Relatively recent developments in assisting reproductive technology have increased the occurrence of multiple fetal gestation with fertility treatment (Exploitable, 2013). Multiple birth pregnancy is not always welcomed by parents or physicians. The risk of prematurely and low birth weight increases with multilateral pregnancy. In this case, the perennial practitioner has ethical obligations to both the pregnant and fetal patients (Coherence & McCullough, 2013). Clinical circumstances may generate offering the procedure of multilateral pregnancy reduction (MIFF) 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 (Exploitable, 2013). Grant & Ballard (2011) suggest some may view the Issue as Immoral; as tampering with nature. Issues Surrounding Multilateral Pregnancy Reduction A multilateral pregnancy reduction involves a flirts-trimester or early second-trimester procedure for reducing by one or more the total number of fetus in a multilateral pregnancy (American College of Obstetricians and Gynecologist, 2013).
The procedure is most often performed in higher order pregnancies that include three or ore fetus. Reduction decreases 3 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 multilateral pregnancy reaction, ten Tutees to De reach are chosen oases on technical considerations (American College of Obstetricians and Gynecologist, 2013). For instance, the fetus that are the most accessible to intervention (potassium chloride injection) are usually chosen.
Selective reduction is an additional controversial ethical issue, that involves choosing fetus for reduction based on heir health, gender, or anomalies after chronic villous 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 fetus. Benefits and Risks Associated with Higher-order Pregnancies and MIFF Maternal kiss associated with multilateral pregnancy are the increased incidence of (a) hypertension, (b) proclaims, (c) gestational diabetes, and (d) postpartum hemorrhage (American College of Obstetrics & Gynecologist, 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 prematurely, low birthright, cerebral palsy, learning disabilities, delayed language development, behavioral difficulties, chronic Eng disease, and death. 4 The intention of MIFF is to decrease the maternal and infant risks associated with multiple fetal pregnancies (American College of Obstetrics & Gynecologist, 2013). There are risks related to the procedure of MIFF and long-term effects.
A woman may have adverse outcomes from the procedure including; bleeding, infection, or even loss of more than the reduced fetus 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 exult in premature birth, low birthright and associated complications (American College of Obstetrics & Gynecologist, 2013). Ethical Dilemma Mrs.. C. , a 39 year-old fertility and peregrination 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 septets 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 multilateral 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 ten Neal AT Mrs.. C. Ana some AT ten Tutees. He extols ten Detentes AT ten 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 (CNN) about selective reduction. The CNN has strong beliefs about informed consent, patient autonomy, and termination of life. Additionally, she feels that the physician has made a recommendation and not 5 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 CNN is experiencing moral distress. There are several ethical and legal reasoning constructs that the CNN 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 CNN 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 Girdled (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 Girdled (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 (Moon, 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, loud 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 6 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 Tanat Interpretation In legal reasoning Is Titling rotational support Tort legal conclusions. Coherence in Legal Reasoning
Coherence in legal reasoning refers to the ability to know exactly what the law states (Moon, 2013). It is the degree to which a case follows established law (Levelness, 1984). Additionally, it may be a condition for legal Justification (Berate, 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 (Moon, 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. 7 Case Law Legal reasoning may involve analysis directly from prior cases at hand (Tellurium, 2012). Case law establishes a precedent for future cases to follow (Lament, 2014).
Precedent is a prominent feature of legal reasoning. It occurs when an earlier decision is followed in a later case when similarity exists. Lament (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 ambition 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 tentacle Issue (Valentine & Bateman, 2 ) I nee TLS step In ten process AT tentacle reasoning is to identify the ethical issue present. The situation is then evaluated wrought different moral frameworks and an ethical Judgment is formulated. The reasoning from this process leads to ethical behavioral 8 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 9 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- exceptional. Humans need to unearths Tanat tenet Demeanor NAS consequences Tort 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 Slouching (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 unavailability’s in certain fields such as bioethics.
