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ethics among physicians  

post #1 of 53
Thread Starter 
(wish there was an emeticon for soapbox)

I have commented on several threads about HCP's who appear unethical in the way they treat clients/patients with bullying, abuse, etc.

When it comes to my midwifery colleagues I am sometimes disappointed that so few will talk about the other midwives they have first hand knowledge of being negligent and abusive.

Physicians frequently seem to be labeled as protecting each other as part of the "good old boys network". I have commented that, if, as midwives, we don't speak up about this, we are as bad as the physicians for covering for their own. However, I had no idea how bad it was.

Our local paper editorialized yesterday on an article recently printed in the Annals of Internal Medicine about a first of its kind study. Here are the highlights:

"NEARLY half of all United States doctors fail to report incompetent or unethical colleagues, even though they agree that such mistakes should be reported, researchers said on Monday.

They found that 46 per cent of physicians surveyed admitted they knew of a serious medical error that had been made but did not tell authorities about it.

'There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do,' said Dr Eric Campbell of Massachusetts General Hospital and Harvard Medical School in Boston, who led the survey.

In 2000, the US Institute of Medicine reported that up to 98,000 people die every year because of medical errors in hospitals alone.

Dr Campbell and colleagues surveyed more than 1,600 physicians in 2003 and 2004 for their report, published in the Annals of Internal Medicine.

Up to 96 per cent of those surveyed said they should report all instances of significant incompetence or medical errors to the hospital clinic or to authorities. The exception was among cardiologists and surgeons, with just about 45 per cent agreeing.

And 85 per cent of most doctors said they should tell patients or relatives about significant errors.

But this did not translate into practice.

Forty per cent of the doctors said they knew of a serious medical error in their hospital group or practice but 31 per cent admitted they had done nothing about it at least once."

It would be really easy to just blame the physicians for behaving this way, but as midwives, doulas, CBE's which of us can say we have direct knowledge of a colleagues' carelessness or incompetence, but haven't said anything?
post #2 of 53
I think it isn't always black and white.

Let's say I have a close relationship with a midwife. This midwife takes on a relatively high-risk client who complicates things by not being very compliant with recommendations the midwife makes in her care. Several times in the pregnancy the midwife and I talk about management of the clients' care and I offer my opinion -- I say that the pregnancy has gotten to be too high risk and that the client needs to be referred out. Midwife waffles, she says that the client has called crying several times, begging her to not send her to the hospital. Midwife also has not insisted on certain diagnostic tests or monitoring because her client has insisted that her pregnancies always progress this way and everything has been fine before.

Baby is born, there is a bad outcome. Midwife admits she made mistakes to me and other midwives in a peer review. Now, what is to be gained from "reporting" her? She has already learned from her experience -- does she need to be punished? How much responsibility does the client have for her own bad outcome? Is it always incompetance to not use techno-medical diagnostics when there are derivations from normal? Are all mistakes worth punishment?

I have an aunt who lives paralyzed because a resident nicked her spinal cord during a surgery 30 years ago. Her injury was complicated by the fact that he tried to conceal what he had done and closed her up knowing that she had an injury. But what if he hadn't been so dishonest? Should he have been sanctioned for a slip of the hand? If another surgeon at the operation had been able to fix the damage somehow would the team be unethical because they didn't report the error?
post #3 of 53
Here is your soapbox!!
post #4 of 53
Thread Starter 
Stacia
That appeared to be the point of the survey. That there is a disconnect between ethics espoused and actual practice.
I am pretty sure that much of what you write about the hypothetical situation is the same sort of rationalizations that the physicians used in not reporting the negligence and incompetence of their colleagues.

This is the discussion that needs to be had.

For me, ethically, if a patient was harmed and the HCP tried to justify their end of things by placing some of the blame with the client (she didn't do what I told her), then I likely would report her. A client hires an HCP for their knowledge and hopefully ability to be objective in emotional situations. I can see where it would be very difficult to admit that someone you know is not acting in the client's best interest and was partially or totally at fault for the outcome. Reporting that HCP may be the end of a friendship and result in the whistle blower being ostracized and marginalized.

