Chapter 5 Ethics in midwifery
Modern midwifery involves many different practices and conflicts. The days of clinical practice being clear-cut, right or wrong are long gone. Increasingly, uncertainties are present, causing midwives to make decisions in the absence of robust evidence. There is a need to explore what it is about current practice that causes these dilemmas and to offer support mechanisms to manage situations when they arise. Changes in society over the last two decades have meant changes in healthcare provision. The publication of the patient’s charter (DH 1991), Your Guide to the NHS (DH 2001), along with The NHS Plan (DH 2000) and the NHS Complaints Regulations (2004) have raised public awareness of the choices available as well as raising people’s expectations regarding involvement in care decisions.
The area of ethics is complex, difficult and could be seen, by some, as off-putting. This need not be so. It should be used as a daily tool to support decision-making and to enable rather than disable practice. If used like this it should be liberating and empowering. Being ethically aware is a step towards being an autonomous practitioner. It means taking responsibility, empowering others and facilitating professional growth and development.
When attempting to explore a new area, one of the initial problems is often the terminology used. Consider for a moment your first experiences within a clinical setting. The language used may have been familiar but the terminology was so new you may have felt lost. Ethics is the same; some of the terminology used is different and the words need greater explanation and understanding. Other parts of the terminology appear, on the surface, to be easier and more commonplace (Box 5.1). Even so, when asked to clarify or explain your understanding of these words, it is often not so easy.
| Informed consent | Information regarding options for care/treatment |
| Rights | Justified claim to a demand |
| Duty | A requirement to act in a certain manner |
| Justice | Being treated fairly |
| Best interests | Deciding on best course for an individual |
| Utilitarian | Greatest good for greatest number |
| Deontological | Duty of care |
| Beneficence | Doing good |
| Non-maleficence | Avoiding harm |
What you will find is there can be more than one interpretation for a word. Different people may understand different things from the same words. So, ethics is often about exploring values and beliefs and clarifying what people understand, think and feel in a given situation, often from what they say as much as what they do.
Beliefs and values are very personal. They are dependent on many things, not least an individual’s background, society and personal views developed over time. Time for reflection to explore these issues is important. It is also essential for health professionals to be open and honest about practice dilemmas.
A potential area of conflict is that of law. Law and ethics are often seen as complementary to one another, yet at times they are also seen to be placed on opposite sides of a coin. Any exploration of ethics should also be able to guide the reader to such areas of overlap or conflict. The study of ethics will provide the framework for exploration and aid resolution of dilemmas. However, it has to be remembered that ethics will not provide a quick fix, or an easy answer.
Jones (2000, p 8) has outlined ethics as being ‘the basic principles and concepts that guide human beings in thought and action’. The same could be said of philosophy, in that moral philosophy is often the foundation of modern ethical decision making and ethics itself is the application of philosophical principles to everyday situations. To understand this better there is a need to explore the theories surrounding ethics and their supportive philosophical frameworks.
When first exploring the ethics of a situation it is helpful to have a framework with which to work. There are many ethical frameworks that could be adopted to use in clinical situations. Edwards (1996) advocates a four-level system based on the work of Melia (1989, p 6–7). Edwards believes that there are four levels of moral thinking that can help formulate arguments and discussions and ultimately assist in solving moral dilemmas (Box 5.2).
Box 5.2 Edward’s levels of ethics
(After Edwards 1996).
| Level one | Judgements |
| Level two | Rules |
| Level three | Principles |
| Level four | Ethical theories |
Judgements are frequently made readily, based on information gained. Such judgements may have no real foundation except the belief of the individual who made it.
Throughout our daily lives we make judgements about each other, whether it is on the bus, in the supermarket or during a shift on a busy ward. What is important to remember is that it is often an instant judgement that has been made, possibly biased, and it may not necessarily have been well thought through or based on all available evidence. How judgements are made is interesting. What informs a judgement is often linked to personal values and beliefs, society, as well as experiences of similar past events. All these and more shape the decision-making processes and to be aware of them is the first step to understanding yourself and your own moral values. It can be helpful to reflect on past judgements and consider whether, in retrospect, they were well founded or based on personal bias or prejudice.
