Tomorrow's Ethics for Today's Practice

The new millennium, with its ever-increasing advances in information and biomedical technologies, can be a stressful time for women, their families, and those who provide health and illness care services. Public and private discussions are questioning the very foundations of what it means to be a moral agent or ethical person and how to promote a moral or ethical society where all have a positive right to a predetermined basic level of health and illness services. Should our society continue its support of the ethical concept of autonomy and individual self-determination—rights, without due consideration and balance of what is best for society as a whole?1 What about those individuals and families who are poor, disenfranchised or marginalized, and required to fend for themselves when it comes to health services that are a market commodity rather than a social “good” in the United States? Midwives and other women's health care practitioners know that our most vulnerable populations are women and children and that the United States is the only industrialized country that does not guarantee access to prenatal care and other childbearing services—an embarrassment for those committed to making pregnancy and birth safer for all women and their newborns.2 This home study issue focuses on everyday ethical concerns surrounding the health of women and services provided for women. The focus of this issue is continued learning in ethics for the experienced clinician. Our society is riding the crest of a new wave of technologies, including the human genome project, which is raising more questions than answers when it comes to understanding how the human body works. Everyday experiences of midwives and other health professionals working with women throughout their lives are addressed. Selected authors provide information on the need to know how to think through and process complex issues and how to make decisions that affect the very core values and rights of both women seeking health care and the professionals who serve them. We can no longer ignore the need to be competent in moral reasoning and ethical decision making, because ethical practice is the essential core of being a professional.3 Professional health care providers caring for women need to understand both the foundations of ethics (theory base) and the application of this understanding in daily practice (applied ethics). One of the goals of this home study on ethics is to encourage midwives and other health professionals to read, explore, discuss, and apply a new understanding of what it takes to be a professional today and tomorrow. The series of articles in this issue begins with foundational content: a human rights framework in midwifery practice is described in the first article by Joyce Thompson CNM, DrPH, also guest editor of the series. Rosemary Mann, CNM, JD, PhD, addresses the important interface of law and ethics in reproductive health, and Anne Thompson, RM, RN, MTD, provides a vital international perspective on the teaching of ethics. Judith Fullerton, CNM, PhD, and Georgia Sadler, PhD, MBA, focus on research ethics and the ethical implications of including women in clinical trials. Following this overview of ethics theory as applied to health care of women, the issue continues with a focus on the application of ethics in practice. Because communication and values clarification are essential components of the “how” to practice ethically, there is a large section of content on counseling—the what, how, why, and when of sharing information with clients in a variety of situations as well as the impact of that information sharing on women and their families. Margaret Commerford-Freda, EdD, RN, CHES, lays the groundwork on counseling techniques, and Marcia Van Riper, RN, PhD, and Wendy McKinnon, MS, CGC, address ethical concerns present in genetic testing and counseling for breast and ovarian cancer susceptibility. Elena Gates, MD, focuses on risks and counseling related to prenatal testing, and Lisa Mitchell, PhD, describes Canadian women's experiences with unexpected ultrasound findings of fetal abnormalities or demise. This section on ethical concerns within reproductive health is completed by the article by Janet Singer, CNM, MSN, which addresses one of the more emotional and difficult ethical issues in the field: options counseling for women with unintended pregnancies. As the reader will realize, addressing ethics in daily practice is very complex and often difficult. Prenatal and labor care are among the most basic activities of midwives and are certainly areas requiring ethical decision making on a daily basis. The final section of this issue provides practical advice on how to analyze the ethical dimensions of one's practice using a prenatal case example analyzed by Deborah Narrigan, CNM, MSN, and an analysis of an ethical approach to the discussion and use of pain relief techniques during labor by Nancy Lowe, CNM, PhD. The final article is an invited commentary by Patricia Benner, RN, PhD, on the dangers of geneticism— what may be seen as the frontier of tomorrow's ethics. A brief disclaimer is indicated when it comes to producing this home study on ethics. When it comes to selecting the relevant content to be included in a limited publication, one is placed in a difficult position. There simply is not enough room to include everything needed to understand both the theoretical foundations (the “why” of ethics) as well as the application (the “how”) of moral reasoning and ethical decision making in clinical practice. The obvious gaps not covered in this issue of JMWH include ethics theory, values development and clarification, professional codes of moral behavior or conduct, and the ethics of health/public policy. The reader with limited knowledge of these is referred to the Resources for Clinicians column and the printed version of the International Confederation of Midwives' International Code of Ethics for Midwives (1999 revision) and the American Nurses Association Code for Nurses 2003. As this issue is going to press, the American College of Nurse-Midwives (ACNM) Code of Ethics for Midwives 1990 is under revision, considering some of the new ethical concerns raised by global attention to human rights, safer pregnancy and birth, and personal accountability in counseling women with ever-emerging genetic information. Everyday ethical concerns raised in midwifery (women's health) practice span the entire range of health care ethics. This includes one's decision in how much time to spend with a given woman/family in view of other responsibilities, how and what information to share to promote informed decision making, and how to resolve one's personal value conflicts when a woman asks for information or a service you cannot support. Maintaining confidentiality; understanding the rights, duties, and obligations of the professional; acknowledging client self-determination and responsibilities; conducting informed consent; and recognizing the interface of law and ethics in health care are but a few of the ethical issues that arise in the daily practice of midwives. I close with a request that the reader “listen” to the voices of women and families—their poignant stories—included in these articles, that you “hear” their concerns and the concerns of the midwives caring for and with them, and above all, that you “act” responsibly/ethically, following the moral code of the profession and principles of accountability that result from being a moral agent—a professional midwife—who knows, understands, and practices in an ethical manner at all times! These are exciting times for women and their health services, and it is hoped that this ethics home study will peak your interest in learning more about tomorrow's ethics for today's midwifery practice.

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