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Bridging the Gap: Teaching Ethics in Midwifery PracticeAnne Thompson, RM, RN, MTD, BEd(hons)

Teaching is an integral part of all midwives’ practice, wherever they work. Midwives face ethical issues ofgreater or lesser significance throughout their careers. In a multitude of different situations and culturesworldwide midwives confront, on a daily basis, the need to make or help others make critical decisions thatwill impact lives. Midwives need tools to address this reality constructively, consistently, and respectfullyif they are to remain true to themselves. They need also to be able to transmit such skills to the students theyteach and the women to whom they offer care. Translating ethical thought and reflection into action—bridging the theory-practice gap—is the perennial challenge. This article presents some of the tools availableto professionals who take up the challenge of using ethical thinking to shape best practice in anysetting. J Midwifery Womens Health 2004;49:188–193 © 2004 by the American College of Nurse-Midwives.

keywords: ethics, midwifery, teaching, women’s health, values, human rights, values clarification

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NTRODUCTION

ll midwives teach at some time, whether or not theyembers of an academic faculty. All midwives face eth

ssues of greater or lesser significance throughoutareers. In the world’s great cosmopolitan cities anemote rural villages, midwives constantly face the neeake or help others make critical decisions that im

ives other than their own. Yet the marvelous pluralityhe world confronts them with the challenge of a multipty of values (some of them conflicting), which hamerged within different cultures over time.1

Midwives need tools to address this reality constively, consistently, and respectfully if they are to remrue to themselves, guide the emergent thinking oftudents, and share the journey of many women througabyrinth, and often the pain, of decision making. Transng ethical reflection into action—bridging the theoractice gap—is the perennial challenge of any teaaybe more in midwifery than elsewhere. Midwiferactice has rarely offered such a range and complex

ssues to the perplexed practitioner as it does today.rticle discusses the midwife’s role as teacher of etheflection, whether formal or informal, sensitive to isspecific to women’s health and cultural differencedentifies some of the tools available to the midwiferactitioner, manager, or teacher—who takes up the

enge of enabling others to develop skills in ethical deciaking.

RITICAL REFLECTION: THE BEDROCK OF ETHICS TEACHINGND PRACTICE

thics is still too frequently perceived as a somewhat scademic, and at times remote discipline. The issue isrrival in many health care professional curriculaemains daunting for many. Surely it is unreasonabl

ddress correspondence to Sister Anne Thompson, 63 Sea Road, We

tn-Sea, Kent CT8 8QG, UK. E-mail: thompsona@ukonline.co.uk

882004 by the American College of Nurse-Midwives

ssued by Elsevier Inc.

xpect that sooner or later every midwife will, explicitlymplicitly, “teach” ethics. Yet that task is unavoidabecause one day every midwife will face the studentays “why?” or will sit with a woman who asks “what shdo?” To be able to offer a meaningful reply requires

he midwife has learned the discipline of critical reflectnd practices it systematically. This will prevent the p

itioner from leaping to judgment based on emotionultural conditioning. Such critical skills involve graduaearning to examine all aspects of a situation, its originsmplications, and the views of all involved, before ideying a resolution rooted in principle.

here Are the Problems?

he first step in critical reflection lies in spotting wherethical problems lie and identifying the issues raised. Sre more obvious than others. Midwives will frequenncounter clients and colleagues whose values and b

ead them to conclusions that conflict with the valuesy the practitioner. Such conflict can be uncomfortabl

he practitioner experiences personal intellectual andional turmoil about issues in practice. Grappling wontroversial issues can be at an almost banal levatters regarding honesty, confidentiality, or standardractice. At other times the issues will be more compleore universal (e.g., the great debates around devents in genetics, advanced reproductive technoloomen’s rights, or even the morality of war as a receclaration about the effects of war released by the Iational Confederation of Midwives [ICM] makes clea2

ometimes the “big” problems will be at the heartidwifery practice: caring for women who have a s

tance abuse problem, termination of life for the feturolongation of life for the very sick newborn, “whislowing” where practice is abusive or harmful, dilemmaesource allocation, or the ever-rising cesarean birth r3

A sometimes forgotten aspect of ethical dilemmaidwifery is what can be called the “structural issue-

hose problems and challenges that arise from the way in

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hich a health system, an economy, or even an entireociety is arranged. Examples of such structural constraintsnclude,

Lack of access to reproductive health careInjustice in the way in which services and benefits areadministeredDiscrimination against women and girls at all levels:economic, cultural, and educational