Personally, I would find it even harder to live with myself if I didn't report negligence and incompetence because I wanted to avoid the unpleasantness.

These are the things that NCD advocates believe are wrong with the medical model of maternity care. All I'm asking is, if it is wrong for that model, why the double standard of saying it's alright for the midwifery model?

: (thank you fyrestorm)
post #5 of 53
I think there's a view in our community that Doctor=Bad, midwife=Good that just doesn't allow us to envision incompetent or dangerous practice by a midwife. I know when a doctor does something heinous, I'm sad and distressed but not surprised. When I hear of a midwife who does something heinous, I'm sad, distressed, AND shocked and alarmed.

So I don't think people think it's OK, they just don't acknowledge or want to talk about that a midwife could be malevolent or even just negligent.

The gray zone gets larger the longer I practice. Unless and until I become a court case reviewer, I will NEVER judge what a midwife did or didn't do unless I can have ALL the facts of the case.

Let's say I have a close relationship with a midwife. This midwife takes on a relatively high-risk client who complicates things by not being very compliant with recommendations the midwife makes in her care. Several times in the pregnancy the midwife and I talk about management of the clients' care and I offer my opinion -- I say that the pregnancy has gotten to be too high risk and that the client needs to be referred out. Midwife waffles, she says that the client has called crying several times, begging her to not send her to the hospital. Midwife also has not insisted on certain diagnostic tests or monitoring because her client has insisted that her pregnancies always progress this way and everything has been fine before.

For me, ethically, if a patient was harmed and the HCP tried to justify their end of things by placing some of the blame with the client (she didn't do what I told her), then I likely would report her. A client hires an HCP for their knowledge and hopefully ability to be objective in emotional situations.

This raises the uncomfortable gray zone of patient consent and their legal right to refuse testing, of paternalism vs. us meeting professional standards. Look around this site, ladies. Entire threads are dedicated to how to refuse testing and how awful the medical establishment is for trying to force tests upon poor unsuspecting pregnant women everywhere.

So what happens when a woman's entire chart reads, "patient decline testing for...." ....gestational diabetes, anemia, GBS, fill in the blank. Everything.

Regarding the bolded statment above-in a court of law, if thorough documentation of discussions around monitoring and diagnostic testing is recorded, I would have a hard time finding the midwife negligent or liable. I don't see how "not insisting" is different from "forcing".

In my practice I have a consent form that includes, among other things, that "if the midwife refers me to a doctor I will go." I am clear at my consultation visit that our relationship is a two way street-that if either of us are uncomfortable with choices that the other is making, that we will be open and honest about it, and reach some kind of mutuality. I would like to think that clients like the one described above screen themselves out at the consultation visit.

I have lots more to say, but I have to run for now. I'm looking forward to everyone's input! This is absolutely something that needs to be talked about!
post #6 of 53
Thread Starter 
jengacnm,
your agreement sounds much the same as mine. It is a discussion that we have at the interview before care ever starts. My clients know that there are times when I will need to refer them to the perinatologist because a situation is a little on the edge of safety for OOH birth. I just want them to talk with someone else who has seen these situations and can give another opinion. They can decline, and it will be documented and we'll try to find another way to get the answers.

I have only had 1 client that I have had to discharge from care. The father decided at the last moment that he would not allow me to bring an assistant to the home birth. He had a history of sexual abuse, both as the perp and a survivor, and a history of physical abuse toward his wife. His actions made me seriously question the safety of the situation. When I informed him that I couldn't budge on the no assistant part, he threatened, cajoled, argued, and begged. It was very emotional and like the hypothetical situation Stacia brought up, I could have caved, but my gut feeling said this was not a good situation for the birth and they had hired me partly to ensure the birth was safe. They had a hospital birth and the nursing staff ordered a social work consult because of his abusive behavior.

