Ethics and Childbirth Educators: Do Your Values Cause You Ethical Distress?

Abstract

The Code of Ethics for Lamaze Certified Childbirth Educators outlines the ethical principles and standards that are derived from childbirth education's core values to assure quality and ethical practice. This article presents a summary of the history of ethics and medical ethics that informs a value-oriented decision-making process in childbirth education. The role of evidence in ethics is explored from the childbirth educator's viewpoint, and scenarios are used to reflect on situations that are examples of ethical distress. The conclusion is that the practice of ethics and ethical decision making includes regular reflection.

WHAT IS ETHICS?

Most professional organizations have a code of ethics that reflects the values of the organization's members. Ethical codes primarily encompass standards of what one ought to do in terms of rights, obligations, fairness, specific virtues, and benefits to society. Those rights are entitlements to information, privacy, free expression, and safety. Secondly, ethics refers to the study and development of one's ethical standards (Velasquez, Andre, Shanks, & Meyer, 1987). It follows that all individuals and professional organizations need to periodically reflect on their moral beliefs to ensure that they, and the institutions they help shape, live up to reasonable standards relevant to the professional activities of the organization. As Lamaze Certified Childbirth Educators (LCCE educators), we need to do the same. The Code of Ethics for Lamaze Certified Childbirth Educators was established by the Lamaze Certification Council to assure quality and ethical practice. It outlines “a process by which unethical or other objectionable practice may be addressed” (Lamaze International, 2006, paragraph 1).

HISTORICAL BACKGROUND

The historical framework for ethical approaches originated more than 2,000 years ago with the writings of Plato, Aristotle, and Cicero, using the common-good approach. This approach challenges us to recognize what values and goals we have in common, as members of a community, in order to pursue social policies, social systems, institutions, and environments that benefit all. Aristotle's writings describe the fairness-and-justice approach, in which favoritism and discrimination are unjust (Velasquez, Andre, Shanks, & Meyer, 1996). The virtue approach assumes there are pillars of character for which we should strive. Six of these pillars—trustworthiness, respect, responsibility, fairness, caring, and citizenship—are often included in value statements. The assumption is the virtuous person is an ethical person. Historically, the rights approach follows the philosophy of Immanuel Kant in the 18th century. According to Kant and others of his time, human dignity is based on the ability to choose freely what to do in life and on the fundamental moral right to have those choices respected. More recently, the utilitarian approach of Jeremy Bentham and John Stuart Mill in the 19th century suggests that ethical actions are those that produce the greatest good and the least harm (Velasquez et al., 1996).

Medical ethics is an example of applied ethics, the purpose of which is to put theory into practice. Most people have heard of the phrase “First, do no harm,” which is one of the main tenets taught to medical students, and of the Hippocratic Oath, which is a pledge physicians take related to the ethical practice of medicine. The traditions of medical ethics are based in Catholic, Islamic, and Jewish teachings. The term medical ethics was coined in the 18th century by a British doctor, Thomas Percival. His writings were the foundation of the anticompetitive thinking on which the American Medical Association based its first code of ethics (Wikipedia, 2008b). In the 20th century, the Protestant approach of Joseph Fletcher and more liberal thinkers in the 1960s and 1970s led to a shift in thinking related to procedural justice and what we know today as bioethics (Wikipedia, 2008b). Some of the origins of the Lamaze code of ethics are based on nursing ethics, which emphasizes maintaining dignity and collaborative care.

VALUES IN MEDICAL ETHICS

The definitions of the terms most often associated with values in medical ethics are:

• Beneficence—clinical benefit, the practice of doing good.

• Autonomy—concept found in moral, political, and bioethical philosophy; capacity to make an informed, uncoerced decision.

• Justice—concept of moral rightness based on ethics, rationality, and law.

• Dignity/Respect—an ethical discussion closely related to the virtues of respect and autonomy.

• Choice—concept found in moral, political, and bioethical philosophy; assumes a “free choice” of all the alternatives, with the right to select.

• Exploitation—small benefit to a large risk.

• Informed consent—assumes adequate agreement based on obtaining, defining, and measuring comprehension.

• Medical evidence—objective and scientific information based on clinical trials in comparison to other treatments.

THE ROLE OF EVIDENCE IN ETHICS

Frank Chervenak, MD, is Chair of Obstetrics and Gynecology at Cornell Medical School and is a noted medical ethicist who focuses on the balance between beneficence, justice, and autonomy. He often reminds obstetric providers that the physician is an authority not in authority, and when there is insufficient medical evidence to guide decision making, the principles in ethics are secular and universal. According to Chervenak, ethics is more important than laws. He maintains that a greater force in medical judgment should be the negative right of being left alone, which represents autonomy. Obligations to beneficence are more important than the positive right of demanding a medical procedure, which represents choice. Chervenak acknowledges that decision making is not easy; it is a process that must be balanced with judgment (F. Chervenak, personal communication, September 23, 2008).