Such realities constitute human rights abuses,4 yet theyre sometimes so firmly rooted in a culture that they passnrecognized and unchallenged, even by those who sufferost from the resulting inequities. When they are recog-

ized, people easily feel helpless faced with the institutionsnd authorities in which these injustices are embedded.idwives and midwifery organizations have a duty to

ncrease awareness of and work to redress such situations

nne Thompson, RM, RN, MTD, BEd(hons), has spent a professionalifetime in midwifery practice and education. Her early experience in Africa,nd later at the Royal College of Midwives and the Safe Motherhood Team ofhe World Health Organization, as well as some years as Treasurer of the ICM,harpened a sense of urgency regarding the need for respect for women’s

Figure 1. Ethical issues in the m

pealth care rights worldwide.

ournal of Midwifery & Women’s Health • www.jmwh.org

here possible, particularly with local communities andomen’s groups.5

tarting the Process: Looking at Values

nce the issues are identified, a whole range of intrinsicnd extrinsic factors have to be examined (Figure 1). Theidwife who sets out to teach has to remember the multiple

nfluences that shape reactions to any given situation. Totart with, in a world of many cultures and heightenedensitivities, it is essential to walk carefully, to be attentiveo the values and beliefs of others—clients or col-eagues—in a word, to be respectful of the “otherness” ofthers.6 Only in the presence of such respect is trust gained,nd without trust little can be achieved. Trying to see theorld as “ the other” sees it—the woman who is HIVositive, the father who demands extraordinary interventionor a grossly malformed newborn, the drug-dependentregnant teenager, or the illegal immigrant—shifts ouronsciousness from its well-worn, unexamined paths and, ifothing else, halts our rush to judgment. Once that rush haseen slowed to a crawl, there is time to explore the context;o look at the world in which the particular problemresents itself with its economic, religious, cultural, and

y curriculum: a process flowchart.

idwifer

olitical aspects. That exploration already sheds light on the

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alues that shape the attitudes of “ the other,” which guidection and which also frequently give rise to conflict.eople and institutions whose values or action-guidingriteria may not coincide with those of the midwife include,

The client and her familyProfessional and regulatory bodiesService institutionsEducation institutionsMedical staffSocial services agencies

EY CONCEPTS IN CHILDBIRTH

rincipled decision making is the end goal of ethicaleflection: “doing the right thing.” When well done, deci-ion making is based on a whole range of considerations,nternal and external factors, beliefs, and facts. Amonghese, concepts that have won overwhelming acceptance inociety weigh heavily. The concepts of personal “choice”nd “control” have featured largely over the past couple ofecades, particularly in the debate around childbirth, linkedlosely with the dominant ethical principle of autonomy.7

istorically, this seems to be a consequence of the powerfulovement for women’s rights that swept the world during

he second half of the last century.8 Both concepts, appliedo pregnancy and childbirth, have profound ethical ramifi-ations. However, their uncritical acceptance can result inheir becoming a mantra whose repetition may replace theard work of examination, reflection, and analysis. Ques-ions have to be asked about whose choice? Whose control?nd in what circumstances? When caring for pregnantomen, a midwife always has to keep in mind the interestsf the “silent” client, the fetus, as well as those of theother. The fact that their best interests may not always

oincide only increases the complexity of the situation.dentifying the appropriate locus of control throughout thehildbirth process may sound reasonably simple, and maye so as long as there is only a woman-midwife relationshipo consider. When labor or birth leaves the domain of thenormal,” more actors enter the scene, and the potential foronflicting perceptions of what is the “best thing to do”ncreases significantly. At such moments the midwife maynd herself cast more as negotiator and advocate thantraightforward partner in care.

EACHING ETHICS: ISSUES AND CHALLENGES

thics is about wrestling with the search for “ the right thingo do.” That in itself is challenge enough. Transmittinghose skills to others is a further challenge. Every time theuestion “What is the right thing to do?” comes up inractice, the midwife who addresses it acts as teacher, orather, as guide and mentor to others. There are, of course,rofessionals with an expertise in ethics, whose formalraining enables them to grapple “coherently, consistently

9

nd comprehensively” with ethical issues. Nonetheless, in m

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ractice, it is the midwife as primary care provider who isharged with the careful, systematic processes of informa-ion gathering, evaluation, analysis, and eventually decisionaking or working with and supporting others whose

ecision it is. This fact makes the importance of laying aound foundation for ethical reflection during the years ofrofessional education a compelling issue for midwiferyducation.10 Like any skill, it is only maintained byrequent practice.