Most of the time I can find enough evidence to give the family choices when there are gray areas, and I can support them in the choices that are made. I'm sure there are physicians who would not agree with me, but those choices also don't come under the heading of incompetence or negligence.

It is the negligence and incompetence I most worry about. One of the scariest situations I encountered was a midwife who obtained liquid morphine and gave a dropperful to the patient during labor. When that didn't quite work, she gave her more. When I asked her how much she gave, she didn't know how many milligrams were in a dropperful and didn't know what the appropriate dose for labor should have been. Twelve hours later the mom still couldn't walk w/o assistance and the baby was so sleepy from the drugs, it couldn't wake up to nurse properly for 3 days. IMHO this midwife did something that could be judged illegal, unethical, negligent, and incompetent. I would have reported her if I wasn't worried about the other midwife it also would have hurt. So yes, even ethical me has seen negligence and looked the other way. I hate the fact that I had to choose.
post #7 of 53
Quote:
Originally Posted by mothercat View Post
Stacia
That appeared to be the point of the survey. That there is a disconnect between ethics espoused and actual practice.
I am pretty sure that much of what you write about the hypothetical situation is the same sort of rationalizations that the physicians used in not reporting the negligence and incompetence of their colleagues.

This is the discussion that needs to be had.

For me, ethically, if a patient was harmed and the HCP tried to justify their end of things by placing some of the blame with the client (she didn't do what I told her), then I likely would report her. A client hires an HCP for their knowledge and hopefully ability to be objective in emotional situations.
It is just not that simple for me. I think that it is totally fine for you to work with women with the understanding that you are responsible for their care and that they have hired you to be a neutral, objective expert and leader, but when I take on a client it is much more like a partnership. There is a distinct understanding (we talk about it and it is in the informed choice agreement) that they are partners in their care. There are some strings attached to that. If I send someone home with a glucose monitor and they tell me that they are getting 110 after meals, I have to trust that they aren't really getting 160 and lying to me. If someone goes through a whole informed choice discussion and decides to have a VBA3C at home and then has a uterine rupture or a placenta accreta, then we share the responsibility for that poor outcome. When the client is in this model of care there is more power but there is also more responsibility.

On the other hand, when taking on a client, I have two lives I am helping guard, and only one of them gets a voice. When I have someone whom I believe is not acting honorably on their end and I feel that a baby is in danger, I may speak with a stronger voice. I might even refuse to continue care.

The example that you gave with the abusive spouse wasn't really about the baby or mom's safety -- it was about yours. But I think that you were absolutely right not to continue care with them. They weren't acting honorably or honestly and you were put in a situation where your physical safety might have been compromised.

The example that you gave with the morphine is really very different from mine. You have the triple whammy of someone practicing far outside the standards of care (using narcotics at home), practicing with a tool she didn't understand, and giving medication through a non-standard method (much harder to control dosing/absorption orally). I think that one of the things that bugs me about that example is that in a partnership it is important for the care provider to be able to explain fully the impact of a suggested treatment and get consent. There is no "informed" consent if the midwife isn't informed!

So, as you can see, for me, it is a lot about honor/truthfullness. I can forgive mistakes of judgement in a profession where we are about art as much as science, but I would have a hard time excusing a colleague who acted dishonorably.
post #8 of 53
Quote:
Originally Posted by Defenestrator View Post
I think it isn't always black and white.

Let's say I have a close relationship with a midwife. This midwife takes on a relatively high-risk client who complicates things by not being very compliant with recommendations the midwife makes in her care. Several times in the pregnancy the midwife and I talk about management of the clients' care and I offer my opinion -- I say that the pregnancy has gotten to be too high risk and that the client needs to be referred out. Midwife waffles, she says that the client has called crying several times, begging her to not send her to the hospital. Midwife also has not insisted on certain diagnostic tests or monitoring because her client has insisted that her pregnancies always progress this way and everything has been fine before.

