Legal and ethical aspects in midwifery

Legal and ethical aspects in midwifery

1. LEGAL & ETHICAL ISSUES
IN MIDWIFERY
Sridevi D
MscNursing (OBG)

2. INTRODUCTION
•Weliveinahighlylitigioussociety.Knowledgeof
thelawanditseffectontheHealthcaresystemis
essentialfortoday’spracticinginMidwifery.
•Midwivescanpro-activelyidentifylegalrisksand
developstrategiestoreducethem.
•Theprocessofcriticalexaminationoflegalrisks
canimprovematernalnewborncare.

3. Contd…
•Informedconsentisoneexample.
•Providinginformedconsentprotectsthehealth
careprofessionalsandalsoprovidesan
opportunityforeducation.

4. Definition of Law
•Lawisdefinedasthatwhichislaiddown,ordainedor
established(Black,1990).
•TheLawisabodyofrules,actionorconductprescribed
byacontrollingauthorityandhavingabindinglegal
force.
•It’sabodyofprinciples,rulesorstandards,commands
thatcauseapersontoactinacertainmanner.

5. ORIGINS OF LAW
•Lawisderivedfromoneofthethreesources:
legislation,judicialprecedentsorcaselawor
custom.
•NursepracticeActs:definethepracticeof
nursingandallowadministrativebodyto
imposevariousdisciplinaryactions.

6. CLASSIFICATION OF LAW
•Administrative Law -Licensing
•CIVIL LAW –Contract, Tort, Negligence
•CRIMINAL LAW –Assault, Fraud
•Nurses are very rarely involved in criminal actions
relating to delivery of nursing care.
•Civil laws are those laws serve to protect the interest
of the individual.

7. •WrongfulBirth/Wrongfullife:thehealthcare
providernegligentlycounseled,testedandtreated
themotherofchildregardinggeneticdefectsand
disabilities.Makingparentstobeunawareofthe
possibilityofthechild’shavinghereditary
condition,deprivingthemoftheopportunityto
choosenottoconceiveorabortthepregnancyor
negligencewasacauseofthechildbeingbornetc.

8. THEORIES OF LIABILITY
•UNINTENTIONALTORTS
•Professionalnegligence
•Lackofinformedconsent
•Negligentinflictionofemotionaldistress
•Wrongfuldeath–motherdiedasaresultof
malpracticeorfetuswasbornalive,butfailedto
survive.

9. INTENTIONAL TORTS
•SPOILATIONOFEVIDENCE:Destroying/damaging/
losingthepatientrecordseg.InOG–portionsoffetal
monitorstripsareunabletobelocated.
•BATTERY:Lackofinformedconsent
•FRAUD:Fraud:-anactthatmaycauseharmtoapersonor
property.E.g.-changingthedocumentationwhichhave
doneornotdoneinthepatientsheetforownmeans
•Intentionalinflictionofemotionaldistress

10. STANDARDS OF CARE
•Standardsarebasisfornursingpracticeandare
instrumentalindeterminingwhetherornotanurseis
foundnegligent.
•Nursingpracticeacts
•ANAStandards
•JCAHO(JointCommissiononAccreditationof
HealthcareOrganizations)
•Hospitalpolicies&procedures

11. Critical care obstetrics
•SOURCESOFLIABILITY
•Failuretoassessandmonitorpatientstatus
•Failuretointerveneeg.Changeinmaternalposition,
timelycommunicationwiththeDretc.
•Failuretodocumentaccuratelyandappropriately

12. •Failuretovalidatetheinformedconsent
•FailuretoappropriatelyuseTechnologyand
Equipment
•Improperuseofrestraints
•Improperadministrationofmedication

13. STRATEGIES TO LIMIT LIABILITY
•Standardsofcare
•Standingorders
•Organizationalsupportforstaffingandstaffdevelopment
•MaternalstabilizationandTransport
•Eg.Frequencyofmonitoringfetalmaternalcondition
duringfirststagelabour–lowriskevery30mtsandhigh
risk–15mts,secondstageevry15mtsforlowriskand5
mtsforhighriskmohers.

