The Professional Responsibility Model of Perinatal Ethics

Frank A. Chervenak, Laurence B. McCullough

• Publisher: De Gruyter
• Year: 2014
• ISBN:
  9783110389746
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

This book provides the first clinically comprehensive and practical approach to ethical challenges in perinatal medicine. The first chapter introduces and explains the professional responsibility model of perinatal ethics. The professional responsibility model is based on the medical ethics of two major physician-ethics in the history of Western medical ethics, Dr. John Gregory (1724-1773) of Scotland and Dr. Thomas Percival (1740-1804) of England. The professional responsibility model is used to articulate the ethical concept of the fetus as a patient and to operationalize the ethical principles of beneficence and respect for autonomy. The book provides practical guidance for clinical judgment and decision making with patients about the responsible clinical management of the wide range of issues encountered by perinatologists in clinical practice and research. Topics included: periviability; feticide; intrapartum management; maternal-fetal conflict; innovation for fetal benefit; research for fetal benefit; non-aggressive obstetric management; managing the transition from pregnancy to birth; destructive procedures such as cephalocentesis; critical care for the pregnant patient; home birth; patient-choice cesarean delivery; neonatal care as a trial of management; and setting limits on neonatal care on the basis of clinical judgments of futility.

1 The professional responsibility model of perinatal ethics

1.1 Introduction

Perinatologists confront an impressive range of ethical challenges in clinical practice and in research designed to benefit maternal and fetal patients. The responsible management of these ethical challenges, therefore, becomes essential to the professional practice of perinatology and to perinatal research. The purpose of this book is to introduce the reader to the two basic tools of ethics – ethical analysis and ethical argument – and to demonstrate how these two tools of ethics generate a practical, clinically comprehensive, professional medical ethics for perinatal practice and research.

Throughout the chapters that follow, we emphasize a preventive ethics approach.^1,2 Preventive ethics aims to prevent ethical conflict in clinical practice by anticipating the potential for ethical conflict and designing ethically justified, practical approaches designed to minimize the occurrence of ethical conflict and to respond rapidly and effectively to ethical conflicts when, despite sustained effort to prevent them, they nonetheless occur.

The methodological basis for the approach to perinatal ethics taken in this book is the professional responsibility model of perinatal ethics. In this chapter, we introduce this model, after first providing definitions of ethics, medical ethics, and perinatal ethics.

1.2 Ethics, medical ethics, and perinatal ethics

1.2.1 Ethics

Ethics has been understood for millennia in global intellectual, cultural, and religious traditions to constitute the disciplined study of morality. Morality concerns our beliefs about what sort of people we should aspire to become; our obligations to each other, to our communities, to organizations, and society; the obligations of organizations to individuals, communities, and society; and the obligations of society to individuals, communities, and organizations. Ethics seeks to identify and critically assess those beliefs, with the goal of improving morality.

Ethics undertakes this task by asking, What ought morality to be? To make this question more manageable and to generate practical answers that will guide the improvement of morality, this general question is broken down into specific questions: What sort of persons should we become? How should we act toward each other, communities, organizations, and society? How should organizations act toward each other, individuals, communities, and society? How should society act toward individuals, communities, and organizations?

The tools of ethical reasoning. These questions are addressed using the two basic tools of ethics; ethical analysis and argument. Ethical analysis requires us to be clear about concepts, such as being a patient and professional integrity, that we invoke and to use those concepts with a consistent meaning to give reasons for our judgments and behavior based on them. Ethical argument requires us to join ethical concepts together in a coherent way to provide reasons that together support conclusions. Simply listing disconnected ethical considerations does not count as argument. Neither does starting with conclusions, and then going in search of supportive ethical considerations.

The discipline of ethics comes from two sources. The first relates to ethical analysis: adhering to the requirements of clarity and consistency in the articulation of ethical concepts. The second relates to ethical argument: identifying the implications of clearly articulated, ethical concepts for clinical practice and research, or going where our arguments take us and nowhere else. The discipline of ethical argument has an important feature: If one is not willing to accept the conclusion of an argument, one must show an error in the reasoning that supports it, correct the error, and then identify the revised or even new conclusion that follows from the revised reasons. If one cannot do so, then one is required to change one’s mind by adopting the conclusion. This discipline of ethical argument is directly analogous to the discipline of deliberative (evidence-based, rigorous, transparent, and accountable) clinical judgment: When the evidence requires one to change one’s clinical judgment, the professionally responsible physician does so. The professionally responsible physician, by submitting to the disciplined study of morality that is ethics, sometimes will be required to change his or her clinical ethical judgment.