Ethical reasoning can also be combined with a coherence model of Justification. The author ports 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 issue (Valentine & Bateman, 2011). Legal reasoning is the determination of how the law is applied in a legal decision (Girdled, 1984).
Legal reasoning may also be how one develops a 10 sense of legal consciousness and evaluates the rules of society (Moon, 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 Gynecologist, 2013).
One could view the dilemma through the lens of the unreduced fetus and center their argument on maximizing benefits for the surviving fetus after a MIFF (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 multilateral pregnancy reduction (MIFF) are controversial and consist of varying shades of gray (Ralston, 2011). Aligning the interests of all the fetus and the mother is simply not possible.
Evans & Bruit (2010) argue that all involved in MIFF may struggle to reconcile the potentially oppositional elements of religious beliefs and the risks associated with Geiger-level pregnancies. Ethical Justification for choices and actions are based on the principles of informed consent, autonomy, beneficence, and malefaction (Simmons, 2 2) All AT tense principles are consolable In ten case Ana seclusion- 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 (Demotion, et al. , 2011). The principle of autonomy will be violated if the physician 11 and/or CNN 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 & Gynecologist, 2013).
As previously noted, to ensure the principle of autonomy, the decision ultimately rests with the parents of the fetus. 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 Gynecologist, 2013; Grant & Ballard, 2011).
Beneficence would be providing benefit to the woman and the remaining fetus for a successful pregnancy. Malefaction is more problematic in this case, as some of the fetus would need to be harmed to help the mother and the remaining fetus. Justice would be concerned with the costs associated with prematurely 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 fetus 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 (CACM) is the provision to form a partnership with women and their implies in a shared decision-making model. This includes listening, providing information, guidance, and counseling.
The standards of practice for nursemaid’s care include the support of individual rights and self-determination within the 12 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 provoke Motormen consent. Cams are required to provoke retell to toner providers if necessary when the care required is out of the scope of practice for the CNN (CACM, 2011). Ethical and Legal Principles Involved in the Case The principle of autonomy may be violated if the CNN does not provide information.
Grant & Ballard (2011) suggest that autonomy forms the basis for informed consent. Demotion, Pips, Pintos, & Dollar (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 accessory 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 CNN 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. CACM (2011) clearly delineates the scope of practice for the CNN and certified midwife (CM). Included in the scope of practice are the services, education and core impenitence 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. Suppers (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. 13 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 201 1), the CNN 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 CNN and necessitates a referral (American College of Nurse-Midwives, 2011). However; in this case, as a CNN she has a duty to listen to concerns and provide information and support. At this point, the CNN 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 ten erects Ana strategies to prevent a Torture salary occurrence.
Additional recommendations are made to assist the CNN 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 (Lachrymal, 2010). This may assist all professionals in problem-solving for ethical situations and practice. The third recommendation is specific ethics education (Lachrymal, 2010). Ethics education is also suggested for all professionals involved in the case to raise awareness of 14 potential distressing situations and understand the relevant principles and application of them.
Changing the environment to remove barriers to the CNN acting in what she deems a moral manner may be helpful for all disciplines involved (Radian, 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 (Jehovah, 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 CNN 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 (Jehovah, n. D. ).
Applying the model to the case scenario, the CNN considers all of the following for the PLUS step of the decision making model scope of practice information and core nets 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, 15 informed consent, beneficence, and malfunctioned (American College of Nurse Midwives [CACM], 2012).
I nee TLS Ana Tremors reticence to consult Tort Loretta would De ten American College of Nurse-Midwives (CACM) 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 CNN.
CACM (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 CNN, one must also follow the Standards of Practice for Midwifery as presented by the CACM (2011). The CACM also has a formal Code of Ethics (Center for the Study of Ethics in the Professions at IT, 2011). The code points out the professional moral obligations of the CNN.
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 CNN 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 16 patients is necessary (American College of Nurse Midwives, 2012; American College of Obstetricians and Gynecologist, 2013). Step two is concerned with identifying the alternatives. Essentially there are three alternatives in this situation; the physician discloses the information, the CNN 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 Gynecologist, 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).