice has, likewise, become more complex; indeed, it is increasingly difficult to accomplish the good as defined by the profession. New care options have created perplexing choices that often raise ethical issues for women and their families, the health care professions, and other groups in society. Implications for Women and Their Families New Care Options. Electronic fetal monitoring and ultrasonography, biochemical and hormonal assays, and advances in surgical techniques, especially laparoscopy, hysteroscopy, and microsurgical techniques, have all made obstetric care more complex, have increased contraceptive options, and have advanced the treatment for infertility. Moreover, computer technology has promoted the statistical manipulation of large data sets leading to the identification of risk factors for health problems across the reproductive cycle. In turn, the attention given to screening for and eradicating identified links to poor outcomes in reproductive health has inJournal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

creased the work of health care systems and required more of women and families. New Categories of Patients. Newly acquired knowledge and advanced technology have created new patients. The fetus has become a treatable patient in its own right through electronic fetal monitoring, ultrasonography, and in utero procedures (12). Future populations become “patients” as the beneficiaries of genetic testing and engineering (13). In addition, men are becoming reproductive health care patients as part of infertility, genetic, and sexually transmitted disease (STD) assessments and treatments that bring couples to reproductive health care. Interrelatedness of Women’s Choices. Advances in the last half of the 20th century have remarkably expanded the choices for women and their partners. The reproductive component of one’s life is built on a series of choices, one choice leading to another choice. Decisions—to become sexually active, to use contraception, to become pregnant, to have an abortion, or to maintain a pregnancy—all carry with them consequences, some of which can be unhealthy and undesirable. Although these significant life choices are the woman’s to make, they also are influenced by others within the societal context; choices made in one phase of the reproductive cycle affect the choices that are to be made in another phase. For example, the choice made by a woman to delay pregnancy may affect her fertility at a later time, whereas unprotected sexual intercourse without knowing the partner’s sexual history may result in STDs that could impair future fertility and place the woman at risk for cervical cancer. Expectations of Society. Computerized data that reveal how well the country is attaining health goals in relation to such population characteristics as age, ethnicity, geographic location, and health services are being cited by the media to focus national attention on the progress of reproductive health in comparison to goals set forth by the government (14) and health care systems. Such scrutiny pressures health care professionals, including midwives, to achieve good outcomes; legislators and administrators, in turn, have a vested interest in promoting healthy choices for women, although some of the newly emphasized risk factors such as smoking, alcohol and other substance abuse, unsafe sex, and domestic violence represent behaviors that are difficult for women to overcome on their own and require the support of health and social resources. Increased societal demands for optimal reproductive outcomes have resulted in more accessible, but costlier, technologic interventions, especially in the care of obstetric patients with complications, newborns at high Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

risk, and couples with fertility problems. In contrast, two other components of reproductive health care, planning of pregnancies and the prevention of STDs, recently have become the subject of national study and the impetus to the promulgation of recommendations that take into account the economic burden of unintended pregnancies (15) and STDs (16). Paradoxically, prenatal care has been proclaimed as a cost-benefit program from a preventive perspective (17). Therefore, economic considerations are attracting increased attention for health promotion and disease prevention along with the continued push for improved outcomes. Moral Pluralism. With new options in medicine, reproductive health processes can be controlled, altered, and manipulated far beyond the imagination of previous eras. Of significance is that these advances are related to birth, pregnancy, STDs, and sexual practices about which people establish personal beliefs and values that form their moral orientation, often in conflict with the beliefs and values of others. The diversity of value systems related to reproductive health contributes to the moral pluralism that exists in society today. In addition, health care professionals have their own personal beliefs and values related to reproductive practices and health care. As health care has become more specialized with generalists and specialists in each of the health professions, patients may be exposed to numerous health care providers who have beliefs and values different from each other. This is especially true for women as they move back and forth from fertility control services to care during the maternity cycle, from low- to high-risk obstetrics, and from well-women gynecology health services to care for pathologic conditions. Implications for Midwifery As diverse beliefs and values are coupled with increased options for the care of patients, the ethical domain of health care becomes more obvious and important to take into account in the care of a given patient. In applying professional ethical codes, philosophy, and standards, the midwife often finds it necessary to balance respect for the autonomy of the woman with the implementation of proven health care options that can make a positive difference to the woman and her fetus or infant and cause no harm to others in society. The judicious use of evidence-based medicine by midwives will promote care options that have been scientifically proven to be beneficial (18). There are unique circumstances in midwifery that have threatened the accomplishment of the good by the profession. Observable differences in practice between physicians and nurse-midwives surfaced in the 1950s as nurse-midwifery services moved from home and birth

