ETHICS IN MIDWIFERY

INTRODUCTION
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 growing, 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 dilemmas. "Changes in society over the last two decades have meant
changes in health care provision.
Beliefs and values are very personal. They are dependent oh many things,
not least an individual's background, society and personal views developed over
time. Time of reflection to explore these issues is important. It is also essential for
health professionals to be open and honest about practice dilemmas.
Another 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 opposites sides of a coin. Any exploration of ethics should also be able to guide
the reader to the areas of overlap or conflict. The study of ethics will provide the
framework for exploration and aid resolution of dilemmas.
FRAMEWORK AND THEORIES
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), Edwards believes that there are four levels of
moral thinking that can help formulate arguments and discussions and ultimately
assist in solving moral dilemmas.

Edward's levels of ethics

Level one

Judgments

Level two

Rules

Level three

Principles

Level four

Ethical theories

LEVEL ONE: JUDGMENTS

Judgments are frequently made readily, based on information gained.
Judgments may have no real foundation except the belief of the individual, who
made it. In this case scenario the midwife could have made a judgement about
Mary before any real information had been gained. That judgement may have been
based on past experiences of requests.
LEVEL TWO: RULES
Rules govern our daily lives. When looking at ethics, rules are what guide
our practice and control our actions. Rules come in many forms and from many
sources. 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.
LEVEL THREE: PRINCIPLE
Principles are based on four main aspects that underpin general morality The
first o these is respect for autonomy.
The second principle is non-maleficence, interpreted as avoiding harm. It
could be said that.
The third principle is that of beneficence - doing good or balancing the
benefits against the harms in a situation.
The fourth principle, justice, means to be treated fairly.

LEVEL FOUR: ETHICAL THEORIES

Theories are taken to mean the two main ethical theories of utilitarianism
and deontology. Many texts outline these two theories as they are the most widely
used and form the foundation of much ethical decision making.
Utilitarian theory. 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.
Deontology. Deontology is the second of these theories Jones (2000) tells us
this term is from 'the Greek word 'deon' meaning duty.
CONSENT/INFORMATION GIVING
Informed consent is a relatively recent term; indeed, 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.
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.
lack of time
clients will forget
most clients do not want to know
most clients would not understand
it could be harmful if clients refused treatment based on information given
considering all these, gaining informed consent is .impracticable.
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
CARING
The public sees those who work in the health services as belonging to the
caring profession. It is usually accepted that health professionals care for their
clients and as such would always have their best interests in mind. But caring can
mean different things to different people/There is a need to be clear on what those
involved in providing care understand by the term caring.
It is suggested that doctors and nurses/midwives may have different ideas on
what constitutes caring. Doctors have traditionally followed the medical model of
care. This means that principles of beneficence and paternalism are more likely to
be followed by doctors in preference to the principle of autonomy, which is more
frequently associated with nurses' and midwives' style of care
EMPOWERMENT AND ADVOCACY
It has already been seen that an important part of the midwife's role is
supporting women and enabling them to exercise their autonomy. This is seen as
empowerment. This term is difficult to find in many ethical textbooks and a
dictionary definition is, 'to give power' and 'authorise'. Power is often a perception
of another's influence over someone or something. It has also been said that
knowledge is power. As health professionals, midwives are perceived as being
knowledgeable in the subject of midwifery and related health issues. It is
understandable then that many of their clients would see them as powerful people,
having influence over them and their pregnancies.
CHOICES
Having explored informed consent and caring, we find that much of what
has been said concerns the area of choices. Choices arid decisions are made every

day, most often without us thinking about them. Thompson et al (2000) suggest
that life events often "influence how we make decisions and also how we
"react to them. This is often true in our professional lives also, with past experience
playing a large part in our decision-making processes.
These are just a few from many. Whatever model is used. The important
things are to:
Be clear what die problem or decision is. This may take some time to sort
out. There is a need to, discuss the issues with a wide range of people.
Collect all relevant information. This may mean talking to many people to
gain an insight into the facts of a situation.
Weigh up the benefits or harms of a situation. Here it may help to call on the
principles of beneficence non-malencence: trying to do good while avoiding
harm.
COLLABORATIVE RELATIONSHIPS
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; such calls are now also being extended to
public health and social care.
For any partnership to work there is a need to build a trusting relationship.
Mutual trust and respect for each other's views and practices is important. For
some there is a need to break through the power barrier.
Trust and truthfulness are fundamental aspects of the work of any health
professional. Within ethics these are seen as virtues to be commended in a person.
When someone is trusted it is believed that the person will act in a proper manner
and make decisions for the right reasons.

