GROUP 4

1.NSM MAZITA BINTI MD JUSOH

2.NSM MAZTURA SAHRINI BINTI MUHAMMAT SAH
3.NSM NORLIM BINTI AZIZ
4.NSM NURAKHRIMAH BINTI CHE OTHEMAN
5.NSM NURUL FATIN BINTI YUNUS
6.NSM NUR SYAHIDAH BINTI MUHAMAD
7.NSM SITI SARAH HANIS BINTI IBRAHIM
8.NSM ZAPINAH BINTI ZAINON
At the end of the learning session,the student should be
able to:
Define key term used in ethics

Describe the common ethical theories

Discuss ethical decision making in midwifery

Discuss the scope of midwifery practice

#applying bioethics
#strategies for practice
Means of legal
-ralating to the law
-something enabling one to achieve end
Means of ethic
Is defined as moral principle that governs or
influence a person’s behaviour
Ethics is thus a benchmark of human behaviour

The conduct of human being is influenced either

by the emotion of life or the action people perform
in different situation
The coordination of action and emotions generates
ethics
 Being ethically aware is a step towords being an
autonomous practitioner,its means taking
responsibility,empowering order other facilitating
professional growth and development.
 Ethic is often about exploring values and believed
and clarifying what people understand,think and feel
in a certain situation.the language and terminology is
hard to comprehend and need greater explanation.
 Information regarding option for care/treatment
 Explain to patient before prosiding prosedur to
get consent and cooperation
 Synonym:violence,assault ,mugging “assault and
battery”

 (refer code of conduct no 4)

 Competent person have the right in law to consent to any
touching of the person.
 Prevent an action for that negligence arising on the ground
that they was a breach of duty to care and inform the patient
 It is law to inform consent before any procedure can be
proceed
 Justified claim to a demand
 Respecting others right to self determine a course
of action pricinpal of autonomy is based on the
understanding for choice made by people
 Eg:

-right to refused medication

-antivacine
 A requirement to act in a certain manner
 Eg:

-patient request for female staff only

(refer code of conduct no 1)
 Being treated fairly
 Eg:

-midwife have ensure safety to the both of mother

and fetus/child during labour and pueperium

(refer code of conduct no 10)

 Deciding on best course for an individual
 Eg:

-the midwife maybe taking a position that she sees

as her duty to care of mother acting in the best
intrest of both her and child
 Consequence of the climax experiencing an act of trespass
to their person by the defendant or suffering harm from the
defendant action that could be proven as negligence
 Include 5 part
 Preliminaries
 Requirement for practice
 Obligations and scope of practice
 Supervision and reporting
 Action by the local supervising authority
 Make the care of people you first concern
 Works with others
 Provide a high standard of practice and care
 Be open and honest
 Undertakes a minimum of 450 hours in clinical practice
 Undertake the minimum of 35hours study relevant practice
 Maintain a professional portfolio of their learning activity
 Undertake reten to practice programme if they have been
out of practise
Level 1: Judgement
Level 2: Rules
Level 3: Principles
Level 4: Ethical Theories
 Based on information on individual gain
 May have no real foundation except the believe
of the own individual
 Often links to personal value

 Example:

-Hiv patient,single parents

 Depending on the society and the culture
 Guide our practice and control our action

 Ex:

- A community do not approve usage of extanox

gas during labours, so that delivery happen
naturally
 Autonomy: Respect the invidual freedom
 Non-maleficence: doing right thing
 Benificence: doing good in practice of
midwife
 Justice: to be trait faily
 Ethics may be considered to be about behaviour
and doing treating people well
 Term given to the explaination of and application
of reasoning based upon personal value,moral
and behaviour
 Ethical issue occurs when there is different in
opinion or understanding of what right or wrong
 In midwife it is regarding aproblem or issue
which arise in the context of midwifery practice
1. Principalism – 10. Paternalism
Beauchamp & 11. Utilitarianism or
Childress Consequentialism
2. Autonomy 12. Deontology or duty based
3. Beneficence 13. Ethics of Care
4. Non-maleficence 14. Virtue Ethics
15. Rights
5. Justice
6. Utility
7. Veracity
8. Charity
9. Self-improvement
1.Principalism – Beauchamp & Childress

 The four principles of Beauchamp and Childress -

autonomy, non-maleficence, beneficence and justice -
have been extremely influential in the field of medical
ethics, and are fundamental for understanding the current
approach to ethical assessment in health care.
 This study tests whether these principles can be
quantitatively measured on an individual level, and then
subsequently if they are used in the decision making
process when individuals are faced with ethical dilemmas.
 Autonomy means to respect the right of the
individual.Respect for autonomy enters the
clinical practise by the informed consent.this
process usually understood to have 3
elements,disclosure by the physician to the
patient condition and it’s
management ,understanding of that information
by the patient and a voluntary decision by the
patient to authorize or refuse treatment.
3.Beneficence
Is a concept in research ethics which states that
researchers should have the welfare of the research
participant as a goal of any clinical trial or other research
study.
The antonym of this term, maleficence, describes a
practice which opposes the welfare of any research
participant.

Ex:liftingside rails on a patient’s hospital bed to

prevent falls
 This is commonly known as first to do no harm.Physicians
must not harm patient through carelessness, malice,
vengeance, or dislike, or even through treatments
intended to help the patiens. This principle is balanced
with beneficence in that any risks of a treatment or
procedure to a patients must be outweighed by benefit.
Some treatments always carry a risk of harm. But when
the treatment is very risky, the benefit must be great, or
the risk not perfoming the procedur must be great.

 Double effect is an offshoot of non-maleficence. A

treatment that is normally used to help someone may
have an unintended negative effect. For instance, a
vaccine used to prevent disease can, in rare cases,
actually cause the infection it is intended to prevent. This
principle provides specific guidance when determining
when unintended effects are justified and when they are
not.
 Refers to fairness with respect to the distribution
of medical resources. This principles draws upon
ethics, the law, and public policy. Who should
receive scarce medical resources, and how
should we distribute them in order to realize the
best outcomes. Making the system as a whole
more fair is one of the goals of justice.

 Ex:ofa nurse demonstrating this etical principle

is by holding a dying patient’s hand.
 The principle of utility can be formulated in this
way : we should act in such a way as to bring
about the greatest benefit and the least harm.
 Is the very foundation of the moral theory of
utilitarianism. However, the principle need not be
regarded as unique to utilitarianism.
 It can be thought of as one moral principle among
others that present us with a prima facieduty, and
as such, it need not be regarded as always taking
precedence over others.
 In particular, we would never think it was justified
to deprive someone of a right, even if by doing so
we could bring benefit to many others.
 The principle of truth telling, and it is grounded in respect
for persons and the concept of autonomy.
 In order for a person to make fully rational choices, he or
she must have the information relevant to his or her
decision.
 Moreover, this information must be as clear and
understandable as possible.
 Truth telling is violated in at least two ways. The first is
by the act of lying, or the deliberate exchange of
erroneous information.
 However, the principle of veracity is also violated by
omission, the deliberate with holding of all or portions of
the truth.
 An organization set up to provide help and raise
money for those in need.

9. Self improvement

 The improvement of one's knowledge, status, or

character by one's own efforts
10. Paternalism
 Not strictly an ethical theory making a decision on
behalf of someone else or pre- empting a decision
that they are able to make on their own behalf, on the
grounds that it is for their own good.
 Paternalism is common in health care settings where
caregivers are torn between their feelings of duty to
be beneficent and their desire to respect the
autonomy of the patient.
 Human duality of autonomy and need make it
necessary to consult authorities.
 Authorities may know best what skills and information
to apply, but they lack the relevant information about
the individual. {
 Only the individual can know this with any certainty,
only they are authorities about themselves.
 Hence the authorities have limited expertise in
particular cases because their expertise cannot
include the patient's knowledge of herself.
11. Utilitarianism or Consequentialism
 Places moral emphasis on the consequences or
outcomes of an act rather than the act itself.
 An action is morally correct, provided its
consequences are beneficial. But beneficial to whom?
It may be the good of particular individuals.
 However, some, namely Utilitarians, say it is to the
greatest number of people; hence the motto: "the
greatest good for the greatest number". Or the action
ought to cause the least amount of harm possible.
 Consequentialism presents two major problems.
 First, it is impossible to predict which act will produce the
best or least harmful outcomes. It would require
clairvoyant knowledge
 Second, it may be necessary for Consequentialism to
praise or blame an act for its unforeseen and unintended
outcome.
 So, if A intends to harm B and is successful, then A is
punishable according to Consequentialism. But equally, if
A intends to help B and instead accidentally causes B
harm, then A is still punishable according to
Consequentialism.
 Emphasises the correctness of an action, regardless of the
possible benefits or harm it might produce.
 There are particular duties that must be upheld at any cost.
Kant's categorical imperatives are three such duties:

 1)Act in such a way that your actions can and ought to be

universalizable.
 2) Treat persons as ends in themselves and never solely as
means to an end.
 3) Act in such a way as you would have others act toward
you.

 This theory is also concerned with the rational intentions of

actors. Thus accidentally correct actions are not praiseworthy;
the actor must intend to do her duty.
 The fundamental problem with Deontology is that it demands
that the actor perform his or her duty regardless of the
consequences.
 A second problem with Deontology is that there is no consensus
regarding a list of duties, or how to respond when two or more
duties clash.
13. Ethics of Care
 Feminist ethics, eg Carol Gilligan.

 A direct response to the inherent coldness of

liberal tolerance.

 Advocates decision making in a way that best

supports the good of the individual in the long run.

 Requires us to assume responsibility for those

who need our help, and to do whatever it takes to
further their best interests.
 Care involves compromise in order to work out
the best possible solution, even if this means
changing the rules.

 Accepts interference with the autonomous

actions of others in order to preserve or enhance
their future autonomy.

 Ethics of care is usually criticised as a disguise

for paternalism
14 . Rights
 Protect a form of behaviour that is considered valuable in its own
right.
 Thus a right may be considered a special form of behaviour which
needs no justification.
 Rights always need some kind of assistance in order to be upheld.
 It follows from this that rights confer duties to help the right- holder
accomplish a desire or fulfil a need.
 There are two types of rights distinguished by the sort of duties
they confer:
1) Positive Rights: require others to actively support them.
Positive rights confer active duties.
2) Negative Rights: requires non-interference on the part of
others. Negative rights confer passive duties and usually hold
greater weight than positive rights.
 Sanctions ensure rights are properly supported.
 There is a possibility of competing rights. This occurs when more
than one right is at stake and both cannot be upheld
simultaneously; or when the rights of two or more individuals
conflict.
 The result of the conflict is an ethical problem
15.Virtue Ethics
 Aristotelian approach based upon character and habit.
 Places value upon moral character, not acts or
outcomes.
 Assumes people can learn to act in a virtuous manner
through training until they acquire the habit of virtue.
 Behaving virtuously entails choosing the best
approach to create happiness, or deliberating upon
general principles until the best decision is reached.
 Rejects the reliance upon rules for resolving moral
problems, for which it has been heavily criticised – if
there are no rules to follow how do we know we are
making the virtuous decision? The response is, we
know because we are virtuous.
 A second criticism of virtue ethics is that there is no
defined set of approved virtues, so it is never certain
when one is behaving virtuously or not.
1) Nature law
2) Deontology
3) Utilitarianism
4) Virtuatory
Immanuel kent
•Kant is responsible for the most prominent and well-
known form of deontological ethics.
•Kant moral theory is based on his view of the human
being as having the unique capacity for rationally
•The ability that requires human being to act in
accoradance with and for the sake of moral law or duty
•We need to take into account the final consequence of
oyr action,even if the act itself is not morally good
Jeremy Bentham(1748-1832)
•English utilitarian philosopher and social reformer

•Formulated the principle of utility,which approves

of an action has an overall tendency to promote the
greatest amount of happiness
•The principle utility is right or at least not wrong,it
ought to be done,or at least it is not he case that it
ought not be done.
 Holds that most important aspect in our life
 Rightness and wrongness of and act in our life
 The deontological theory states that people should adhere
to their obligation and duties when analysing an ethical
delemma
 Ex:

-beribadah mengikut kepercayaan agama masing-masing

-kewajipan seorang jururawat bukan hanya kepada kebaikkan
pesakit sahaja malah jururawat sendiri mendapat
kebaikkan
 Is a moral theory that implements fair choices in
an effort to ensure the leas amount of harm is
done to all parties involved.
 Promote goods and value ends

Eg:
-give proper health education.so that patient will do
the right thing to patient for apply the true
-do good no matter what
 A development of a good habit
 Reflection of one ownself
 What makes one a good or excellent person

 Eg:reflect on what is best and right in every

action
 -fix every mistake to be a better
Inmidwifery practice,clinical decision making
involving higher cognitive skills is critical to the safety
and outcome of mother’s and infants.Therefore ,the
development of this skill in midwifery is
mandatory.Use of simulation can facilitate the
development of these higher cognitive skills

(Robert ,while,& Fitzpatrick,1992)

 Simulation provide an experiential learning the
strategy for decision making that focuses on
process,including the used of clinical
information,The information-processing
sequeece,the rules used to combining information
and the decision made(Corcaran perry &
Bungert,1992)
 Indicated that set of rules used in clinical decision
making,which contain midwifery specific
knowledge,can be collected from experienced
midwives
 Decision making process there is need to work with
others.To collaborate in attempting to come to the
right decision.
 For any partnership to work there is need to build the
trusting relationship.Mutual trust and respect for
each orther view and practice more important
 Trust and truthfulness are fundamental aspects of the
work.within ethic there are seen as virtues to be
recommended in a person.when someone is trusted it
is believed that persons will act in a proper manner
and make decision for the right reasons
1.informed decision making
Patient or individuals who require health care
service have right to make their own decision about
the opinion for treatment or other related issues.The
process of obtaining permission is call informed
consent.
The health care provider should disclose the
following details
The individual is currently assessed health status
regarding the general or reproductive health
Reasonably accessible medial,social and other
means of response to the individual’s condition
including predictable success rates,side effect and
risks
 The implications for the individual;s
general,sexual and reproductive health and
lifestyle declining any of option or suggestion.
 The health provider’s reasoned recommendation
for a particular treatment option or suggestion.
2.Privacy and confidentiality
A patient family,friend or spiritual guide has no right

to medical information regarding the patient unless

authorized by the patient
Health care provider duties to protect patient’s

information against unauthorized disclosures

Health care providers duties to ensure that patient who

authorize release of their confidential health related

information
3.Competent delivery services:
Every individual has a right to receive treatment by a
competent health care provider who knows to handles
such situation quite well.According to the
laws,medical negligence is shown when the following
4 elements are all established by a complaining a
party
A legal duty of care must be owed by a provider to
the complaining party
 Breach of the established legal duty of care must
be shown,which means a health care provider has
failed to meet the legally determined standards of
care
 Damage must be shown
 Causation must be shown
4.Safety and efficacy of product:
Health care providers are responsible for any
accidental or deliberate use of product that differs
from their approved purposes or method use,for
instance for dosage level drug.Look for drug
contraindication,drug expiry,damage of diluted
sterilization sovents etc

5.Adhere to midwives code of practice

Ethic in gynaecology practice
Beneficence- based and autonomy-based clinical
judgement in gynaecologic practise are usually in
harmony,like management of rupture ectopic
pregnancy.
Negotiated in clinical judgement and practise to
determine which management strategies protect and
promotes the patient interest
Ethics and assisted reproduction
It involves many issues like donor
insemination,ivf,egg sharing,freezing nad storing of
embryos,and surrogacy,still many ethical issues are
involved in ivf
Conception and the young girl
Sometimes teenaged girls request for oral
contraception.They are already in an active sexual
relationship.They do not want that their parents
should know about them taking contraceptive.
Lord Fraser’s recommendations include:

We should assess whether the patient understands

advice
 We should encourage the parent involvement
 We should assess whether the physical,mental
health would likely to suffer,if contraceptive
advice is not given
Ethics is involved with moral judgement and the
law,however concerns public policy.At one level it
defines what can/cannot or must,must do not to
avoid risk of legal penalty.Ethics encompasses
much more than law.Ethic can determine what is
right in the sense that it is good
Multiple pregnancy
It is high risk pregnancy involving two fetal
lives.Management problem is such a case may
cause fetal complication which will invite legal
problems
Intaruterine death
The causes of iufd must be explored
Shoulder dystocia
Various clinical risk factor like diabetes leading to
big baby etc,must be identified to predict and
prevent this condition and associated injury.But if
we face such situation in emergency obstetric care
it must be tackled by experienced obstetrician
 Instrumental delivery-forcep/vacuum
 High forcep must be avoided,only low forcep can
be indicated in special circumstances to expedite
the labour process
 Concerned personnel may be sued doe unfollow
effects like facial palsy or visceral injury of
mother and baby
 The nurse practice act:
I. Law of Malaysia
II. Act 436
III. Midwives act 1996
IV. Incorporating all amendments up to 1 Jan 2006