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center sites to hospital settings and the two groups began to work in close proximity. At that time, there was considerable pressure for nurse-midwives to adapt to patterns of prevailing obstetrical practice to gain acceptance (19). The pressure to conform was heightened as parturients began to be viewed as high risk, until proven otherwise (20). In the technologic era of obstetrics, it has been difficult for nurse-midwives to promote normal processes of reproduction, especially labor, when intravenous therapy, continuous electronic fetal monitoring, episiotomy, and, in some settings, epidural anesthesia, are accepted as almost routine practice (21). Another threat to midwifery has been the emerging practice of employing midwives as physician substitutes, thereby compromising the expressive functions intrinsic to midwifery care. For example, the support of women during labor and the provision of patient education may have to be relinquished within the time constraints imposed by managed care. Furthermore, the midwife may rush to accomplish the traditional medical components of care and curtail or leave some aspects of midwifery care to be completed by other health care providers. As care is transferred from one care provider to another, essential components may be lost or left undone. This erosion of traditional midwifery comes at a critical time when there are more issues to address in providing reproductive health care for women than in the past. Prevention, screening, and treatment of health problems are time consuming and make education, support, and problem-solving that patients require in a sustained, trusting relationship difficult to achieve in today’s changing health care environment. In essence, midwifery practice that has evolved in the United States, with its dual emphasis on both the instrumental and expressive roles, is now in jeopardy. Diminishing functions of the expressive role would redefine midwifery as a departure from the good already specified in the professional documents and applied by many nurse-midwives over the years.

RESOLVING ETHICAL DILEMMAS IN REPRODUCTIVE HEALTH CARE

Bioethics: An Emerging Discipline Diverse expectations of care, moral pluralism, and the influence of managed care have clearly directed the nation’s attention to the ethical components of health care delivery, especially in light of the increased screening, diagnostic, and treatment options available today. A new discipline, bioethics, focuses on ethics in health care (22) and has applied classical ethical theories and accompanying principles and rules or action guides to health

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care. Specifically, the principles of respect for autonomy, nonmaleficence, beneficence, and justice have been applied to ethical deliberations related to health care issues. As the field of bioethics has matured, other theories have emerged, such as relationship-based ethics of care and case-based casuistry. However, the interest in principle-based ethics has persisted, albeit not without challenge (23), so that ethical discourse is patterned along the principle-based approach frequently, or at least includes some attention to principles. For a more detailed discussion of ethical theories and principles, the reader is referred to Beauchamp and Childress (24). This article focuses on the prevailing approach of principlebased ethics. In contemporary society, where preeminence has traditionally been placed on the individual, respect for autonomy and beneficence have taken on great importance; this is reflected in ACNM documents. Nonmaleficence, the principle of not causing harm, however, can take on new meaning as technologic advances impose stress on women to comply with health choices that are believed to be of benefit to them and their developing babies but are incompatible with their strongly held philosophies of nonintervention. As cost and distribution of health care have become important issues, justice, the ethical principle that pertains to members of society being treated fairly and impartially, is moving toward achieving parity with the other major principles. The interest in justice in health care today is based on the issue of who in society bears the high costs of health care. This justice issue is not often discussed forthrightly in patient care decisions, possibly because justice related to the cost of health care has not yet been clarified as it relates to societal values. Although the adaptations of classical approaches, as well as new theoretical approaches in bioethics that go beyond principle-based ethics, guide the ethical application of new scientific knowledge and technology, ethical discourse at times is frustrating and indeterminate. Nevertheless, when science and research do not definitively answer questions related to the application of new knowledge and technology, bioethics can serve as a means for seeking answers. Levels of Ethical Engagement in the Health Care System The expression and resolution of ethical issues, concerns, and dilemmas occur at two interrelated levels: the macrolevel and the microlevel. At the macrolevel, policy decisions are made that frequently affect the allocation of funds and lead to the promulgation of policies and regulations that are applied at different levels within the health care systems. These may be intrainstitutional in Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

