Legal and ethical aspects in midwifery

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

2. INTRODUCTION
• We live in a highly litigious society. Knowledge of
the law and its effect on the Health care system is
essential for today’s practicing in Midwifery.
• Midwives can pro-actively identify legal risks and
develop strategies to reduce them.
• The process of critical examination of legal risks
can improve maternal newborn care.

3. Contd…
• Informed consent is one example.
• Providing informed consent protects the health
care professionals and also provides an
opportunity for education.

4. Definition of Law
• Law is defined as that which is laid down, ordained or
established ( Black, 1990).
• The Law is a body of rules, action or conduct prescribed
by a controlling authority and having a binding legal
force.
• It’s a body of principles, rules or standards, commands
that cause a person to act in a certain manner.

5. ORIGINS OF LAW
• Law is derived from one of the three sources:
legislation, judicial precedents or case law or
custom.
• Nurse practice Acts : define the practice of
nursing and allow administrative body to
impose various disciplinary actions.

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. • Wrongful Birth/ Wrongful life: the health care
provider negligently counseled, tested and treated
the mother of child regarding genetic defects and
disabilities. Making parents to be unaware of the
possibility of the child’s having hereditary
condition, depriving them of the opportunity to
choose not to conceive or abort the pregnancy or
negligence was a cause of the child being born etc.

8. THEORIES OF LIABILITY
• UNINTENTIONAL TORTS
• Professional negligence
• Lack of informed consent
• Negligent infliction of emotional distress
• Wrongful death – mother died as a result of
malpractice or fetus was born alive, but failed to
survive.

9. INTENTIONALTORTS
• SPOILATION OF EVIDENCE : Destroying/ damaging/
losing the patient records eg. In OG – portions of fetal
monitor strips are unable to be located.
• BATTERY : Lack of informed consent
• FRAUD:Fraud:- an act that may cause harm to a person or
property. E.g.- changing the documentation which have
done or not done in the patient sheet for own means
• Intentional infliction of emotional distress

10. STANDARDS OF CARE
• Standards are basis for nursing practice and are
instrumental in determining whether or not a nurse is
found negligent.
• Nursing practice acts
• ANA Standards
• JCAHO(Joint Commission on Accreditation of
Healthcare Organizations)
• Hospital policies & procedures

11. Critical care obstetrics
• SOURCES OF LIABILITY
• Failure to assess and monitor patient status
• Failure to intervene eg. Change in maternal position,
timely communication with the Dr etc.
• Failure to document accurately and appropriately

12. • Failure to validate the informed consent
• Failure to appropriately use Technology and
Equipment
• Improper use of restraints
• Improper administration of medication

13. STRATEGIES TO LIMIT LIABILITY
• Standards of care
• Standing orders
• Organizational support for staffing and staff development
• Maternal stabilization and Transport
• Eg. Frequency of monitoring fetal maternal condition
during first stage labour – low risk every 30 mts and high
risk – 15mts, second stage evry 15mts for low risk and 5
mts for high risk mohers.

14. ANTENATALPERIOD
• 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& POSTNATALPERIOD
• 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. • Childbirth is a cheerful process. The advancement in
genetics and fetal surveillance and technology
improvement has enhanced the expectation of people.
The responsibilities & duties of maternity nurse is
important to save the life of mother & child.
• To decrease the risk of malpractice we must be careful to
accurately assess the patient, follow a developed plan of
care and be alert for sudden changes in maternal or fetal
status.

17. Values/Ethics/Morals
• Values are statements of what we consider as an
ideal – it is what we hope to achieve
• Morals are the rules which people use to guide
their behaviour and thinking
• Ethics offer a direction for action to take place
that is derived from what is the desired outcomes.

18. Definition of Ethics
• Ethics: The study of values in human conduct or study
of right conduct. It is an intellectual approach –
critical, rational, systematic to determine what is right
or best in a difficult situation

19. Ethical Problems
• Ethical violation – neglect of moral obligation
• Ethical dilemma – when ethical reasons both for and
against a course of action are present.

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
• Advances in medical and information technologies,
increasing economic stress,
• Renewed emphasis on team-based approaches to care
• Expanding roles for nursing professionals
• Medical paternalism
• Perspective of health

22. PRINCIPLES
• As a professional nurse or midwife you must
demonstrate respect for people.
• As a professional nurse or midwife you must be
trustworthy
• As a professional nurse or midwife you must practice in
a safe and competent manner
• As a professional nurse or midwife you must maintain
confidentiality and privacy.

