Multifetal Pregnancy Reduction Paper
Running head: MULTIFETAL PREGNANCY REDUCTION
Multifetal Pregnancy Reduction:
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MULTIFETAL PREGNANCY REDUCTION
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Multifetal Pregnancy Reduction:
Conflicting values or beliefs about the right or best course of action often form the basis for moral dilemmas (Simmonds, 2012). Moral distress is associated with how the nurse perceives her role (Burston & Tuckett, 2012). The advanced practice nurse may experience moral distress when faced with an instance of knowing the correct course of action; however, not being able to pursue it. Ethical justification for choices and actions are based on the principles of autonomy, beneficence, nonmaleficence, and justice.
Relatively recent developments in assistive reproductive technology …show more content…
have increased the occurrence of multiple fetal gestation with fertility treatment (Zapletalova, 2013). Multiple birth pregnancy is not always welcomed by parents or physicians. The risk of prematurity and low birth weight increases with multifetal pregnancy. In this case, the perinatal practitioner has ethical obligations to both the pregnant and fetal patients (Chervenak & McCullough, 2013).
Clinical circumstances may generate offering the procedure of multifetal pregnancy reduction
(MFPR) in the process of informed consent to ensure autonomy. Some may argue that this is not the termination of a pregnancy, but is a procedure to ensure successful continuation of the pregnancy (Zapletalova, 2013). Grant & Ballard (2011) suggest some may view the issue as immoral; as tampering with nature.
Issues Surrounding Multifetal Pregnancy Reduction
A multifetal pregnancy reduction involves a first-trimester or early second-trimester procedure for reducing by one or more the total number of fetuses in a multifetal pregnancy
(American College of Obstetricians and Gynecologists, 2013). The procedure is most often performed in higher order pregnancies that include three or more fetuses. Reduction decreases
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maternal risks and increases the chance of at least one live birth. There are many ethical complexities involving continuing or reducing a high order pregnancy.
In multifetal pregnancy reduction, the fetuses to be reduced are chosen based on technical considerations (American College of Obstetricians and Gynecologists, 2013). For instance, the fetuses that are the most accessible to intervention (potassium chloride injection) are usually chosen. Selective reduction is an additional controversial ethical issue, that involves choosing fetuses for reduction based on their health, gender, or anomalies after chorionic villus sampling, amniocentesis or ultrasound.
Screening for the explicit purpose of sex selection for social reasons is not appropriate. However, information should not be withheld from parents if they request it.
Reduction to a singleton pregnancy from a twin or greater pregnancy remains controversial and some physicians may offer this option depending upon the woman’s circumstances and her values. To ensure the principle of autonomy, the decision ultimately rests with the parents of the fetuses. Benefits and Risks Associated with Higher-Order Pregnancies and MFPR
Maternal risks associated with multifetal pregnancy are the increased incidence of (a) hypertension, (b) preeclampsia, (c) gestational diabetes, and (d) postpartum hemorrhage
(American College of Obstetrics & Gynecologists, 2013). Additional complications may include maternal depression, severe parenting stress, child abuse, and an increased divorce rate.
Significant medical costs and adverse economic consequences are associated with multiple pregnancy. Infants born to multiple pregnancy may have an increased risk of prematurity, low birthweight, cerebral palsy, learning disabilities, delayed language development, behavioral difficulties, chronic lung disease, and …show more content…
death.
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The intention of MFPR is to decrease the maternal and infant risks associated with multiple fetal pregnancies (American College of Obstetrics & Gynecologists, 2013). There are risks related to the procedure of MFPR and long-term effects. A woman may have adverse outcomes from the procedure including; bleeding, infection, or even loss of more than the reduced fetuses including spontaneous abortion of the entire pregnancy. Couples may experience sadness, grief, or depression for months or years to come (Attaining Fertility, 2014).After reduction, the pregnancy may still result in premature birth, low birthweight and associated complications (American College of Obstetrics & Gynecologists, 2013).
Ethical Dilemma
Mrs. C., a 39 year-old fertility and perinatology patient is 10 weeks pregnant. After many miscarriages and several cycles of assisted reproduction, Mrs. C. and her husband are thrilled to be expecting their first child. They have been counseled it is likely they will have a multiple gestation with triplets or greater. The parents find out today they are expecting septulets and the physician and advanced practice nurse are consulting with the couple about the pregnancy.
Included is a discussion regarding the risks and benefits of multifetal gestation. The physician feels it is necessary to offer the option of selective reduction to the woman and her husband. The physician recommends selective reduction to the woman and her husband to preserve the health of Mrs. C. and some of the fetuses. He extolls the benefits of the procedure while minimizing the risks of losing the pregnancy.
Initially, Mr. & Mrs. C. recoil in horror at the thought of terminating even one of the babies they have worked so hard for. Mrs. C. asks the certified nurse midwife (CNM) about selective reduction. The CNM has strong beliefs about informed consent, patient autonomy, and termination of life. Additionally, she feels that the physician has made a recommendation and not
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provided sufficient information. She examines the context of the dilemma, her professional responsibilities, scope of practice, and her personal beliefs to determine what actions she should take in communicating with the physician and couple and in decision-making. The CNM is experiencing moral distress.
There are several ethical and legal reasoning constructs that the CNM must consider before arriving at a decision on how to act in this case. In-depth knowledge and details of the process of reasoning hopefully will assist the CNM in resolution of the moral dilemma presented.
Critically thinking about how the law would be applied in this case is important. Identification, evaluation, and application of the ethical principles of the case are equally necessary.
Legal Reasoning Constructs
Gordley (1984) suggests that legal reasoning constructs are principles involved in determination of how the law is applied in a legal decision. It also includes how a decision is reached when there are insufficient preexisting cases to pave the way. Interpretation, coherence, logic, case law, and legal analysis are the main principles in legal reasoning constructs. Each principle will be discussed in the following paragraphs.