nature or influenced by extrainstitutional policies and decisions made by governmental agencies, voluntary and professional organizations, and/or managed care organizations. Midwives often function under policies of more than one system or service when their ambulatory and inpatient services are provided at different facilities. While policies at the intrainstitutional level are subject to extrainstitutional macrolevel decisions, the service institutions also create their own mission, policies and procedures, and codes of ethical conduct. In addition, the midwifery service itself establishes policies specific to midwifery practice, with careful attention to consistency among institutional mission and policies and the good described in ACNM documents. Therefore, the interactions between the patient and health care professionals are influenced by administrative policies from several sources that may become the focus of ethical issues and deliberations for either a particular patient or for many patients. The microlevel represents the care provided for one individual as the midwife and patient focus together on decision-making and implementation regarding components of care; the midwife also may work directly with the woman’s partner and/or her family. At this level, the woman’s preferences, relevant circumstances, and the concerns and obstacles related to implementing various health promoting options and behaviors are considered. In the application of the “midwifery management process” (10), ethical concerns and conflicts are identified and incorporated into the deliberations over a woman’s choices for promoting her health and that of her developing baby. At times, the midwife may have direct interactions with other health care professionals and staff in relation to aspects of care that engender ethical issues. Unresolved differences and interprofessional conflicts, often with ethical overtones, may negatively affect direct patient care. For example, the physician consultant, supported by the hospital attorney, may believe strongly that the woman must have antepartum testing at 42 weeks and be notified by mail of the dangers to herself and her baby if she does not comply. In contrast, the midwife may object to sending such a letter and prefer to work with the woman in a more personalized, less threatening approach while still addressing the problem and maintaining safety for the mother and fetus. Institutional practices, whether based on specific policies or not, also shape the options of care that are available and can determine the nature of the woman’s experiences as she negotiates the health care system. When institutional policies and practices impede care consistent with the good of professional practice, midwives often adapt care to offset negative institutional effects; for example, they may circumvent long waits by performing the care themselves or extend ambulatory Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

visits during their own lunch time to allow more time for each patient. Ultimately, such temporary fixes at the microlevel impinge on midwives’ overall ability to accomplish the good and, therefore, need to be explored and resolved at the macrolevel. As important as it is for midwives to pursue changes in policies and practices that impede patient care at the microlevel, effecting change is complex and difficult in the presence of diverse missions, beliefs, and value systems and can be rendered impossible by unequal power bases and politics among those involved (25–27).

Uniqueness of the Patient in Relation to Reproductive Health Care Women of reproductive age often are placed in stressful and burdensome positions of responsibility that other women and men do not experience. First, they are viewed as being in a current or potential fiduciary role in relation to the fetus and are expected to act in its best interest (28). Second, they incur significant burdens as they proceed to carry out numerous and often complicated preventive and curative health care recommendations, some of which are incompatible with their beliefs, circumstances, and resources. Nevertheless, they share with health care professionals the pressure to achieve good reproductive outcomes. While women have much to consider in the role of promoting their own health and that of their potential newborn, there is usually little relief from other social role responsibilities. Parsons (29) introduced the notion of the sick role whereby patients are relieved of their social roles while they are obliged to fulfill the role of patient. Generally, women are not sick during their reproductive years; however, they are expected to alter their lives, often at great effort and cost, to achieve healthy reproductive outcomes. Furthermore, many women are in nonsupportive environments and lack the resources to follow through on health recommendations. It is within this framework that midwives are challenged in their instrumental role to ensure that health care options are designed in the least complicated way. In addition, they are challenged in their expressive role to assist women in carrying out options that have been selected. Ethical sensitivity and responsiveness to women in their efforts toward good health during their reproductive years is highly complex and oriented to the uniqueness of the particular woman. In the sections that follow, the complex processes of care that take into account some of the recurring ethical dimensions of midwifery care are presented.