Rules govern our daily lives and differ depending on the society or culture in which we live. When looking at ethics, rules are what guide our practice and control our actions. Rules come in many forms and from many sources. Beauchamp & Childress (2001) outline different types of rules. These include substantive rules covering such things as privacy, truth telling or confidentiality, authority rules determined by those in power and enforced on a country or section of society, and procedural rules defining a set course of action or line to be followed. Rules can also be enabling, they can define the limits or boundaries of practice and can allow freedom to act knowing the safe limits of those actions. The Nursing and Midwifery Council (NMC) in the UK sets rules for midwives in the form of the Midwives Rules and Standards (2004). These are statutory rules bound by legal processes, and if used appropriately can guide and enable practice and so ease dilemmas. Supporting rules is the NMC Code (NMC 2008a). Codes are less formal or obligatory than rules and are seen as guidelines to support safe practice.
Four main principles underpin this level. Beauchamp & Childress (2001) have explained these in considerable detail. The first of these is respect for autonomy. This term has been used extensively over the last few years. The focus of modern healthcare has been around the professional’s duty to respect individuals’ autonomy and whenever possible to promote or enable them to exercise their autonomy. This is especially true in maternity services where women are placed at the centre of care and their views and wishes are seen as key to care delivery. The second principle is non-maleficence, interpreted as avoiding harm. It could be said that most healthcare professionals would be trying to do this. Brown et al (1992) advised us that this principle is a strong one and as such should not be taken lightly. Harm may sometimes be a consequence of an action in healthcare; the aim should be to minimize harm as much as possible. The third principle is that of beneficence – doing good or balancing the benefits against the harms in a given situation (Beauchamp & Childress 2001). This entails positive action on one person’s part to benefit another person. This can be difficult for health professionals when a client/patient chooses a course of action that may not be in their best interests. This may be made more difficult for midwives when there is a need to consider the best interests of both the woman and her fetus/baby. Balancing benefits and harms can in itself cause dilemmas.
The fourth principle, justice, means to be treated fairly. In many instances this is all people want. It is important that healthcare professionals are seen to be acting fairly and treating all clients as equals. Gannon (2005) outlines that justice is about people’s rights, duties and obligations. It is about the equal sharing of these to the people who are owed them. He feels that people should be able to have equal access to healthcare based on need. Within the maternity services justice is important in that all women should be treated as equals, all should have access to the same level of care and services, all should have the same options for care and choices for such aspects as place of birth, method of delivery, levels of antenatal and postnatal care (NPEU 2007, DH 2007). Justice and fairness will be explored further later in this chapter.
There are a number of theories that could be explored and applied to midwifery/healthcare. Liberalism, communitarianism and casuistry, are a few that are explained in more depth by Beauchamp & Childress (2001). Feminism is another that some find of use and a classic text for this would be Tong (1997). Generally, theories are taken to mean the two main ethical theories of utilitarianism and deontology. Many texts outline these two theories in more detail as they are the most widely used and form the foundation of much ethical decision making (Beauchamp & Childress 2001, Jones 2000, Thompson et al 2000).
Utilitarian theory has been widely adapted over the years. It is based on the idea of balancing the consequences of following certain actions or rules. This can be thought of as a very large pair of scales, with the benefits of an action on one side and the harm or consequences of taking the action on the other. There is a need to tip the scales in favour of the benefits over the possible harms that could occur. This theory stems from the work of Jeremy Bentham and later John Stuart Mill in the nineteenth century (Raphael 1989). They believed that pleasure was more desirable than pain and that anything that increased pleasure for the majority of people must be a morally right action. Practically, this theory is attractive in that it can aid decision-making for the masses; an action is good if it provides benefits for the many. Scarce resources within the NHS have meant that very difficult decisions have to be made. Determinations of where the greatest good lies and how to do the least harm in any given situation have become important. Such decision making may be made easier by applying ethical theories (Tschudin 1994).
