Marie-Anne Boivin a été en son temps une des sages-femmes françaises les plus célèbres. Son parcours professionnel et scientifique est présenté ici, illustrant l’espace laissé aux femmes dans les professions médicales. Reconnue d’abord pour ses ouvrages techniques concernant l’obstétrique, elle sort de son champ traditionnel de compétence pour aborder de façon novatrice la gynécologie naissante, à l’instar des médecins, avec son Traité pratique des maladies de l’utérus (1833), devenu un classique. Cette œuvre scientifique lui vaut un succès d’estime, mais ne (...) lui permet pas d’atteindre une véritable reconnaissance institutionnelle dans son pays. (shrink)

Obstetrics and gynaecology always has reputation for being a highly litigious. The field of obstetrics and gynaecology is surrounded by different circumstances that stimulate the doctors to practice defensive..

Introduction The provision of abortion services in the Republic of Ireland is legally restricted. Recent legislation that has been implemented allows for abortion if there is a real and substantial risk to the woman's life, but in general Irish women must travel abroad for abortion services. The aims of this study were to investigate the clinical experiences of Irish obstetric non-consultant hospital doctors that work in this environment and to assess their attitudes towards termination of pregnancy. Methods We conducted (...) an online cross-sectional descriptive survey of 184 Irish obstetric NCHDs. Quantitate and qualitative analysis was performed. Results There was a 28% response rate. 88% of respondents thought that ToP should be permitted for fatal fetal abnormality if the parents choose, 96% if the woman's health is severely affected and 86% in cases of rape and incest. Over 90% of respondents believed a woman's health suffers because of the need to travel abroad to undergo a ToP. Physical, psychological and social reasons were explored. The research also highlights that obstetric trainees are actively involved in the provision of preabortion and postabortion care. Conclusions The clinical experiences and opinions of the respondents suggest that the current legal availability of abortion in Ireland is insufficient to guide best clinical practice and does not represent the views of those that provide obstetric care. (shrink)

The Dutch system of obstetric care is often recommended for midwife-attended births, the high number of home deliveries, and the low rate of intervention during pregnancy and labour. In this contribution, the question is addressed whether processes of medicalization can be demonstrated in the Dutch midwife practice. Medicalization of pregnancy and childbirth is often criticized because it creates dependency on the medical system and infringement of the autonomy of pregnant women. It is concluded that medicalization is present in the practice (...) of Dutch independent midwives, however it is less clear and outspoken than in hospital policies. (shrink)

Background This paper examines the degree of agreement among simple dichotomous self-report, validated screening results, and biochemical screening results of prenatal alcohol and other drug use among pregnant women. Method Secondary analysis was conducted on a cohort of pregnant women 16 years or older, presenting for prenatal care in the greater Cape Town, South Africa. Dichotomous verbal screening is a standard of care, and pregnant patients reporting alcohol and other drug use in dichotomous verbal screenings were asked to engage in (...) screening using the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) and urinalysis. Results Significant agreements between dichotomous and ASSIST scores were observed (K = 0.73–0.76). A higher rate of self-reported (36.9%) alcohol use was detected, relative to urine screening (19.6%) with a predictive value of 34.9; while underreporting of illicit substance use was observed (3.6% self-report vs. 8.8% urine screening) with an overall predictive value of 50.0. Conclusion Dichotomous verbal screening was considered valid after comparison with the ASSIST; however, combined use with urine screenings can be recommended especially for identifying illicit substance use in order to accurately detect alcohol and other drug use in pregnancy, so that women can be identified and referred for appropriate interventions where needed. (shrink)

Background: Obstetric labor and childbirth are mostly regarded as a physiological process, whereas social, cultural, psychological and transcendental aspects have received less attention. Labor support has been suggested to promote labor progress. The aim of this study was to investigate whether continuous labor support by a midwife promotes labor progress and vaginal delivery.Material and Methods: A randomized controlled study at a university hospital in Sweden in 2015–17. Primiparous women with singleton pregnancy and spontaneous labor onset were randomized to continuous support (...) or standard care during delivery. The primary outcome was the duration of active labor. Secondary outcomes were delivery mode, women's need of labor analgesia and satisfaction with delivery, maternal cortisol levels, and neonatal morbidity.Results: Continuous support was followed by shorter active labor 11.0 ± 5.7 h compared to 13.7 ± 3.9 h with standard care. Women in the continuous support group tended to have lower cortisol levels and low cortisol during the first and second stages of labor were correlated with shorter active labor. Continuous support was followed by spontaneous delivery in 73%, instrumental delivery in 24% and emergency cesarean section in 3% in contrast to standard care which was followed by spontaneous delivery in 62%, instrumental delivery in 24% and cesarean in 14%. The continuous support group received combined analgesic methods more often. Women's satisfaction with delivery and neonatal morbidity were comparable.Conclusion: Continuous labor support was followed by shorter active labor compared to standard care. Women with continuous support had a high rate of vaginal delivery and tended to have lower cortisol levels during all stages of active labor reflecting a lower stress level. Low cortisol was correlated to shorter active labor. Based on these results, we recommend continuous labor support for all primiparous women during active labor. (shrink)

In France between 1780 and 1815, doctors opened a broad correspondence with medical faculties and public officials about foetal anomalies . Institutional and legal reforms forced doctors to encounter monstrous births with greater frequency, and they responded by developing new ideas about heredity and embryology to explain malformations to public officials. Though doctors achieved consensus on pathogenesis, they struggled to apply these ideas in forensic cases, especially with doubtful sex. Medical networks simultaneously allowed doctors to explore (...) obstetrical techniques, as licensing regulations forced practitioners into emotional encounters with child anomalies. Doctors thus developed a new ethics for treating monstrosities, viewing them as pathological specimens, forensic objects, and obstetrical tragedies. (shrink)

January 2018, the American College of Obstetrics and Gynecology issued a position statement opposing the punishment of women for self‐induced abortion. To those unfamiliar with emerging trends in abortion in the United States and worldwide, the need for the declaration might not be apparent. Several studies suggest that self‐induced abortion is on the rise in the United States. Simultaneously, prosecutions of pregnant women for behavior thought to harm the fetus are increasing. The ACOG statement responds to both trends by urging (...) doctors to honor the integrity and confidentiality inherent in the doctor‐patient relationship. Seen in the context of the larger battle over legal abortion, the statement has far broader implications. By acknowledging the role doctors play in enforcing pregnancy‐related crimes, the ACOG position statement wisely anticipates the ways in which doctors will be implicated should access to legal abortion be further restricted. To understand the need for the ACOG directive, you must first understand that the story of what will happen if abortion becomes a crime in the United States is not to be found in history books; it is staring at us across our southern border. (shrink)

By their very nature, overseas medical missions (and even domestic medical charities such as free clinics ) are designed to serve vulnerable populations. If these groups were capable of protecting their own interests, they would not need the help of medical volunteers: their medical needs would be met through existing government health programs or by utilizing their own resources. Medical volunteerism thus seems like an unfettered good: a charitable activity provided by well-meaning doctors and nurses who want to give (...) of their time, skills, and resources to help those who would not otherwise be able to take care of their medical needs. In this article, I argue that if medical volunteerism is to be good, however, it must always meet certain basic ethical requirements. These requirements may be (and perhaps often are) overlooked in the rush to organize and carry out short-term medical missions. I illustrate my point with special reference to short-term medical missions designed to provide surgical repair of obstetric vesico-vaginal fistula, a condition in which the tissues that normally separate the bladder from the vagina are destroyed by obstetric trauma, leading to continuous and unremitting incontinence in the affected woman. (shrink)

Background While prenatal surgery historically was performed exclusively for lethal conditions, today intrauterine surgery is also performed to decrease postnatal disabilities for non-lethal conditions. We sought to describe physicians' attitudes about prenatal surgery for lethal and non-lethal conditions and to elucidate characteristics associated with these attitudes. Methods Survey of 1200 paediatric surgeons, neonatologists and maternal–fetal medicine specialists. Results Of 1176 eligible physicians, 670 responded. In the setting of a lethal condition for which prenatal surgery would likely result in the child (...) surviving with a severe disability, most respondents either disagreed or strongly disagreed that they would recommend the surgery. Male physicians were twice as likely to recommend surgery for the lethal condition, as were physicians who believe that abortion is morally wrong. Older physicians were less likely to recommend surgery. For non-lethal conditions, most respondents agreed that they would recommend prenatal surgery, even if the surgery increases the risk of prematurity or fetal death. Compared with MFMs, surgeons were less likely to recommend such surgery, as were physicians not affiliated with a fetal centre, and physicians who were religious. Conclusion Physician’s attitudes about prenatal surgery relate to physicians’ beliefs about disability as well as demographic, cultural and religious characteristics. Given the variety of views, parents are likely to receive different recommendations from their doctors about the preferable treatment choice. (shrink)

Politicians, employers, courts, and health insurance companies are often discussed as problematically preventing access to birth control. However, doctors have more direct control over women's health and quietly have been much more effective at preventing patients' access to contraception. Obstetrician/Gynecologists routinely deny their patients access to contraception ostensibly in the name of health by withholding birth control until patients undergo yearly pap smears. I argue that those in the medical field are motivated by similarly sexist concerns as those in (...) other major institutions in the United States, but that they are often overlooked in discussions of biomedical ethics. After providing background, I argue that using birth control as a bargaining chip to control patients is morally impermissible, is paternalistic, and is contrary to consent. I next argue that sexism explains, though does not justify, this practice. I discuss the medical harms of routine pap smears and withholding birth control. These claims make medical malpractice likely. Withholding birth control to coerce individuals seeking medical care is medical malpractice, paternalistic, violates autonomy, and is contrary to consent. (shrink)

In this commentary, I respond to an ethical analysis of a case study, reported by Jankowski and Burcher, in which a woman gives birth to an infant with a known heart anomaly of unknown severity, at home, attended by a midwife. Jankowski and Burcher argue that the midwife who attended this family acted unethically because she knowingly operated outside of her scope of practice. While I agree that the authors’ conclusions are well supported by the portion of the story they (...) were able to gather, the fact that the midwife and mother declined to engage in the ethics consult that informs their piece means that critical segments of the narrative are left untold. Some important additional considerations emerge from these silences.I explore the implicit assumptions of the biotechnical embrace, the roles of the political economy of hope and the obstetric imaginary in driving prenatal testing, and institutional blame for the divisiveness of the home-hospital divide in the United States. The value of Jankowski and Burcher’s case study lies in its ability to highlight the intersections and potential conflicts between the principles of beneficence, patients’ autonomy, and professional ethics, and to begin to chart a course for us through them. (shrink)

