Ethico-Moral considerations of maternal and child practice

Ethical and Social issues in peri-natal nursing

The following discussion is a largely referenced synthesis of the article “Ethical

Issues in Maternal and Child Health Nursing: Challenges Faced by Maternal and Child

Health Nurses and Strategies for Decision Making” by Aderemi R. A. I’ve referred my

report from the said article because it was comprehensive regarding the topic I was

assigned to discuss. The topics discussed and its flow follows the presentation of topics

in the referenced material. I highly recommend reading the sourced article for a more

elaborate discussion of the topics, and better reading experience and studying.

INTRODUCTION

Maternal and child nursing is a wide and dynamic area of nursing practice. As

such, it cannot be avoided that health care practitioners of such nursing practice face

challenges every day, as they interact with individual clients and families. Most of which

involve ethical and social issues. Thus, it is important for health care providers to be

guided and be able to reflect safe and evidence-based nursing care in maternal and child

nursing, that is responsive to the needs of women and families.

ETHICAL PRINCIPLES AND FRAMEWORKS

According to Aderemi (2016), “ethical principles are a set of rules that can be

applied to all situations.[9] They provide a framework for helping nurses and others

evaluate ethical issues… Nurses are autonomous professionals who are required to

provide ethically competent care.”

Aderemi mentions that some ethical principles related to patient care include:

• Autonomy - the right to self determination

• Respect for others - principle that all persons are equally valued

• Beneficence - obligation to do good

• Nonmaleficence - obligation to do no harm

• Justice – principle of equal treatment of others or that others be treated fairly

• Fidelity - faithfulness or obligation to keep promises

• Utility - the greatest good for the individual or an action that is valued.

Aderemi further discusses that “the ethical principles that guide ethical action include

four primary moral principles: respect for beneficence, non-maleficence, justice, and

autonomy, which upholds the rights of individuals and families.”

“An ethical dilemma is a choice that has the potential to violate ethical principles. In

nursing, it is often based on the nurse’s commitment to advocacy. Action taken in

response to our ethical responsibility to intervene on behalf of those in our care is patient

advocacy. Advocacy also involves accountability for nurses’ response to patients’

needs.” (Aderemi, 2016) As much as medical practitioners are concerned, maternal

nursing is unique in the aspect wherein they are concerned about the well being of both

the woman and the fetus, making the maternity’s nurses’ effort to uphold their advocacy

more challenging.

The following are clinical examples of perinatal ethical dilemmas mentioned by Aderemi:

• Court-ordered treatment

• Withdrawal of life support

• Harvesting of fetal organs or tissue

• In vitro fertilization and decisions for disposal of remaining fertilized ova

• Allocation of resources in pregnancy care during the previable period

• Fetal surgery

• Treatment of genetic disorders or fetal abnormalities found on prenatal screening

• Equal access to prenatal care

• Maternal rights versus fetal rights

• Extraordinary medical treatment for pregnancy complications

• Using organs from an anencephalic infant

• Genetic engineering

• Cloning
• Surrogacy

• Drug testing in pregnancy

• Sanctity of life versus quality of life for extremely premature or severely disabled

infants

• Substance abuse in pregnancy

• Borderline viability: to resuscitate or not

• Fetal reduction

• Preconception gender selection

Key points to remember regarding ethical dilemma:

• “Ethical dilemma” refers to when there is difficulty in deciding which action takes

precedence over the other, while a “dilemma” has been described as a situation

requiring a choice between what appears to be equally desirable and or

undesirable alternatives.

• Ethical dilemmas occur in maternal and child health nursing (and are common in

perinatal and neonatal care) because the wellbeing of mother and her neonate

must be considered.

As technologies and sciences rapidly advance, along with it comes difficult questions

that that challenge the ethics in maternal nursing. What treatment is in the best interest

of a client? Who decides? What is the role of the nurse as client advocate? What is the

legal liability of the hospital ethical committing regarding the decision?

ETHICAL APPROACHES

According to Aderemi, “clinical situations arise where ethical principles conflict with each

other. Consideration of ethical approaches can help nurses as they encounter ethical

dilemmas. There are a variety of ethical approaches.” Aderemi mentions the following

key approaches:
 The Rights Approach The Utilitarian Approach
Focuses on the individual’s right to The approach posits that ethical actions
choose, of which includes: are those that provide:
• the right to privacy • the greatest balance of good over
• the right to know the truth evil
• the right to be free from injury or • the greatest good for the greatest
harm number.