It sounds so simple, yet we live in a world that isomplex and very uncertain. Few are clear about preciselyhere lines are to be drawn in moral issues, and, sadly,

ome of those who are certain and clear about drawingines, at times use that assurance to bludgeon others intoonformity with their certitudes. For all sorts of historicalnd geopolitical reasons, it is no longer possible (if it everere) to assume the existence of a moral consensus. On topf all this (and conveniently forgotten in many of thebstract debates) is the element of the unforeseen andncontrollable: what is often called “ luck” 11 or chance.

How then is the midwife to function as a moral agent, letlone a “ teacher of ethics” in a professional setting,articularly if personal control over the consequences ofecisions is limited or the outcome not entirely predictable?hat are the stepping stones to resolution when values

onflict? To start with, would-be teachers have to

Know themselves: their own beliefs, their prejudices, andtheir assumptionsKnow their students: their backgrounds, their cultures,their fearsKnow their subject: its content, its history, its theory, itspractice, its limitations, and its contradictionsFinally, and above all, they must know their clients: theirhopes and fears, their beliefs, and their traditions

Such knowledge takes time and hard work, sensitivitynd application, and there are few short cuts.

now Yourself

he midwife who accepts the task of transmitting skills inthical reflection and decision making to others must firstace the task of self-scrutiny. Little real headway can beade without awareness of the values and beliefs in which

he teacher’s own responses are grounded.12 Such self-wareness includes acknowledging the prejudices that hidehemselves behind unspoken assumptions and unexaminedttitudes. Although this process is part of normal growth inuman maturity, much of it taking place unobserved andnvoluntarily, the person who deliberately takes on therofessional care of women and their families has aarticular responsibility to take stock of a personal “moralramework.” Reflection, alone or with others, is an indis-ensable part of the process and is deepened by deliberatexercises such as journal keeping, peer discussion, and

entoring.

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now Your Learner

tudents also bring complex emotional and intellectualaggage to the business of learning to do ethics. Theidwife teacher has to be aware of the diversity of

ackgrounds from which learners come. No one’s mindorks in a vacuum. No one’s conscience only starts

unctioning in midwifery school. Each one’s roots, cultural,piritual, and intellectual provide the basis for whom theyecome and how they respond. “Professional ethics” (ethicsn midwifery practice) will lead the practitioner into newerritory and expand understanding, but its origins lie inhose roots. In a seminal work of the late 1980s, a periodarked by an explosion of sophisticated technologies in

eproductive health care, Englehardt, while arguing for themportance of a secular ethical framework, simultaneouslynderlines the indispensable nature of what he calls “moralommunities.” 13 After discussion of the particular value ofuch apparently disparate belief systems as Southern Bap-ists, Muslims, Irish Catholics, Texan Protestants, and Jewsrom San Francisco, he writes,

Secular bioethics . . . is an attempt to secure moralauthority and purpose for common action acrossmoral communities, it always presupposes the exis-tence of a number of competing moral viewpointsand the richness of moral life they contain. Taken byitself, secular bioethics would be an empty frame-work (p. 53).

Engelhardt maintains that what he calls the differentoral communities are

. . . creative endeavors of the spirit to fashion a viewof the good life. In their diversity . . . they expressthe creative power of the human spirit in appreci-ating meaning in human birth, growth, sexuality,health sickness, suffering and death (p. 50).

In other words, those who are born and reared in theraditions and values of such communities (and that in-ludes many students of midwifery) are already equippedith a specific moral framework. Nonetheless, to use it in

reedom and justice, in respect for the rights and freedomsf others, it is vital to open the mind to the range of valuesnd approaches by which other traditions, including theon-theistic, give meaning to their lives. Life experienceill often do this, but the midwife teacher can nurture therocess.The skilled midwife will use a range of approaches to

timulate the students’ willingness to engage in criticalrocesses of reflection in the classroom, in personal tutori-ls and especially by encouraging peer group discussion.n outline of a process by which this may be achievedithin the formal midwifery curriculum is shown in Figure. This figure identifies a 3-strand simultaneous process that

nvolves, s

ournal of Midwifery & Women’s Health • www.jmwh.org

Identifying the questionThe learning processTeaching strategies

Modified forms of the process may help develop aacility for systematic, coherent critical reflection andthical decision making.