Baby is born, there is a bad outcome. Midwife admits she made mistakes to me and other midwives in a peer review. Now, what is to be gained from "reporting" her? She has already learned from her experience -- does she need to be punished? How much responsibility does the client have for her own bad outcome? Is it always incompetance to not use techno-medical diagnostics when there are derivations from normal? Are all mistakes worth punishment?

I have an aunt who lives paralyzed because a resident nicked her spinal cord during a surgery 30 years ago. Her injury was complicated by the fact that he tried to conceal what he had done and closed her up knowing that she had an injury. But what if he hadn't been so dishonest? Should he have been sanctioned for a slip of the hand? If another surgeon at the operation had been able to fix the damage somehow would the team be unethical because they didn't report the error?
The key here IMO is maternal choice. I don't think there should be any such thing as "risking out." Mothers should be provided with all available info about their pregnancies, health, etc., then be allowed to choose their attendant and birth place. A midwife should be allowed to attend a fully informed woman's high risk birth without fear of legal action. At the end of the day it should ALWAYS be the woman's choice. In your scenario, the midwife went against government/medical standards perhaps, but she did so to honor a fully informed woman's choice to give birth at home. So in my mind, she risked her own practice to honor that woman's wishes and I don't see anything wrong with that from an ethical standpoint.

It also sounds like there is a peer review process in place-what if there weren't? To me there is no need to get the government involved when professionals are willing to step up and do the right thing, hold each other and themselves accountable in keeping the profession safe/honorable. What if the other midwives had refused to get involved in the process of the peer review? Or what if there were true negligence, and the other local midwives turned a blind eye because of professional loyalty? It happens, and that's not any more okay than when OBs and hospitals do the same.
post #9 of 53
This is a fascinating discussion. Making mistakes is something that I fret about to an amazing degree - sometimes to the point that I wonder if I can continue to practice in a field where making mistakes has the potential to be so costly.

I am human. I have made mistakes before, and I will again. To date, any error that I have made has been shared with the client and discussed with my partners with the goal of making sure I understand what happened and how to not have it happen again. I've made at least a couple errors that could be classed as negligence - in one, I prescribed a medication that had a potentially life-threatening interaction with another medication that patient was taking and she ended up in the ICU. Fortunately, she made a full recovery, and I apologized to her and have instituted some practices that will hopefully prevent me from ever doing it again. Who should I have been reported to and what would have been gained?

It's a terrible burden to live with as a physician to know that a simple mistake - a slip of the hand, losing a test result, writing a number iincorrectly - could harm or kill someone. It is something I worry about every day of my life as I believe most physicians and other health care providers do. Having a good, non-punitive way to report errors both to colleagues and patients I think would help to insure that errors don't become repetitive.

On the other hand, I have experienced situations where a colleague was practicing outside the range of standard of care repeatedly, without any obvious attempt on their part to remedy the situation. It is difficult as a colleague to know what to do in this situation. For one, you feel that if you start reporting your colleagues your own practice will be up to so much more scrutiny. If you don't have all the facts, you can't be sure that the harm you suspect is actually due to negligence. And also, most discouraging for me, there is no support for "whistle blowers" in my profession. I've been involved in a situation where I've made such a report to hospital administration and basically have had my allegations swept under the rug and been accused myself of violating patient confidentiality. Worse, the practices I was concerned about appear to continue to go on, now with better defensive charting in place to make it look like they are valid decisions.

I think we need a couple changes in both medicine and midwifery care. One, I think true partnership with our clients is vital. I tell my clients that I don't expect them to listen to me just because I tell them to do something. They have a right to understand my reasoning behind any decision and to ask me to back up what I tell them. They have a right to do independent research as well. I have no problem telling my clients that I am human and make mistakes, but will try hard not to and to correct them as soon as I can if I do. Some clients don't like this type of relationship and move on, but I feel obligated to work against the doctor-as-God image that prevails so much in my profession. If every patient/client was demanding that their provider explain their reasoning for the decisions they make and planning to be involved in those decisions, I think there is less opportunity for error.