Many aspects of midwifery care have been organized on utilitarian principles. Antenatal clinics allow many women to be seen by skilled professionals under one roof. Many screening tests are offered to all irrespective of need or individual assessment, and team midwifery often means what fits with the midwives rather than with individual women (Flint 1993, p 59). There may be times when such practices are appropriate; for example for some safety issues everyone should follow set procedures to ensure standards of care are maintained. When you are next called on to make a decision ask yourself how the balance of benefits and harms would weigh on a scale. If you have time try to discuss the range of consequences each option carries before making the final decision.
Deontology is the second of these theories. Jones (2000) tells us this term is from the Greek word ‘deon’ meaning duty. As health professionals you would all say you have a duty towards your clients/patients. But there is a need to explore where else your duty lies. This list could be quite long (Box 5.3).
The list could be longer if you added personal duties (i.e. family, friends, etc.). Recognizing that you have a duty of care is one thing, balancing the competing demands of those duties is quite another. Conflicting duties can cause dilemmas in deciding the best course of action. It is often difficult to prioritize such duties, but some prioritization needs to occur to enable decision making to be meaningful.
There are no easy answers here. This work is based on that of Immanuel Kant (Hollis 1985) and there have been a number of interpretations of his writings over time (Edwards 1996). Kant emphasized that to do one’s duty is the most important thing, irrespective of any consequences that carrying out this duty may produce. How you interpret your duty may vary depending on your situation, values or beliefs. Some may base their duty on natural laws, others religion and the ten commandments.
This is where a difference is seen between utilitarianism and deontology. In following a utilitarian theory it would be essential to consider the consequences and choose the best course of action – that is, the one that produces the best outcome for the most people. Following a deontological approach on the other hand would require the person to carry out something that is seen as a duty irrespective of any consequences. This would be very hard in practice for most people as it suggests certainties of actions, and an attitude of irrelevance towards consequences of actions. Life is often more complicated, however, and as such many other factors need to be considered.
Another aspect of Kant’s work was the emphasis on respect for persons. To this end, he believed that people are individual and should be treated with respect, not merely as a means to an end. Beauchamp & Childress (2001) believe that if an action necessitates treating someone without respect then it is the action that is wrong. Respect for persons is important within maternity care. Each woman is an individual and her experience will be personal to her and respecting women as individuals is a fundamental part of a midwife’s role.
Having considered the four levels of judgements, rules, principles and theories, consider the case scenario in Box 5.4 for a few minutes. It may help you apply the framework to your practice. Make a few notes of what ethical issues it raises. It can be seen that in working with Susan, a midwife would call on all four of Edward’s levels.
Susan is 23 years old and is pregnant with her second child. She has requested that she have minimal interventions during the pregnancy and a natural birth, no interventions, no vaginal examinations, no drugs and a quiet environment. Her previous pregnancy was complicated by raised blood pressure, which culminated in Susan having a caesarean section. Susan is adamant that nothing will go wrong this time. She is happy to have her baby in hospital, in light of the first pregnancy’s events, but would like to maintain more control and feels that provided her blood pressure remains within normal limits there should be no reason a midwife should intervene. Her midwife is anxious to ensure safety of mother and fetus/child, while also building Susan’s trust.
Using Edward’s four levels, the midwife supporting Susan during her pregnancy can work through what she should do. On talking to Susan and discovering her wishes for pregnancy and birth it is clear that she holds strong views about the type of experience she wants. It would be easy for the midwife to make an immediate judgement about both Susan and her reasons for wanting a low technology pregnancy and birth. During the course of the meeting between Susan and her midwife it would be important for the ground rules to be set and the midwife would have to outline the legal and moral rules that govern her practice. One such moral rule that would be vital is that of truth telling. In order for Susan and her midwife to build a trusting relationship that would be of benefit throughout the pregnancy it is important that honesty is established and both parties are truthful with each other. What the midwife has to acknowledge and promote in this relationship is the principle of autonomy. Principles are rather general, but autonomy is based on the understanding of respect for choices made by people.
