I am just back from an amazing conference. The 56th annual meeting of the American College of Nurse Midwives was held in San Antonio last week, ending yesterday. One speaker, Dr. Andrew Kotaska, was so well-received that the conference added a repeat of his standing-room-only presentation entitled “When Autonomy and Beneficence Collide”. Dr. Kotaska works as an obstetric consultant in Yellowknife, Northwest Territories. 700 miles from the nearest tertiary care center, he is dedicating his services to making sure the women of his district are well-cared for and supported in their childbirth choices. I’d like to highlight here the most important points of Dr. Kotaska’s speech.
It’s important to understand how we are defining the terms “autonomy”, “beneficence”, and “non-maleficance”. The University of Colorado San Francisco School of Medicine has an interesting webpage about the ethics of medicine. It defines these terms, and places them in a clinical context: how do we balance the principle of “first do no harm” with the principle of supporting our patient’s autonomy?
For the purposes of this discussion, we’ll say that autonomy means the patient’s right to make her own decisions about her medical care. “Beneficence is action that is done for the benefit of others. Beneficent actions can be taken to help prevent or remove harms or to simply improve the situation of others. Non-maleficence means to ‘do no harm.’ Physicians must refrain from providing ineffective treatments or acting with malice toward patients. This principle, however, offers little useful guidance to physicians since many beneficial therapies also have serious risks. The pertinent ethical issue is whether the benefits outweigh the burdens.” UCSF School of Medicine Ethics Fast Facts.
Dr. Kotaska posed the question, how does a physician or midwife stay with a patient when she declines your recommendations? The “therapeutic alliance”, or the relationship between the provider and the patient, needs to be carefully protected. Yet few physicians understand the importance of guarding the therapeutic alliance, and instead, protect their own interests.
In the May 2011 issue of Obstetrics and Gynecology, a commentary entitled Obstetric ethics: An essential dimension of planned homebirth contains this quote: “Pregnant women also have beneficence-based obligations to the fetal patient, and the child it is expected to become, to take reasonable clinical risks. When a clinical intervention is expected to benefit the fetus and the child it is expected to become, and there are not unreasonable clinical risks to the pregnant woman, she is ethically obligated to accept and authorize such clinical intervention.” That statement chills me to the bone. Ethically obligated to accept and authorize the clinical intervention your doctor recommends? The fact that the authors of the commentary go on to cite the now thoroughly-debunked Wax study as evidence that home birth should not be allowed gives me pause when it comes to embracing the idea that a pregnant woman is obligated to accept whatever clinical intervention her doctor thinks will benefit the fetus.
Dr. Kotaska argues that we need to promote the policies that systems like those Britain and Ontario, Canada have adopted. The Royal College of Midwives policy is “If a woman rejects your advice, you must continue to give the best care you possibly can, seeking support from other members of the health care team as necessary”.¹ Midwives in these areas do not have to remove themselves from their patients’ care (effectively abandoning them), but are expected to continue to support and care for the woman even if she refuses to follow the midwife’s advice.
Dr. Kotaska urges providers to “explicitly state your commitment to her [the woman's] autonomy over your idea of beneficence”. He emphasizes that each provider should embrace these three points:
- Your job, as a provider, is to inform your patient
- She is free to decline your recommendations
- She will not lose your support if she declines your recommendation
What is the result of a provider maintaining this type of attitude with their patient? Dr. Kotaska asserts that women trust these providers because they have not threatened the therapeutic alliance. He also stated that “informed consent” is not truly an informed consent if the woman will not be supported in her choices. For example, giving a woman informed consent about the risks and benefits of a trial of labor after cesarean, while telling her that your hospital does not allow VBACs, is not truly giving her an informed consent because she has only one option.
When asked how a woman should respond when she is refused a trial of labor, Dr. Kotaska replied that a woman should create her own “informed consent” form that she asks the provider to sign. It should state that:
- she does not want a repeat cesarean section
- she is aware of the potential risks of a repeat c-section, including placenta accreta, hemorrhage, increased risk of stillbirth, infection, increased risk of maternal death, and four-fold increases in neonatal respiratory distress
- she is not being offered a choice of how she will give birth
- if she experiences any complications as a result of being forced to have a c-section, she will be pursuing legal action against the provider who would not support her in a trial of labor.
With this proposal, Dr. Kotaska received a standing ovation from the midwives attending his presentation. What was clear to me is that midwives and mothers are fed up with the status quo in modern obstetric care today, and if change will only happen through women creating an informed consent form they ask their provider to sign, so be it. It’s time for a birth revolution, and it has to start with midwives, mothers, and a few progressive physicians who are not afraid to challenge the status quo.
1. Royal College of Midwives. Nursing and Midwifery Council (Midwives) Rules & Standards. London: Author, 2004. Accessed
May 29, 2011. Available at: http://www.nmc-uk.org/Documents/Standards/nmcMidwivesRulesandStandards.pdf.