Moral conflict

A moral conflict could be considered to be a show of strength within a moral principle, for instance the autonomy of the woman versus that of the midwife or, more commonly, the autonomy of two or more professionals. A conflict could also arise between two or more different principles. On closer examination of the conflict, one side becomes a clear winner. Consider the following case.

Ethically, telling the truth wins. The mother has the right to know, especially as a positive test will indicate to her that she was initially deceived and this could affect her ability to trust the midwives, or other healthcare professionals, in future encounters. Added to which, the mother’s permission should be sought regarding tests to be performed on her baby; she cannot consent unless she has the information. It is hoped that the reader can see, from this example, that a conflict is logical in resolution once thought through properly. It is also acknowledged that in some units, in circumstances similar to this example, not all practitioners take this particular action; they obviously find that their clear solution is to protect the mother.

Moral dilemma

When examination of an apparent conflict between principles indicates two or more options, none of which is morally ideal, then this is a dilemma, such as the following case.

The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC 2008:4) states that you must ‘make the care of [women] your first concern, treating them as individuals and respecting their dignity.’ What the woman feels is in her best interests may not correspond with the midwife’s view; it could be considered detrimental to the woman’s condition, or that of her fetus. However, where at one time paternalism was virtually encouraged, The Code now states: ‘You must respect and support people’s rights to accept or decline treatment and care’ (NMC 2008:4).

Utilitarianism

Utilitarianism is a consequentialist theory, where possible actions are considered in terms of their probable consequences. The original aim was for all actions to create the greatest happiness for the greatest number of people. Current thinking would probably use the term benefit rather than happiness, which would describe the essential outlook of those managing the National Health Service (NHS). It would also describe the intentions of Hitler in the Second World War, with his views of improving the human race, as, unfortunately, a belief within this theory is ‘the end justifies the means’.

There are two forms of the theory: act-utilitarianism and rule-utilitarianism. The first is the purer form, developed in the 18^th and 19^th centuries by Bentham, Mill and Sidgwick, which expects every potential action to be assessed according to its predicted outcomes in terms of benefit. The second form does not look directly at the actual benefit of each act, rather it considers moral rules which are intended to ensure the greatest benefit, and each act is assessed as to its conformity to the rules.

Using in-vitro fertilization (IVF) as an example, a technique initially researched in the concentration camps of the Second World War, it can be shown how these two schools of thought differ. Act-utilitarians would view the actions taken in light of the anticipated outcomes: many people today benefit from IVF, therefore, they may believe that this beneficial consequence justifies the research methods used. Rule-utilitarians, however, would want the benefit but would consider whether society would accept the means by which it was achieved. It is likely that they would want to find a more acceptable method of achieving the outcome.

Deontology

Deontology is a duty-based theory. Consequences are not considered, as deontologists believe that what is good in the world is brought about by people doing their duty. This theory divides into three schools of thought, each competing with the others as well as with utilitarianism. A well-known name in philosophy is Immanuel Kant. He developed rational monism which he believed was how people already thought – that one’s actions should be rational and stem from ‘good will’; he believed in duty for its own sake – the ‘categorical imperative’. He used two tests for the moral value of an action. The first was whether it would be suitable if universalized, i.e. if everyone was to do it. The second test involved whether the act would use anybody as a means to an end, which would not be acceptable, or as an end in himself, which would be acceptable as this is the basis of autonomy, which was paramount. For instance, in a healthcare research project, is the research to benefit the individual (i.e. treating him as an end in himself), or to benefit others – e.g. treatment of future patients; achievement of academic acclaim for the researcher; making a profit for a company (i.e. in each case, a means to someone else’s end)?

The second school is traditional deontology; this is firmly seated in a belief in God and the sanctity of life. Each religion has its own model for behaviour; for instance, Christians have the Ten Commandments. With this system there is little room for conflict as it is possible to carry out all the commands at one time.