The midwife needs to establish that what is being asked for is Susan’s choice of how she would like events in her pregnancy to be managed; it is important these are informed and rational requests, based on sound judgements and beliefs. This having been established, the midwife then has a duty to uphold that choice if she is to respect Susan’s autonomy and earn her trust. As long as this relationship continues to be founded on the above judgements, rules and principles, then the midwife would be seen to be demonstrating aspects of ethical theories. The midwife is taking a position that she sees as her duty to care for Susan, acting in the best interests of both her and her unborn child. In moral philosophy, this would be called a deontological stance. She is also utilizing aspects of consequentialism, as she is weighing up the benefits and harms of Susan’s requests and will be trying to advocate a position which causes the least harm, but also maximizes the possible benefits. Both these positions have been outlined by Beauchamp & Childress (2001) and Thompson et al (2000).
Having outlined the levels of decision-making (Edwards 1996), it is important that we now explore some other influences on the midwife’s role. There are aspects that are either part of or develop from the basic moral frameworks outlined above. These are aspects of ethics that are seen daily in professional life, but they could still cause problems, dilemmas or conflicts in one form or another.
Informed consent is a relatively recent term; indeed, Beauchamp & Childress (2001, p 77) suggest that it was not until the mid-1970s that the term was explored in any real detail. It has been claimed that within ethics, informed consent means ‘giving patients and clients as much information as they need’ (Jones 2000, p 104). This is traditionally what ethical consent is held to be. This principle is very different, however, to the legal standpoint in that ‘consent’ within legal frameworks is taken to be based on the reasonable person standard, or the ‘Bolam’ test (Dimond 2006, p 245). Consent within ethics means that the client has listened, understood and agreed to the procedure or treatment being proposed. For many reasons this may not be realistic. Johnstone (2000, p 210) outlines some reasons why consent may not be realistic in everyday clinical practice. These are summarized as:
These reasons seem plausible; there will always be situations where a client has said ‘what do you think?’ or you find the client has asked two or three of your colleagues for the same information after you have spent 10 minutes explaining things. One other important aspect that is not on Johnstone’s list is that of the professional’s knowledge base. To be able to provide information and then gain a valid consent, the professional attempting to gain that consent has to be at least as knowledgeable as the client from whom consent is being sought. With increasing use of the World Wide Web, this is becoming an almost impossible task. Health professionals have a duty to keep up-to-date and be able to inform their clients to the best of their ability (NMC 2004 point 3, NMC 2008a).
Consider once again the case scenario in Box 5.4. There will be many times during Susan’s pregnancy when consent may be required. To ensure that the consent given is valid, the midwife will have to hold wide-ranging discussions on such things as antenatal screening tests, ultrasound scanning, birth choices and birth interventions such as pain relief, positions for birth and active management of the third stage of labour. The midwife must also be sure that Susan understands the options and alternatives open to her. Susan has asked for minimal interventions, so without being judgemental or coercive, the midwife will have to explore Susan’s views and recommend what she believes is ‘best practice’. Respecting a person’s right to exercise choice and decision-making can be difficult. What if Susan was requesting something that did not meet the standards of best practice? How would the midwife be expected to react then? The Midwives Rules and Standards (NMC 2004) can be used in such a situation to inform and enable the midwife to act in the woman’s best interests. The midwife would have backup support systems from both her supervisor of midwives (see Ch. 52) and her immediate line manager.
Enabling informed consent to occur and empowering women to decide what is best for them are fundamental parts of ‘respect for autonomy’ (Brown et al 1992). When attempting to support the midwife in such situations, there is an apparent need to fall back on the legal definition of a ‘reasonable person’. However, Brown et al (1992) have explored this issue and advise caution in following a reasonable person standard. They argue that if all reasonable people would choose one procedure but Susan chooses another then Susan could be seen as being unreasonable because she is the only one to choose the other type of procedure. It may be easier and possibly more desirable for some in today’s litigation-conscious health service to abide by a legal definition of competence that Maclean (2001, p 46) outlines as an ability to ‘comprehend, retain and use information and weigh it in the balance’ (see also NMC 2008a.)
For a health professional it can be very difficult to respect a person’s autonomy when current evidence tells you their request is not best practice. At times, the courts have been called on to decide; for example in the case of Re S (Savage 1998) both the mother and fetus’s lives were at risk, yet the mother refused treatment that could have saved the fetus and lessened the risk of morbidity or mortality for herself. These cases are rare, but they can damage the client– professional relationship if not managed well.
When faced with clients who, despite all information, support and encouragement, are still reluctant to act or speak up for themselves, many midwives are finding they need to take on an advocacy role on their behalf. Advocacy is seen as speaking out on another’s behalf (Gates 1994). There is, again, a fine dividing line between advocacy and paternalism. Put simplistically, paternalism is acting on another’s behalf, whereas advocacy is speaking out on another’s behalf.
When taking on the role of advocate there is a need to be clear on a number of points. Acting as an advocate can be difficult and involves putting personal views or values aside. Advocacy means speaking out for someone’s rights.
Within any decision-making process there is a need to work with others, to collaborate in attempting to come to the right decision. There have been many calls for health professionals to work together (Audit Commission 1997); such calls are now also being extended to public health and social care (WAG 2005, DH 2007, NPEU 2007).
The position of law, ethics and reproductive health has been widely explored (Callahan 1995, Dimond 2006, Mason & McCall Smith 2000). There are times when these seem to work together to support each other and when calling on one may clarify the position of the other. There are also times when there appears a great divide between the two and no middle ground can be found.
To examine these issues more closely, there is a need to look towards modern society. Many of the modern laws are developed from and stand firmly in the foundations of society (Mason & McCall Smith 2000). The values and practices of society often inform the development of laws, although Mason & McCall Smith (2000) suggest that the laws take such a considerable time to change, and that the healthcare professions are often left unsure of their legal position.
A dilemma for the maternity services of today is that of provision of a home birth service. The governmental policies (NMC 2006) and professional advice (www.rcmnormalbirth.org.uk) is that home birth should be a real option for women. Should a woman choose such a birth, she should be supported in her choice and have the appropriate professionals available to be with her during the birth. Yet the midwifery service, like many parts of the NHS, is under funded and many maternity units cannot offer such a service without compromising the care of other women (House of Commons Health Committee Report 2007). Utilitarian principles may have taken priority in this incidence. To provide a home birth service for all who request it could mean harm coming to other users of the maternity services; the greatest good here may be to restrict or not offer a home birth service until it can be fully staffed and safe for all women.
It may be seen that in being supported by the law you may also be constrained by it. Fear of litigation appears to be a guiding principle of modern practice. Risk management and clinical governance are high on most health service agendas (Symon & Kirkham 2006). The underlying reason for the development of these within clinical practice has been improvement in practices and the establishment of common standards and provision of safe care. It is important that midwives are aware of and become involved in these initiatives if collaboration and cooperation between disciplines are to be promoted.