Background: While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings. Research objective: The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker. Research design and participants: (...) A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials. Ethical considerations: After receiving ethics approval, signed informed consent was obtained from participants before data collection. Results: Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage. Discussion: The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women. Conclusion: Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice. (shrink)

In this special issue of The Journal of Clinical Ethics, different views on both the ethical desirability of women delivering in hospitals or at home with midwives are discussed. What careproviders, including midwives, should recommend to mothers in regard to the place of giving birth is considered. Emotional concerns likely to be of importance to mothers, fathers, midwives, and doctors are also presented. Finally, possible optimal approaches at the levels of both policy and the bedside are suggested.

Daniel Taylor and Dawn Goodwin present a case study of the Morecambe Bay Inquiry (MBI), which examined the high rate of maternal and neonatal deaths over a period of 9 years (2004–2013), within the small maternity unit of Furness General Hospital (FGH), one of the three hospitals comprising Morecambe Bay Hospitals Trust.1 They examine this through a conceptual lens, and provide a solution involving changes in medical education. This commentary explores both these elements. First, they use the lens of ‘Normalisation (...) of Deviance’ (NoD) to explain organisational failure. However, other available lenses such as ‘Sociology of Disasters’, ‘Organisational Silence’ and ‘Comfort-seeking Behaviour’ may point to different problems and solutions. More justification for their choice of the lens of NoD would have been useful. Similarly, more justification for their focus on a cluster of five ‘serious untoward incidents’ (SUIs) occurring in 2008 would also have been useful. They suggest that before 2008, the perinatal mortality rate was low, patient satisfaction was high and recent level 2 accreditation of maternity services by the Clinical Negligence Scheme for Trusts all suggested standards of care within the obstetric department were adequate. This stream of positive signals is likely to have contributed towards a genuine belief of safe operation within the maternity unit by staff and board members. However, as they acknowledge, the first problem can be seen in 2004. According to the MBI,2 there were SUIs in the years before and after 2008, but this …. (shrink)

Doctors, nurses and midwifes from developing countries migrate to affluent countries in large numbers, often leaving behind severely understaffed healthcare systems. One way to limit this ‘brain drain’ is to restrict the freedom of movement of healthcare workers. Yet this seems to give rise to a conflict of human rights: on the one hand rights to freedom of movement, on the other hand rights to health. By motivating its own account of human rights, this paper argues that the conflict (...) is not as acute as it seems, since rights to freedom of movement are in fact more limited than often acknowledged. Weak restrictions of the freedom to leave and strong restrictions of the freedom to enter are in principle compatible with the rights of healthcare workers. Hence, policies that involve restrictions of both kinds can be justified in order to secure the human right to health. (shrink)

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion (...) between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

The bioethical principle of respect for a person’s bodily autonomy is central to biomedical and healthcare ethics. In this article, we argue that this concept of autonomy is often annulled in the maternity field, due to the maternal two-in-one body (and the obstetric focus on the foetus over the woman) and the history of medical paternalism in Western medicine and obstetrics. The principle of respect for autonomy has therefore become largely rhetorical, yet can hide all manner of unethical practice. We (...) propose that large institutions that prioritize a midwife–institution relationship over a midwife–woman relationship are in themselves unethical and inimical to the midwifery philosophy of care. We suggest that a focus on care ethics has the potential to remedy these problems, by making power relationships visible and by prioritizing the relationship above abstract ethical principles. (shrink)

Unlike sonographic examinations, sonic fetal heartbeat monitoring has received relatively little attention from scholars in the social sciences. Using the case of fetal heartbeat monitoring as part of midwifery prenatal care in Germany, this contribution introduces music as an analytical tool for exploring the aesthetic dimensions of obstetrical surveillance practices. Based on ethnographic stories, three orchestrations are compared in which three different instruments help audiences to listen to what becomes fetal heartbeat music and to qualify fetal and pregnant lives in (...) relation to each other. In the Doppler-based orchestration, audible heartbeat music is taken as a sign of a child in need of parental love and care cultivated to listen. The Pinard horn makes esoteric fetal music that can be appreciated by the midwife as a skilled instrumentalist alone and helps to enact a child hidden in the belly. The cardiotocograph brings about soothing music and a reassuring relationship with a child but also durable scripts of juridical beauty. This material-semiotic analysis amplifies how well-being is shaped in midwifery prenatal care practices. (shrink)

This chapter contains sections titled: Abortion and Mother‐Fetus Conflict Moral Obligations to the Unborn The Obstetrical Cases: Forced Cesareans Fetal Surgery Conclusion References Further reading.

Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion. We conducted a systematic review (...) of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection. Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons. The reasons and their associated mentions in this category outnumber those in the sum of the other three categories. We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals. (shrink)

Women most fully experience the consequences of human reproductive technologies. Men who convene to evaluate such technologies discuss "them": the women who must accept, avoid, or even resist these technologies; the women who consume technologies they did not devise; the women who are the objects of policies made by men. So often the input of women is neither sought nor listened to. The privileged insights and perspectives that women bring to the consideration of technologies in human reproduction are the subject (...) of these volumes, which constitute the revised and edited record of a Workshop on "Ethical Issues in Human Reproduction Technology: Analysis by Women" (EIRTAW), held in June, 1979, at Hampshire College in Amherst, Massachusetts. Some 80 members of the workshop, 90 percent of them women (from 24 states), represented diverse occupations and personal histories, different races and classes, varied political commitments. They included doctors, nurses, and scientists, lay midwives, consumer advocates, historians, and sociologists, lawyers, policy analysts, and ethicists. Each session, however, made plain that ethics is an everyday concern for women in general, as well as an academic profession for some. (shrink)

Childbearing is an increasingly complicated matter, which has evolved significantly over the past several decades. Treatment options for infertility have expanded. Prenatal testing and treatment have led to an evolution in obstetrical decision-making, wherein the risks and benefits to the fetus and future child are better understood and more strongly considered in medical management of the pregnant woman. Obstetrics appears to be increasingly interventional; one in three babies in the United States is now born by cesarean section. Neonatal intensive care (...) has markedly improved outcomes for premature babies. A pregnant woman may now be presented with many options— obstetrician or midwife, home or hospital delivery, choices among prenatal testing and monitoring, early induction of labor, cesarean delivery. Health care professionals face similar decisions with regard to what they recommend and the boundaries of safe and responsible care they should make available. Preterm Babies, Fetal Patients, and Childbearing Choices, by John D. Lantos and Diane S. Lauderdale, provides an excellent overview of the available information relevant to these questions. (shrink)

This article comprises a short case exemplifying ethical challenges arising for a participatory researcher working with Afghan women refugees during the Covid-19 pandemic in Germany. The researcher is an Iranian-German woman, qualified as a midwife, undertaking doctoral research on refugees’ access to reproductive health care. Disclosures about some women’s experience of domestic violence are made, which raise ethical issues for the researcher relating to personal-professional boundaries, roles and responsibilities. Two commentaries are given on this case from participatory researchers based in (...) Germany, UK and Austria. Both commentaries highlight the relevance of the ethics of care for participatory research and for this research in particular, which entails very close relationships between the doctoral researcher and the refugee women with whom she is researching. The first commentary analyses the research process in terms of Tronto’s five phases of care, while the second illustrates the importance of caring institutions in supporting researchers working on sensitive topics. (shrink)