now Your Content

t is obvious from the earlier discussions that there is nohortage of material for reflection in midwifery practice.he problem is less a lack of situations in which to exerciseritical ethical analytical skills than of identifying clear,onsistent, and coherent theoretical guidance through themoral maze.” The midwife teacher’s own critical thinkingkills come into play in selecting the most appropriatethical framework for the work undertaken in the classroomr practice.There is no shortage either of “medical ethics” texts,

lmost all of which survey the different theoretical schoolsf thought, which are commonly used to guide decisionaking and action. These distinguish between “ rule-based”

deontological) theories (the Kantian imperative, theGolden Rule,” rights-based theories, or natural law) andoutcome-based” (teleological) theories (consequentialism,tilitarianism, “ the greatest good for the greatest number” ).eyond this there is “ intuitionism,” virtue theory,14 relativ-

sm, and so on. Many texts attempt to put flesh on thehilosophical bones by using case histories to illustrate howhe theories work in practice and how the great ethicalrinciples, such as justice, autonomy, and beneficence, findxpression in them. Midwives may well find that this ishere the texts written expressly for their discipline are ofarticular value, because it is very much easier to wrestleith abstract concepts if one can identify with the particu-

arities of the situation.15,16 However, there is much to beained by exploring the more general texts, because theyeflect a wider world and a broader view of the implicationsf the adoption of a given ethical framework.17

now Your Client

lthough the administration and the school can presentheir own problems, most of the ethical issues faced byidwives arise within the clinical practice area. Quality

are normally supposes knowledge of the client. This mayot always be possible, but where it is, such knowledge willncrease the midwife’s awareness of what values andeliefs are likely to color the client’s approach to decisionaking.Bringing together all these elements—the situation, the

earner, the principles and theories, the client, and theeacher—is a challenge. Working with groups over theears, the author has found that much is gained by using aynamic, process approach to ethical reflection and deci-

ion making rather than a static framework. The approach

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utlined in Figure 1 offers a systematic yet flexible frame-ork for teaching ethics.

OOLS FOR THE TASK

earning the skills of ethical reflection, learning to interactonstructively with others who do not share one’s ownthical framework, and learning to help others facingthical dilemmas take time and commitment. The ethicalecision making and the learning process outlined in Figureare supported by a range of tools, each of which can shedparticular type of light on a problem. These include,

Ethical frameworks and modelsEthical principles and theoriesProfessional codes of practice and codes of ethicsLegal frameworksReligious prescriptions

A glance at the literature of the past two decades presentsbewildering array of frameworks, models, and processes

ll designed to help health care practitioners order theirhoughts and structure the work of ethical reflection andnalysis described above.18–20 The very multiplicity of suchexts suggests a search for one single, infallible pathwayoward a sound, “ right” decision in the face of an ethicalilemma. Would that there was such a path. Yet it is aefining characteristic of our humanity to have the freedomnd the capacity to grapple with conceptual challenges torotect what is deemed to be the right course of action.One size fits all” answers, tick-box answers, cannot workn the pluralistic society of the 21st century; even if theyxisted, their very facility would not be consonant with theravity of the issues under consideration. Good decisionsnd ethical decisions require a longer, harder path involvingnowledge of and critical reflection on all the elementsnvolved.

HICH APPROACHES TO TEACHING ETHICS WORK BEST?

oot It in Practice

rguably, ethics is taught as much by “doing” as byheoretical “ learning,” if the “doing” is habitually accom-anied by the practice of reflective review. This may takeany forms, personal or collective, informal or formal, asith perinatal and maternal “near-miss” or death reviews.21

ost practitioners will find that the effort of discussing andeviewing a situation that presents ethical problems withthers is richly rewarded. Critical incident analysis and rolelay can help practitioners become aware of differentspects of a situation, especially the different values held byhe various protagonists. The more such exercises, formalr informal, become “custom and practice,” the less daunt-ng ethics will be and the more each practitioner will gainonfidence. It is essential that students feel free to explorelternative approaches and to voice reasoned dissent. In

ddition, maintaining a personal journal and developing a f

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entor relationship can be valuable tools for developingkills in ethical reflection. This may be particularly usefulor the independent practitioner whose contact with a peerroup may be necessarily limited, particularly if her prac-ice is geographically remote.

earn About the World

ssues of cultural and ethnic differences constantly presenthemselves in practice.22,23 Such differences offer the pos-ibility of great enrichment, but, if unrecognized or ignored,an also be the source of misunderstanding and mistrust,ith potentially serious consequences. Part of any mid-ife’s professional responsibility is to anticipate such

ituations and prepare for them as far as possible byecoming familiar with the customs, beliefs, and values ofthers. Just as midwives leaving to practice in the Amazonasin, central Africa, or south Asia will add some knowl-dge of tropical diseases to their professional “ toolkit,” soill they expand their moral framework by learning asuch as they can about the history, religion, and practices

f the peoples they plan to work with.24

se the Code

he ethical codes of midwifery regulatory bodies or pro-essional associations offer a further classic support forthical reflection and teaching. The Code of Ethics of thenternational Confederation of Midwives2 has already beenentioned. On the basis of global consultation and, there-