Second, there needs to be better checks in place and ways to weed out bad providers. Currently, I have peer review (quite difficult in a small hospital like mine where there are just a few docs and peer review is not binding - I can say that someone did the wrong thing, but they don't have to believe me or make any changes in practice and aren't monitored for change) and other than that I guess I could report someone to the medical board, who generally investigates by asking the physician in question to defend themselves, giving a lot of opportunity for cover up.
post #10 of 53
Quote:
Originally Posted by doctorjen View Post

I think we need a couple changes in both medicine and midwifery care. One, I think true partnership with our clients is vital. I tell my clients that I don't expect them to listen to me just because I tell them to do something. They have a right to understand my reasoning behind any decision and to ask me to back up what I tell them. They have a right to do independent research as well. I have no problem telling my clients that I am human and make mistakes, but will try hard not to and to correct them as soon as I can if I do. Some clients don't like this type of relationship and move on, but I feel obligated to work against the doctor-as-God image that prevails so much in my profession. If every patient/client was demanding that their provider explain their reasoning for the decisions they make and planning to be involved in those decisions, I think there is less opportunity for error.
This is so important, and is very, very rare among doctors IME. We SHOULD be partners, not an Authority Figure God and a lowly human who doesn't have the capacity to understand simple decisions. When doctors and patients see *each other* as equals (because docs would not be nearly as likely to see themselves as superior if they weren't so often put on pedestals), things will improve greatly for everyone.
post #11 of 53
Thread Starter 
Stacia,
Sorry I didn't explain the situation with the father better.
His physical intimidation was threatening to the mother (but she chooses to stay with him), his refusal to allow anyone but me to attend the birth had the potential to endanger his wife and the baby if both had complications concurrently. He was not always rational in what he would allow me to do in terms of care, and in a crisis such as PPH may have decided at the last moment not to permit me to offer any treatment, I know this because he told me so. It would not have mattered if his wife wanted me to, she was afraid to go against him. This was not about a partnership between midwife and the client and informed choice, it was about him maintaining control.

I also think you may have misunderstood my relationship with my clients. It is not nearly as authoritarian as you describe. Your description of guarding two lives and acting honorably is similar to mine but I don't see it as mom vs. baby like the medical model does. As other posters have said being a physician (or a CNM) does not automatically mean the person is bad and authoritative. Just as not all OOH midwives are automatically good and loving. The midwife with the morphine also mixed Cytotec with arnica oil and told another mom she was just going to massage a little arnica into a swollen cervix. Mom had no idea that Cytotec was used. The midwife thought it was a good joke, as she laughed about "that should get things moving".

The point of OP was about ethics, not about nitpicking how each of us thinks the other practices. I just wanted to start this conversation about how midwives and those of us that practice in the midwifery model should be doing at least a good a job as physicians in being ethical and here was the starting point for physicians. For the most parts midwives haven't even started this process aside from a few who feel it is their ethical obligation to themselves, their clients, and their profession.

I like Dr. Jen's approach and that is what the OP quoted-mistakes should be acknowledged and disclosed to the client. If the HCP is not doing this, then their actions should be reported to the facility, the credentialing board, or the licensing board.
post #12 of 53
Thread Starter 
Quote:
Originally Posted by doctorjen View Post
T Having a good, non-punitive way to report errors both to colleagues and patients I think would help to insure that errors don't become repetitive.
Time for an asimile (sp?). I wonder if this is an issue that Dr. Campbell addressed in his research. That the reason so few errors, and additionally incompetence and negligence, are reported is that there is no effective, non-punitive way to address these issues.

This is akin to telling a woman in an abusive relationship that she needs to leave the abuser, but not giving her the resources, or worse yet, there not being safety resources available.

If we are concerned about clinical practice or witness negligence/incompetence and reporting this won't result in change, but will get us ostracized and marginalized, why bother.

This also brings up another ethical point. What if someone asks what we know about that HCP and we don't tell what we know? Not all the details, just enough to let them know to seriously consider other choices. If they chose that provider and are harmed are we then complicit?