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Decision-Making Regarding Options of Care Thoughtful deliberation precedes the presentation of ethical health care options to an individual. Consistent with the professional notions of the good, each instrumental or expressive function must be considered for efficacy, safety, cost containment, and some estimation of how an option will be perceived by the patient. If more than one option exists for the same condition or response, fair representation of all options is crucial to maximize patient choice. Although there are examples related to decisionmaking regarding any number of health care options, the selection of screening tests has been chosen for discussion. In more general terms, the renewed emphasis on promotion of normal reproductive processes and the need for midwives to have input into administrative decisions will be considered because of their timeliness in today’s health care climate. Selection of Screening Tests. The plethora of screening tests presents ethical concerns for midwives as they decide which tests to offer to their particular patient population. Screening for the presence of preventable or treatable diseases has expanded to include many more tests to identify STDs, genetic aberrations, medical conditions, and, more recently, risk factors such as smoking, substance abuse, and domestic violence. The controversy surrounding the testing for the human immunodeficiency virus (HIV) serves as a timely example of ethical decision making related to screening tests that necessarily balances the respect for autonomy of individuals while taking into account the beneficence and justice issues of screening programs. In addressing the complex issues of maternal and newborn screening for HIV, Faden, Kass, and Powers (30) emphasize that fulfilling the public health criteria for a screening program is essential and basic to the deliberations of ethical and legal conflicts. Specifically, the sensitivity and specificity of the screening test must be acceptable to justify its use. Also, well-grounded information about the morbidity and mortality consequences of the disease must clearly show them to be sufficiently consequential to warrant screening. Then, if the screening results are positive, there must be the capability of preventing exposure and transmission of the disease and/or successful treatment. Ultimately, the information needs to address satisfactorily whether the cost of both screening and treatment programs is bearable by society. The implementation of screening programs may create legal and ethical conflicts. In 1991, at the time of their comprehensive review of HIV screening, Faden, Geller, Powers, et al (31) did not support mandatory screening for HIV for pregnant women. However, with the development of a new therapy, zidovudine, that can

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be given to HIV-infected pregnant women to prevent vertical transmission of HIV to the fetus (32), reassessment of screening policies for HIV during pregnancy is now taking place. The dynamics of the ethical issues are clearly shifting from primacy of respect for autonomy of pregnant women who are concerned about being tested to the potential beneficence of treatment favorable for the newborn based on knowing the HIV status of the mother. As reproductive health continues to identify linkages between such other factors as infections and genetic conditions for which screening could be applied, it is inevitable that midwives will need to make decisions related to public health criteria and the ethical issues that could emerge simultaneously within their own patient populations. Devaluation of Normal Processes. In the wake of recent medical advances, there has been increasing devaluation of normal reproductive processes and the expressive functions of midwifery that promote them. In addition to potentially deleterious side effects and the increased cost of medical interventions, advanced technology may be jeopardizing the woman’s active participation in her own care. This is of concern especially during childbirth; for example, dependence on epidural anesthesia or diminished labor support from the midwife in busier practices may deprive the woman of the source of accomplishment and empowerment achievable in childbirth. Ambulatory reproductive health care also may be jeopardized by time constraints that preclude health promotion, preparation for birth, and attention to the woman’s concerns beyond the immediate problem for which she sought care. If those aspects of midwifery practice that value and promote normal reproductive processes are to be preserved, then advocacy at the macrolevel is needed for implementation at the microlevel. Input into Cost-Related Decisions. With the introduction of managed care, decisions regarding professional practice are increasingly taking into account reimbursement policies. This is understandable in light of the fact that when care options are selected by health care professionals or requested by the patient, often with very compelling rationale, unreimbursed costs may be incurred if the option is not approved for compensation. Chervenak and McCullough (33) recommend that physicians participate in deliberations related to payment for various options of care. Indeed, they have developed an algorithm for cesarean births that proposes conditions when cesarean sections would not be reimbursable, specifically when the operative delivery is not beneficence based but performed to uphold the patient’s request because of her fear of a vaginal birth. The inclusion of midwives in the same macrolevel deliberaJournal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

tions would ensure that the midwives’ experiences with women in labor might convey additional perspectives. Midwifery as an Option for Care. Recent changes in health care systems preclude some midwives from practicing midwifery in its entirety by integrating the instrumental and expressive roles. Just as midwives have been inculcated into a professional practice that is believed to promote the good for women, some women seek midwifery care because of what they expect from midwives. To do less than what the profession espouses and the patient expects when she entrusts herself to a health care professional for care might be conceived of as not fulfilling the virtue and principle of “fidelity to trust” as put forth by Pellegrino and Thomasma (34). As documented by Rooks (35), nurse-midwifery and midwifery have both a strong heritage and tradition in this country and abroad that serve well those who are designing health services for childbearing women. It is, thus, disconcerting that midwives in some settings are having to decide how much of a departure from the good is tolerable and how far afield midwifery can be practiced from the profession’s claims. For some, the answer will be to leave the field; others will continue to practice, learning to tolerate their discomfiture with the dissonance between what they wish to do in practice and what they actually do; still others will work for change at the macrolevel and try to ensure that the essentials of midwifery care are not compromised. The latter will be difficult unless interprofessional collaboration prevails within nonhierarchical relationships that strive toward promoting the overall good for women (26). Resolution of Ethical Dilemmas in Midwifery Practice Midwifery practice is directed toward the application of beneficial health care options and recommendations that take into consideration the woman’s preferences and the interest of others affected by her health care decisions. The primary person with input is the woman herself; however, partners, family members, others significant to the woman, and health care professionals may have reasons for input regarding care. Seeking Consent of the Woman. Health institutions obtain written authorization to provide health care in general or for invasive and risk-associated procedures. This practice leaves many health care decisions subject to interpersonal verbal and nonverbal communication. Although a woman needs to be informed about what is being planned or done on her behalf, many components of health care do not require detailed, intense deliberation to ensure that she is in agreement. For procedures that a woman experiences frequently, her expression of Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

“Yes, it is OK,” or an affirmative nod will suffice. However, nonverbal cues such as a frown, an unexpected silence, or downward glance may be clues that the woman or her partner may not agree; in such instances, further discussion is needed to obtain her consent or to redesign the plan of care. On occasion, only one option for care will be appropriate. When there are multiple options, however, each option should be objectively described in terms of its advantages and disadvantages and implications for the patient if carried out; only then can the options be weighed in a meaningful way to facilitate informed choices. McCullough and Chervenak (36) point out that discussions about possible health actions should begin long before the consent is needed so that any concerns and differences may be thoughtfully considered before the need for a decision arises. This process is termed by them as preventive ethics. Conflicts Between Respect for Autonomy and Beneficence. At times, a woman and midwife may not agree about a course of action. If the woman’s reasons are logical and consistent with her belief and value system, her self-determination should be supported even if the consequences are potentially harmful (37). It is interesting to note that recent court cases have upheld the right of adult Jehovah’s Witness patients to refuse blood even though the refusal may harm the woman or her fetus, whereas earlier cases safeguarded the fetus by overriding the pregnant woman’s preference to refuse blood (38). If, on the other hand, a woman does not convey logical reasons or firmly held beliefs and values to uphold her rejection of a potentially beneficial course of action for herself or for her fetus, there is a moral obligation for the midwife to initiate further deliberation to achieve what appears to be in the woman’s best interest (39,40). Because diagnostic and treatment options often require the involvement of other health care professionals, the midwife may serve as mediator and advocate for the woman and her partner during ensuing discussions with other members of the health team. The basis for a woman’s rejection of a health care recommendation should be explored in terms of its perceived benefits and burdens to her and others (39,40). On the one hand, the real or potential severity of the condition for which the diagnostic or treatment recommendation is made and the certainty of making the correct diagnosis and curing the condition by the treatment should be high, or at least high enough, to encourage the woman to follow the recommendation. Conversely, the risk that the woman or the fetus might incur if the recommendation were implemented, the conflict created between the woman’s reasonable and firm beliefs and values and the nature of the recommen-

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dation, and the degree of difficulty the woman might have in carrying out the recommendation should be weighed against the potential benefits. The midwife and other health care professionals involved might be more likely to encourage and seek acceptance of the recommendation if the variables related to burden were judged to be low. If the difficulty and burdens were considered high, however, knowing the array of variables and the meaning that each contributes to a woman’s situation help to focus the conversation on her reasons for rejecting a recommendation. Attempts can be made to reduce the degree of difficulty and burden that the recommendation means to the woman. A very familiar example to midwives involves the consequences for the woman and her family when there is a need for immediate hospitalization. When it is within the realm of safety, the recommendation can be modified for the woman to make a phone call or to return home briefly to make arrangements for her children so that she will be able to return to the hospital with diminished stress. When a solution cannot be worked out, and the midwife or physician still believes in the benefit of the recommendation for the patient, the next step is persuasion. It begins first by confirming the goals of the woman and the health care professionals. While it may be assumed that the woman is interested in her own well-being as well as that of her developing baby, that assumption needs to be confirmed; once confirmed, the goals of the woman and the midwife and physician, if involved, can be pursued in relation to the recommendation (41). Then, the variables related to benefits and burdens can be revisited in light of stated mutual goals. A nurse-midwife recently related an instance of persuasion involving a patient whose first birth had resulted in a primary cesarean section for a breech presentation and who presented in labor at the end of her second pregnancy with an intrauterine fetal death. The woman was quite insistent on having a repeat cesarean delivery because of her fear of pain during labor; however, both the physician and nurse-midwife believed that a spontaneous vaginal delivery would be in the best interest of the woman. Finally, the nurse-midwife drew on a longstanding relationship with the woman and an awareness that the woman was fearful of the pain during labor, and said, “Trust me, you will recover more quickly and be able to get on with your education; I will stay with you during labor and you will get pain relief.” The patient then agreed and, indeed, was grateful for the experience that she had initially rejected. Resources for Handling Ethical Dilemmas. If it is necessary to move beyond the persuasion stage, it is helpful for the health care team to systematically apply an ethical decision-making model that is familiar to the

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group (42,43). The processing of case data involves weighing and balancing the ethical principles and their derivative guides and rules that are operative in the case and provide the direction for decision making by the team. In addition, the application of ethical terminology and language tends to diffuse interpersonal conflict during case discussions. Without participants’ knowledge of ethical terminology and language, however, the discussions may fall short of the desired intent. If resolution does not occur at the team level, the next step would be to consult the institutional ethics committee (44 – 46). Many institutions now have ethics committees composed of representatives of different disciplines, including bioethics, medicine, nursing, midwifery, social work, clergy, law, and administration. After exploring the issues with the patient and others involved, the ethics committee will make a recommendation based on its deliberations during a systematic, formalized process that includes weighing and balancing the ethical principles involved in the particular consultation. Emergencies, especially those in obstetrics, allow little time for resolving ethical dilemmas and are dependent on the institutional policies that are in place (47). Ethics committees frequently have a system for handling such ethical crises. Seeking court action usually is not the most desirable approach; it is time consuming, adversarial in nature (48), and impractical in an emergency. Furthermore, legal action may set unintended precedents. Recently, accreditation criteria pertaining to organizational ethics have been mandated by the Joint Commission for Accreditation of Health Care Organizations (49). The ethical dimensions encountered in the work of institutions are varied and include organizational values and goals, relationships and responsibilities within the institution, and the relationship between the institution and community (50). Therefore, as health care systems in which midwives function develop their organizational ethics, the ability of the midwives to effect change at the macrolevel may be enhanced. Implementing the Plan of Care. In any phase of the reproductive cycle, numerous health recommendations may be made as part of the total plan of care; obviously, some are more important to follow and difficult to adhere to than others. The midwifery management process is clear that the midwife assumes “primary responsibility for the implementation of individualized plans” (10); this involves assisting the woman with what she is unable to do on her own or putting her in touch with resources that she cannot find on her own. Therein is the essence of the expressive role of midwifery (5). As nurse-midwifery practice moved in the 1950s from home and birth centers to hospitals, there were adaptations in the aspects of nurse-midwifery practice that Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