ETHICAL ISSUES AND CHALLENGES IN MATERNAL AND CHILD HEALTH

NURSING

“Maternal and child health issues often involve conflicts in which a woman behaves in a

way that may cause harm to her fetus or is disapproved of by some or most members of

society. Conflicts between a mother and fetus occur when the mother’s needs, behavior,

or wishes may injure the fetus. Healthcare workers and society may respond to such a

woman with anger rather than support. However, the rights of both mother and fetus must

be examined.” (Aderemi, 2016)

Aderemi discusses several areas of particular importance to the health care of women

and children…

The most obvious instances involve abortion, assisted reproduction (artificial insemination, invitro
fertilization and embryo transfer, and surrogate parenthood), selective reduction in multifetal
pregnancy, intrauterine treatment of foetal conditions, substance abuse, and refusal to follow the
advice of caregivers.[21] Health care workers and society may respond to such a woman with anger
rather than support. However, the rights of both mother and fetus must be examined. Several areas are
of particular importance to the health care of women and children.

Abortion

• Abortion is a volatile, legal, social, and political issue.

• It has become a hotly debated political issue that separates people into two camps:

prochoice and pro-life. The pro-choice group supports the right of any woman to

make decisions about her reproductive functions based on her own moral and

ethical beliefs. The pro-life group feels strongly that abortion is murder and

deprives the fetus of the basic right to life.

• Nurses are taught to be supportive client advocates and to interact with a nonjudgmental attitude
under all circumstances. However, nurses have their own
personal and political views, which may be very different from those of their clients.

• Nurses need to clarify their personal values and beliefs on this issue and must be

able to provide non biased care before assuming responsibility for clients who

might be in a position to consider abortion. Their decision to care for or refuse to

care for such clients affects staff unity, influences staffing decisions, and

challenges the ethical concept of duty.

• The ANA’s Code of Ethics for Nurses upholds the nurse’s right to refuse to care

for a client undergoing an abortion if the nurse ethically opposes the procedure.

Nurses need to make their values and beliefs known to their managers before the

situation occurs so that alternative staffing arrangements can be made.

• Nurses need to understand abortion laws and the conflicting beliefs that divide

society on this issue.

• Implications for nurses

Nurses have several responsibilities that cannot be ignored in the conflict

about abortion.

o They must be informed about the complexity of the abortion issue from a

legal and an ethical standpoint and know the regulations and laws in their

state.

o They must realize that for many people, abortion is an ethical dilemma that

results in confusion, ambivalence, and personal distress.

o They must also recognize that for many others, the issue is not a dilemma

but a fundamental violation of the personal or religious views that give

meaning to their lives.

o Finally, nurses must acknowledge the sincere convictions and strong

emotions of those on all sides of the issue.

• Substance abuse for any person is a problem, but when it involves a pregnant

woman, substance abuse can cause fetal injury and thus has legal and ethical

implications.

• In some instances, courts have issued jail sentences to pregnant women who

caused harm to their fetuses. This punitive approach to fetal injury raises ethical

and legal questions about the degree of governmental control that is appropriate

in the interests of child safety

Fetal therapy

• Some argue that medical technology should not interfere with nature, and thus this

intervention should not take place.

• The risks and benefits of surgery for major fetal anomalies must be considered in

every case… Yet despite the risks, successful fetal surgery may result in birth of

an infant who could not otherwise have survived.

• Parents need help to balance the potential risks to the mother and the best

interests of the fetus. As with any situation involving informed consent, women

need adequate information before making a decision.

Informed consent

• Informed consent has four key components: disclosure, comprehension,

competency, and voluntariness.

• It occurs prior to initiation of the procedure or specific care and addresses the legal

and ethical requirement of informing the client about the procedure. The physician

or advanced practice nurse is responsible for informing the client about the

procedure and obtaining consent by providing a detailed description of the

procedure or treatment, its potential risks and benefits, and alternative methods

available.

• Refusal of medical treatment

All clients have the right to refuse medical treatment (based on the American

Hospital Association’s Bill of Rights). In the case of a child, parental autonomy (the
right to decide for or against medical treatment) is a constitutionally protected right.

• Ideally, medical care without informed consent should be used only when the life

of a client is in danger.

• Refusal of treatment may occur when the treatment conflicts with religious or

cultural beliefs. In these cases, it is important to educate the client and family about

the importance of the recommended treatment without coercing or forcing the

client to agree.

Confidentiality

• In maternal and child health care, information is shared only with the client, legal

partner, parents, legal guardians, or individuals as established in writing by the

client or the child’s parents.

• This law promotes the security and privacy of health care and health information

for all clients.

Selective reduction

Induced ovulation and invitro fertilization sometimes result in multifetal pregnancies. If the

Number exceeds the woman's ability to carry them to the point where they can survive

outside the uterus, physician may recommend selectively terminating one or more

fetuses. In these situations, the ethical dilemmas are much the same as they are for

abortion. Further complicating the issue is that these are long awaited, desired children.

It may be done by potassium chloride injection through needle injection, mere mechanical

Intrauterine treatment of fetal conditions

Advances in intrauterine diagnosis of fetal malformations have led to new, albeit still

experimental, development in intrauterine fetal surgery aimed at improving fetal

outcomes. These new treatments raised ethical and legal questions about maternal vs

fetal rights. Who has the right to give consent? Can a court of law override the mother's

wish if she says ''no''? Similar ethical dilemmas arise during labor if a mother refuses

cesarian section although it is clearly (in the judgement of the health care provider) in the

best interest of her fetus.

• The availability of contraception that does not require taking a regular oral dose,

such as using a hormone-releasing patch or having hormone injections, has led to

speculation about whether certain women should be forced to use this method of

birth control.

• Some people believe that mandated contraception is a reasonable way to prevent

additional births to women who are considered unsuitable parents and decrease

government expenses for dependent children.

• Requiring poor women to use contraception to limit the money spent supporting

them is legally and ethically questionable and does not address the obligations of

the children’s father. Such a practice interferes with a woman’s constitutional rights

to privacy, reproduction, refusal of medical treatment, and freedom from cruel and

unusual punishment. In addition, medication may pose health risks to the woman.

• Access to free or low-cost information on family planning would be more

appropriate and ethical.

Fetal injury

• If a mother’s actions cause injury to her fetus, the question of whether she should

be restrained or prosecuted has legal and ethical implications.

• However, forcing a woman to behave in a certain way because she is pregnant

violates the principles of autonomy, self-determination of competent adults, bodily

integrity, and personal freedom. Because of fear of prosecution, this practice could

impede, not advance, health care during pregnancy.

• The punitive approach to fetal injury also raises the question of how much control

the government should have over a pregnant woman. The decision of just how

much control should be allowed in the interests of fetal safety is difficult.

Infertility treatment

• Perinatal technology has found ways for some previously infertile couples to bear

children. Many techniques are more successful, but ethical concerns include the
high cost and overall low success of some infertility treatments.

• Other ethical concerns focus on the fate of unused embryos. Should they be frozen

for later use by the woman or someone else or used in genetic research? What if

the parents get divorced or die? Who should make these decisions?

STRATEGIES FOR MAKING ETHICAL DECISIONS

Ethical decision-making process

According to Aderemi, “ethical decision making is a step-to-step process of analytical and

intellectual reasoning that is used in making a choice in situations of ethical problem.

Thus, responsible ethical reasoning is rational and systematic. It is an application of

problem-solving process guided by ethical principles and codes. The best ethical decision

is one that protect the best interest of the client and also reserve the integrity of all

concerned.

Aderemi suggest the following steps to help guide a nurse in decision making:

Steps in ethical decision-making in nursing

• Identify the process or clarify the ethical dilemma - this is described as identifying

the problem.

• Gather additional data - to analyze the causes and consequences of the problem,

get as much detailed information about the situation as possible to enable you

make an informed decision.

• Explore optional solutions to the problem - identify options. Identify all the possible

courses of action open to you and weigh the outcome of each when considering

immediate consequences to the people involved as well as long term

consequences to the institution and society.

• Make a decision - think through options identified. Some will be more feasible than

others. Determine which option is most acceptable to you. The best decision is

regarded as one, which is consistent with one's values and does not involve risking
one's life or violating the law. In relation to professional ethics, a good decision is

one that is in the client's best interests and at same time preserves the integrity of

all involved. These decisions must be guided by ethical principle and code of the

profession. Rely on those principles, which you judge to be most important and of

which you feel most sure.

• Act - implement the selected solution. Carry out decision. You may collaborate with

others to implement the decision just as you did to identify the options.

• Evaluate the result - after acting on decision, evaluate its impact, compare the

actual with the anticipated outcome. Through feedback mechanism, ethical

decision making become primarily an educational process. Responsible ethical

reassessing is rational and systematic, based on ethical principles and codes

rather than emotion, intuition, fixed policies or precedent.

Role of nurse in ethical decision making

Aderemi summarized these as right to:

• Identify ethical issues in practice

• Advocate on behalf of patients and families.

• Inform and involve patients in ethical decisions

• Participate in formal and informal processes that address ethical issues

• Evaluate processes

The roles of the nurse in clinical ethical decision making

Recognizing that nurses have both responsibilities and rights to care for the whole person,

we believe that nurses have a responsibility to:

• Be aware of personal values and how they relate to professional practice.

• Develop a basic knowledge of ethical principles and concepts.

• Understand processes and resources available to assist them in ethical decision

making.

• Be aware of the changing legal and health care policy issues to be considered

during ethical decision making.

(Aderemi, 2016)

“Summarily, an ethical dilemma is a condition of no clear "right" or "wrong" resolution.”

- Aderemi (2016)

CONCLUSION

Aderemi concludes that “maternal and child health nurses are faced with complex

ethical issues. Moral courage and advocacy for women and children are necessary

tools to help manage the associated distress. Nurses should adhere to standard

professional ethics in health care decision making.”