One aspect of law that has taken on a more prominent role and gained importance for health professionals in recent years is that of Human Rights. The European Convention of Human Rights (1950) set out to protect fundamental human rights (Caulfield 2005), and the UK was the first signatory to the convention. The principles established at that time have become part of British society’s values and norms. So much so, that 1998 saw the introduction of the Human Rights Act (Dimond 2006). It has become important that midwives are aware of and are encouraged to work within the boundaries of this. The following parts are of particular importance for midwives:
Gruskin & Dickens (2006) have outlined how human rights laws clearly place an obligation on governments to protect individual’s human rights. One benefit of the Act is that it has placed the patient or client at the centre of healthcare. The patient experience has become an important measure of quality and effectiveness of the health services. Caulfield (2005) believes that such changes have led to a review of the NHS complaints system. Certainly within midwifery services, women’s views are becoming stronger and are having an influence in shaping services; this has been seen in the Audit Commission Report (1997) and more recently in the National Perinatal Epidemiology Unit report Recorded Delivery (2007). This latest report is reinforced by the Department of Health’s (2007) strategic vision for improving choice, access and continuity of care. This strategy for England again attempts to ‘put women and their partners at the centre of their local maternity service provision’ (DH 2007, p 7). With this in mind, midwives should remember that when someone has a right to something there is usually a corresponding duty on someone else to facilitate the right (Beauchamp & Childress 2001). Women could be said to have a right to safe and competent care when pregnant. This would fit with Article 5 and it would naturally follow that as midwives are educated to provide midwifery care they have an obligation that the care provided is both safe and competent. It may also be argued that the UK Government, via the NMC also has an obligation in regulating its practitioners, to ensure that they are practising safely and competently. The NMC does this via their Post Registration Education and Practice (PREP) system (NMC 2008b), as well as by setting the Midwives Rules and Standards (2004). The NMC’s statutory function in relation to supervision of midwives is also an important part of this process (see Ch. 52).
It has already been seen that health service resources are limited and to provide care a degree of rationing needs to take place (Gannon 2005). In providing midwifery care there is a need to ensure justice and fairness in the care being delivered. In ethical terms, justice is taken to mean ‘fair, equitable and appropriate treatment in light of what is due or owed to persons’ (Beauchamp & Childress 2001, p 226). If it can be shown that someone is owed something, say a pregnant woman is owed a certain standard of care, then that woman has a right to that standard of care and someone has a corresponding duty to provide the care to the appropriate standard. An injustice is committed if that standard of maternity care is not available and it could be said that the woman has failed to receive the expected standard of maternity care she is entitled to. That duty of care, while owed by the NHS and maternity services, falls ultimately to each and every midwife providing care to the woman.
Edwards (1996) outlines the equity or fairness part of justice in saying that individual treatment should be consistent and equals should be treated equally. A woman asking for information on breastfeeding in the postnatal ward may receive detailed advice and support from the midwife. That same midwife should give any other women asking for help and advice the same level of advice, care and support. Should a woman at home ask for information on baby care, she should be able to expect the same type and quality of information as her friend or neighbour who may have asked the same questions.
A dilemma that arises in attempting to treat all women as equals is that of need. In trying to be equitable, is there a need to determine if all women should be treated equally? A midwife has to weigh up each woman’s needs and alter the care accordingly. The woman who asked for breastfeeding advice earlier may have read widely, had previous experience of breastfeeding and have plenty of support available when she returns home. The second woman by contrast may be a first time mother, who has not attended any parent education classes, not read or know much about breastfeeding and have little support at home. Clearly the information, advice and support needs to be different for these two women. On the face of it, their questions may be the same and one would expect the same type of answer, but in finding out a little background information the midwife would be justified in not treating these two women in the same way as their needs are very different. So, it is clear that midwives must be aware of and consider equity and justice in their dealings with women, but they also have to consider women as individuals and be able to justify different practices in the basis of need.
Any examination of ethics would not be complete without also looking into the ethical implications of research in the maternity services. Robson (1997, p 470) has outlined the British Psychological Society’s research involving human participants, while Cormack (2000) contains a chapter by Hazel McHaffie that uses two case scenarios to emphasize the issues to be considered. Whichever approach is taken there are some common aspects that most authors emphasize. These can be summarized as the ‘five Cs’ (Box 5.5).
