Tuesday, May 31, 2011

Autonomy, beneficence, and non-maleficance

Big words, big issues, and a fantastic post at Birth Sense putting them all together. The blogger at Birth Sense summarized Dr. Andrew Kotaska's recent presentation at the annual ACNM meeting. Dr. Kotaska helped author the new SOGC breech guidelines and is a passionate advocate of maternal autonomy and true informed consent (i.e., informed consent + the ability to make real choices).

Some excerpts from his presentation, via Birth Sense:
Dr. Kotaska posed the question, how does a physician or midwife stay with a patient when she declines your recommendations? ...

Dr. Kotaska argues that we need to promote the policies that systems like those Britain and Ontario, Canada have adopted. The Royal College of Midwives' policy is "If a woman rejects your advice, you must continue to give the best care you possibly can, seeking support from other members of the health care team as necessary." Midwives in these areas do not have to remove themselves from their patients’ care (effectively abandoning them), but are expected to continue to support and care for the woman even if she refuses to follow the midwife’s advice.

Dr. Kotaska urges providers to "explicitly state your commitment to her [the woman's] autonomy over your idea of beneficence." He emphasizes that each provider should embrace these three points:
  • Your job, as a provider, is to inform your patient
  • She is free to decline your recommendations
  • She will not lose your support if she declines your recommendation
What is the result of a provider maintaining this type of attitude with their patient? Dr. Kotaska asserts that women trust these providers because they have not threatened the therapeutic alliance. He also stated that "informed consent" is not truly an informed consent if the woman will not be supported in her choices. For example, giving a woman informed consent about the risks and benefits of a trial of labor after cesarean, while telling her that your hospital does not allow VBACs, is not truly giving her an informed consent because she has only one option.

When asked how a woman should respond when she is refused a trial of labor, Dr. Kotaska replied that a woman should create her own "informed consent" form that she asks the provider to sign. It should state that:
  • she does not want a repeat cesarean section
  • she is aware of the potential risks of a repeat c-section, including placenta accreta, hemorrhage, increased risk of stillbirth, infection, increased risk of maternal death, and four-fold increases in neonatal respiratory distress
  • she is not being offered a choice of how she will give birth
  • if she experiences any complications as a result of being forced to have a c-section, she will be pursuing legal action against the provider who would not support her in a trial of labor.
With this proposal, Dr. Kotaska received a standing ovation from the midwives attending his presentation. What was clear to me is that midwives and mothers are fed up with the status quo in modern obstetric care today, and if change will only happen through women creating an informed consent form they ask their provider to sign, so be it. It’s time for a birth revolution, and it has to start with midwives, mothers, and a few progressive physicians who are not afraid to challenge the status quo.
Read the rest here.


  1. When I was pregnant with #3 my husband was in law school, and I read my OB the riot act! lol, Got pretty high and might with the law stuff-it felt quite empowering to know exactly what my rights REALLY were! I think she was pretty taken back!

    Having delivered in Canada and in the US, hands down would prefer to deliver in Canada!!

  2. It is refreshing to hear a doctor fight for the right for a woman to choose. I never understood why it was so hard for doctors to allow women to make those choices.

  3. I am an ICAN chapter leader. I am going to start handing this out. Thanks for passing this on!

  4. "Non-maleficance"?

  5. I love this post. I do not understand the way doctors treat women when it comes to maternity care. If you are a cancer patient, you are given the choice of treatments (if any) you want to take. As an expecting mother, we are told to stand in line, and go through the system, period. Thank you for your informative and to-the-point posts.

  6. at the virtual midwives day conference I did a talk on ethics in midwifery and the 5 principles of ethics. I tried to turn it into simple practice so midwives can understand everyday how they go against these simple principles to protect themselves. There are many doctors and midwives who don't really get automony, or do no harm. They work to the moral that it is better to be safe than sorry and it's better the devil you know.

  7. And, you know, if random women didn't declare their consent invalid after something *did* go wrong, docs just might be more willing to go along with your riskier ideas. One of the more annoying parts of your "trust birth" idiocy is that you want to refuse all the stuff that might let you know something is going wrong, show up at the hospital with you and the baby in distress, and then bitch blue murder about teh evil docs who couldn't pull one more rabbit out of the hat and save your ass, your baby and your uterus.

    Does it not cross your mind that docs don't like losing babies, and don't like being sued---because in order to be sued, there has to be a bad outcome? And a bad outcome is a dead or injured baby? Midwives have no insurance, little training and less accountability.

  8. It is funny but I actually disagree with Dr. Kotaska. Doctors need to be doctors, highly trained in problems and trusted to offer the best of their very specific education and training. No wonder the midwives gave a standing ovation, he simply described implementing the midwifery model of care to the obstetrical field. Whilst this may sound great on first hearing, really it is creating a dangerous rock and hard place position for obstetricians and the mothers they treat.

    I should have prefaced my comment by stating that "I" believe healthy pregnant women and natural birth have no place in the hospital. Women need to remember their power, strength and ability to take back their births. We need less obstetricians; hospital based and nurse midwives and more of their traditional, spiritual and what I call "cross culturally conscious" counterparts. We need to spend more time looking at the ways we can prevent and avoid complications rather than offering more choice in treating them.

    This reduced amount of hospital based birth professionals would only take care of the truly and ever-reducing number of pregnancies requiring medical attention. In this situation, like all the other medical problems, mothers would actually be able to place their trust in the medical staff as they would know, they had done everything they could but unfortunately their pregnancy was no longer in it's naturally safe state.


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