ore, with a legitimate claim to express professional mid-ifery values across a wide range of cultures, it has

ncouraged a number of midwifery associations to developheir own codes.25,26Apart from their normative function instablishing standards of practice, such codes act as bench-arks when values conflict. Other professional organiza-

ions have taken a rather less structured approach andnshrine their beliefs and values in statements of valuesather than “codes.” 26 Such documents provide valuablerameworks for reflective analysis of practical situations,ither individually or in groups. Some may think that theres little mileage in such retrospective analysis. Nonetheless,he exercise of systematic reflection in the calm of aeminar situation may well build confidence and honekills, which can be called into play rapidly when theidwife is brought up sharply against a difficult situation in

he urgency of clinical practice.

ONCLUSIONS

thics teaching and ethical reflection have only one end iniew: the formulation of better decisions in practice; it isere that the theory-practice gap is bridged. In midwifery,eople from different backgrounds have input into crucialecisions: the woman herself above all, the midwife, theamily, the pediatrician, the obstetrician, and the partner or

amily. The primacy of the woman’s autonomy means that

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he final decision should normally be hers. Nonetheless, theell-prepared midwife can play a crucial role in the

ormation of a truly informed decision, ensuring that allspects have been considered, that the relevant facts haveeen gathered, the evidence weighed, the opinions heard,nd the possible outcomes fully examined. Here the mid-ife enters fully into her role as the woman’s advocate. All

his presupposes a sound basis in the art of critical reflectionnd ethical decision making learned from skilled teachers.

Ethical practice can be described as an ongoing processf conflict resolution—largely internal, moral conflict, ad-ittedly—but often with very significant outcomes for the

ives of the persons concerned. Through pregnancy, child-irth, and the early months of new life the midwife has aey role as negotiator, counselor, and mentor as problem-tic situations arise, for the woman, for the midwife, foreers. It may not always be possible to obtain the idealutcome, for in complex situations many factors will beeyond any one individual’s control, but at the very least,ll the midwife’s skills can be used to ensure that no harms done.

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2. ICM, ICN, WCPT, WDF, WMA. Civilians pay in war. Intidwifery 2003;16:12.

3. Bueckens P. Over-medicalisation of care in developing coun-ries. In De Brouwere V, Van Limberghe W. Safe motherhoodtrategies: A review of the evidence. Stud Health Serv Organ Policy001;17.

4. Cook RJ, Dickens BM, Wilson OAF, Scarrow SE. Advancingafe motherhood through human rights. Geneva: World Health Or-anisation, 2001.

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7. Mander R, Fleming V, editors. Failure to progress. The con-raction of the midwifery profession. London: Routledge, 2003.

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13. Engelhardt HT. The foundations of bioethics. New York: Ox-ord University Press, 1986.

14. Oakley J. A virtue ethics approach. In Parker M, Dickenson D,ditors. The Cambridge medical ethics workbook. Cambridge: Cam-ridge Universtity Press, 2001.

15. Jones SR. Ethics in midwifery, 2nd ed. Edinburgh: Harcourtublishers, 2000.

16. Frith L. Ethics and midwifery. Issues in contemporary practice.xford: Butterworth Heinemann, 1996.

17. Frankena WK. Ethics, 2nd ed. Englewood Cliffs, NJ: Prentice-all, 1973.

18. Johnson AG. Pathways in medical ethics. London: Edwardrnold, 1990.

19. Downie RS, Calman KC. Healthy respect: Ethics in health care.ondon: Faber and Faber, 1987.

20. Seedhouse D. Ethics; the heart of health care, 2nd ed.hichester: John Wiley & Sons, 1998.

21. Langer A. Identifying interventions to prevent maternal mor-ality in Mexico: A verbal autopsy. In Berer M, Sundari TKS, editors.afe motherhood initiatives; critical issues. Reproductive health mat-

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22. Katbamna S. “Race” and childbirth. Buckingham: Open Uni-ersity Press, 2000.

23. Schott J, Henley A. Culture, religion and childbearing in aultiracial society. Edinburgh: Butterworth Heinemann, 1996.

24. Lefeber Y, Voorhoeve HWA. Indigenous customs in childbirthnd childcare. Assen, The Netherlands: Van Gorcum, 1998.

25. Association of Midwives of Newfoundland and Labrador Codef Ethics. Approved January 2001. [Internet] [Cited March 26, 2004.]vailable at http://www.ucs.mun.ca/�pherbert/number12.html.

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