LAW AND ETHICS

The position of law, ethics and reproductive health has "Been widely
explored. 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. In relation to informed consent, within law this is taken to mean the
reasonable person standard, or Bolam test. This means a person should be given as
much information as any reasonable person could be expected to understand. In
ethics, informed consent means full information before treatment; this is taken to
mean that a person should be given as much information as they may require to
make a decision.
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
health care professions often are left unsure of their legal position.
A real dilemma for maternity service staff is that of consent for Caesarean
sections: A pregnant woman cannot legally be forced to have a caesarean section
for a risk to the fetus because she is normally deemed as competent and the fetus
has no rights in law until it is born. In trying to save the life of a fetus, therefore,
health professionals are constrained by the law that protects its mother. This may
sound clear cut, but it is an uncomfortable position for those responsible for the
care of a woman who refused the intervention. While accepting the law, one's
personal code of ethics may be saying it is wrong to sit back and let a fetus die.
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. The underlying reason for the development of these within clinical
practice has been improvement in practices and the establishment of common
standards. It is important that midwives also become involved in these initiatives if
collaboration and cooperation between disciplines are to be promoted.
RESEARCH
Any examination of ethics would not be complete without also looking into
the ethical implications of research in the maternity services.

These

can

be

summarised as the 'five Cs'

Caring. Any research that is undertaken should be performed in a caring
manner. Those who are subjects of research should be able to expect the highest
standards of care and their care would not be adversely affected if they chose not to
participate.
Consent. This has to be gained prior to any research being undertaken.
Those involved in research should
'Five Cs' of ethical research
1. Caring
2. Consent
3. Confidentiality
4. Codes
5. Committees
know what the research is about, what it entails and-the risks, benefits and
alternatives.
Confidentiality. All research should maintain confidentiality of its subjects.
Taking part in research should not put any individual under the spotlight, or
highlighting the person in any way. If there were any need to disclose information

Codes. These are guidelines for practice. They make recommendations

about how practice should be governed in certain situations. There are ethical
codes related to research on human subjects. The' Department of Health issues
advice on these.
Committees. There are statutory committees set up to monitor and control
research involving human subjects within health care. These are called the Local
Research Ethics Committees (LREC),.as outlined in the above DoH report. Since
the publication of this all health authorities have a duty to establish such a
committee to review, monitor and control the research carried out within their
areas. Any health research carried out must be submitted to this committee within
the area it is to be carried out. If the research covered more than three health
authority areas a 'Multi-centred Research Ethics Committee' (MREC) should be
consulted (for details see the website www.corec.org.uk).
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
the
selves.
CURRENT ETHICAL ISSUES
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 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.

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
"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.
CONCLUSION
The area of ethics is growing and the need for health professionals to
become more aware of the issues involved is escalating.
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.
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. But in providing women with these things midwives also have 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.

Abstract Dealing appropriately with ethical problems, including noticing

:
when an ethical dilemma has arisen, is an important part of the
work of junior doctors. In 1998, teachers of medical ethics in UK
medical schools produced a consensus statement on the core
curriculum that should be delivered to medical students in order
to prepare them for this aspect of practice. A working group of the
Institute of Medical Ethics is in the process of reviewing and
updating this statement and it is anticipated that medical schools
will review their teaching programmes when the new statement is
published.
During their training at the University of Cambridge School of
Clinical Medicine, medical students submit reports of ethical
problems that they have encountered, on which educational
discussions of medical ethics are based. These discussions are an
important means of delivering the core curriculum during
attachments in Paediatrics and Obstetrics and Gynaecology. This
type of small-group discussion work is also an important
component of medical law and ethics education in other UK
medical schools. The relationship between the topics that the

students raise for discussion and those highlighted as important in

the consensus statement on the core curriculum has not been
described.
At the seminars in law and ethics, members of the research team
will outline the nature and purpose of the research study, and
then invite the students to indicate whether or not they give their
consent for their reflective portfolio items to be included in the
study dataset.
Consent will be indicated on forms to be collected and stored by
the GP Unit Data Manager (see below).
For all consents, the corresponding case reports will be
thematically analysed by the research team. (using what
procedure?)
The participants will be clinical medical students in the University
of Cambridge School of Clinical Medicine.

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