We tell moms about physicians that have high C/sec rates, about Peds that are not supportive of breastfeeding or that will guilt them into vaccines they don't feel are appropriate. What is the difference?
post #13 of 53
This is a complicated issue. Unless we are actually working with a midwife and personally witness negligence, what can we really do? If we complain to a regulatory agency, we had better have proof. If we tell clients/potential clients, we sound like we are gossiping. I guess we rely on the consumers of midwifery care to make their decisions and to talk to others for referrals to help us police the community. Not a perfect system; would love some way to figure this out...
post #14 of 53
well much of what i would want to say has been said-- the problem with practice is 100% of us make mistakes- 100% of us if we provide care will make mistakes/have made mistakes.
I also think you live in a very different place than I do or have- midwives that I have been around tend to be far more sensitive and judgmental about other's practices and do find it their business to either be outspoken or make trouble for the ones they think are not acting properly--
what I would illustrate though is the difference between the position that midwives are in-- what do you mean by turning someone in? for a midwife in most of the states I know about the STATE not a professional organization is who handles complaints and discipline, most often someone in a medical field but not a LM so judgement isn't fair nor simple and peer review is basically ignored --- in turning in a doctor or a nurse for that matter- complaining even to a state agency actually equals complaining to a professional organization- and there are clear steps,case reviews, peer review -- as much as there may be ethical considerations and things held back by physician peers-- there is also far less compunction in the nursing field more peer complaints and more actions on licenses --
you are in a state that does not license midwives and the first step in being fair would be to have licensing -- New Mexico has a professional peer review process that has legal responsibility and one to model after
----------------------------------------
SublimeBirthGirl wrote>>>>>>>>

I don't think there should be any such thing as "risking out."

I am not going to agree with this statement- maternal/parental rights are fine and well but as a participant I should have some rights as well- I should be able to choose to not do something that I think is unsafe or unethical- I should not be a forced participant--just because someone chose me does not mean I have to provide care --
examples of times I have chose to not participate-- 40 weeks primary outbreak of herpes, she did have a homebirth just not me as a provider, or type 1 diabetic with uncontrolled blood sugars and related health problems including a chronic infection- she attempted a UC and transferred , parents who wanted a DNR on a baby that had a fixable problem if born in the hospital, people who want me to only pray at the birth-- Drug addicts currently using-- situations of abuse where I would be in danger...
and the truth is that the 2 hold outs in the paternalism world is law and medicine and it is such a sick co-dependent relationship, I have had friend midwife in Washington state who had a far better informed consent form than any of the medical providers around her but because the State wanted to use her as a case to define practice-- they wanted a ruling against breech births (everyone lived in this birth) --- infact the ruling on her case basically acknowledged that breech birth is a alternative a midwife can do-- but missing the finer points of details the judge did not know the difference between types of breech so she was "guilty for not providing informed consent" --- another midwife turned her in but the state investigators are nurses-- NOT OB nurses just nurse investigators-- the prevailing thought is that only a medical professional knows the risks and realities and you should know better than to allow someone to hurt themselves or their loved ones.and informed consent is thrown out in court, no matter how well crafted you think it is--
----
I should add it was purely the state after my friend in Washington, complete political motivation the parents testified for the midwife--- and they felt they had recieved good informed choice!!! and said so in court-- did not matter---
post #15 of 53
I am in a state where direct entry midwifery is illegal (but close to getting legalized-keep your fingers crossed!), so a lot of this discussion seems moot-the "reporting mechanism" is criminal court. A bad outcome happens and the midwife gets arrested.

CNMs would get reviewed by the Board of Nursing.

A midwife should be allowed to attend a fully informed woman's high risk birth without fear of legal action.

I agree-in Utopia. I don't see this happening in my lifetime.

If someone goes through a whole informed choice discussion and decides to have a VBA3C at home and then has a uterine rupture or a placenta accreta, then we share the responsibility for that poor outcome.

Every midwife has her line in the sand. If I turn down a patient and another midwife takes her on, then I simply think she's willing to take chances that I'm not.

she risked her own practice to honor that woman's wishes and I don't see anything wrong with that from an ethical standpoint.

SBG, are you licensed in any way? If not, please wait until you are before you say that. If you are, well, you're willing to risk your license in a way I'm not. No one woman is worth my license.

Overall, midwives and patients need to ask themselves-what consequences are they willing to live with? ( I also use this line of questioning for when discussing unassisted birth). The morphine dispensing midwife might think she's doing her patients a favor. ANd her clients (at least one!) accepted it! Things will be fine unless and until she loses a baby or mom to an overdose.
If and when that happens, she's no longer a noble midwife who relieves women's pain, she's facing narcotics charges.

If a midwife serves VBAC clients, she needs to be willing to accept a uterine rupture as a possible and eventual outcome. If she's not, then she shouldn't offer VBACs. She may help 10 or 50 or 200 VBACs at home before she experiences a uterine rupture, but she shouldn't be shocked when it happens.

Parents need to choose their provider and be confident in their decision. They need to know what is being droppered under mom's tongue. (When I give tinctures, I show them the bottle I'm dispensing from.) (The arnica/cytotec thing chills me to the bone. YIKES!)

Ok, I'm just rambling now. Have we come anywhere close to sketching out a solution? Do area midwives get together and hold an intervention for morphine dispensing, cytotec giving midwives? If we midwives tell patients about bad things another midwife does, we could get sued for slander by said midwife, so that doesn't seem wise.

ANy midwife can look bad when all her bad cases are held up to the light, so the gossip mill doesn't seem effective either.

Ideas?
post #16 of 53
mwherbs, I don't think a provider should feel forced to take a certain patient/client, within certain parameters (ie, I don't think an OB should be able to "fire" a patient for not being blindly obedient). I just meant I don't think that the law should lay down rules about where mothers can have babies. Like in states where midwifery is regulated and midwives aren't allowed to attend VBACs at home, or breech births, or whatever.
post #17 of 53
Quote:
Originally Posted by SublimeBirthGirl View Post
I don't think there should be any such thing as "risking out." Mothers should be provided with all available info about their pregnancies, health, etc., then be allowed to choose their attendant and birth place. A midwife should be allowed to attend a fully informed woman's high risk birth without fear of legal action. At the end of the day it should ALWAYS be the woman's choice. In your scenario, the midwife went against government/medical standards perhaps, but she did so to honor a fully informed woman's choice to give birth at home. So in my mind, she risked her own practice to honor that woman's wishes and I don't see anything wrong with that from an ethical standpoint.
This, to me, is ridiculous. i am high-risk. I am too high-risk for midwifery (the care of NORMAL pregnancy and birth, let's not forget) care. Of course I was risked out. My midwife did not have the knowledge and experience to care for me given my risk factors.

If a doc had not transferred a pt they were not qualified to care for, you can bet this board would have been all over that doc for "arrogance".
post #18 of 53
Quote:
SBG, are you licensed in any way? If not, please wait until you are before you say that. If you are, well, you're willing to risk your license in a way I'm not. No one woman is worth my license.
I'm a CBE, not a midwife. And my point is that a midwife (or doctor for that matter) should be free to honor women's choices without fear of losing her license. If it's the woman's choice, and she is fully informed, she bears the responsibility for the outcome in absense of some sort of negligence. A woman wanting, for example, a VBA3C at home should be able to have one, regardless of the risks, if SHE wants one and fully understands the risks. It should be her choice. A midwife should be able to attend her, if she wants to, without fear of losing her license.