Interpretation in Legal Reasoning
Gordley (1984) suggests when the law is clear on a subject, relevant rules can be applied in a logical manner. Legal reasoning focuses on how one develops a sense of legal consciousness and evaluate the appropriateness of formal rules in society (Moone, 2013). It assists in differentiating what is right and what one should do. It can aid in decision making when a practitioner may want to act in one way; however, could find themselves making the wrong decision. Legal reasoning is also a method of addressing a legal issue by arguing the existing rules among all interested parties (Peterson, n.d.). It may exist in two forms (a) application of the
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rules to cases, and (b) legislative drafting. Application of legal reasoning may involve dealing with the interpretation of written law (statutes) or customary law (past practices that now define an essential mode of conduct). Finally, Endicott (2011) suggests that interpretation in legal reasoning is finding rational support for legal conclusions.
Coherence in Legal Reasoning
Coherence in legal reasoning refers to the ability to know exactly what the law states
(Moone, 2013). It is the degree to which a case follows established law (Levenbook, 1984).
Additionally, it may be a condition for legal justification (Bertea, 2009). It is a measure of how a ruling falls in line with the fundamental principles of a legal system. Coherence requires consistency, comprehensiveness, and completeness. It may serve as a normative criterion in following the spirit of the law. Coherence places emphasis on the past and the obligation to remain within former legal decisions.
Logic in Legal Reasoning
Logic in legal reasoning is the ability to view clearly what the law is and how the law works (Moone, 2013). The rules of law apply in that similar cases are decided comparably.
Individual cases should be decided on their own merits and the decision making process must comply with applicable rules and procedures of evidence. To achieve the rules of law, one must articulate and evaluate the elements of legal reasoning (Walker, 2007). This type of reasoning is involved in interpreting constitutions, statutes, and regulations. Legal reasoning uses the concept of syllogism (Ramee, 2002). This consists of three parts (a) major premise – states a general rule,
(b) minor premise – makes a factual assertion, and (c) conclusion – applies the facts to the law. A syllogism must be a logical, valid statement; it is impossible for premises to be true and the conclusion to be false.
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Case Law
Legal reasoning may involve analysis directly from prior cases at hand (Teitelbaum,
2012). Case law establishes a precedent for future cases to follow (Lamont, 2014). Precedent is a prominent feature of legal reasoning. It occurs when an earlier decision is followed in a later case when similarity exists. Lamont (2014) suggests precedents are legally significant and should be understood as (a) laying down rules, (b) the application of underlying principles, and (c) as a decision on the balance of reason. Case law is often referred to as common law (Laws.com,
2013).
Legal Analysis
Legal analysis refers to a statement by a court, judge, or other legal authority as to the legality or illegality of an action, condition, or intent (U.S. Legal, 2014). It is critical examination of the legal issues present in a case and there are four steps (a) identify the issue or legal question,
(b) using enacted law, case or common law, or a combination helps provide an understanding of what applies to the case at hand, (c) a decision is made on how the law applies to the legal question or issues asked in the first place, and (d) an objective conclusion or summary is made.
The most pertinent law, case, or statute is discovered in an analysis that applies to the particular case. Ethical Reasoning Constructs
Ethical reasoning is the cognitive process involved in the analysis of an important ethical issue (Valentine & Bateman, 2011). The first step in the process of ethical reasoning is to identify the ethical issue present. The situation is then evaluated through different moral frameworks and an ethical judgment is formulated. The reasoning from this process leads to ethical behavioral
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intentions. The behavior is then performed and that reinforces the previous steps of ethical reasoning. The Function of Ethical Reasoning
Elder & Paul (2011) suggest the function of ethical reasoning is to critically think about acts that benefit others and acts that harm others. It is a way to set aside and distinguish other domains of thought such as religion, law, and social conventions. Recognizing that an issue has ethical components can form the basis for moral awareness (Valentine & Bateman, 2011). Moral awareness is when one recognizes that their potential decisions may impact the interests, welfare, or expectations of the self or others in a manner that may conflict with one or more ethical principles. The Problem of Pseudo-Ethics
At times in healthcare, there are dilemmas that initially that appear to be ethical issues; however on closer examination are more about communication and frustration. These dilemmas have been misclassified as “ethical issues” (The American Association of Neurosurgeons, n.d.) reports that many hospital ethics committees are reviewing issues that are not truly ethical in nature. Contentious situations have been classified erroneously as ethical for the purpose of the ethical committee review. They suggest that reframing an issue as ethical does not uncover the essence of the problem. It is difficult to apply ethical methodology to non-ethical issues.
The Elements of Ethical Reasoning
Paul & Elder (2006) list the following elements of ethical reasoning (a) “define the purpose, (b) raise questions, (c) use information, (d) utilize concepts, (e) make interpretation and inference, (f) make assumptions, (g) generate implications and consequences, and (h) embodies a
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point of view” (p. 14). The authors suggest if one understands these concepts, they are better equipped to analyze ethical reasoning and follow the ethical implications of their decisions.
The Logic of Ethical Reasoning
Elder & Paul (2011) propose that ethical reasoning must be developed to overcome the human natural tendencies towards egotism, prejudice, self-justification, and self-deception.
Humans need to understand that their behavior has consequences for others and natural tendencies can be resisted through the development of the ethical thought of fair-mindedness, honesty, integrity, self-knowledge and genuine concern for the welfare of others. If a person applies the elements of ethical reasoning, they will be able to ethically analyze a situation and determine appropriate behavior and action.
The Advantages and Disadvantages of Ethical Reasoning
Coughlin (2008) suggests that principle based approaches to ethical reasoning have several advantages including they are adaptive to new situations, offer practical solutions to ethical problems, have explanatory power, and are enduring. They also have the advantage of universalizability in certain fields such as bioethics. Ethical reasoning can also be combined with a coherence model of justification. The author reports limitations to ethical reasoning based on principles. Critics argue they do not provide an action guide or an adequate philosophical theory.
Some feel that the existing principles and rules are imperfect, and coherence between the principles and rules will lead to imperfect ethical decisions.
Differences between Legal and Ethical Reasoning
Ethical reasoning is the cognitive process involved in the analysis of an important ethical issue (Valentine & Bateman, 2011). Legal reasoning is the determination of how the law is applied in a legal decision (Gordley, 1984). Legal reasoning may also be how one develops a
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sense of legal consciousness and evaluates the rules of society (Moone, 2013). Moral deliberation uses the insights of various perspectives to clarify the ethical meaning in a situation; whereas, legal reasoning involves the foundation of enforceable law and court interpretation of application. Resolution of the Ethical Dilemma
There are many ethical complexities involving continuation or reduction of a high order pregnancy (American College of Obstetricians and Gynecologists, 2013). One could view the dilemma through the lens of the nonreduced fetuses and center their argument on maximizing benefits for the surviving fetuses after a MFPR (Ralston, 2011). This utilitarian resolution may be termed “lifeboat ethics”, where one or more is sacrificed for the good of the others. An ethical and legal discussion of the issues involved in this particular case; however, is much more complicated. The ethical issues surrounding multifetal pregnancy reduction (MFPR) are controversial and consist of varying shades of gray (Ralston, 2011). Aligning the interests of all the fetuses and the mother is simply not possible.
Evans & Britt (2010) argue that all involved in MFPR may struggle to reconcile the potentially oppositional elements of religious beliefs and the risks associated with higher-level pregnancies. Ethical justification for choices and actions are based on the principles of informed consent, autonomy, beneficence, and nonmaleficence (Simmonds, 2012). All of these principles are considered in the case and decision-making on the part of the advanced practice nurse, the physician, and the pregnant couple rests on a balance of the principles. Perhaps the most important principle in the case is that of informed consent. Receiving and understanding information forms the basis for informed consent and allows the couple to make an autonomous decision (Demontis, et al., 2011). The principle of autonomy will be violated if the physician
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and/or CNM do not provide information (Grant & Ballard, 2011). Respect for autonomy in this case is the principle that the couple must balance the relative importance of the medical, ethical, religious, and socioeconomic components and choose the best course of action for their unique situation (American College of Obstetricians & Gynecologists, 2013). As previously noted, to ensure the principle of autonomy, the decision ultimately rests with the parents of the fetuses.
The probability of specific adverse outcomes should be discussed, and it is the physician’s ethical and legal obligation to provide adequate information regarding diagnosis, prognosis, and alternative treatment choices, including the option of no treatment (American
College of Obstetrics and Gynecologists, 2013; Grant & Ballard, 2011). Beneficence would be providing benefit to the woman and the remaining fetuses for a successful pregnancy.
Nonmaleficence is more problematic in this case, as some of the fetuses would need to be harmed to help the mother and the remaining fetuses. Justice would be concerned with the costs associated with prematurity and the quality of life of the infants if premature or disabled.
One could also argue that justice could be applied in the case of which fetuses will be spared during the procedure and how the costs of health care are distributed.
Standard of Care and Scope of Practice Issues
The advanced practice nurse practicing in the area of women’s health or nurse-midwifery may practice in a diverse range of settings, including obstetrician or maternal-fetal medicine offices (American College of Nurse-Midwives, 2011). Contained within the scope of practice statement of the American College of Nurse-Midwives (ACNM) is the provision to form a partnership with women and their families in a shared decision-making model. This includes listening, providing information, guidance, and counseling. The standards of practice for nursemidwifery care include the support of individual rights and self-determination within the
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boundaries of safety. This standard addresses autonomy and beneficence. The provision of information in the context of current science is necessary for the woman to provide informed consent. CNMs are required to provide referral to other providers if necessary when the
care required is out of the scope of practice for the CNM (ACNM, 2011).
Ethical and Legal Principles Involved in the Case
The principle of autonomy may be violated if the CNM does not provide information.
Grant & Ballard (2011) suggest that autonomy forms the basis for informed consent. Demontis,
Pisu, Pintor, & D’Aloja (2011) argue that having information is not the same as understanding the information and may be problematic in informed consent. Furthermore, autonomy depends on (a) liberty - lack of coercion, (b) agency - the capacity to understand relevant information, consider options, evaluate risks and benefits, to make and communicate a decision, and (c) having the information necessary to make a decision.
The physician in the scenario is responsible for initially explaining the risks and benefits of the procedure and the effects on the current pregnancy (Grant & Ballard, 2011). If the CNM interprets the professional moral duty to the patient, then she has the responsibility to ensure that the patient has all of the information and understands it in order to give informed consent for the procedure. ACNM (2011) clearly delineates the scope of practice for the CNM and certified midwife
(CM). Included in the scope of practice are the services, education and core competencies required for midwifery practice. This is presented in a document entitled Definition of Midwifery and Scope of Practice for Certified Nurse-Midwives and Certified Midwives. Buppert (2004) suggests an advanced practice nurse must also consult their state law for a source of authority for professional practice. Therefore, the state Nurse Practice Act also specifies the scope of practice.
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In the case scenario, the advanced practice nurse is practicing in collaboration with the physician, and is not in independent practice. According to Grant & Ballard (2011), the CNM is practicing in a collaborative manner with the physician in this case, and the physician is responsible for providing informed consent. Treating a woman with a complex multiple gestation is out of the scope of practice of the CNM and necessitates a referral (American College of
Nurse-Midwives, 2011). However; in this case, as a CNM she has a duty to listen to concerns and provide information and support. At this point, the CNM should not make suggestions for care or provide counsel. Her main purpose is to provide information in addition to what the physician has provided.
Three Recommendations to Resolve Moral Distress
The use of an ethical decision making model allows the advanced practice nurse to examine all of the relevant aspects of an ethical dilemma (Park, 2012). This provides a comprehensive review process of (a) identifying the ethical problem, (b) collecting additional information to identify the problem an formulate solutions, (c) develop alternatives for comparison, (d) select the best alternatives and justification, (e) develop practical, diverse ways to implement the ethical decisions and actions, and (f) evaluate the effects and strategies to prevent a future similar occurrence.
Additional recommendations are made to assist the CNM is resolving moral distress; both in the case and future situations. The second recommendation is improving skillful, assertive communication to foster the nurse-physician relationship (Lachman, 2010). This may assist all professionals in problem-solving for ethical situations and practice.
The third recommendation is specific ethics education (Lachman, 2010). Ethics education is also suggested for all professionals involved in the case to raise awareness of
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potential distressing situations and understand the relevant principles and application of them.
Changing the environment to remove barriers to the CNM acting in what she deems a moral manner may be helpful for all disciplines involved (Radzvin, 2011).
Implement an Ethical Decision Making Model
The J. PLUS Decision Making Model is utilized to apply to the ethical dilemmas presented in the case scenario (Kovach, n.d.). The PLUS is applied at several steps of the decision-making process and stands for P – polices, L – legal, U – universal and S – Self. The questions the CNM needs to ask herself are (a) Is this consistent with my organization’s policies, procedures, and guidelines? (b) Is it acceptable under the applicable laws and regulations? (c)
Does it conform to universal values/principles my organization has adopted? and (d) Does it satisfy my personal definition of good, right, and fair?
The model includes six steps to ethical decision making:
Step 1: Define the problem PLUS
Step 2: Identify alternatives
Step 3: Evaluate the alternatives PLUS
Step 4: Make the decision
Step 5: Implement the decision
Step 6: Evaluate the decision PLUS (Kovach, n.d.).
Applying the model to the case scenario, the CNM considers all of the following for the
PLUS step of the decision making model scope of practice information and core tenets of midwifery as specified in the (a) Definition of Midwifery and Scope of Practice for Certified
Nurse-Midwives and Certified Midwives, (b) Standards for the Practice of Midwifery, (c) the
Midwifery Code of Ethics (d) state Nurse Practice acts, (e) the ethical principles of autonomy,
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informed consent, beneficence, and nonmalificence (American College of Nurse Midwives
[ACNM], 2012).
The first and foremost reference to consult for direction would be the American College of Nurse-Midwives (ACNM) Vision, Mission & Core Values Statement (American College of
Nurse-Midwives, 2012). This statement specifically speaks to the core values of (a) excellence,
(b) evidence-based care, (c) formal education, (d) inclusiveness, (e) woman-centered care, (f) primary care, (g) partnership, (h) advocacy, and (i) global outreach. Of particular importance, the core values of partnership and advocacy speak to the advocacy role of the CNM. ACNM (2012) states the nurse-midwife “acts to amplify the voice of women on health issues” and to form a partnership with women and their families in a shared decision-making model. This includes listening, providing information, guidance, and counseling.
As a CNM, one must also follow the Standards of Practice for Midwifery as presented by the ACNM (2011). The ACNM also has a formal Code of Ethics (Center for the Study of Ethics in the Professions at IIT, 2011). The code points out the professional moral obligations of the
CNM. It specifies that decision-making is a shared, ongoing process with the woman, and the process considers cultural diversity, individual autonomy, and legal responsibilities. It includes nondiscrimination, confidentiality, and protection of clients from harm in the instance of unethical or incompetent practice.
Once the CNM has considered the PLUS components, it is appropriate to apply the steps of the J. PLUS Model of Decision Making. The first of six steps is to define the problem. In the case, the couple’s right to informed consent and autonomy has been violated. In addition, the physician has not provided the couple with all of the relevant information and has minimized the risks. Full disclosure of the information from both practitioner’s scope of practice and duty to the
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patients is necessary (American College of Nurse Midwives, 2012; American College of
Obstetricians and Gynecologists, 2013).
Step two is concerned with identifying the alternatives. Essentially there are three alternatives in this situation; the physician discloses the information, the CNM discloses the information, or no further information is given to the couple. Nondisclosure of the information is not an option in this case as it is necessary for the couple to possess relevant and current scientific information to make an informed decision (American College of Nurse Midwives,
2012; American College of Obstetricians and Gynecologists, 2013).
The third step of the model is to evaluate the alternatives. The physician is responsible for providing information for informed consent (Grant & Ballard, 2011). The advanced practice nurse (CNM) in this case also practices in a shared decision-making manner with the patients and she has the professional responsibility to communicate with the physician in a collaborative relationship (American College of Nurse Midwives, 2012). It is necessary for her to exhibit moral courage and communicate openly with the physician and make him understand her perception of the obligations to the patient. The CNM can additionally provide information to the parents so they can make an informed decision.
The decision is made in step four and the physician and midwife determine how to implement the decision regarding (a) what information is needed, (b) who will impart the information, and (c) in what manner will the information be presented (Kovach, n. d.). Step five is implementation of the decision and the actual provision of information to the couple.
Step six consists of evaluation and this is completed by questioning the couple regarding their understanding of the purpose of the procedure, associated benefits and risks, and possible complications (Kovach, n. d.). The physician and the CNM need to allow for plenty of time to
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fully answer questions and be available for questions that may arise after the couple leaves the office. They must respect and honor the patient’s autonomy. Ultimately, the couple is responsible for making the decision. If the providers do not feel comfortable with performing the MFPR, they are responsible for timely referral to another provider that can assist the couple with MFPR
(American College of Obstetrics and Gynecology, 2012).
Improving Communication
Burston & Tuckett (2013) suggest that improved communication is a strategy that may be utilized to decrease the frequency and intensity of moral distress. The collaborative approach of an interdisciplinary forum may be useful to facilitate understanding of other disciplines’ decision making strategies. This approach additionally may improve collaboration and inter-disciplinary dialogue. Lachman (2010) suggests moral courage is the ability to skillfully communicate with assertiveness and negotiation and focuses on problem solving. Assertive communication requests a change of behavior from another person and is a demonstration of respect for the person, not the behavior. The author proposes the following statement model is helpful when requesting a behavior change, “when you do x, I feel y, because of z” followed by “I would like instead …..”.
The CNM could state, “When you provide the couple with incomplete information, it makes me feel we are not providing sufficient information for informed consent or an autonomous decision”. “I would like instead for a complete discussion of the all the risks and benefits of continuation or reduction of a pregnancy”. “I feel this would assure increased comprehension of the information we have given the couple”.
Education and Policy Establishment
Ethics education will serve the purpose of improving ethical understanding of situations where dilemmas may arise (Burston & Tuckett, 2013). Education may raise awareness of
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potential ethical issues and provide understanding of relevant laws and issues. Review of scenarios, ethics rounds, and staff meetings appear to be helpful in education for all participants.
Identification and implementation of strategies to alleviate the occurrence of moral distress need to be employed by supervisory personnel including policies that eliminate constraints affecting the ability to act in what the advanced practice nurse perceives as a morally correct manner
(Radzvin, 2011).
MULTIFETAL PREGNANCY REDUCTION
References
19
Multifetal Pregnancy Reduction:
1
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Multifetal Pregnancy Reduction:
Conflicting values or beliefs about the right or best course of action often form the basis for moral dilemmas (Simmonds, 2012). Moral distress is associated with how the nurse perceives her role (Burston & Tuckett, 2012). The advanced practice nurse may experience moral distress when faced with an instance of knowing the correct course of action; however, not being able to pursue it. Ethical justification for choices and actions are based on the principles of autonomy, beneficence, nonmaleficence, and justice.
Relatively recent developments in assistive reproductive technology …show more content…
have increased the occurrence of multiple fetal gestation with fertility treatment (Zapletalova, 2013). Multiple birth pregnancy is not always welcomed by parents or physicians. The risk of prematurity and low birth weight increases with multifetal pregnancy. In this case, the perinatal practitioner has ethical obligations to both the pregnant and fetal patients (Chervenak & McCullough, 2013).
Clinical circumstances may generate offering the procedure of multifetal pregnancy reduction
(MFPR) in the process of informed consent to ensure autonomy. Some may argue that this is not the termination of a pregnancy, but is a procedure to ensure successful continuation of the pregnancy (Zapletalova, 2013). Grant & Ballard (2011) suggest some may view the issue as immoral; as tampering with nature.
Issues Surrounding Multifetal Pregnancy Reduction
A multifetal pregnancy reduction involves a first-trimester or early second-trimester procedure for reducing by one or more the total number of fetuses in a multifetal pregnancy
(American College of Obstetricians and Gynecologists, 2013). The procedure is most often performed in higher order pregnancies that include three or more fetuses. Reduction decreases
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maternal risks and increases the chance of at least one live birth. There are many ethical complexities involving continuing or reducing a high order pregnancy.
In multifetal pregnancy reduction, the fetuses to be reduced are chosen based on technical considerations (American College of Obstetricians and Gynecologists, 2013). For instance, the fetuses that are the most accessible to intervention (potassium chloride injection) are usually chosen. Selective reduction is an additional controversial ethical issue, that involves choosing fetuses for reduction based on their health, gender, or anomalies after chorionic villus sampling, amniocentesis or ultrasound.
Screening for the explicit purpose of sex selection for social reasons is not appropriate. However, information should not be withheld from parents if they request it.
Reduction to a singleton pregnancy from a twin or greater pregnancy remains controversial and some physicians may offer this option depending upon the woman’s circumstances and her values. To ensure the principle of autonomy, the decision ultimately rests with the parents of the fetuses. Benefits and Risks Associated with Higher-Order Pregnancies and MFPR
Maternal risks associated with multifetal pregnancy are the increased incidence of (a) hypertension, (b) preeclampsia, (c) gestational diabetes, and (d) postpartum hemorrhage
(American College of Obstetrics & Gynecologists, 2013). Additional complications may include maternal depression, severe parenting stress, child abuse, and an increased divorce rate.
Significant medical costs and adverse economic consequences are associated with multiple pregnancy. Infants born to multiple pregnancy may have an increased risk of prematurity, low birthweight, cerebral palsy, learning disabilities, delayed language development, behavioral difficulties, chronic lung disease, and …show more content…
death.
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The intention of MFPR is to decrease the maternal and infant risks associated with multiple fetal pregnancies (American College of Obstetrics & Gynecologists, 2013). There are risks related to the procedure of MFPR and long-term effects. A woman may have adverse outcomes from the procedure including; bleeding, infection, or even loss of more than the reduced fetuses including spontaneous abortion of the entire pregnancy. Couples may experience sadness, grief, or depression for months or years to come (Attaining Fertility, 2014).After reduction, the pregnancy may still result in premature birth, low birthweight and associated complications (American College of Obstetrics & Gynecologists, 2013).
Ethical Dilemma
Mrs. C., a 39 year-old fertility and perinatology patient is 10 weeks pregnant. After many miscarriages and several cycles of assisted reproduction, Mrs. C. and her husband are thrilled to be expecting their first child. They have been counseled it is likely they will have a multiple gestation with triplets or greater. The parents find out today they are expecting septulets and the physician and advanced practice nurse are consulting with the couple about the pregnancy.
Included is a discussion regarding the risks and benefits of multifetal gestation. The physician feels it is necessary to offer the option of selective reduction to the woman and her husband. The physician recommends selective reduction to the woman and her husband to preserve the health of Mrs. C. and some of the fetuses. He extolls the benefits of the procedure while minimizing the risks of losing the pregnancy.
Initially, Mr. & Mrs. C. recoil in horror at the thought of terminating even one of the babies they have worked so hard for. Mrs. C. asks the certified nurse midwife (CNM) about selective reduction. The CNM has strong beliefs about informed consent, patient autonomy, and termination of life. Additionally, she feels that the physician has made a recommendation and not
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provided sufficient information. She examines the context of the dilemma, her professional responsibilities, scope of practice, and her personal beliefs to determine what actions she should take in communicating with the physician and couple and in decision-making. The CNM is experiencing moral distress.
There are several ethical and legal reasoning constructs that the CNM must consider before arriving at a decision on how to act in this case. In-depth knowledge and details of the process of reasoning hopefully will assist the CNM in resolution of the moral dilemma presented.
Critically thinking about how the law would be applied in this case is important. Identification, evaluation, and application of the ethical principles of the case are equally necessary.
Legal Reasoning Constructs
Gordley (1984) suggests that legal reasoning constructs are principles involved in determination of how the law is applied in a legal decision. It also includes how a decision is reached when there are insufficient preexisting cases to pave the way. Interpretation, coherence, logic, case law, and legal analysis are the main principles in legal reasoning constructs. Each principle will be discussed in the following paragraphs.
Interpretation in Legal Reasoning
Gordley (1984) suggests when the law is clear on a subject, relevant rules can be applied in a logical manner. Legal reasoning focuses on how one develops a sense of legal consciousness and evaluate the appropriateness of formal rules in society (Moone, 2013). It assists in differentiating what is right and what one should do. It can aid in decision making when a practitioner may want to act in one way; however, could find themselves making the wrong decision. Legal reasoning is also a method of addressing a legal issue by arguing the existing rules among all interested parties (Peterson, n.d.). It may exist in two forms (a) application of the
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rules to cases, and (b) legislative drafting. Application of legal reasoning may involve dealing with the interpretation of written law (statutes) or customary law (past practices that now define an essential mode of conduct). Finally, Endicott (2011) suggests that interpretation in legal reasoning is finding rational support for legal conclusions.
Coherence in Legal Reasoning
Coherence in legal reasoning refers to the ability to know exactly what the law states
(Moone, 2013). It is the degree to which a case follows established law (Levenbook, 1984).
Additionally, it may be a condition for legal justification (Bertea, 2009). It is a measure of how a ruling falls in line with the fundamental principles of a legal system. Coherence requires consistency, comprehensiveness, and completeness. It may serve as a normative criterion in following the spirit of the law. Coherence places emphasis on the past and the obligation to remain within former legal decisions.
Logic in Legal Reasoning
Logic in legal reasoning is the ability to view clearly what the law is and how the law works (Moone, 2013). The rules of law apply in that similar cases are decided comparably.
Individual cases should be decided on their own merits and the decision making process must comply with applicable rules and procedures of evidence. To achieve the rules of law, one must articulate and evaluate the elements of legal reasoning (Walker, 2007). This type of reasoning is involved in interpreting constitutions, statutes, and regulations. Legal reasoning uses the concept of syllogism (Ramee, 2002). This consists of three parts (a) major premise – states a general rule,
(b) minor premise – makes a factual assertion, and (c) conclusion – applies the facts to the law. A syllogism must be a logical, valid statement; it is impossible for premises to be true and the conclusion to be false.
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Case Law
Legal reasoning may involve analysis directly from prior cases at hand (Teitelbaum,
2012). Case law establishes a precedent for future cases to follow (Lamont, 2014). Precedent is a prominent feature of legal reasoning. It occurs when an earlier decision is followed in a later case when similarity exists. Lamont (2014) suggests precedents are legally significant and should be understood as (a) laying down rules, (b) the application of underlying principles, and (c) as a decision on the balance of reason. Case law is often referred to as common law (Laws.com,
2013).
Legal Analysis
Legal analysis refers to a statement by a court, judge, or other legal authority as to the legality or illegality of an action, condition, or intent (U.S. Legal, 2014). It is critical examination of the legal issues present in a case and there are four steps (a) identify the issue or legal question,
(b) using enacted law, case or common law, or a combination helps provide an understanding of what applies to the case at hand, (c) a decision is made on how the law applies to the legal question or issues asked in the first place, and (d) an objective conclusion or summary is made.
The most pertinent law, case, or statute is discovered in an analysis that applies to the particular case. Ethical Reasoning Constructs
Ethical reasoning is the cognitive process involved in the analysis of an important ethical issue (Valentine & Bateman, 2011). The first step in the process of ethical reasoning is to identify the ethical issue present. The situation is then evaluated through different moral frameworks and an ethical judgment is formulated. The reasoning from this process leads to ethical behavioral
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intentions. The behavior is then performed and that reinforces the previous steps of ethical reasoning. The Function of Ethical Reasoning
Elder & Paul (2011) suggest the function of ethical reasoning is to critically think about acts that benefit others and acts that harm others. It is a way to set aside and distinguish other domains of thought such as religion, law, and social conventions. Recognizing that an issue has ethical components can form the basis for moral awareness (Valentine & Bateman, 2011). Moral awareness is when one recognizes that their potential decisions may impact the interests, welfare, or expectations of the self or others in a manner that may conflict with one or more ethical principles. The Problem of Pseudo-Ethics
At times in healthcare, there are dilemmas that initially that appear to be ethical issues; however on closer examination are more about communication and frustration. These dilemmas have been misclassified as “ethical issues” (The American Association of Neurosurgeons, n.d.) reports that many hospital ethics committees are reviewing issues that are not truly ethical in nature. Contentious situations have been classified erroneously as ethical for the purpose of the ethical committee review. They suggest that reframing an issue as ethical does not uncover the essence of the problem. It is difficult to apply ethical methodology to non-ethical issues.
The Elements of Ethical Reasoning
Paul & Elder (2006) list the following elements of ethical reasoning (a) “define the purpose, (b) raise questions, (c) use information, (d) utilize concepts, (e) make interpretation and inference, (f) make assumptions, (g) generate implications and consequences, and (h) embodies a
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point of view” (p. 14). The authors suggest if one understands these concepts, they are better equipped to analyze ethical reasoning and follow the ethical implications of their decisions.
The Logic of Ethical Reasoning
Elder & Paul (2011) propose that ethical reasoning must be developed to overcome the human natural tendencies towards egotism, prejudice, self-justification, and self-deception.
Humans need to understand that their behavior has consequences for others and natural tendencies can be resisted through the development of the ethical thought of fair-mindedness, honesty, integrity, self-knowledge and genuine concern for the welfare of others. If a person applies the elements of ethical reasoning, they will be able to ethically analyze a situation and determine appropriate behavior and action.
The Advantages and Disadvantages of Ethical Reasoning
Coughlin (2008) suggests that principle based approaches to ethical reasoning have several advantages including they are adaptive to new situations, offer practical solutions to ethical problems, have explanatory power, and are enduring. They also have the advantage of universalizability in certain fields such as bioethics. Ethical reasoning can also be combined with a coherence model of justification. The author reports limitations to ethical reasoning based on principles. Critics argue they do not provide an action guide or an adequate philosophical theory.
Some feel that the existing principles and rules are imperfect, and coherence between the principles and rules will lead to imperfect ethical decisions.
Differences between Legal and Ethical Reasoning
Ethical reasoning is the cognitive process involved in the analysis of an important ethical issue (Valentine & Bateman, 2011). Legal reasoning is the determination of how the law is applied in a legal decision (Gordley, 1984). Legal reasoning may also be how one develops a
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sense of legal consciousness and evaluates the rules of society (Moone, 2013). Moral deliberation uses the insights of various perspectives to clarify the ethical meaning in a situation; whereas, legal reasoning involves the foundation of enforceable law and court interpretation of application. Resolution of the Ethical Dilemma
There are many ethical complexities involving continuation or reduction of a high order pregnancy (American College of Obstetricians and Gynecologists, 2013). One could view the dilemma through the lens of the nonreduced fetuses and center their argument on maximizing benefits for the surviving fetuses after a MFPR (Ralston, 2011). This utilitarian resolution may be termed “lifeboat ethics”, where one or more is sacrificed for the good of the others. An ethical and legal discussion of the issues involved in this particular case; however, is much more complicated. The ethical issues surrounding multifetal pregnancy reduction (MFPR) are controversial and consist of varying shades of gray (Ralston, 2011). Aligning the interests of all the fetuses and the mother is simply not possible.
Evans & Britt (2010) argue that all involved in MFPR may struggle to reconcile the potentially oppositional elements of religious beliefs and the risks associated with higher-level pregnancies. Ethical justification for choices and actions are based on the principles of informed consent, autonomy, beneficence, and nonmaleficence (Simmonds, 2012). All of these principles are considered in the case and decision-making on the part of the advanced practice nurse, the physician, and the pregnant couple rests on a balance of the principles. Perhaps the most important principle in the case is that of informed consent. Receiving and understanding information forms the basis for informed consent and allows the couple to make an autonomous decision (Demontis, et al., 2011). The principle of autonomy will be violated if the physician
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and/or CNM do not provide information (Grant & Ballard, 2011). Respect for autonomy in this case is the principle that the couple must balance the relative importance of the medical, ethical, religious, and socioeconomic components and choose the best course of action for their unique situation (American College of Obstetricians & Gynecologists, 2013). As previously noted, to ensure the principle of autonomy, the decision ultimately rests with the parents of the fetuses.
The probability of specific adverse outcomes should be discussed, and it is the physician’s ethical and legal obligation to provide adequate information regarding diagnosis, prognosis, and alternative treatment choices, including the option of no treatment (American
College of Obstetrics and Gynecologists, 2013; Grant & Ballard, 2011). Beneficence would be providing benefit to the woman and the remaining fetuses for a successful pregnancy.
Nonmaleficence is more problematic in this case, as some of the fetuses would need to be harmed to help the mother and the remaining fetuses. Justice would be concerned with the costs associated with prematurity and the quality of life of the infants if premature or disabled.
One could also argue that justice could be applied in the case of which fetuses will be spared during the procedure and how the costs of health care are distributed.
Standard of Care and Scope of Practice Issues
The advanced practice nurse practicing in the area of women’s health or nurse-midwifery may practice in a diverse range of settings, including obstetrician or maternal-fetal medicine offices (American College of Nurse-Midwives, 2011). Contained within the scope of practice statement of the American College of Nurse-Midwives (ACNM) is the provision to form a partnership with women and their families in a shared decision-making model. This includes listening, providing information, guidance, and counseling. The standards of practice for nursemidwifery care include the support of individual rights and self-determination within the
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boundaries of safety. This standard addresses autonomy and beneficence. The provision of information in the context of current science is necessary for the woman to provide informed consent. CNMs are required to provide referral to other providers if necessary when the
care required is out of the scope of practice for the CNM (ACNM, 2011).
Ethical and Legal Principles Involved in the Case
The principle of autonomy may be violated if the CNM does not provide information.
Grant & Ballard (2011) suggest that autonomy forms the basis for informed consent. Demontis,
Pisu, Pintor, & D’Aloja (2011) argue that having information is not the same as understanding the information and may be problematic in informed consent. Furthermore, autonomy depends on (a) liberty - lack of coercion, (b) agency - the capacity to understand relevant information, consider options, evaluate risks and benefits, to make and communicate a decision, and (c) having the information necessary to make a decision.
The physician in the scenario is responsible for initially explaining the risks and benefits of the procedure and the effects on the current pregnancy (Grant & Ballard, 2011). If the CNM interprets the professional moral duty to the patient, then she has the responsibility to ensure that the patient has all of the information and understands it in order to give informed consent for the procedure. ACNM (2011) clearly delineates the scope of practice for the CNM and certified midwife
(CM). Included in the scope of practice are the services, education and core competencies required for midwifery practice. This is presented in a document entitled Definition of Midwifery and Scope of Practice for Certified Nurse-Midwives and Certified Midwives. Buppert (2004) suggests an advanced practice nurse must also consult their state law for a source of authority for professional practice. Therefore, the state Nurse Practice Act also specifies the scope of practice.
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In the case scenario, the advanced practice nurse is practicing in collaboration with the physician, and is not in independent practice. According to Grant & Ballard (2011), the CNM is practicing in a collaborative manner with the physician in this case, and the physician is responsible for providing informed consent. Treating a woman with a complex multiple gestation is out of the scope of practice of the CNM and necessitates a referral (American College of
Nurse-Midwives, 2011). However; in this case, as a CNM she has a duty to listen to concerns and provide information and support. At this point, the CNM should not make suggestions for care or provide counsel. Her main purpose is to provide information in addition to what the physician has provided.
Three Recommendations to Resolve Moral Distress
The use of an ethical decision making model allows the advanced practice nurse to examine all of the relevant aspects of an ethical dilemma (Park, 2012). This provides a comprehensive review process of (a) identifying the ethical problem, (b) collecting additional information to identify the problem an formulate solutions, (c) develop alternatives for comparison, (d) select the best alternatives and justification, (e) develop practical, diverse ways to implement the ethical decisions and actions, and (f) evaluate the effects and strategies to prevent a future similar occurrence.
Additional recommendations are made to assist the CNM is resolving moral distress; both in the case and future situations. The second recommendation is improving skillful, assertive communication to foster the nurse-physician relationship (Lachman, 2010). This may assist all professionals in problem-solving for ethical situations and practice.
The third recommendation is specific ethics education (Lachman, 2010). Ethics education is also suggested for all professionals involved in the case to raise awareness of
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potential distressing situations and understand the relevant principles and application of them.
Changing the environment to remove barriers to the CNM acting in what she deems a moral manner may be helpful for all disciplines involved (Radzvin, 2011).
Implement an Ethical Decision Making Model
The J. PLUS Decision Making Model is utilized to apply to the ethical dilemmas presented in the case scenario (Kovach, n.d.). The PLUS is applied at several steps of the decision-making process and stands for P – polices, L – legal, U – universal and S – Self. The questions the CNM needs to ask herself are (a) Is this consistent with my organization’s policies, procedures, and guidelines? (b) Is it acceptable under the applicable laws and regulations? (c)
Does it conform to universal values/principles my organization has adopted? and (d) Does it satisfy my personal definition of good, right, and fair?
The model includes six steps to ethical decision making:
Step 1: Define the problem PLUS
Step 2: Identify alternatives
Step 3: Evaluate the alternatives PLUS
Step 4: Make the decision
Step 5: Implement the decision
Step 6: Evaluate the decision PLUS (Kovach, n.d.).
Applying the model to the case scenario, the CNM considers all of the following for the
PLUS step of the decision making model scope of practice information and core tenets of midwifery as specified in the (a) Definition of Midwifery and Scope of Practice for Certified
Nurse-Midwives and Certified Midwives, (b) Standards for the Practice of Midwifery, (c) the
Midwifery Code of Ethics (d) state Nurse Practice acts, (e) the ethical principles of autonomy,
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informed consent, beneficence, and nonmalificence (American College of Nurse Midwives
[ACNM], 2012).
The first and foremost reference to consult for direction would be the American College of Nurse-Midwives (ACNM) Vision, Mission & Core Values Statement (American College of
Nurse-Midwives, 2012). This statement specifically speaks to the core values of (a) excellence,
(b) evidence-based care, (c) formal education, (d) inclusiveness, (e) woman-centered care, (f) primary care, (g) partnership, (h) advocacy, and (i) global outreach. Of particular importance, the core values of partnership and advocacy speak to the advocacy role of the CNM. ACNM (2012) states the nurse-midwife “acts to amplify the voice of women on health issues” and to form a partnership with women and their families in a shared decision-making model. This includes listening, providing information, guidance, and counseling.
As a CNM, one must also follow the Standards of Practice for Midwifery as presented by the ACNM (2011). The ACNM also has a formal Code of Ethics (Center for the Study of Ethics in the Professions at IIT, 2011). The code points out the professional moral obligations of the
CNM. It specifies that decision-making is a shared, ongoing process with the woman, and the process considers cultural diversity, individual autonomy, and legal responsibilities. It includes nondiscrimination, confidentiality, and protection of clients from harm in the instance of unethical or incompetent practice.
Once the CNM has considered the PLUS components, it is appropriate to apply the steps of the J. PLUS Model of Decision Making. The first of six steps is to define the problem. In the case, the couple’s right to informed consent and autonomy has been violated. In addition, the physician has not provided the couple with all of the relevant information and has minimized the risks. Full disclosure of the information from both practitioner’s scope of practice and duty to the
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patients is necessary (American College of Nurse Midwives, 2012; American College of
Obstetricians and Gynecologists, 2013).
Step two is concerned with identifying the alternatives. Essentially there are three alternatives in this situation; the physician discloses the information, the CNM discloses the information, or no further information is given to the couple. Nondisclosure of the information is not an option in this case as it is necessary for the couple to possess relevant and current scientific information to make an informed decision (American College of Nurse Midwives,
2012; American College of Obstetricians and Gynecologists, 2013).
The third step of the model is to evaluate the alternatives. The physician is responsible for providing information for informed consent (Grant & Ballard, 2011). The advanced practice nurse (CNM) in this case also practices in a shared decision-making manner with the patients and she has the professional responsibility to communicate with the physician in a collaborative relationship (American College of Nurse Midwives, 2012). It is necessary for her to exhibit moral courage and communicate openly with the physician and make him understand her perception of the obligations to the patient. The CNM can additionally provide information to the parents so they can make an informed decision.
The decision is made in step four and the physician and midwife determine how to implement the decision regarding (a) what information is needed, (b) who will impart the information, and (c) in what manner will the information be presented (Kovach, n. d.). Step five is implementation of the decision and the actual provision of information to the couple.
Step six consists of evaluation and this is completed by questioning the couple regarding their understanding of the purpose of the procedure, associated benefits and risks, and possible complications (Kovach, n. d.). The physician and the CNM need to allow for plenty of time to
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fully answer questions and be available for questions that may arise after the couple leaves the office. They must respect and honor the patient’s autonomy. Ultimately, the couple is responsible for making the decision. If the providers do not feel comfortable with performing the MFPR, they are responsible for timely referral to another provider that can assist the couple with MFPR
(American College of Obstetrics and Gynecology, 2012).
Improving Communication
Burston & Tuckett (2013) suggest that improved communication is a strategy that may be utilized to decrease the frequency and intensity of moral distress. The collaborative approach of an interdisciplinary forum may be useful to facilitate understanding of other disciplines’ decision making strategies. This approach additionally may improve collaboration and inter-disciplinary dialogue. Lachman (2010) suggests moral courage is the ability to skillfully communicate with assertiveness and negotiation and focuses on problem solving. Assertive communication requests a change of behavior from another person and is a demonstration of respect for the person, not the behavior. The author proposes the following statement model is helpful when requesting a behavior change, “when you do x, I feel y, because of z” followed by “I would like instead …..”.
The CNM could state, “When you provide the couple with incomplete information, it makes me feel we are not providing sufficient information for informed consent or an autonomous decision”. “I would like instead for a complete discussion of the all the risks and benefits of continuation or reduction of a pregnancy”. “I feel this would assure increased comprehension of the information we have given the couple”.
Education and Policy Establishment
Ethics education will serve the purpose of improving ethical understanding of situations where dilemmas may arise (Burston & Tuckett, 2013). Education may raise awareness of
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potential ethical issues and provide understanding of relevant laws and issues. Review of scenarios, ethics rounds, and staff meetings appear to be helpful in education for all participants.
Identification and implementation of strategies to alleviate the occurrence of moral distress need to be employed by supervisory personnel including policies that eliminate constraints affecting the ability to act in what the advanced practice nurse perceives as a morally correct manner
(Radzvin, 2011).
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References
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