overlapped with functions of the nurse and physician. Attempts to delineate responsibilities sometimes involved turf-guarding and created ambivalence for nursemidwives as they negotiated how much of the expressive role they should retain, especially when other care providers, such as lactation consultants, nurses on the labor and delivery service, or counselors in family planning clinics, provided similar aspects of care. In recent years, many nurse-midwives have been assigned to function as physician-substitutes while some of the expressive functions of midwifery, such as teaching, supporting, and problem-solving, have been reassigned to other health care professionals or eliminated. Perhaps the answer to this ethical dilemma of potentially jeopardizing care lies in the answers to three questions. First, how many times should a woman have to repeat her story to different health care professionals in the depth that is required for the next health care professional to provide meaningful care? Second, how essential is a trusting relationship in order for a woman and her partner to feel comfortable in sharing sensitive, essential information about their reproductive concerns with a health care provider? Third, what is the impact on patient care of shortchanging expressive functions to conform to time constraints? The following illustration demonstrates the complexity of midwifery practice when attention is focused on the expressive role. A nurse-midwife recently worked with a young couple early in their first pregnancy. The young woman had a STD for which the partner also required treatment. Because the partner was not enrolled in the same health care plan as the patient, he did not have health care coverage within the same health care system. Several lengthy prenatal discussions helping the couple to realize the necessity of his treatment were followed by unsuccessful efforts to arrange transportation for them to the STD clinic. Finally, the nurse-midwife made other arrangements for obtaining a prescription for the partner. The relationship and trust established with the nurse-midwife seemed to make the difference in the couple confiding that they did not initially get the prescription for the woman or go to the clinic for treatment for the partner. Thus, the nurse-midwife fulfilled both instrumental and expressive midwifery roles that required a trusting relationship and time. Both of these parameters of care have been found to be important to women receiving midwifery care (51). Although it is well documented that nurse-midwives have achieved safe outcomes for mothers and newborns (52,53), there is a paucity of research specific to the expressive functions in relation to the instrumental role of midwifery practice. One might interpret midwives’ efforts to retain the expressive elements of their practice as turf-guarding. It is more likely, however, that they are convinced that it is in the intact practice of combining the Journal of Nurse-Midwifery • Vol. 43, No. 3, May/June 1998

instrumental and expressive roles that seems to make the difference to women. Thus, it is urgent that such research be conducted to lend support to midwifery practice remaining intact, or to document expressive functions of midwifery practice that can be shared without jeopardizing the overall good in patient care. Reaching Out: Potential Threat to Autonomy. In providing health care to women, the inevitable question arises: what is the responsibility of midwives for engaging and retaining women in reproductive health care? The following case (modified for anonymity) prompted controversy over the reexamination of the follow-up policy when patients do not keep scheduled appointments. A patient who was referred to the nurse-midwifery service following an initial prenatal visit did not keep the first appointment nor three appointments rescheduled by mail. The nurse-midwife assistant telephoned the patient’s aunt and learned about the problems the patient was having in caring for her children and her diabetic mother. The assistant left a message for the patient to contact or to come to the clinic but there was no response. After a public health nurse could not locate the patient, the assistant called the housing project director and asked that the patient be given a message to come to clinic. The patient responded to this message, returned to clinic, and asked for the assistant by name, saying, “I want to see the person who cared about my coming.” Some of the nurse-midwives were uncomfortable with this aggressive follow-up because both privacy and confidentiality, elements of respect for the patient’s autonomy, were violated. This experience raised the necessity of clarifying with patients during initial contact why telephone numbers of relatives and addresses were obtained and how they might be used in follow-up. Ideally, the responsibilities of the patient and midwifery staff also could be clarified and the conditions for follow-up discussed. This case also raised the issue of the locus of responsibility for the woman’s involvement in prenatal care. Some of the nurse-midwives believed that the patient should be responsible and that follow-up represented undesirable paternalism, albeit weak paternalism in comparison to strong paternalism (54), in that the patient’s wishes were unknown and unobtainable. Other nursemidwives in the group believed that, at times, weak paternalism could be beneficial to help with problems that are barriers to care. After grappling with the ethical issues of autonomy versus paternalism, it became apparent that the nurse-midwives needed group clarity and cohesiveness in establishing ethically based guidelines for patient follow-up at the midwifery service macrolevel in concert with the institutional macrolevel policies.

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CONCLUSION

7. American College of Nurse-Midwives. Philosophy of the American College of Nurse-Midwives. Washington (DC): ACNM, 1989.

