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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).
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.
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.
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.
- 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.
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: