Wednesday, December 13, 2006

Moral responsibility and homebirth gone wrong

Who bears moral responsibility for a homebirth gone wrong?

In the last few months, I have read several accounts of homebirth resulting in the death of the baby or permanent neurologic injury to the baby. Who is morally responsible for the bad outcome? The midwife? The mother? No one?

Notice that I am referring specifically to moral responsibility, not legal responsibility. Legal responsibility is, of course, related, but it is primarily determined by existing laws and previous court cases. While most instances of legal responsibility derive from moral responsibility, the opposite is not true. People can bear moral responsibility for certain outcomes without facing any legal action.

Let's look at what our existing practices tell us about how we view moral responsbility for bad outcomes in childbirth.

First, our legal system allows people to take action against medical professionals. Simply put, we believe that medical professionals have a duty to provide the best medical treatment commonly available. If a baby dies because it did not receive a known and easily accessible (as opposed to experimental) treatment, we believe that the doctor or midwife bears a responsibility for that bad outcome.

Second, not understanding or not believing that the treatment was necessary does not absolve the doctor of moral responsibility. It is not enough for a doctor or midwife to claim that he or she did not believe the treatment was necessary or did not understand that the treatment was necessary.

Let's look at what natural childbirth philosophy tells us about the status of the mother as a moral actor.

Natural childbirth philosophy utterly rejects passivity and demands the ongoing active involvement of the mother in planning every phase of childbirth. This concept if felt to be so important that the descriptive language has been modified in order to better encapsulate it; babies are not delivered, they are "birthed".

It goes almost without saying that women are autonomous moral actors, capable of making their own decisions.

How can we use these concepts to decide who bears moral responsibility for bad outcomes at homebirth?

Clearly, some bad outcomes will be the moral, and often the legal responsibility of the homebirth midwife. If she made poor medical judgments, she will be subject to legal action. What happens, though, if the mother declines to accept the midwife's recommendations or if the mother deliberately plans an unassisted homebirth?

Since the mother is an autonomous moral actor, since she makes childbirth decisions from the persepective that she is educated, prepared and the active decision maker, isn't she morally responsible if the baby dies or is injured because of her decision? Is not understanding or not believing in the seriousness of a medical problem a plausible defense for rejecting moral responsibility? If a mother takes credit for a good outcome (based on her planning, self care, etc.) doesn't she bear moral responsibility for a bad outcome?

We know that an attitude of "stuff happens" does not absolve parents of moral responsbility for the health care of children. If parents do not seek appropriate medical treatment for children who are ill or injured, we call it medical neglect. If a mother refuses obstetrical treatment or deliberately puts herself in a situation where such treatment is unavailable, and the baby is injured as a results, is that also medical neglect? Does the mother have any moral responsibility to seek the best and safest care for childbirth?

These are not simple questions, and they do not have simple answers. In reading a number of stories about preventable death and neonatal injury at homebirth, I have been struck by the fact that some women act as if the outcome had nothing to do with their decisions, when, of course, the deliberate decision to deliver away from the hospital or in the case of UC childbirth, the deliberate decision to deliver without any medical assistance at all was directly responsible for the death of the baby. Don't these women bear moral responsibility for their choices?


0 Old Comments: