Informed Consent in Midwifery - Research Paper Example

INFORMED CONSENT 0. INTRODUCTION The story of nursing is marked by stories of people encountering and meeting during time of vulnerability. It tells the story of the vulnerated given respect and treated with dignity at the instance of their vulnerability; thus, paving the way for the possibility of an authentic encounter between persons. The face to face interaction that happens between nurses and clients creates a framework of care which moves beyond the customary opinion and understanding of care towards a moral perception, awareness and appreciation of nursing care (Howell, 2002). This remarkable shift of care gives rise to the moral dimension of nursing care (Gastmans et al, 1998; Gastmans, 1999; Cronquest et al. 2004; Tuckett, 2005; Tarlier, 2004; Patistea, 1999; van Hooft 1999; Covington 2005). Being such, it becomes the “supreme test of solicitude, when unequal power finds compensation in an authentic reciprocity of exchange, which in the hour of agony, finds refuge in the shared whisper of voices, or the feeble embrace of clasped hands.” (Ricoeur 1992, p 191) Thus, the subjectivity, personhood and humanity of both the nurse and the client are supported as “nurses respond with authentic presence to a call from another” (Boykin & Schoenhofer, 1990, p 150) at the moment of health vulnerability. It is in this context of care that the midwife and client scenario becomes the paramount exemplar of support for the dignity and humanity of the client as their relation affirms the subjectivity and autonomy of the women client to decide over their bodies (Dekkers, 2001; 2004). And the power to decide over one’s body is concretely manifested by informed consent. However, what is informed consent? 1.1. AIMS OF THE PAPER In lieu of the significance attributed to informed consent, this paper intends to look into the concept of informed consent in order to gain deeper understanding and appreciation of informed consent as it is applied in midwife – client relation. Moreover, this paper aims to compare some of the identified approaches in the understanding and application of informed consent. Finally, this paper aims to identify points, which may need further study as the notion of informed consent is clarified. These aims are to be accomplished via a review of existing relevant literatures pertinent to the subject matter at hand. 1.2. STATEMENT OF THE PROBLEM In this regard, this paper will try to address two important questions. These are: First, what is informed consent? Second, how does informed consent though applied in differing context become a concrete manifestation of autonomy and human dignity? 1.3. SCOPE AND LIMITATION This paper will primarily focus on the conceptual analysis of informed consent. As such, it will look into the nature and definition of informed consent. Moreover, it will go over the guidelines of the proper implementation of informed consent. However, as this paper goes over the concept of informed consent, it will limit its discussion of informed consent with the framework of midwife-client relation. Furthermore, it will keep the discussion within the purview of comparing informed consent from different approaches but still within the framework of midwife-client context. Being such, this paper assumes that although there may be a common understanding and appreciation of informed consent as significant in health and social care relations. Nevertheless, there is a difference in the manner of implementing the ideals and principles that support the informed consent as it is applied in actual health encounters between healthcare and patient/client in general and midwife and client in particular. 1.4. SEARCHED METHODS The electronic databases PubMed, Biomed Central and CINAHL were searched using a combination of the following key terms: informed consent, midwife, women’s bodies, consent nurse, nursing, profession, midwife-client relationship and nurse-patient relationship. Articles written only in English and published in journals from the period of 2000 till 2010 were selected. The fundamental book in bioethics was also included as it provides the foundation with which the concept of informed consent is to be appreciated. Moreover, articles that provided a conceptual analysis of informed consent within the framework of midwife – client relation were included in the search. Likewise, included in the search are ethics codes and articles that used qualitative and quantitative research in analyzing informed consent. Correspondingly, excluded in the selection were editorials, case studies, position papers, pamphlets and monographs. The reference list of the articles was searched to identify additional relevant publications. 1.5. SEARCH OUTCOME 12 Articles have been identified as meeting the set inclusion criteria. 9 of the 12 articles directly deals with the conceptual analysis of informed consent while the remaining 3 are guidelines and codes pertaining to the proper implementation of informed consent in the actual midwife- client set-up. These 12 articles, all written in English, are the primary articles for it has provided a thorough conceptual analysis of informed consent and presented the guidelines regarding its proper implementation. The other articles used act as a support to the developed argument of this paper. In the end, a clearer understanding of informed consent may hopefully open and create a more humane and responsive relation between the midwife and the client. 1.6. INFORMED CONSENT: ITS NATURE The concept of informed consent is a recent development in the healthcare provider- client relation. This is primarily because there is a long standing tradition of patriarchy (especially seen in medicine)– the patient is simply going to follow whatever the doctor will say since the doctor is the one who has the specialized knowledge that will cure the patient and doctor is working and being guided by the principle of benevolent father (ten Have, 1995). However, “rapid developments in science and technology, its effect and application in the human life and the recognition that human being can reflect on their experiences, look into their existence and environment and assume responsibility, to seek cooperation and to exhibit the moral sense that gives expression to ethical principles” (Universal Declaration on Bioethics and Human Rights, 2008). Thus, in the Principles of Biomedical Ethics, Beuchamp and Childress (1994) states that the client/patient, who is the subject, should be considered and treated as “competent to make decision if he or she has the capacity to understand the relevant information, to make judgment about the information in light of his or her values, to envisage a certain outcome and to freely communicate his or her wish to caregivers or researchers” (135). This approach in appreciating the client/patient asserts that the client in the health relation has the capacity in making decisions and competence in acting on the decision. This supposition has close ties to the principles of autonomy and independence (Dekkers, 2001b). Though there are strong counter arguments on this position namely: first, how can one make a competent decision if one is dizzy and suffering from extreme pain as one is about to go to labour? Second, dependency (which is clearly manifested during time of vulnerability like illness) can be seen as recognition of the fact that human existence is always being with others, thus making life more meaningful (Dekkers, 2001b). However, despite this seeming limitation posited, informed consent is a very significant development in health relations and is defined as “is an ongoing agreement by a person to receive treatment, undergo procedures or participate in research, after risks, benefits and alternatives have been adequately explained to them.” (Royal College of Nursing, 2006:1). This definition of informed consent highlights the four elements necessary to ascertain that informed consent has been furnished. These elements are: capable of making that particular decision, acting voluntarily, that is, they must not be under pressure from you or anyone else to make a particular decision provided with sufficient information to enable them to make the decision, capable of using and weighing up the information provided during the decision-making process SOURCE: Professional Standards and Guidance for Patient Consent, 2007 Moreover, as informed consent affirms the principles of autonomy and independence in lieu of respect for the individuality of the human person, it asserts at the same time that the human person is a rational being who is capable of making decisions based on information that are deemed as relevant to the clients condition (Habiba et al, 2004). Thus, as the client is empowered by the ability to make a decision and to act on that particular decision, clients become autonomous moral agents, thereby, upholding the “human dignity, human rights and fundamental freedom of the individual (Art 3, Universal Declaration on Bioethics and Human Rights, 2008). In this regard, informed consent driven by “shared decision making... by pressures from the bioethical and legal field to move away from paternalism and to respect patient autonomy” (Habiba et al, 2004: 422) also becomes the tool with which the interest and welfare of the individual is given priority over that of science and society (Art 3, Universal Declaration on Bioethics and Human Rights, 2008). Thus, informed consent” operationalised through the act of signing a consent form, is promoted as a means by which these ideals may be achieved” (Habiba et al, 2004: 422). As such, clarification regarding cases wherein the client cannot give an informed consent has been addressed via proxy consent for people who are deemed not capable of providing one (RCN, 2006; Universal Declaration on Bioethics and Human Rights, 2008; Professional Standards and Guidance for Patient Consent, 2007). In the same regard, the midwife is introduced and given the requisite forms which maybe used in order to secure the client’s informed consent (Dimond, 2003). And this theoretical framework of informed consent becomes clearer in the context of actual midwife-client scenario. 