BackgroundImplementation of recommendations from clinical practice guidelines is essential for evidence based clinical practice. However, the most effective methods of implementation are unclear. We conducted a national, cluster-randomised, blinded implementation trial to determine if midwife or doctor local implementation leaders are more effective in implementing a guideline for use of oral dextrose gel to treat hypoglycaemic babies on postnatal wards. To prevent any conscious or unconscious performance bias both the doctor and midwife local implementation leaders were kept unaware of the (...) trial. This paper reports the ethical dilemmas and practical challenges of ensuring clinicians remained unaware of their involvement in an implementation trial.MethodsWe sought approval from the National Health and Disability Ethics committee to keep clinicians unaware of the trial by waiving the standard requirement for locality approval usually required for each district health board. The ethics committee did not approve a waiver of consent but advised that we approach the chief executive of each district health board to ask for provisional locality approval. Ultimately it was necessary to seek ethics approval for three separate study designs to keep clinicians unaware of the trial.ResultsThe median time for chief executive approval was 16 days and for locality approval was 57 days. We completed 21 different locality approval forms for 27 hospitals.ConclusionsKeeping clinicians unaware of their involvement in a national implementation cluster-randomised trial is feasible. However, despite a national ethics committee, significant logistical challenges were time consuming and delayed trial completion. Co-ordination of the locality approval process would help facilitate multi-centre trials. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:I Am Not Sure?Paul E. LevinIt was a beautiful Friday morning, a few weeks into the summer. My schedule appeared lighter than usual and I even envisioned leaving work a bit early. Maybe a challenging bike ride before dinner. I was sitting in the chairman’s office having our weekly meeting. One of our junior faculty members called... he needed help. He was on call and a 32–year–old pregnant woman (...) with a displaced femoral neck fracture had just been transferred to our emergency department (ED). Ms. B tripped in her kitchen last evening. She was unable to stand and was brought to the local ED by ambulance.My colleague was concerned that he wouldn’t be able to successfully reduce the fracture. The long–term prognosis of the hip joint depended on a successful reduction of the femoral neck fracture. In addition, there was an ongoing debate in the orthopaedic literature related to the urgency of operative care to prevent osteonecrosis of the femoral head. I reviewed the x–rays, didn’t anticipate a problem and let him know that I would come to the operating room (OR) to assist. “No”, he responded, “I am not comfortable caring for this patient”. I immediately left the office, went to the hospital and assumed care of the patient. Clearly, my plans for a bike ride were gone, but I had the opportunity to help a woman in need of expert orthopaedic care.Ms. B had been admitted to the obstetrical service. She was a 32–year–old woman of Haitian descent who had recently immigrated to the United States. She had very limited English comprehension and her primary spoken languages were French and Creole. She was alone, in a hospital in a foreign country. She was 24 weeks pregnant with her first child and had no other co–morbidities. Her pregnancy had ben progressing uneventfully.When I first met Ms. B she was lying on a stretcher in an observation unit on the obstetrical floor. She appeared frightened. Two orthopaedic residents were present and obtaining consent for surgical repair of the hip. In their minds there was nothing to discuss, the patient had a displaced femoral neck fracture and needed to have surgery immediately. In their minds, no other options were available and obtaining consent would be straightforward. I introduced myself, sat down on a lab stool by the bed and began a conversation. I needed to meet the patient, understand who she was and discuss treatment. I am not sure that obtaining an informed consent is ever “straightforward” when [End Page 14] a doctor is explaining to a patient that they require emergency surgery. This discussion surely would not be easy or straightforward.We utilized a telephone interpretation service. Every question and response required the transfer of the handset between the patient and physician. Ms. B was in pain and frightened. She immediately expressed concern about her pregnancy and her baby. I arranged for her to meet all of the physicians who would possibly be involved in her care and the care of her baby. Each consultant could explain their area of expertise and potential involvement in the care of Ms. B and her child. She met and had an opportunity to talk with the obstetrician on call, a maternal fetal medicine (MFM) fellow and a neonatologist. I supplied the orthopaedic information. I explained the severity of the injury, the risks of osteonecrosis either with or without surgery as well as concerns over non–union and traumatic arthritis of the hip. Undoubtedly, in a healthy 32–year–old woman who wasn’t pregnant, early surgical intervention would be the most appropriate management in hopes of preserving a normal hip joint. We also discussed the possibility of treating her without surgery. She would be administered pain medication, which were known to be safe during pregnancy, and allowed to begin to ambulate with a walker or crutches. I explained potential problems without surgery and what options would be available to treat any problems that developed with her hip after the child was born. Of course, hip fractures in pregnant woman are very rare, and as a result treating a... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hume Studies Volume XXVI, Number 1, April 2000, pp. 129-142 Hume on ''Greatness of Soul" GRAHAM SOLOMON The "great-souled man" was first described in detail in Book iv of Aristotle's Nicomachean Ethics. Simon Blackburn concisely summarizes Aristotle's portrait of this "lofty character": "The great-souled man is of a distinguished situation, worthy of great things, 'an extreme in respect of the greatness of his claims, but a mean in respect (...) of the Tightness of them', perfectly virtuous, good at conferring benefits but ashamed of receiving them, neither humble nor vain. The combination involves proper pride or magnanimity." Such men will enter politics with the aim of preserving justice and working for the good of society, or they will exhibit great personal courage in battle, or, more generally, they will aim at virtuous action at all times, even when faced with painful choices and life-threatening circumstances. Historians disagree about whether Aristotle held that the great-souled man is motivated in part by a desire to be admired by others, but certainly he held that the great-souled man was capable of performing great and virtuous actions that would be admired.1 By the mid-eighteenth century, greatness of soul could be found in much less distinguished situations. Consider, for example, Laurence Sterne's Tristram Shandy. Tristram attributes greatness of soul to his mother for wanting to give birth to him under the care of a midwife rather than a doctor. His father thinks that turning down a large purse of money offered in exchange for naming one's son Judas is an act of greatness of mind. And Tristram says his friend Jenny exhibited greatness of soul by purchasing a much less expensive piece of silk than the one she initially wanted, deferring to Tristram's unvoiced but Graham Solomon is at the Philosophy Department,Wilfrid Laurier University,Waterloo, Ontario, Canada N2L 3C5. e-mail: [email protected] 130 Graham Solomon obvious judgment.2 For an example from the nineteenth century, consider the following passage from the novel The Wrecker (1891) by Robert Louis Stevenson and Lloyd Osbourne. The narrator, a wealthy young American, is slumming as a bohemian art student in the Latin Quarter of Paris: "I always looked with awful envy... on a certain countryman of my own, who had a studio in the Rue Monsieur Ie Prince, wore boots, and long hair in a net, and could be seen tramping off, in this guise, to the worst eating-house of the quarter, followed by a Corsican model, his mistress, in the conspicuous costume of her race and calling. It takes some greatness of soul to carry even folly to such heights as these."3 There the character's greatness of soul seems to involve an ability to ignore or overlook or misinterpret the opinions others might have of him. While the phrase "greatness of soul" or "greatness of mind" is not commonly used nowadays,4 the Latin form "magnanimity" is still in use in ordinary, everyday, reasonably educated discourse. And occasionally "highmindedness " is used. The capacity to make magnanimous gestures is still widely felt to be a virtue. "Magnanimity" nowadays refers to a mix of unselfishness, generosity, the capacity to rise above petty feelings of resentment and revenge, and more generally and vaguely to a kind of nobility of heart and mind. These are features that Aristotle would recognize. But, it seems to me, we are prepared to apply the term to a far wider class of people than Aristotle would. Magnanimity is nowadays thought to be a virtue that can be exhibited by almost anyone. The first extended discussion in English-language philosophy of the concept of greatness of soul or mind is in David Hume's Treatise III iii 2, a section titled "Of greatness of mind." Hume's discussion contributed to a domesticated and democratized understanding of the concept, a more serious ancestor of the concept found in Tristram Shandy5 and The Wrecker. Donald Siebert argues in the chapter "In Search of the Hero of Feeling" in The Moral Animus of David Hume6 that after the initial exploration of the concept in the Treatise, Hume eventually settled in The History... (shrink)

BackgroundRespect for confidentiality is important to safeguard the well-being of patients and ensure the confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which there has been a breach of confidentiality, by means of direct observation in clinical practice.MethodsBy means of direct observation, our study examines real situations in which there has been a breach of confidentiality in a tertiary hospital. To observe and collect data on these situations, we recruited students (...) enrolled in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics; Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology; and Ophthalmology.ResultsFollowing 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach per 62.5 h. As regards the typology of the observed breaches, the most frequent were related to the consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient’s clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas, such as corridors, elevators, the cafeteria, stairs, and locker rooms.ConclusionsIn addition to aspects related to hospital organization or infrastructure, we have shown that all healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed unintentionally, a non-negligible number are severe, repeated breaches, thus suggesting a certain carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality. (shrink)

Before anaesthesia, surgery used to be agony. It’s hard to imagine that anyone could have been anything but pleased when painless surgery was introduced in the mid-19th century. And yet, although many welcomed anaesthesia, some did object. In Zurich, anaesthesia was even outlawed. “Pain is a natural and intended curse of the primal sin. Any attempt to do away with it must be wrong,” claimed the Zurich City Fathers. Painless delivery in childbirth was a particularly contentious issue. Some insisted that (...) “in sorrow thou shalt bring forth children” (Genesis 3:16). Others, like Doctor Charles Delucena Meigs (1792-1869), Professor of Obstetrics and Diseases of Women at Jefferson Medical College, believed that labour pains were “a most desirable, salutary and conservative manifestation of the life force.” There was even a belief, expressed in 1847 in The New York Journal of Medicine, that pain was vital to surgical procedure. (shrink)

Gaining ethical clearance to conduct a study is an important aspect of all research involving humans but can be time-consuming and daunting for novice researchers. This article stems from a larger ethnographic study that examined research capacity building in Irish nursing and midwifery. Data were collected over a 28-month time frame from a purposive sample of 16 nurse or midwife research fellows who were funded to undertake full-time PhDs. Gaining ethical clearance for their studies was reported as an early ‘rite (...) of passage’ in the category of ‘labouring the doctorate’. This article penetrates the complexities in Irish clinical research ethics by describing the practices these nurse and midwife researchers encountered and the experiences they had. The key issue of representation that occurred in the context of ‘medicalized’ research ethics is further explored including its meaning for nursing or midwifery research. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:American Journal of Philology 124.4 (2003) 613-616 [Access article in PDF] KONSTANTINOS KAPPARIS. Abortionin the Ancient World. London: Duckworth, 2002. viii + 264 pp. Cloth, £40. In his introduction, Kapparis states that he has tried to "produce a 'readable and synthesized' treatment of the available evidence, without losing sight of time and place" (5). In this book Kapparis does collect, in English, most of the sources and results of (...) the work that has been done on abortion in the ancient world since the publication of Enzo Nardi's Procurato aborto nel mondo Greco-Romano (Milan, 1971), and most of the conclusions collected at the end of each chapter I find unobjectionable. To this extent, this is a useful book. However, the general tenor and the organization of the discussion within each chapter does, I think, lose sense of time and place, especially in the case of classical Athens, which is the main focus of Kapparis's interest.Rather than treating each culture chronologically, Kapparis presents the material in six main chapters: (1) "Methods of Abortion"; (2) "When Does Human Life Begin?"; (3) "The Doctor's Dilemma"; (4) "The Woman's Point of View"; (5) "The Man's Point of View"; (6) "Abortion and the Law." Even the subsections within each chapter are not chronological periods. Within each subsection, Kapparis clearly strives for a chronological arrangement, but he is not always successful, and there are times when the chronological progression will not be clear to the non-specialist. When discussing the role of midwives, for instance, Kapparis begins with Soranus' description of their role, saying, "The few available references to the role of the midwife in the community reveal that Greek midwives were well-respected figures with an important role to play as health advisers, and a daunting list of responsibilities" (85). There is no initial indication that Soranus' remarks are directed to midwives in Rome of the second century C.E. After backtracking to take account of a remark in Plato's Theaetetus, Kapparis concludes, "the tasks of the midwife had not really changed much from the classical period to the time of Soranus (second century AD)" (87). The conclusion from just these two citations is questionable in the extreme, but without further cultural embedding, the statement is virtually meaningless. In ancient Greece, for example, a midwife was expected to have given birth herself, and the role would often have been filled simply by the older female members of a household, whereas Soranus says that personal experience in childbirth is not a prerequisite for a midwife because he sees it as a far more professional position. Even when Kapparis does present the material with strong chronological and cultural markers, it would be very hard for a non-specialist to separate out from each subsection the strands that go together to make a cohesive society.One of the biggest problems in the tenor of Kapparis's discussion derives from his projecting the later, largely Christian, concern over the fate of the fetus into the classical Greek period. Obviously there was a range of opinions on the subject in antiquity, just as there is today; and there were probably many people, especially pregnant women and prospective fathers, who felt a strong emotional attachment to the fetus at all stages. However, one cannot begin to assess the [End Page 613] attitude towards abortion in ancient Athens without acknowledging that the society countenanced the exposure of newborn infants. Kapparis does not deal with this issue at any length until pages 154-62. On page 69 he tries to downplay its significance by saying, "An individual's conscience, strength of religious feeling, and broad perception of human identity would be important factors in the decision over the fate of an unwanted infant." But conscience, religious feeling, and perception of human identity for the vast majority of people are largely shaped by the culture in which they live. Athenians, and other Greeks, lived in a society in which they could, with impunity, expose a newborn simply for being female. While I am sure that in many cases it was a... (shrink)

This article puts the spotlight on the world’s largest artificial reproduction technology (ART) industry—that of Japan, seeking to explain the exceptional tardiness of the government there to install a comprehensive legal framework that regulates these practices. By relying on minutes from a conversation with an influential parliamentarian active in this area, as well as official documents, media reports, and an interview conducted with key physicians, the article reconstructs the historical trajectory leading to the enactment in December 2020 of the Assisted (...) Reproduction Technology Act. The author contends that it is only on the background of an overview of what happened in the two decades preceding the promulgation of this Act that a sense can be made of why the latter came to be as scant and evasive as it is in terms of provisions, de facto leaving unaltered the socially and ethically undesirable situation of self-regulation in ART application by the Japanese doctors. This article adds credence to the hypothesis with regard to the issue of regulatory governance of emerging technologies more broadly that the direction of travel is toward soft, as opposed to hard, law. (shrink)

The medical model of childbearing assumes that a pregnancy always has the potential to turn into a risky procedure. In order to advocate humanized birth in high risk pregnancy, an important step involves the enlightenment of the professional’s preconceptions on humanized birth in such a situation. The goal of this paper is to identify the professionals’ perception of the potential obstacles and facilitating factors for the implementation of humanized care in high risk pregnancies. Twenty-one midwives, obstetricians, and health administrator professionals (...) from the clinical and academic fields were interviewed in nine different sites in Japan from June through August 2008. The interviews were audio taped, and transcribed with the participants’ consent. Data was subsequently analyzed using content analysis qualitative methods. Professionals concurred with the concept that humanized birth is a changing and promising process, and can often bring normality to the midst of a high obstetric risk situation. No practice guidelines can be theoretically defined for humanized birth in a high risk pregnancy, as there is no conflict between humanized birth and medical intervention in such a situation. Barriers encountered in providing humanized birth in a high risk pregnancy include factors such as: the pressure of being responsible for the safety of the mother and the fetus, lack of the women’s active involvement in the decision making process and the heavy burden of responsibility on the physician’s shoulders, potential legal issues, and finally, the lack of midwifery authority in providing care at high risk pregnancy. The factors that facilitate humanized birth in a high risk include: the sharing of decision making and other various responsibilities between the physicians and the women; being caring; stress management, and the fact that the evolution of a better relationship and communication between the health professional and the patient will lead to a stress-free environment for both. Humanized birth in a high risk pregnancy is something that goes beyond just curing women of their illnesses. It can be considered as a token of caring, and continued support, which positively consolidates the doctor-patient relationship. As yet, it has not been described as a practiced guideline, due to its ever-changing complexities. (shrink)

Melanie presented at twenty weeks of gestation to an obstetrics clinic in a critical access hospital in rural Vermont. She was excited to undergo routine fetal ultrasonography, but her obstetrician gave her grave news: the ultrasound revealed hypoplastic left heart syndrome, a devastating congenital heart defect. Initially, Melanie agreed in general to pursue surgical care for her fetus—a three‐stage process that has somewhat uncertain results and could only be done in tertiary care facilities far from her home in Vermont. A (...) week later, while the maternal fetal medicine and pediatric cardiology units made arrangements with colleagues in Boston, Melanie began having second thoughts. An ethics meeting was called to discuss conflicting clinician reactions to Melanie's dilemma. Most of the clinicians were stunned that the patient would change her mind. What advice should the ethics consultant offer the team about caring for Melanie? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hildegard and HolismSuzanne M. Phillips (bio) and Monique D. Boivin (bio)Keywordsbiopsychosocial, integration, medieval, mental illnessWe appreciate the careful and enriching commentary offered by Kroll and by Radden on our paper about holistic views of mental illness in the writings of the twelfth-century abbess and healer Hildegard of Bingen. Both reviewers are well-established figures in the study of historical perspectives on mental illness, an area that we have just begun (...) to explore. We are glad for the opportunity to respond to their observations and thereby to continue the dialogue.First, we would like to clarify our purpose in preparing this paper. Nowhere do we claim that Hildegard used a biopsychosocial model of mental illness, either in addressing the needs of the particular case of Sigewiza, or more generally in her writings on illness and health. In fact, we agree with Kroll (2007, 370), when he states that Hildegard did not use a biopsychosocial model. We use the term “biopsychosocial” only three times in the paper, always by contrast with what we see in Hildegard’s writings. The present-day biopsychosocial model focuses on getting a range of perspectives on the table, encouraging the consideration of biological, psychological, and social issues when thinking about mental illness. This is a good thing, but we argue that it does not go far enough. Specifically, there has been insufficient attention to ways these perspectives might interact.How, then, might we describe Hildegard’s way of conceptualizing mental illness? In place of the label “biopsychosocial model,” Kroll suggests that Hildegard’s approach could be described as a “religious model” (p. 372). Here we disagree. By our reading, Hildegard’s description of mental illness involves religious components, certainly, but also humoral, astrological, interpersonal, community, and intrapsychic components. Radden correctly notes that we are not so much interested in the particular components as we are in their interactions. We are attracted to Hildegard’s writings because she attends to these interactions. Our students, like Kroll’s (p. 371), are curious about mind–body relationships, which represent one example of the interplay between components. Our concern is that the current biopsychosocial model often fails to satisfy our own, and our students’, interest in the nature of those interactions. Our hope is that Hildegard’s writings might help us to think more richly about the interactions.As Radden (2007, 373) points out, present-day psychiatrists and psychologists do in fact use mul-ticausal accounts of depression. And we agree that such accounts need not be reductionistic (Kroll, 371). But we also recognize that psychology and psychiatry have well-established reductionist (more specifically, materialist) habits. To borrow [End Page 377] Kroll’s phrase, the biological model threatens “to swallow all other models” (p. 371). We must guard against such reductionism, given the habits of our disciplines. As we noted, McHugh and Slavney (1998) respond to that threat by building walls between the perspectives, suggesting that we might use different perspectives when thinking about different sorts of problems. We think that there ought to be more synthetic, holistic ways of responding to that threat, and we are hopeful that Hildegard’s writings can help us to develop those.At a basic level, we see Hildegard asking different questions than people ask today. On the first page of his commentary, for example, Kroll poses the question of “which of these three modalities [bio-, psycho-, social] may be sufficient” (p. 369) in the particular medieval text. We found that the sufficiency of one modality or another does not concern Hildegard. We are not able to speak to the general point that Kroll raises, that one or another element is emphasized depending on the goal of the medieval text; we can report our experience in reading Hildegard, where we found no sense in which one or another component is privileged. Even though Hildegard operated within a thoroughly religious context, we did not find examples of her subsuming other factors under religion. Everything interacts with spiritual concerns, to be sure, but everything also interacts with the biological, and with the interpersonal, and with the astrological. Although it may seem odd to us post-Darwinian thinkers, Hildegard’s model is essentially... (shrink)

This study investigated the effect of stroking vs. simple human presence on later reactions of dairy cows to routine veterinary handling. While in two groups of cows the experimenter stroked the ventral part of the neck or the withers for three consecutive weeks, the third group was exposed to close visual presence. After the treatment period the cows were subjected to rectal palpation. The three groups differed significantly in stepping during rectal palpation, which occurred less often in Neck- and Withers-animals (...) than in control animals. Heart rate increase was significantly higher in the control group than in the two stroking groups. Previous stroking led to fewer stress reactions during the rectal palpation, possibly due to a combined effect of improved relationship towards and thus perception of humans and lasting anti-stress effects of tactile stimulation. Keywords: cattle; tactile stimulation; human–animal relationship; animal welfare. (shrink)

Doctoral programs at U.S. universities play a critical role in the development of human resources both in the United States and abroad. This volume reports the results of an extensive study of U.S. research-doctorate programs in five broad fields: physical sciences and mathematics, engineering, social and behavioral sciences, biological sciences, and the humanities. Research-Doctorate Programs in the United States documents changes that have taken place in the size, structure, and quality of doctoral education since the widely used 1982 editions. This (...) update provides selected information on nearly 4,000 doctoral programs in 41 subdisciplines at 274 doctorate-granting institutions. This volume also reports the results of the National Survey of Graduate Faculty, which polled a sample of faculty for their views on the scholarly quality of program faculty and the effectiveness of doctoral programs in preparing research scholars/scientists. This much-anticipated update of such an essential reference will be useful to education administrators, university faculty, and students seeking authoritative information on doctoral programs. (shrink)

Current efforts to think holistically about mental disorder may be assisted by considering the integrative strategies used by Hildegard of Bingen, a twelfth-century abbess and healer. We search for integrative strategies in the detailed records of Hilde-gard’s treatment of the noblewoman Sigewiza and in Hildegard’s more general writings. Three strategies support Hildegard’s holistic thinking: the use of narrative approaches to mental illness, acknowledging interdependence between perspectives, and applying principles of balance to the relationships between perspectives. Applying these three strategies to (...) the present-day conceptualization and treatment of mental disorder could move us toward a more thoroughly integrated understanding of the field. (shrink)

Dubljević and company’s proposed approach for incorporating a socio-political perspective into neuroethics has clear potential to help mitigate the effects of research ‘hype’ relating to neuroethics. Their approach serves as a social regulation meant to improve the realizability of neuroethics research. Drawing on Dubljević et al. s suggestion, we consider how incorporating a socio-political perspective in other scientific disciplines could help the scientific community as a whole move beyond the infamous ‘reproducibility crisis’ in science. The reproducibility crisis is a concern (...) in science stemming from the revelation that most scientific results are difficult, or impossible, to replicate (Frias-Navarro et al., 2020). By applying the four principles proposed by Dubljević et al., the scientific community can avoid many of the pitfalls that have led to the reproducibility crisis, such as the file drawer effect, a publication bias preventing negative results from being published, or the publish-or-perish culture - the pressure for scientists to publish highly influential papers in high impact journals in order to keep their funding (Rosenthal, 1979; Begley & Ioannidis, 2015). As such, we argue that, in its final form, this socio-political framework begs for true open science, wherein systematically sharing data would enable enlightened policymaking by showing a picture closer to the ground-level realities of scientific research. (shrink)