To carry it a step further-I really think the system of self-regulation would work better than anything else. Let's say midwives were able to determine what was beyond their skill level/ability to deal with. There would be some variability here-for some midwives, breech birth is high risk; to others it's a variation of normal. Ditto twins. But it's not a government agency that determines this-it's the midwife with the knowledge of what she can handle and what she can't. If a mother is extremely high risk, she will face a choice: go to the hospital or have a UC. This system would allow more women to have homebirths, by getting rid of random requirements (ie, no homebirth past 42 weeks), and causing women who are truly high risk to realize, when no midwives are willing or able to attend them, that perhaps the hospital truly is the best option for them.

maxmama, I'm not bashing doctors or midwives here. I'm saying that the final choice should always lie with the mother. I realize that the practical application won't always work-what midwife would want to attend a birth of a cocaine addict with HIV and schizophrenia (to use an extreme example)? But within reason, women should have the right to make their own choice and have those choices respected no matter WHERE they give birth. You've been told you're high risk, and in your evaluation, you agree with that assessment. So don't have a midwife. It's YOUR choice and nothing to me. But what about women who are forced to have a RCS because "VBACs are dangerous?" We know that's BS but it's happening more and more. What about women who are coerced into antibiotics, or Pit, or an IV, or (fill in the blanks) because "birth is dangerous without it. You baby might die!" Where do YOU draw the line where women's choices should stop being their own?
post #19 of 53
Quote:
Originally Posted by SublimeBirthGirl View Post
maxmama, I'm not bashing doctors or midwives here. I'm saying that the final choice should always lie with the mother. I realize that the practical application won't always work-what midwife would want to attend a birth of a cocaine addict with HIV and schizophrenia (to use an extreme example)? But within reason, women should have the right to make their own choice and have those choices respected no matter WHERE they give birth. You've been told you're high risk, and in your evaluation, you agree with that assessment. So don't have a midwife. It's YOUR choice and nothing to me. But what about women who are forced to have a RCS because "VBACs are dangerous?" We know that's BS but it's happening more and more. What about women who are coerced into antibiotics, or Pit, or an IV, or (fill in the blanks) because "birth is dangerous without it. You baby might die!" Where do YOU draw the line where women's choices should stop being their own?
I would think, and hope, that any midwife practicing would consider someone with a history of HELLP syndrome, renal damage from said HELLP syndrome, Kell isoimmunization and insulin-dependent gestational diabetes to be outside midwifery's scope. Hell, my OBs think I'm almost outside their scope. Some women genuinely are high-risk, and no matter how they choose to call themselves, remain so.

Midwives are experts in normal pregnancy and birth.

It's not the patient's right to rewrite their own risk factors because they don't want to think they exist.
post #20 of 53
Quote:
Originally Posted by mothercat View Post
The point of OP was about ethics, not about nitpicking how each of us thinks the other practices. I just wanted to start this conversation about how midwives and those of us that practice in the midwifery model should be doing at least a good a job as physicians in being ethical and here was the starting point for physicians. For the most parts midwives haven't even started this process aside from a few who feel it is their ethical obligation to themselves, their clients, and their profession.
I think that it is important to the discussion to define the role of client and provider in shared decision making. You had said that you viewed the midwife as objective expert and I felt that I needed to counter that because that is not often the model under which I practice. I am not saying that this model is exclusive to lay midwives, just that it is in contrast to what you had laid out as your version of the midwives' role.

When thinking about "reporting" other midwives, I think that it is vital to consider these practice models, in part because they help define our standards of care. I absolutely think that other midwives can make different decisions than I do about what they are willing to take on, risk-wise, and am very reluctant to try and use coercion to bring them back into the fold. I absolutely cannot support lying to clients -- that is the one thing that I would be a whistle-blower about, but short of abuse, there is very little else that I would take to any kind of governing body. Negligence or incompetance I would take up with the midwife herself. I don't think that a midwifery board can legislate competance -- lots of people can pass tests or complete coursework without truly understanding the material.

I guess that the biggest problem that I have with this process is that I don't want someone distant from me (a legal authority, a state midwifery board) to have more power over me than what they already have. I feel that there is a dark side to every attempt to set standards for care and when I think of all of the problems facing midwifery, the actions of renegade midwives don't even make the top 10. So many forces are trying to break us apart and destroy us -- do we really need to add to the effort?
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