1.7. INFORMED CONSENT: DIFFERENT CONTEXTS IN MIDWIFE-CLIENT RELATION Churchill & Benbow (2000) claims in a study that they have conducted that midwifes have been given very good ratings by their clients in terms of their clients perception of shared and informed decision regarding their labour. This, in turn, made 83% of their respondents feel that “that they had taken an active part in decision- making about the birth of their babies” (42). With this high rate, it can be assumed that, midwives take all the necessary steps in giving an “unbiased information so that the child-bearing woman can make an informed decision about her care.”(Changing Childbirth as cited in Marshall, 2000). In this regard, two forms of consent are accepted. One is the consent given by the woman which is manifested in non-verbal beahviours (Marshall, 2000). And the other is the expressed consent (oral or written) which is necessary especially in procedures with significant risk (Marshall, 2000). However, when it comes to breastfeeding, especially in case where the mother is HIV carrier, the midwife should be objective and should provide the mother with all the information necessary to make the right decision (Drozdowska, 2001). This becomes significant as there is strong campaign for mothers to breast feed their babies. However, it should be noted and bear in mind that women “women still have the right to decide how to feed their babies” (Drozdowska, 2001: 370). In terms of NT screening, “The main source of information that underpinned women’s knowledge of NT screening were: health-care professionals; literature from the hospital; family and friends” (French, 2000: 635). In this regard, midwives are espoused to take a more active participation in information dissemination regarding NT screening. It is important to note, informed consent as perceived in the context of midwife –client relation takes a different turn the moment the client is being recruited for research. There is an additional information that midwives have to inform their client that it requires a long term participation and that included in this are the benefits and risk that are entailed in joining the research. The midwife has to take an extra effort in order to inform the client all the necessary details in order for the client to make an informed consent (French, 2000). These contexts discuss shows that midwives respond to the demand of informed consent depending on what is the appropriate scenario of their client. Informed consent empowers the midwives’ clients and this truism is something that midwives regardless of the condition upholds. 1.8. CHALLENGES Although midwives are trusted health care providers in terms of upholding informed consent, there is still a need to further fortify and strengthen the ethical underpinnings of informed consent as encountered in midwife-client relation (Chaloner, 2007). In fact, Thompson (2002), claims that the challenge to midwives is to go beyond the codes of conducts to embrace ethics not merely as part of the profession but to see ethics as part and paradigm of midwife service, or midwife – nursing care. And that this perspective can be attained by focusing on health care ethics education that is not only centred on theories but is lived and fleshed in practice (Aveyard et al, 2005). In the end, the midwife-client relation, regardless of the context and condition of the encounter, provides the paradigm wherein informed consent is not just a lip service but a reality that empowers the clients as they, the clients, make decisions that are shared and well –informed, thus, affirming their human dignity, respecting their human rights and fundamental freedom. 1.9. CONCLUSION Informed consent as a contemporary development upholds the autonomy, independence, rationality, competence and individuality of the client. In this sense, informed consent empowers the client in deciding what the appropriate action for her condition is. The midwife as one of the most trusted health care providers that support and affirm informed consent, is further challenged to become advocates of their patients by taking a more active role in information dissemination and in embracing ethics not just as codes but as a way of service and care to their clients. REFERENCES: Primary Articles Aveyard, H., Edwards, S., & West, S. (2005). “Core topics of health care ethics. The identification of core topics for interprofessional education”, JOURNAL OF INTERPROFESSIONAL CARE, VOL. 19, NO. 1, 63 – 70. DOI: 10.1080/13561820400021692. Beuchamp,T.L. & Childress, J.F. (1994). Principles of Biomedical Ethics. New York/Oxford: Oxford University Press. Churchill, H., & Benbow, A. (2000). “Informed choice in maternity sevices”, British Journal of Midwifery, Vol. 8, No 1, 41 - 48. Chaloner, C. (2007). “An introduction to ethics in nursing”, Nursing Standard, 21, 32, 42 – 46. Dimond, B. 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