1.2.2 Medical ethics

Medical ethics is the disciplined study of morality in medicine. Medical ethics undertakes this study by asking specific questions: What does it mean to say that a physician is a professional? What obligations do physicians owe their patients, healthcare organizations, and society? What obligations do patients owe their physicians, healthcare organizations, and society? What obligations do healthcare organizations owe their patients, healthcare professionals, and society? What obligations do societies have to physicians, patients, and healthcare organizations?

Medical ethics should not be confused with the many sources of morality in a pluralistic society. These include, but are not limited to, law, the world’s religions, ethnic and cultural traditions, families, and personal experience. Professional medical ethics seeks to bridge these differences and identify the obligations of physicians to their patients in all global cultures, religions, and national settings.

Medical ethics as secular. The first step in doing so is to recognize that professional medical ethics is secular. This recognition was achieved in the eighteenth-century European and American Enlightenments.⁴ Secular professional medical ethics makes no reference to deity or deities, or to revealed tradition, but to what reasoned, evidence-based discourse requires of our judgments and behavior. At the same time, secular professional medical ethics is not intrinsically hostile to but respectful of religious beliefs. Therefore, ethical principles and virtues should be understood to apply to all physicians, regardless of their personal religious and spiritual beliefs, and regardless of their nationality or place of practice.⁵ The advantage of secular medical ethics is that it is transreligious, transcultural, and transnational.³

The traditions and practices of medicine constitute an obvious source of morality for physicians. These traditions provide an important reference point for professional medical ethics because they are based on the obligation to protect and promote the health-related interests of the patient. This obligation tells physicians what morality in medicine ought to be, but only in very general, abstract terms. Providing a clinically applicable account of that obligation is, in clinical practice, the central task of professional medical ethics, using ethical principles.^2,5 We start with ethical principles that play a central role in professional medical ethics; beneficence and respect for autonomy. The ethical principle of justice will be introduced in Chapter 2, and more extensively in Chapter 3.

The ethical principle of beneficence. In ethics, generally, the ethical principle of beneficence requires one to act in a way that is reliably expected to produce a greater balance of benefits over harms in the lives of others.^2,5 In professional medical ethics, this principle requires the physician to seek a greater balance of clinical gods over clinical harms in the lives of patients.² The task of beneficence-based clinical judgment is to reach reasoned judgments about the appropriate balance of clinical goods and harms in a particular clinical situation, such as the decision to perform a cesarean delivery (see Chapter 4).

Beneficence-based clinical judgment has an ancient pedigree. Its first expression in the history of Western medical ethics occurs in the Hippocratic Oath and accompanying texts.⁶ These texts make an important claim: to reliably interpret the health related interests of the patient from a deliberative clinical perspective. This perspective is provided by accumulated scientific research, clinical experience, and reasoned responses to uncertainty. A rigorously evidence-based, beneficence-based clinical judgment is not based on the idiosyncratic judgment of the physician, i.e. merely on the clinical impression or intuition of an individual physician. On the basis of this deliberative clinical perspective, focused on the best available evidence, beneficence-based clinical judgment identifies the clinical benefits that can be achieved for the patient by the clinical application of the competencies of medicine. These competencies are the prevention and management of disease, injury, disability, loss of functional status, and unnecessary pain, distress, and suffering, and the prevention of premature or unnecessary death. Pain and suffering become unnecessary when they do not result in achieving the other goods of clinical care, e.g. allowing a woman to labor without effective analgesia.²

In beneficence-based clinical judgment, pregnancy is not a disease. It is, instead, a clinical condition: a naturally occurring biological process that creates risks of disease, injury, disability, loss of functional status, and unnecessary pain, distress, and suffering. As a consequence, the clinical management of the clinical condition of pregnancy comes under beneficence-based clinical judgment.

The ethical principle of non-maleficence. The ethical principle of nonmaleficence requires the physician not to cause harm. This is sometimes treated as an absolute, allowing no exceptions. This is a common mistake; non-maleficence is best understood as expressing the limits of beneficence-based clinical judgment. This ethical principle is also known as Primum non nocere or “first do no harm.” This commonly invoked dogma is really a latinized misinterpretation of the Hippocratic texts, which emphasized beneficence while avoiding harm when approaching the limits of the competencies of medicine, especially to maintain or improve the patient’s condition, or to a...

Table of contents

• Hot Topics in Perinatal Medicine
• Title Page
• Copyright Page
• Dedication
• Preface
• Table of Contents
• 1 The professional responsibility model of perinatal ethics
• 2 Induced abortion and feticide
• 3 Periviability
• 4 Intrapartum management
• 5 Planned home birth
• 6 Pregnant patients with mental disorders
• 7 Neonatal management
• 8 Perinatal innovation and research
• 9 Women and children first: Advocacy in perinatal medicine
• 10 Critically appraising the literature of perinatal ethics
• 11 Acknowledgements
• Index