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
• Prior to conception
• Related to the diagnostic procedures
• Related to abortion
• Related to the fetal therapies
• While caring for the sick mother and neonate

25. Ethical issues prior to conception
• Artificial insemination by donor
• In-vitro fertilization and embryo transfer
• Surrogate motherhood

26. Artificial insemination by donor
• Written informed consent by all parties – wife,
husband and donor.
• Anonymity of all parties is recommended.
• Physician given the right to select the donor.
• Consent involves a clause removing liability from
health professionals if the child is born with
abnormalities.

27. Couplesethicaldilemmas
• 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
• The moral status of the fetus
• Safety and efficacy of the procedure
• Funding and cost

29. Surrogate motherhood
• Mothers who need money may sell themselves.
• Stress of involving a stranger in the intimate relationship
• Surrogate may experience depression when giving up the
child.
• Couple may continue the relationship with the mother due to
indebtedness
• Lineage of the children may become confused and the fabric
of the marriage may be damaged.

30. Cont……
• The amount of control the couple can exert over the
surrogate is an issue. (may regulate her nutrition and
life style)
• Issues related to surrogate’s right to privacy and
freedom of choice come into play.
• Inconvenience of synchronizing the donor and
recipient’s cycles.

31. Ethical considerations in diagnostic procedures
• Amniocentesis – errors of omission or commission
• Case study example
The couple’s dilemmas:
Should they terminate this very precious pregnancy
with the knowledge that the women may not become
pregnant again?

32. • Is it better to have a baby with a handicap than no baby
at all?
• Will they be able to cope up with a handicapped child?
• Dilemma of the midwife when the couple ask for
advice

33. Ethical considerations in abortion
• Aborting damaged fetuses and not healthy ones.
• Who determines healthy fetus?
• Pro-choice advocates stress responsible use of
contraceptives, and use of amniocentesis
• Pro-life advocates believe fetus is human right from
conception and destroying it is a murder.

34. Ethical considerations in caring for fetus, mother, sick
newborn
• Women and her fetus are viewed as two treatable
entities.
• Efficacy of fetal interventions and experimenting on
fetus based on animal research findings – is the
risk/benefit ratio favorable?
• Who will be required to pay for these experimental
procedures

35. Ethical issues surrounding the mother
• Whether pregnant women must be compelled
by law to receive medical or surgical treatment
for the benefit of the fetus?

36. The sick newborn
• Effects of invasive procedures and their iatrogenic
effects
• Newborn has no choice to refuse the treatment
Ethical questions:
Should the lives of certain newborns be saved only to have
them led through pain, disability and deprivation?

37. • Should the newborn with major anomalies be left to
die? If so who makes the decision?
• What is the family’s role in this decision?
• What kind of care does one deny or give a newborn to
allow death with comfort and dignity?

38. Nurses’guide to make an ethical decision
• Ethical principles
• Ethical decision making model

39. ETHICALDECISION-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: message the dilemma
• Identify and define issues in the dilemma
• Determine who owns the problem, the information, the
decision, and the consequences of it.
• Establish the facts as best as possible.
• Consider the options, values, and moral position of the
major players.
• Identify value conflicts

41. O: outline the options
• Examine all options fully, including the less realistic
and conflicting ones
• Identify pros and cons of all the options
• Fully comprehend the options and alternatives
available

42. R: RESOLVE THE DILEMMA
• Review the issues and options
• Apply ethical principles to each option
• Decide the best option for action on the views of all
those concerned
A: ACT BY APPLYING THE CHOSEN OPTION
• Implement the chosen option

43. L: LOOK BACKAND EVALUATE THE ENTIRE
PROCESS
• Evaluate the entire process.
• Ensure that all those involved are able to follow
through on the final option
• Revise the decision as indicated, starting the process
with the initial step.

44. Ethical decision making model
1. Identify the Problem
2. Apply the Code of Ethics for nurses
3. Determine the nature and dimensions of the
dilemma
4. Generate potential consequences of all options and
determine a course of action

45. 5.Consider the potential consequences of all options and
determine a cause of action.
6.Evaluate the selected course of action.
7.Implement the course of action

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