The imperative for change in health care requires more than knowledge and technologic advances. Ethical deliberations related to their application are inescapable. The profession of midwifery is challenged to continually assess the relevance of its professed notion of the good to be accomplished for the benefit of women and their families in the context of societal requirements and expectations. In the existing health care climate, midwifery is being challenged to change in ways that sometimes seem detrimental to women. The proliferation of options and possibilities for health care, made available by progress in knowledge and technology, are often in conflict with the values and realities in the lives of women and their families and society at large. Therefore, women frequently need help in adapting to the new health care demands; the expressive role of midwifery addresses this need for help. Midwives will have to work at both the microlevel and macrolevel to benefit their patients through direct care and advocacy. The practice of midwifery requires time for the development of a relationship with the woman as well as time for working through the woman’s complex problems. The purposeful design of infrastructures to eliminate barriers to care and to promote respectful, supportive, and collaborative relationships among health care professionals contributes to the accomplishment of the good.

8. American College of Nurse-Midwives. Code of ethics for certified nurse-midwives. Washington (DC): ACNM, 1990. 9. American College of Nurse-Midwives. Standards for the practice of Nurse-Midwifery. Washington (DC): ACNM, 1993. 10. American College of Nurse-Midwives. Core competencies for basic midwifery practice. Washington (DC): ACNM, 1997. 11. International Confederation of Midwives. International code of ethics for midwives. London (UK): ICM, 1993. 12. Chervenak FA, McCullough LB. Perinatal ethics: a practical method of analysis of obligations to mother and fetus. Obstet Gynecol 1985;66:444. 13. Jonsen AR. The new medicine & the old ethics,1 34. 14. U.S. Department of Health and Human Services, Public Health Service. Healthy people 2000: midcourse review and 1995 revisions. Washington (DC): U.S. DHHS, PHS. 15. Institute of Medicine. The best intentions: unintended pregnancy and the well-being of children and families. Washington (DC): National Academy, 1995:4. 16. Institute of Medicine. The hidden epidemic: confronting sexually transmitted diseases. Washington (DC): National Academy. 1995: 58 – 61. 17. Harvey B. Financing perinatal health care in the US. In: Goldworth A, Silverman, W, Stevenson DK, Young EWD, editors. Ethics and perinatology. New York: Oxford University, 1995:349 –50. 18. Murphy P. Evidence-based care: a new paradigm for clinical practice. J Nurse Midwifery 1997;42:1–3. 19. Hellman LM. Nurse-midwifery: fifteen years. Bulletin of the American College of Nurse-Midwives 1971;16:71–9. 20. Wilson R, Schifrin B. Is any pregnancy low risk? Obstet Gynecol 1980;55:653– 6. 21. Rooks JP. Midwifery and childbirth in America. Philadelphia (PA): Temple University, 1997:295–343. 22. Thompson JE, Thompson HO. Bioethical decision making for nurses. Norwalk (CT): Appleton-Century-Crofts, 1985:219.

The author wishes to recognize Lizabeth Andrew for her editorial assistance with the preparation of this manuscript. The author also gratefully acknowledges the collegial relationship since 1988 with Kathleen Kinlaw, associate director, Emory University Center for Ethics in Public Policy and the Professions. Her review of this article is appreciated. An internal research grant of the Nell Hodgson Woodruff School of Nursing, A Pilot Study: Exploring Ethical Dimensions in Prenatal Care Provided by Nurse-Midwives, provided the two clinical examples of nurse-midwifery care. The research was approved by the Institutional Review Board of the School and the two nurse-midwives granted permission for the data to be included in this manuscript.

23. Beauchamp TL. Principalism and its alleged competitors. Kennedy Institute of Ethics J 1995;5:181–98. 24. Beauchamp TL, Childress JF. Principles of biomedical ethics. 4th ed. New York: Oxford University, 1994. 25. Breece C, Israel E, Friedman L. Closing of the nurse-midwifery service at Boston City Hospital: what were the issues involved? J Nurse Midwifery 1989;34:41– 8. 26. Clark-Collier T. Collaborative practice: beyond the bureaucratic shadow. J Nurse Midwifery 1998;43:1–2. 27. Graham SB. A structural analysis of physician-midwife interaction in an obstetrical training program. Soc Sci Med 1991;32:931– 42. 28. Chervenak FA, McCullough LB. Perinatal ethics: a practical method of analysis of obligations to mother and fetus,12 443.

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