The fundamental principle when considering whether research is ethical is that of protection of the vulnerable; this may be the staff, clients or the researchers themselves (Cormack 2000). Although advancement of knowledge is important, it should not be made at the cost of compromising any one group of society. It is not only those involved in carrying out research who should be aware of the research protocols but also those involved in it and those who may simply be working within the same clinical area. To this end, it can be helpful to ask some very simple questions such as those in Box 5.6.
(Adapted from DH 1992.)
When studying ethics you become aware of so many aspects of life that have ethical implications that can and do make working within the maternity services challenging. The media, in their many forms, play an important role in today’s society and often force us to become ethically aware of issues we may not have particularly thought about, or that may not have become ‘public’ until they became headline news.
At times like this it is to professionals that clients turn for answers to their many questions. This has been seen on a number of occasions in the last few years. In France a 62-year-old woman received IVF (Dimond 2006, p 548); this became headline news prompting many discussions on the implications for the child and the rights of older women to access such treatments. A woman recently lost her case to have her embryos implanted because her ex-fiancé did not now wish to become a father (Laurance 2007), this prompted much discussion on the rights of the partner under the Human Fertilisation and Embryology Act (HFEA 1990). These embryos were at the limit allowed for storage under the Act and would then have to be destroyed.
Such events can be very distressing for any health professional involved. Having a structured framework to work through the issues can help. But having open and meaningful discussions with colleagues is vital if a deeper understanding of the situation is to be gained. Such things as rights of individuals, protection of the vulnerable, duty of care and where the best interests lie should be explored openly and safely away from the client’s bedside (Dimond 2006). That is not to say that clients should not be involved, but the moment of crisis may not be the best time to explore sensitive issues, and sometimes a client representative may be better placed to speak out in a time of distress.
The area of ethics is growing and the need for health professionals to become more aware of the issues involved is escalating. This chapter has raised the possibility of using a framework (Edwards 1996) to organize your thoughts and decision-making processes.
A starting point must be the clarification of personal values, beliefs and moral principles. Without this it will be difficult to move forward and assist others with their problems and dilemmas. Many things, family, friends, society and professional life (Jones 2000) will have shaped your individual values and beliefs. By examining and reflecting on these you will be able to acknowledge any biases you may hold and start to work through them. Reflection skills have become important in modern professional life as a means of critically reviewing events and learning from them.
Moving forward may not be easy, but it is important if care is to improve and standards are to be maintained. Many reports in recent years have recommended that the midwifery profession include its client group in decision-making. Pregnant women should have an increased number of choices, they should have more control over events and midwives should be providing them with continuity of care (DH 2007). But in providing women with these things midwives are also having to confront the fact that women need more information. The quality of information giving is dependent, in part, on midwives’ knowledge base. Midwives must also ensure that once women have the options for care the choices they make are informed and are based on sound research-based evidence (Price 2001, RCM 2000).
Another aspect of moving forward is that of collaborative care. There have been many calls for health professionals to work more closely together (Audit Commission 1997; NMC 2008a). To work together means to resolve any differences between professions. Doctors and midwives might have different starting points, but this should not mean that a middle ground cannot be found. Sharing codes of practice and developing a joint code may be the first step towards closer relationships.
Studying ethics will raise many questions, some of which will not lend themselves to satisfactory answers. Although that is frustrating, sharing of dilemmas and gaining different viewpoints may help. Multidisciplinary case conferences, seminars and study sessions could be one way forward. Medical, midwifery, health visiting and social work professionals are just some of those whose viewpoints could be included to broaden the discussion and add to the overall quality of care provided.
Midwives may find their PREP profile (NMC 2008b) provides a tool to reflect upon many private dilemmas and conflicts. Within the profile there is an opportunity to address a number of ethical questions. Such questions could be: ‘who has rights in a situation?’, ‘was there a duty of care?’, ‘what was in the client’s best interests?’, and ‘how can one balance the good of one action against any possible harm it could cause?’. These may help you explore the issues and organize your thoughts in preparation for the next time that you are faced with a similar issue.
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Laurance J. Woman loses final round battle to use frozen embryos. The Independent. 2007. 11 April. Online. Available http://news.independent.co.uk/europe/article2439528.ece.
Maclean A. Briefcase on medical law. London: Cavendish, 2001;46.
Mason JK, McCall Smith RA. Law and medical ethics. London: Butterworth, 2000.
Melia K. Everyday nursing ethics. London: Macmillan, 1989;6-7.
National Patient Safety Agency. National Research Ethics Service. 2007. Online. Available www.nres.npsa.nhs.uk/recs/index/htm.
National Perinatal Epidemiology Unit (NPEU). Recorded delivery: a new survey of womens’ experience of maternity care. Oxford: NPEU, 2007.
NHS (Complaints) Regulations. HMSO, London, 2004. SI 2004 No 1768
Nursing and Midwifery Council. Midwives Rules and Standards. London: NMC, 2004.
Nursing and Midwifery Council. Midwives and Home Birth Circular 8–2006. London: NMC, 2006.
Nursing and Midwifery Council. The PREP handbook. London: NMC, 2008.
Nursing and Midwifery Council. NMC Code: NMC, London, 2008.
Price S. Using the MIDIRS informed choice leaflets in clinical practice. MIDIRS Midwifery Digest. 2001;11(2):261-263.
Raphael DD. Moral philosophy. Oxford: Oxford University Press, 1989.
RCM (Royal College of Midwives). Vision 2000. London: RCM, 2000.
Robson C. Real world research. Oxford: Blackwell Science, 1997.
Savage W. The right to choose. Nursing Standard. 1998;12(35):14.
Symon A, Kirkham M. Risk and choice in maternity care: an international perspective. London: Churchill Livingstone, 2006.
Thompson IE, Melia KM, Boyd KM. Nursing ethics, 4th edn. London: Churchill Livingstone, 2000.
Tong R. Feminist approaches to bioethics. Oxford: Westview, 1997.
Tschudin V. Deciding ethically: a practical approach to nursing challenges. London: Baillière Tindall, 1994.
WAG (Welsh Assembly Government). Designed for Life: creating a world class health and social care for Wales in the 21st Century. Cardiff: WAG, 2005.
Frith L. Ethics and midwifery: issues in contemporary practice. Oxford: Butterworth Heinemann, 1996.
An interesting book focusing on a variety of aspects related to midwifery practice. Clearly discusses midwifery issues and relates to the ethical theories that underpin them. This is an easy book to read and would be useful as a supportive text for midwifery students.
Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th edn. Oxford: Oxford University Press, 2001.
An ethical theories book that most readers will find useful to dip into. Not a book for bedtime reading, rather a text that is essential to support any enquiry into ethics. It is nicely linked to healthcare and uses case studies to apply the theories to clinical practice.
Jones S. Ethics in midwifery, 2nd edn. London: Mosby, 2000.
A good basic introduction to ethics in the midwifery setting. Easy to read and compact enough to carry around. Divided into two sections this book first outlines the main theory standpoints and uses a case study approach in the second section to lead the reader through the process of ethical enquiry and decision-making.
Thompson IE, Melia KM, Boyd KM. Nursing ethics, 4th edn. London: Churchill Livingstone, 2000.
A comprehensive text written from a nursing perspective but has many good aspects that the student midwife will find useful. Easy to read and navigate, it is a good reference text, which is well referenced.
Bowden P. Caring. London: Routledge, 1997.
This has a feminist focus and uses the basic ethical theories to examine the issues raised. Highlights the four roles of mothering, friendship, nursing and citizenship.
Ford N. The prenatal person: ethics from conception to birth. Oxford: Blackwell, 2002.
Explores ethics at a difficult time; reproductive technologies are explored with some background on the technologies, with links to ethical and religious implications.
Freeman M. Human rights. Oxford: Blackwell, 2004.
Explores the concept of human rights and the moral rules. Leads the reader from the history of the concept to exploring application and cultural differences.