 Broad definition of permissible boundaries of practices within a state

 Part 11
 Midwiwes board
 establishment and compasitions of the midwiwes board
 There shall be established a midwife board(here in after to as “the
board”)
 DISTINGUISHES UNTRAINED OR UNLICENSED
INDIVIDUAL FROM PRACTICING NURSING
-part v
-offences
-practising midwifery without registration
-14(1)any person who not being a midwife registered
under this act,practises midwifery,shall be guilty of an
offence and shall be liable on conviction to a fine not
exceeding two thousand ringgit or to imprisonment
for a period not exceeding one year or to both
 Part V
 OFFENCES
 Practising midwifery without registration
 14.(1) Any person who, not being a midwife
registered under this Act, practises midwifery,
shall be guilty of an offence and shall be liable on
conviction to a fine not exceeding two thousand
ringgit or to imprisonment for a period not
exceeding one year or to both.
-part v
-offences
-practising midwifery without registration
-14(1)any person who not being a midwife registered
under this act,practises midwifery,shall be guilty of an
offence and shall be liable on conviction to a fine not
exceeding two thousand ringgit or to imprisonment for
a period not exceeding one year or to to both
 -part vi
 -general
 -intention to practise midwifery
 -16.every person registered under this act,except
those in the government service,intending to practise
midwifery shall before so practising and thereafter
on 1January every year,in the prescribed form,inform
the Registrar of such intention
 Bioethics is the study of the ethical issue emerging
from advances in biology and medicine.it is also
moral discernment as it relates to the medical policy
and practise
 Bioethics are concerned with the ethical question that
arise in the relationship among life
sciences,biothecnology,medicine,politic,law and
philosopy
 It includes the study of values(the ethics of the
ordinary)relating to primary care and other branches
of medicine.
 Learn to anticipate ethical dilemmas
 Identify attitudes,values, and beliefs about ethical dilemmas
taking into consideration the influence of cultural,religious,
and social factors on the development of values.
 Recognize the influence personal values have on care
provided for clients by engaging in self-values clarification
activities.
 Review and update theoretical bases: gather
current information on technological advances and
changing trends in maternity nursing, review ethical
principles and practice codes in regard to new
technology and trends, become familiar with the
client’s knowledge base by reading lay literature
related to maternity and neonatal advances
 Attend cont. ed. Programs related to ethical
issues and decision making-- participate in
ethics committees with other healthcare
professionals and inservice peers on ethical
issues and decision making.
 Review research journals regarding current
trends in ethical decision making .comparing
and contrasting the results with what is
occurring in the clinical practice.
 Evaluate current social norms by following
social,legal,religious, and political debates that may
influence clinical decision making and quality care
for clients experiencing dilemmas in the maternal,
neontal, or women’s health areas.
 Avoid judgements about the life decisions of others
 Aim to accept the values of others and their
decisions regarding issues and provisions of
care.
 Don’t allow personal beliefs and values to
interfere with provision of quality care.
 Understand the legal implications of the
issues
 Develop appropriate strategies for ethical
decision making.
 Beauchamp and Childress 1983 Principles of Biomedical
Ethics. Oxford University Press; Oxford
 Downie R and Calman K 1994 Healthy Respect. Oxford
University Press, Oxford
 Dworkin Ronald 1978 Taking Rights Seriously. Duckworth,
London
 Gilligan Carol 1982 In a Different Voice. Harvard University
Press
 Jones S 2000 Ethics in Midwifery. Mosby. { Mill JS On Liberty
 Flagler S et al Bioethics for Clinicians in Singer P et al
available on eCMAJ http://www.cmaj.ca/cgi/reprint/156/12/1729
 Wilson K 2003 Vaginal birth after caesarean section and the
issue of home birth. Canadian Jrl of Midwifery Research and
Practice, Vol 2, 1:7-9