Perhaps the most challenging and heart wrenching ethical dilemmas occur in perinatal and neonatal nursing practice. In the perinatal section of this issue, Armour and Callister explicate the need for informed consent in the treatment of infertility. The bioethical principle of fidelity has been applied in nursing as acting faithfully. They also make the case for regulation of Assisted Reproductive Technology in the United States because of the financial, physical, emotional, and spiritual burden to families and societies related to births of high-order multiples.
Ethical and legal issues related to reproductive healthcare for adolescent women are described by Tillett, with a focus on contraception, abortion, prenatal care, testing for and treatment of sexually transmitted infections, as well as confidentiality and paternity issues. Zindler focuses on ethical issues related to fetal screening and testing with a strong emphasis on education of childbearing women and their partners regarding their options. Emancipation in decision making includes empowerment, personal knowledge, social norms, reflection, and a flexible environment.1
Simpson and Thorman share their perspectives on the alarming and growing practice involving obstetrical interventions, which are used for "convenience" rather than being based on clinical indications. They ask for whose convenience are such interventions implemented? An example is a recent report mentioning the risk of cesarean birth following elective induction, with the individual provider seen as a significant contributing factor.2 The use of technology has become a powerful force in healthcare, particularly in the care of childbearing women. Evidence is controversial and does not support elective obstetric interventions.
In a related work, Carlton and associates pose difficult ethical questions about the nurse's role in decision making in laboring women regarding childbirth pain management. Inviting women to share their stories has implications for nursing ethics and demonstrates respect.3 How does the "ethics of caring" frame support choices in pain management, including nonpharmacologic strategies, as well as presence and advocacy by nurses? What is the context and process of informed consent in the administration of epidural analgesia/anesthesia? Giving birth is a powerful life changing event that not only leaves a lasting impact on childbearing women, but also influences future healthcare decisions for not only the woman but also her family.
The neonatal section of this issue features 4 articles on ethics topics related to caring for prematurely born infants in neonatal intensive care units (NICUs). NICU nurses and nurse practitioners work daily as members of provider teams to save and care for infants born at the margins of viability. They work equally closely with the families of these infants, helping parents understand and cope with the often numerous emotional ups and downs, the visual images of their fragile infants clinging to life with technologies that support life and cause sequelae, and the reality of death and uncertain outcomes. It is rewarding and challenging work.
Infants born under 28 weeks' gestation are at significant risk for long-term sequelae as birth gestational age decreases. Fast-paced decisions and highly skilled interventions in the immediate newborn period can establish the transition to extrauterine life. Parents find themselves in the position of trying to assimilate medical information in order to make critical decisions. Difficulties arise when parents and the NICU team disagree and there are not standards to guide consistency of process, define parental rights, and comprehensively consider risks and benefits. Experimental interventions have saved lives in the short term and become practice even without long-term outcome data. Research is necessary and must be carefully considered for such a vulnerable population. All of these realities create ethical issues, which are considered in this volume.
Dr Irene Hurst provides part 1 of a 2-part series with a review of significant legal cases and decisions that have emerged from disagreements between parents and NICU teams beginning with the baby doe regulations and their legacy. Dr Hurst analyzes how basic legal issues create risks that affect nurses' practice.
Dr Anita Catlin presents a conceptual and provocative piece on the idea of including fetal development and prematurity education in prenatal care to provide parents with information in case they experience a premature birth and allow them to consider a perinatal advanced directive. While a perinatal advanced directive may be a difficult concept, leaving parents only the option of learning about prematurity as they live it and making decisions with potentially incomplete information seems ethically questionable. Authentic consideration of other difficult issues in neonatal care has resulted in important care advances such as neonatal and pediatric hospice.
Dr Linda Franck's piece on neonatal research focuses on the neonatal nurse's role in setting the neonatal care research agenda and in protecting the rights of infant research participants and their families. These are 2 important areas of contribution for neonatal nurses to be engaged in.
Dr Joy Penticuff presents her original research on parent-professional collaboration in the NICU. This research was funded by the National Institute for Nursing Research and seeks to measure the effectiveness of an intervention process to improve parental understanding of medical care. This research begins to offer nurses strategies as they carry out their essential role in communicating and collaborating with parents.
Lynn Clark Callister, PhD, RN, FAAN, Guest Editor
Perinatal Section
Susan Bakewell-Sachs, PhD, RN, APRN-BC, Editor
Neonatal Section
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