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.
It is time women use their voices loud and clear and demand that their choices are followed and respected. As a mother of 4, my desire was that my unborn children had the best chance for survival and I fought for that right. I look at outcomes, percentages and use a prayer and intuition and choose where I felt was the safest birth place for both of us. I have had 4 all natural births with one homebirth. All were equally amazing! I was very clear what I expected and had a wonderful supportive husband who made sure my wishes were followed.A woman must take personal responsibility and be well practiced and prepared if she is to have an all natural or even a vaginal birth… particularly in this medical climate. It is our right to have our children where we choose and how we choose, home or hospital and for that matter, doctor or midwife. It is time for change, growth, and unity
I hate the divide-and-conquer attitude inherent in that quote from the O and G commentary you cite above. Besides legal issues, and the difficulty of defining what’s “reasonable” (to whom?), it also ignores the fundamental physical, emotional and some may say spiritual interconnectedness of mothers and their babies as well as their families. One situation I’ve been thinking about is having a c-section when you already have a living, breathing child. Would the ethical thing to do be to potentially sacrifice your own life (increased mortality rate from c-section), so that both children may live, but without their mother (and for the partner to be a single parent)? Or do I protect my ethical obligations to my already existing child to mother her? I sure hope I never have to make this choice…clearly a loss of a baby would be devastating, but I also don’t feel like it would be fair to deprive my daughter of her mother…it’s these gray zones that creep up all over the place when it comes to maternity care, and so far I haven’t seen a systematic and nuanced enough discussion of those ethical issues beyond the dead baby card and charges of maternal selfishness.
VW, that scenario of risking a c-section with living children is what has brought me to demand a VBA2C now. With my youngest, my non-researched, uneducated belief was that a VBAC was more likely than a repeat c-section to leave my living children without a mothher; it was the strongest reason I held for my choice to elect a repeat c-section. Now, having done some research and having more factual information on the various risks of repeat c-sections and VBACs, I know that I took the riskier option last time, and I won’t make that mistake again with even more children at home who need their mother more than they need a sibling. It is so very difficult to ponder the possibility of losing my yet unborn child in order to be a mother to my other children, but it is a scenario that must be considered in my situation. And, you’re absolutely right that it never gets brought up in the discussions about whether or not a VBAC should be attempted.
Gina, I’m so sorry you’re facing this situation in real life. I hope all turns out the way you want it to, and even if you do have a RCS, you’re safe!
This is the part that I believe cannot be emphasized enough.
“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.”
As long as individual obstetricians, and ACOG as a group, continue to rely on poor science which only supports their opinions and their attempt to monopolize pregnancy and birth care, women cannot trust them and are forced to look upon their recommendations with suspicion. Women cannot trust that recommendations are being made in their best interest. They have to suspect that recommendations are being made in the best interest of the doctor, the hospital, and/or the insurance company.
It is a sad state when women cannot trust their care providers.
What a powerful idea to create an ‘informed consent’ form for the dr. to sign. Wonderful post, as usual. Thank you.
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Fabulous post!
Love this:
“… 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
Exactly! Plus the information that is provided should be evidence informed and accurate!
I love the informed consent form for the care provider to sign. Thank you for this post.
Gratitude for the likes of Dr Kotaska, he got a standing ovation at a conference in Brisbane in 2009 too
and rightly so. Very sensible man.
When I had my 2nd baby in the hospital (quite against my wishes), I had my OB sign my birth plan confirming she had read and understood it. It was amazing the difference when she saw the place to sign. At first she had simply flipped through the birth plan without really reading it (and clearly she had no idea what it actually contained). Then she saw I wanted her signature, she stopped, stared at it for a moment, then went back and, slowly and pausing to discuss certain areas with me, carefully read the entire thing line by line before she signed it. I think it’s a near reaquirement for any woman wanting to be taken seriously to require their doctor to sign a consent form as suggested above or sign their birth plan. And, if something does go horribly wrong, you have a signature to hand to a lawyer, judge, or medical board.