14. ANTENATAL PERIOD
•Diagnosis of pregnancy
•Antenatal check up and Detection of high risk cases
•Genetic testing
•Determination of Fetal sex
•Caring high risk & women with complications during
pregnancy
•AIDS in Obstetrics –Testing of HIV can only be done
after counselling and informed consent

15. INTRANATAL & POSTNATAL PERIOD
•Labour monitoring
•Use of Anaesthesia and Analgesia
•FHR Monitoring
•Use of Pitocin in labour
•Application of Fundal pressure
•Use of medication
•Maternal mortality & morbidity-Unsafe abortion,
Eclampsia, obstructed labour, PPH

16. •Childbirthisacheerfulprocess.Theadvancementin
geneticsandfetalsurveillanceandtechnology
improvementhasenhancedtheexpectationofpeople.
Theresponsibilities&dutiesofmaternitynurseis
importanttosavethelifeofmother&child.
•Todecreasetheriskofmalpracticewemustbecarefulto
accuratelyassessthepatient,followadevelopedplanof
careandbealertforsuddenchangesinmaternalorfetal
status.

17. Values/Ethics/Morals
•Valuesarestatementsofwhatweconsiderasan
ideal–itiswhatwehopetoachieve
•Moralsaretheruleswhichpeopleusetoguide
theirbehaviourandthinking
•Ethicsofferadirectionforactiontotakeplace
thatisderivedfromwhatisthedesiredoutcomes.

18. Definition of Ethics
•Ethics:Thestudyofvaluesinhumanconductorstudy
ofrightconduct.Itisanintellectualapproach–
critical,rational,systematictodeterminewhatisright
orbestinadifficultsituation

19. Ethical Problems
•Ethicalviolation–neglectofmoralobligation
•Ethicaldilemma–whenethicalreasonsbothforand
againstacourseofactionarepresent.

20. Meaning of Ethical Dilemma
•Ethical dilemma involves the need to choose from among two
or more morally acceptable courses of action, when one choice
prevents selecting the other; or, the need to choose between
equally unacceptable alternatives (Hamric, Spross, and Hanson,
2000).

21. Reasons for Ethical Dilemmas
•Advancesinmedicalandinformationtechnologies,
increasingeconomicstress,
•Renewedemphasisonteam-basedapproachestocare
•Expandingrolesfornursingprofessionals
•Medicalpaternalism
•Perspectiveofhealth

22. PRINCIPLES
•Asaprofessionalnurseormidwifeyoumust
demonstraterespectforpeople.
•Asaprofessionalnurseormidwifeyoumustbe
trustworthy
•Asaprofessionalnurseormidwifeyoumustpracticein
asafeandcompetentmanner
•Asaprofessionalnurseormidwifeyoumustmaintain
confidentialityandprivacy.

23. •As a professional nurse or midwife you must obtain consent
before you give any treatment or care
•As a professional nurse or midwife you must collaborate with
others in the team
•As a professional nurse or midwife you must act to identify
and minimize the risk to patients and clients

24. Ethical considerations in midwifery
•Priortoconception
•Relatedtothediagnosticprocedures
•Relatedtoabortion
•Relatedtothefetaltherapies
•Whilecaringforthesickmotherandneonate

25. Ethical issues prior to conception
•Artificialinseminationbydonor
•In-vitrofertilizationandembryotransfer
•Surrogatemotherhood

26. Artificial insemination by donor
•Writteninformedconsentbyallparties–wife,
husbandanddonor.
•Anonymityofallpartiesisrecommended.
•Physiciangiventherighttoselectthedonor.
•Consentinvolvesaclauseremovingliabilityfrom
healthprofessionalsifthechildisbornwith
abnormalities.

27. Couples ethical dilemmas
•Will their cultural and religious demands on their emotions
perhaps cause them to have doubts during their pregnancy?
•Will the potential father fully accept the child?
•Whether all the members of the health care team would
maintain confidentiality of donor details?

28. IVF -ET
•Themoralstatusofthefetus
•Safetyandefficacyoftheprocedure
•Fundingandcost

29. Surrogate motherhood
•Motherswhoneedmoneymaysellthemselves.
•Stressofinvolvingastrangerintheintimaterelationship
•Surrogatemayexperiencedepressionwhengivingupthe
child.
•Couplemaycontinuetherelationshipwiththemotherdueto
indebtedness
•Lineageofthechildrenmaybecomeconfusedandthefabric
ofthemarriagemaybedamaged.

30. Cont……
•Theamountofcontrolthecouplecanexertoverthe
surrogateisanissue.(mayregulatehernutritionand
lifestyle)
•Issuesrelatedtosurrogate’srighttoprivacyand
freedomofchoicecomeintoplay.
•Inconvenienceofsynchronizingthedonorand
recipient’scycles.

31. Ethical considerations in diagnostic procedures
•Amniocentesis–errorsofomissionorcommission
•Casestudyexample
Thecouple’sdilemmas:
Shouldtheyterminatethisverypreciouspregnancy
withtheknowledgethatthewomenmaynotbecome
pregnantagain?

32. •Isitbettertohaveababywithahandicapthannobaby
atall?
•Willtheybeabletocopeupwithahandicappedchild?
•Dilemmaofthemidwifewhenthecoupleaskfor
advice

33. Ethical considerations in abortion
•Abortingdamagedfetusesandnothealthyones.
•Whodetermineshealthyfetus?
•Pro-choiceadvocatesstressresponsibleuseof
contraceptives,anduseofamniocentesis
•Pro-lifeadvocatesbelievefetusishumanrightfrom
conceptionanddestroyingitisamurder.

34. Ethical considerations in caring for fetus, mother, sick
newborn
•Womenandherfetusareviewedastwotreatable
entities.
•Efficacyoffetalinterventionsandexperimentingon
fetusbasedonanimalresearchfindings–isthe
risk/benefitratiofavorable?
•Whowillberequiredtopayfortheseexperimental
procedures

35. Ethical issues surrounding the mother
•Whetherpregnantwomenmustbecompelled
bylawtoreceivemedicalorsurgicaltreatment
forthebenefitofthefetus?

36. The sick newborn
•Effectsofinvasiveproceduresandtheiriatrogenic
effects
•Newbornhasnochoicetorefusethetreatment
Ethicalquestions:
Shouldthelivesofcertainnewbornsbesavedonlytohave
themledthroughpain,disabilityanddeprivation?

37. •Shouldthenewbornwithmajoranomaliesbeleftto
die?Ifsowhomakesthedecision?
•Whatisthefamily’sroleinthisdecision?
•Whatkindofcaredoesonedenyorgiveanewbornto
allowdeathwithcomfortanddignity?

38. Nurses’ guide to make an ethical decision
•Ethicalprinciples
•Ethicaldecisionmakingmodel

39. ETHICAL DECISION-MAKING
FRAMEWORK
•M:message the dilemma
•O:outline the options
•R:resolve the dilemma
•A:act by applying the chosen option
•L:look back and evaluate the entire process

40. M:messagethedilemma
•Identifyanddefineissuesinthedilemma
•Determinewhoownstheproblem,theinformation,the
decision,andtheconsequencesofit.
•Establishthefactsasbestaspossible.
•Considertheoptions,values,andmoralpositionofthe
majorplayers.
•Identifyvalueconflicts

41. O:outlinetheoptions
•Examinealloptionsfully,includingthelessrealistic
andconflictingones
•Identifyprosandconsofalltheoptions
•Fullycomprehendtheoptionsandalternatives
available

42. R: RESOLVE THE DILEMMA
•Reviewtheissuesandoptions
•Applyethicalprinciplestoeachoption
•Decidethebestoptionforactionontheviewsofall
thoseconcerned
A: ACT BY APPLYING THE CHOSEN OPTION
•Implement the chosen option

43. L: LOOK BACK AND EVALUATE THE ENTIRE
PROCESS
•Evaluatetheentireprocess.
•Ensurethatallthoseinvolvedareabletofollow
throughonthefinaloption
•Revisethedecisionasindicated,startingtheprocess
withtheinitialstep.

44. Ethical decision making model
1.IdentifytheProblem
2.ApplytheCodeofEthicsfornurses
3.Determinethenatureanddimensionsofthe
dilemma
4.Generatepotentialconsequencesofalloptionsand
determineacourseofaction

45. 5.Considerthepotentialconsequencesofalloptionsand
determineacauseofaction.
6.Evaluatetheselectedcourseofaction.
7.Implementthecourseofaction

46. WAYS TO MINMISE LEGAL PROBLEMS
•Awareness of legal problems
•Good personal rapport & Communication
•Standards of care
•Appropriate training
•Proper counselling
•Informed consent
•Timely referral
•Record keeping
•Professional Auditing