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Chapter 11 Values, ethics and advocacy
b. Think the ethical problem through
Basic moral principles
: The good of patients (beneficence) should be the midwife’s primary concern; this strongly sug-
gests that the midwife should act, but it does not address the midwife’s obligation to do so if she feels it would jeopardise
her own good (job security).
Respect for persons would suggest that the patient’s autonomy (right to self-determination) should be respected
unless there is strong justification for not doing so.
Justice would suggest that whether a patient pays the obstetrician privately should have no bearing on the quality of
care received.
Care-based ethics would obligate Jean to serve as an effective advocate for her patient, respecting the midwive’s com-
mitment to be faithful to the clinician–patient relationship.
c. Make a decision
Jean feels from past interactions with this obstetrician that her speaking up will not influence his decision to have the
patient put to sleep. She decides to speak with the obstetrician after the delivery and follow up with whatever approach
is necessary to avoid recurrence.
Steps 4–5: Implement and evaluate your decision
Jean will never know if speaking up would have resulted in the woman’s wishes being respected. Although she is dis-
satisfied with the outcome of this case, she hopes to prevent this from happening to other public patients in the future.
In this instance, a hospital committee was formed to study the problem and make recommendations. If Jean had been
told to ‘mind her own business unless she wanted trouble’, she would have to make a decision weighing patient benefit
on one hand with potential personal risk or harm on the other.
BOX 11-5 Resolving ethical conflict: A care study
(continued)
ences family members and significant others will be better
able to appreciate how this influences decisions about care,
and can bring this information to the interdisciplinary team.
This is especially true for midwives, who play such a direct
role in family care.
Relationship between clinicians and patients
The healing encounter is central to nursing ethics. In
nursing, reasoning ethically about what action to take is
always done in the context of the relationships, which hold
us accountable to patients and their families, and the profes-
sional carers with whom we work. Much ethical distress for
nurses results from the strong conviction that we owe indi-
vidual patients more than present work environments allow
us to deliver.
Professional integrity of clinicians
While the International Council of Nurses’ Code of Ethics
for Nurses (see Box 11-3) clearly states that the primary
commitment of the nurse is the patient, it also states that the
nurse owes the same duties to self as to others—including
the responsibility to preserve integrity, to maintain compe-
tence, and to continue personal and professional growth.
Nurses should think long and hard when they find them-
selves asked to sacrifice personal integrity to meet the needs
of another. The midwifery codes of ethics in Australia and
New Zealand also state the same principles.
of treatment and what are the related harms, since their
relationships with patients enable them to see more than
physiological effects.
Disclosure, informed consent and shared
decision making
There are three basic models of healthcare decision making.
In the
paternalistic mode
l, clinicians acting to benefit the
patient decide what ought to be done and inform the patient,
and the patient’s role is to comply. In the
patient sovereignty
model, patients or their surrogates, expressing their right to
be autonomous, tell the clinician what they want, and the
clinician’s role is to comply. Most ethicists reject these
models in their extremes and recommend a model of shared
decision making, which respects and uses the preferences of
the patient and the expertise and judgement of the clinician.
The objectives of all clinical decision making are to secure
the health and well-being of the patient and that the deci-
sions honour and respect the integrity of all participants in
the decision-making process. Nurses and midwives can play
an important role in ensuring that patients and their surro-
gates receive the information and support they need to make
healthcare decisions that secure their interests.
Norms of family life
Most patients do not present as isolated individuals. Nurses
who are sensitive to how a person’s injury or illness influ-