Nayna Campbell Philipsen (2000a), an attorney and LCCE educator, stated, “First, do what the patient wants. Second, do no harm. Third, do all the good that you can” (p. 49). Doing no harm and doing good is based on the principle of beneficence, whereas doing what the patient wants is based on the 1991 Patient Self-Determination Act as an amendment to Title XVIII of the Social Security Act. The intent of this federal law is to assure that citizens receive information to help them assert their autonomy in health decision making. The purpose of discussing risks and benefits in perinatal education is to provide information in order to aid informed consent and to give childbearing women the authority to decide what options are in the best interest of themselves and their babies.

In discussions with childbirth educators, there is often a sense of frustration related to their perception of limits on choice and autonomy in today's birth culture due to an unbalance between individual needs and institutional needs. An example is a hospital policy in which augmentation of labor is determined to be a hospital routine in order to increase “efficiency.” Policies that make interventions routine can be in conflict with evidence-based practice and with practices that support normal labor. Childbirth educators teaching perinatal education within the hospital setting have expressed feelings of conflict between their values and their professional duties.

If, an LCCE educator works at Hospital X, which has a policy of augmentation of labor as a routine procedure, the educator faces a dilemma. The preamble of the Code of Ethics for Lamaze Certified Childbirth Educators states, “The primary mission of Lamaze Childbirth Education is to promote, protect, and support normal birth” (Lamaze International, 2006, paragraph 2). The Lamaze educator's values flow from this unique purpose and perspective, influenced by the core values of childbirth education and ethical responsibilities (see Boxes 1 and 2). If, at Hospital X, whether to augment labor is not presented as a choice but as an example of “how things are done” or of “soft paternalism” (i.e., “doctor knows best”), then augmentation becomes a routine procedure foregoing the process of informed consent. The LCCE educator might see this as the patient's loss of the right to self-determination; however, as an employee of Hospital X, she is obligated to abide by the institution's policies and procedures.

BOX 1. Core Values of Childbirth Education.

• Dignity and worth of the person

• Respect for the normal, natural processes of pregnancy, birth, breastfeeding, and women's inherent ability to give birth

• Integrity

• Competence

BOX 2. Code of Ethics for Lamaze Certified Childbirth Educators.

Standards concerning a childbirth educator's ethical responsibilities:

• to childbearing women

• to colleagues

• in practice settings

• as a professional

• to the childbirth education profession

• in the broader society

Nayna Campbell Philipsen (2000b) addressed paternalism in her article titled “In the Patient's Best Interest: Informed Consent or Protection from the Truth?” Citing the American Medical Association's Principles of Medical Ethics, Philipsen noted that the first of the six elements in The Fundamental Elements of the Patient-Physician Relationship is, “The patient has the right to receive information from physicians and to discuss the benefits, risk, and costs” (p. 46). The second fundamental element states, “The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment” (p. 46).

In her article entitled “Choice, Autonomy, and Childbirth Education,” Judith Lothian discussed choice in childbirth as being so limited today that it is “probably a myth” (Lothian, 2008, p. 37). Lothian noted that in order for each birthing woman to be truly autonomous, she must be respected, valued, and honored for her authoritative knowledge. If in today's birth culture women are denied autonomy and the capacity to make an informed, uncoerced decision, then their “inner wisdom,” a key concept in the Lamaze Philosophy of Birth, is not respected either. Women need both autonomy and respect of their “inner wisdom” to effectively make safe decisions for themselves and their babies.

The failure of applying evidence and using ethics to balance competing interests has led to practices that exploit childbearing women. In the United States, examples of not using the evidence for decision-making autonomy includes practices such as denial of food and drink during labor (Declercq, Sakala, Corry, & Applebaum, 2006; Declercq, Sakala, Corry, Applebaum, & Risher, 2002). Apparently, these practices are applied in order to avoid a small risk of aspiration. A warning in the report Evidence-Based Maternity Care: What It Is and What It Can Achieve is that maternity care today fails to implement evidence-based practice that “gives priority to care paths and practices that are effective and least invasive, with limited or no known harms whenever possible” (Sakala & Corry, 2008, p. 21).

