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Autonomy,
Paternalism, and Informed Consent
Taken in part from “Midwifery Ethics” by
Ida Darragh
Autonomy is an individual’s
right to make choices on their own behalf; Being able to exercise autonomy is
seen as having the ability to understand, reason, evaluate options and make
decisions for yourself.
Paternalism is making choices on
behalf of the client without seeking or heeding their views.
Paternalism is usually seen as
the opposite of autonomy, but it is usually not harmful in INTENT. People who
behave paternalistically do so in the true belief that they know what is best
for the client. Paternalism is Utilitarian- based on the belief that the end
(good outcome) justifies the means (disregarding the client’s will or not
seeking the client’s input).
Myles:
Whether power is real or
perceived is irrelevant; the fact that someone feels less powerful than someone
else means that any relationship that develops is unequal. Those with less
power (real or imagined) will always react differently and there is the very
real risk of coercion and paternalism creeping into a relationship. When clients
are unable or unwilling to act or speak for themselves, midwives are taking on
an advocacy role in their behalf. Advocacy is speaking on another’s behalf;
paternalism is acting on another’s behalf.
Informed Consent
Walsh:
The ethical doctrine of informed
consent contains the mandate to explain, to offer alternatives, to discuss
risks and benefits of a particular choice or action, to make sure the
information is understood by the client, to encourage the client to choose the
action best for her.
Issues:
Much of the information shared
with the client is “filtered” by and through the values of the teacher, whether
it be midwife, childbirth educator, doula, or physician.
More issues:
- Sometimes the woman doesn’t want to make the decision.
- Sometimes the provider is not aware of her or his own value biases.
- Sometimes the emergency nature of the situation does not allow time for fully shared decision-making.
Legally, a mentally competent
patient has an absolute right to refuse consent to medical treatment for any
reason, rational or irrational, or for no reason at all, even when that
decision will lead to death. (Jones, Ethics
in Midwifery, 2000, quoting Judge Wall, 1996)
Key word is “competent.”
Competent means that the person can
· Comprehend and retain treatment information
· Believe the information
· Weigh information to make a decision
Permission granted under duress
is not true consent.
From Myles
(2000) quoting Brown (1992):
Enabling informed consent to
occur and empowering women to decide what is best for them are fundamental
parts of respect for autonomy.
What happens when a client’s
wishes differ from the midwife’s professional judgment? Ethical dilemma: when
compliance with a woman’s choice would lead to self-compromise for the midwife.
One action could lead to higher risk or to unnecessary complications, while
another action breaches the autonomy of the client.
Bibliography:
Foster and
Lasser, Professional Ethics in Midwifery Practice, Jones and Bartlett, 2010
Walsh,
Linda; Midwifery; Community Based Care During the Childbearing Year; Saunders
2001
Myles
Textbook for Midwives; Churchill Livingstone, 2003
Sweet,
Betty; Maye’s Midwifery; Bailliere Tindall, 2002
Joens,
Shirley; Ethics in Midwifery, Mosby 2003
For more reading on informed consent:
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