The third form is intuitionistic pluralism, where it is believed that there are a number of moral rules which are of equal importance; unfortunately, the possibility of rule conflict exists. To minimize this, Ross considered seven prima facie duties which he felt were reasonable for people to abide by:

As these duties are equal in importance, it is still possible for conflict to arise between them. However, there is a system which can assist in such a conflict – casuistry; this system allows for the duties to be prioritized according to the circumstances.

Readers have probably already identified that, although the NHS is generally essentially utilitarian, midwifery, medicine and other similar disciplines tend towards a deontological approach. In fact, the duty with which we are most familiar – the duty of care – would appear to encompass at least the first four of the above duties. This deontological approach is certainly apparent in the text of The Code (NMC 2008).

To assist understanding of the different focus of utilitarianism and deontology when faced with a dilemma, the following non-midwifery story is offered; readers are invited to determine the end:

If you are utilitarian, then your decision would be to shoot one (which one is another problem), thus saving the other 19 as a consequence. As a deontologist, however, you would feel a duty ‘not to harm’ each man; nor would you don a mantle of responsibility and guilt for Pedro’s actions.

As midwives, whatever our personal leanings may be, we may be professionally schizophrenic with regard to our ethical actions. Consider the midwife in the next scenario.

It must be remembered, however, that most people have to deal with conflicts and dilemmas in their lives without knowledge of these theories. However, whether we wish to embrace formal or informal approaches, it is important for healthcare professionals to know something about each of them, if only to understand how and why some decisions are made. It is also useful to have some idea of the approach which managers or clinicians might take when proposals for implementing schemes or changes are being made.

The duty of fidelity

The duty of fidelity requires us to avoid deceiving women and their families; this suggests, therefore, that promises should not be made if they cannot be kept and that truth telling is paramount. An example used earlier, to illustrate a moral conflict, involved a baby with suspected Down syndrome. If the practitioners involved were to withhold the truth from the mother, then they would be failing in their duty of fidelity, however good their motives might be. Anecdotal reports by students and qualified midwives suggest that this deception does occur sometimes, in the paternalistic belief that the mother is being protected.

The duty of beneficence

The duty of beneficence creates the obligation to help women. This is a positive duty which covers numerous activities, ranging from the various ways of helping to make them comfortable, to the educational aspects of caring for their babies. What this duty does not include is the paternalistic attitude so often experienced within the health service, where practitioners feel that they ‘know what is best’. This attitude, although generally well meant, deprives the woman of her right to self-determination (autonomy).

The duty of non-maleficence

The duty of non-maleficence is a negative duty – to do no harm. On the surface, this would suggest that conducting unpleasant or painful procedures may breach this duty; this would be the case if the intention was to hurt the woman. If the intention is to eventually benefit her and, knowing that she might experience pain or discomfort, she is in agreement, then there is no breach in duty. Administration of analgesic injections, the siting of an epidural analgesic or urinary catheterization would come into this category. This duty, although negative in its statement, can have a positive aspect: that of safety and protection from harm. This includes, among other things, consideration of the environment, observance of drug policies, and adequate education and training of practitioners.

The duty of justice

The duty of justice requires us to treat women equally, without discrimination. For many people, the word ‘discrimination’ is immediately associated with terms such as race, skin colour or ethnic origin. While it is essential that we consider these areas, it is also important that we are aware of the other forms of discrimination that can occur, such as between articulate and less articulate women. It is often easier to spend more time with the articulate women, giving as much information and as much choice as possible, than it is with those who require greater explanations or who ask fewer questions. It could be argued that, to consider equality, we should aim to get all women to the same endpoint; this would then necessitate that more time be spent with the less articulate women.

Autonomy

Autonomy involves self-direction and self-control of one’s actions and destiny. It could be argued that it is impossible to be totally autonomous, as society imposes certain rules, often sitting in judgement on the actions of individuals. However, there is a broad band of acceptability in most areas of life, at least in democratic societies, which gives individuals varying degrees of freedom of choice. What is expected of individuals is that their actions and decisions should be rational, i.e. based on sound reasoning. These decisions should then be accepted, whether or not they match the views of others, such as midwives and doctors.