VALUE-ORIENTED DECISION MAKING IN CHILDBIRTH EDUCATION

The goal of the Code of Ethics for Lamaze Certified Childbirth Educators is to assure quality and ethical practice. Given that some decisions are more difficult to make than others and that many maternity care practices are made without the input of childbirth education, using the principles and standards of the code will guide your decision-making process by outlining your obligations as an LCCE educator. Using a decision-making process takes the place of “burying your head in the sand,” relying on random methods such as tossing a coin, accepting the first opinion, or yielding to the person with the most authority. Decision making is a continuous process that takes place by interacting with the environment. It benefits from both intuitive and explicit processes. It is affected by both cultural differences and personal cognitive style. For example, behavioralist Isabel Briggs Myers, who developed the Myers-Briggs Type Indicator for personalities, believed a person's decision-making style is based on a set of four bipolar dimensions (Wikipedia, 2008a).

Decision-making processes abound. Plato and Benjamin Franklin recommended listing the advantages and disadvantages of each choice. Decision-making processes emphasize steps in a logical problem-solving activity that relies on reasoning. Decision making is also an emotional process, which can be rational or irrational. When considering if the choices will be more beneficial than harmful—an uncertain outcome—neurobiological theory maintains that decisions are actually aided by emotions. One resource for making ethical decisions is Michael Josephson's (2002) “The Seven-Step Path to Better Decisions” (see Box 3). Like most decision strategies, the first step is to stop and think. Sometimes, that means counting to 10 or to 100 if you are angry. “Sleeping on it” allows our implicit or inner knowing-what-is-right perception to surface. More importantly, the first step of stopping and thinking allows us time to apply our discipline, in this case Lamaze childbirth education. The second step is to clarify the short- and long-term goals, and the third step is determining or reviewing the facts.

BOX 3. The Seven-Step Path to Better Decisions.

• Stop and think

• Clarify goals

• Determine facts

• Develop options

• Consider consequences

• Choose a course of action

• Reassess and modify

All decision-making strategies include some gathering of evidence. Reviewing the evidence does not eliminate bias; sometimes we gather facts that simply support our idea and ignore other evidence. In gathering information, we need to consider the reliability and credibility of those who are providing the facts. Also, consider whether you have the same values and respect the character of those who are providing information. Importantly, when considering the options and their consequences, go back to the core values.

Values are the principles and standards to guide decision making and conduct when ethical issues arise. Many codes of ethics include value statements that reflect the six pillars of character. The Lamaze code of ethics emphasizes the values that relate to our mission and are the “foundation for childbirth education's unique purpose and perspective” (Lamaze International, 2006, paragraph 2). These core values are the dignity and worth of the person; respect for the normal, natural processes of pregnancy, birth, breastfeeding, and a woman's inherent ability to give birth; integrity; and competence (see Box 1). In some decisions, the best choice is clear; however, when choices are difficult, consider what the most ethical person you know would do. Decisions will be made that will be considered wrong, not because they were not the “best” at the time but because, lastly, we need to continuously reassess and make new decisions.

Perhaps an ethical scenario that you have been personally involved in or know of has come to mind in this discussion of ethics. A number of principles and standards of the Lamaze code of ethics might play into the decision-making process when you reflect on the situation. The following are examples of situations that might be similar to ones you have encountered or a colleague has encountered. Remember, the most important principle is that childbearing women's interests are foremost when considering the dignity and worth of each person involved in the decision-making process.

Ethical Scenario #1

In a childbirth education reunion class, a mother tells her birth story. She shares that she wanted to give birth without medications. Her nurse's reply to this was, “You're not going to be able to do this without an epidural, because the pitocin will make your contractions too hard.” “Pitocin?” the mother asks. “Yes,” her nurse answers, explaining that all patients get pitocin so their labors are shorter. “Hearing this was a blow to my confidence,” the mother shares. What is your ethical response to the mother and the class regarding the mother's story?

How do you respond? Remember, the first step is to think. According to the Lamaze code of ethics, you “respect the normal, natural processes of pregnancy, birth, and breastfeeding, and women's inherent ability to give birth” as a broad, ethical principle that is a core value of being an LCCE educator. If, as Judith Lothian and Charlotte DeVries noted in the Lamaze Official Guide, the childbirth educator “should be an advocate who shares all the information [women] need to make truly informed decisions” (Lothian & DeVries, 2005, p. 93), then the prime standard and responsibility is our “commitment to childbearing women,” as stated in the Lamaze code of ethics. You believe the facts are as the client states. One course would be to have the class participants brainstorm a list of possible actions and discuss how they may play out. To develop a list of options, encourage them to, as Dr. Seuss (1975) would advise, “Think left and think right and think low and think high. Oh, the thinks you can think up if only you try!” (p. 1).

One action a client recently shared with me was invoking her own self-determination. She wrote, “My water broke, which started my labor, but the first 5 hours I progressed very slowly, the contractions were very mild and I was only at 1 cm, they started to talk about pitocin, but I asked to have some more time. We began doing all the exercises we could think of, using the birth ball, etc., and then 7 hours later our daughter was born without augmentation of labor.” This client was informed, and she had clarified her goals. Three months later, when she wrote me about her experience, she was still ecstatic about her birth experience.

If you teach at a hospital facility, how possible is it for a woman to avoid interventions (e.g., intravenous fluids, continuous electronic fetal monitoring, epidural anesthesia, and augmentation)? Do these women have choices? What is your strategy within your commitments to your employing organization? The Lamaze code of ethics states, “Childbirth educators should work to improve employing agencies’ policies and procedures and the efficiency and effectiveness of their services to insure that they are evidence-based” (Lamaze International, 2006, Section 3.04[b]). As an LCCE educator, have you made your employer aware of your obligations according to the Code of Ethics for Lamaze Certified Childbirth Educators? The code states, “Childbirth educators should not allow an employing organization's policies, procedures, regulations, or administrative orders to interfere with their ethical practice of childbirth education. Childbirth educators should take reasonable steps to ensure that their employing organizations’ practices are consistent with the Lamaze International Code of Ethics” (Lamaze International, 2006, Section 3.04[d]). Have you discussed evidence-based practices with your hospital's managers?

Ethical Scenario #2

You work for an organization that employees only certified childbirth educators. You happen to hear that a colleague stated she is certified, but you believe she has not recertified. What is your responsibility?

According to Lamaze International's (2006) code of ethics, one of the LCCE educator's ethical responsibilities as a professional includes the mandate, “Childbirth educators should maintain certification” (Section 4.01[d]). This is part of being competent. The code states, “Childbirth educators should strive to become and remain proficient in professional practice and the performance of professional functions. Childbirth educators should critically examine and keep current with emerging knowledge relevant to childbirth education” (Section 4.01[b]). The question here, though, relates more to the value of integrity. We expect LCCE educators to “behave in a trustworthy manner” (Ethical Principles section, paragraph 9). As a childbirth educator, you “should not participate in, condone, or be associated with dishonesty, fraud, or deception” (Section 4.04). After you have adequate facts that the educator has not recertified, your responsibility is to “discourage, expose, and correct the unethical conduct of colleagues” (Section 2.06[a]). At the same time, it is your responsibility to treat this colleague with respect.

You can show respect, first, by reminding the colleague of her obligations. One way would be to share the code of ethics with her. Another would be to share or remind her of education opportunities. Lamaze International and members of the Lamaze Education Council are committed to the organization's annual conference and to childbirth educator updates. A new update will debut in the fashion of the popular workshops, “Childbirth Education in the 21st Century and Mission Possible: A World of Confident Women Choosing Normal Birth.” Also, Lamaze now offers online educational opportunities in the form of “Webinars.” If there are local opportunities for continuing education, you might help your colleague seek those out. Secondly, be honest with your colleague and tell her that you expect her to correct the misconception that she is certified. If necessary, you should take action through appropriate channels.

Ethical Scenario #3

You are a strong breastfeeding advocate and are responsible for developing the content of and teaching a prenatal breastfeeding class. Another childbirth educator confronts you by stating, “You hurt women. Not all women can breastfeed, and you make them feel guilty.”

No doubt, this would be a hurtful statement. Responding emotionally would be a normal reaction. Most likely, you would feel unjustly accused of intentional or unintentional insensitivity. Consider that your colleague feels distress too, and the goal should be mutual respect. Clearly, there is the need for more facts. Actions do not always need to be immediate. In many cases, talking with another colleague or someone whose opinion you value can help you gain perspective. Reflect on not only your words when promoting breastfeeding but also your tone of voice. You cannot give guilt. It is an emotion.

Sometimes, it is not just what you say but how you say it. Feel confident, though, that promoting breastfeeding is the right course for the benefit of childbearing families. According to Lamaze International's (2006) code of ethics, “Childbirth educators should uphold and advance the values, ethics, knowledge, and mission of the profession. Childbirth educators should protect, enhance, and improve the integrity of the profession through appropriate study and research, active discussion, and responsible criticism of the profession” (Section 5.01[b]). The integrity of the profession of childbirth education extends to the broader society, and breastfeeding is the best choice for nutrition, nurturing, and health.

CONCLUSION

Many more scenarios could be addressed. Each situation has unique qualities. The practice of ethics and ethical decision making includes regular reflection. The Code of Ethics for Lamaze Certified Childbirth Educators gives us a standard and a systematic approach. At the end of the day, we can ask ourselves to reflect on the core values of an LCCE educator: the dignity and worth of the person; respect for the normal, natural processes of pregnancy, birth, breastfeeding, and women's inherent ability to give birth; personal integrity; and our competence to practice as a childbirth educator. Then, ask yourself, “Is childbirth education better because of my contributions?” If not in the classroom at your local hospital, are their other venues or ways to advocate for childbearing women?