For childbearing women to make rational decisions about their care, the carers must ensure that sufficient information is given at the level and pace required by the individual. Many factors need to be considered. The environment should be conducive to the giving and receiving of information. The language that is being used should be in the ‘mother tongue’ of the woman, with the avoidance of jargon and abbreviations. The circumstances in which a decision is required may vary – for example, whether there is time for contemplation or whether a fairly urgent situation is faced. Having given the information, it is also important for professionals to assess the woman’s understanding of it. These points are of particular importance where midwives are caring for disadvantaged women, such as refugees, asylum seekers and others who enter the country with language or customs incompatibility with British maternity services.

Having determined that a woman has made an informed decision based on what she thinks is sound reasoning, i.e. an autonomous decision, health professionals have no right to overrule that decision (Mental Capacity Act 2005). This principle is inextricably bound to informed consent: if the woman is autonomous, then nothing should be done to her without her prior consent; to do so would be to commit a trespass against the person, i.e. battery (Jones 2000). If her consent is being sought, then she is being considered to be autonomous; therefore, a situation should not arise where, on her refusal to consent to a procedure, professionals attempt to overrule her. There are two groups of people who might be deemed to be not autonomous, therefore unable to give consent. One group includes children, but there is no longer a set age, it depends on the circumstances and degree of rationality of the child (Children Acts 1989 & 2004). The other group includes those who are mentally incapacitated, either by disability or by severe mental illness. With both groups, consent by proxy would be sought. There is also the possibility of temporary mental incompetence, in cases of unconsciousness or possibly the effects of substances. In such cases, the professionals would be expected to act out of necessity, in the best interest of the woman, unless there was sound evidence that the woman would refuse consent if aware of the situation, such as a Jehovah’s Witness carrying a card refusing blood products.

The Mental Capacity Act 2005 applies to all healthcare professionals and, from a midwifery perspective, it places into primary law (statute) the position arrived at following decisions made in civil law, in the 1980s/90s, with regard to certain ‘enforced caesarean section’ cases. Therefore, in both statutory and civil law, it is illegal to enforce any care or treatment on a childbearing woman, even for the sake of the fetus, if she is autonomous and her decision is fully informed. Only diagnosis of mental incapacity, by a psychiatrist, can overrule her decisions and, even then, only treatment that is in her best interests, not those of her fetus or her family, can be undertaken. This principle applies also to young women under 16, except where refusal of treatment could result in her death. Statements in the current edition of The Code (NMC 2008) are in line with this Act. It is important that all midwives familiarize themselves with this Act, particularly the following short sections, the last of which would cover ‘living wills’ and birth plans:

It is the author’s firm belief that, if women’s autonomy were truly considered, then it would be unlikely that the varying aspects of the duty of care would be breached. This would not remove situations of conflict and dilemma, but it would make decision making more straightforward, with all practitioners working to the same ground rules.

The use of reflective practice would assist in this area, by midwives analysing and reflecting upon their actions, particularly with regard to their observance of autonomy, then using this experience to formulate their plans for future decision making.

Women’s autonomy is a relatively new concept. The autonomy of the midwife, however, is not new. Midwives have used the term ‘autonomous practitioner’ for many years, particularly when trying to explain to the uninitiated the difference between nurses and midwives. Unfortunately, however, this autonomy is not always evident in practice, particularly in the hospital setting. Midwives often plead that they are constrained by the policies within which they are expected to work. This pleading suggests that, either the policies are too constrictive for both the midwife and the woman, and should be addressed, or that some midwives are comfortably hiding behind them. In a survey carried out by the Healthcare Commission in England in 2007, 67% of women said that they were involved in antenatal decision making, with 70% saying that they were involved in decisions during labour and birth. These figures seem very positive, until one considers the plight of the 33% and 30% respectively who felt that they were not always involved.