Thursday, September 23, 2010

The greatest good.....for the greatest many;

What do we do when we have a moral dilemma? we examine our values and beliefs....where do these values and beliefs come from???? Values determine what we appreciate in life, what we reject and what we feel dispassionate about.

Take our current dilemma within Midwifery - do we? don't we accept the current determination? that is the question; now as I don't have a crystal ball, I have to judge by the facts; before I do I will explore two ethical theories that applies to our dilemma:

Deontology: which is duty bound based on a moral action regardless of their consequences; I like to think of the classic example is that we should not lie, however many people lie to save the feelings of the other person. However you are duty bound to tell the truth regardless of the consequences; for the good of a single person;

Telelogy - Utilitariansism - also known as consequentialism; actions can only be judged right and or good on the basis of the consequences they produce - therefore 'the greatest good for the greatess many' - therefore opposite to Deontology;

I always considered myself more deontology than utilitariansim.... however on this occasion I am the opposite;
A friend of mine gave me a classic analogy about the determination: it goes, " Dear Santa, thank you for the new red bike, but I really don't like red, and the wheels are two small, so no thanks I would rather go without my brand new bike" or the alternative response could be "thanks Santa for the new bike, yes I don't like red and the wheels are two small, but in the mean time I will ride the bike until l save some money paint it and put new wheels on"

I have always considered that the midwife provides continuity of midwifery care to "normal" "low risk" women.... once a complication arises then it is time to collaborate with our colleagues the obstetricians; this is done as professional to professional...... this is not recognised here in Australia.

I have circulated information far and wide about the issues at hand; the majority of feedback from midwives and some women has been to accept the the determination and the main reason being it is the first step to bigger better things; we can change something we have, not something we don't have;

There is much rhetoric about this subject; I fail to see how we are harming by accepting this, if the choice is this or nothing; yes I understand it is not perfect and I for one do not want to be beholding to an obstetrician. However I come back to the same point that this is very new to Australia, midwives are not as autonomous as our counterparts in the UK and NZ... so there has to be a period of trial or adjustment change is always difficult and does not come without a price......this is the first step to massive change... we have to keep working at it to get what we the end of the day you can choose to accept this process or not.... you don't have to have a medicare provider number.... women still can choose an independent midwife.....and not claim a medicare rebate......

The facts remain the same:

The Determination:
Will not prevent private midwives being able to practice (they can still access insurance)

Will not prevent women being able to make choices –If you are having a homebirth and choose not to access Medicare you do not need a signed agreement with a doctor.

Only affects midwives seeking to access Medicare and midwives can choose not to do this.

Is not included in the NMBA Quality and Safety Exemption Framework supporting private midwives providing homebirth services

Does not re-define the ICM definition of a midwife – it does not define the role or scope of practice of midwives in Australia. It only defines how midwives can access Medicare if they choose to do so. Midwives can still work in public and/or private practice and access insurance and register as a midwife (under our current regulatory requirements that have an accepted definition and scope of practice of the midwife in Australia).

Does not mean that midwives must have a signed agreement with a doctor – this is only IF YOU CHOOSE TO ACCESS MEDICARE - Midwives can have
a. an individual signed agreement with a doctor
b. a referral of a woman to you
c. clinical privileging
d. an agreement signed by the medical director of a hospital.

Does not mean you need acknowledgment in writing - we have been told by the Minister’s advisors that a midwife writing in her own clinical notes that results etc have been sent to the hospital/doctor where they have a collaborative arrangement meets this requirement.


Anonymous said...

I can see what you are saying and how it seems to make sense. I guess I am just a little cynical about trusting the process after witnessing the collaborative determination, which initially was workable and agreed by mws get changed and pushed through overnight without consultation.
As for the bike analogy... I am worried that Santa will give all the good girls a red bike on condition that they follow his path and cycling rules. Then next xmas tell all the other girls who are cycling their own bikes on their own paths that they must now paint their bikes red and follow his rules and path.
If someone can guarantee that this will not restrict non-medicare practice in the future I will be a utilitarian.

Debbie said...

A lot of the discussion around the Determination and its implementation is around the control/veto of a doctor over a midwife and women in the midwife's care. To be honest, I see more likelihood of control within the existing hospital sector. An employed midwife can find her/himself constrained (controlled) by the hierarchy of the system and the requirement to adhere to the instructions of a 'superior'. While the structures within the system fail to recongnize the autonomy of midwives this control will continue. Having Medicare provider numbers - it can be argued - provides more of a levelling: two autonomous practioners working together. A credentialled privately practicing midwife working in the same way as a visiting medical officer would (who also has to go through a credentialling arrangement so it subject to a 'veto') may be less controlled. I can't imagine that a midwife would seek a collaborative arrangement with anyone that she doesn't trust and I can't imagine that a doctor would enter into an arrangement he didn't trust and respect either. Hopefully, such an arrangement would be one of trust, respect and understanding - not one of control of one over another. Of course, we have to wait and see how many dr's will be willing to enter into these 'arrangements' - and these are the challenges. We have to monitor what is actually happening and hold Nicola Roxan to her word about making changes if it doesn't work. Of course, there is also the National Maternity Plan - yet to be made public - which will also have an impact.

Lisa Barrett said...

This doesn't just affect medicare as the quality and safety framework draft is already linked to the insurance requirements and we can only assume that this will continue. This affects All midwives. A medical veto is not in the best interests of midwives so is not in the best interest of clients.
Trusting the process is why we are in this mess. We have no idea what the rebates are so access for more women is dubious.
We are far better to accept nothing and retain autonomous midwifery than we are to let them take it from us. It will NEVER return. Medicare for an/pn is not going to be more than for a gp and this is a pittance.
Lets use an example. VBAC wanting a hospital birth. has to see Ob (we assume free of charge?) Ob has agreement with midwife but only as far as she follows the rules. ctg iv access etc. The very reason she would want continuity of care to avoid. Then Ob insists on checking up during labour. Midwife automatically forfeits have her payment but cannot complain as agreement gives Ob the power to veto midwife who doesn't feel a check by him is required. Midiwife/woman only gets approx 750 dollars payment woman has 12 hours max to perform as agreement defaults to Ob standards.
Where is it that woman benefit. Even a low risk woman with a homebirth, baby dies midwife has no insurance for birth but collaborative agreement. Does Ob insurance company allow this?

Lisa Barrett said...

If a private midwife has a hospital birth are the clients private clients? If they are they will incure out of pocket expenses. Will they go in as public patients? If they do Obs will soon want that for their clients too.

It's not just that it's not perfect, it's midwives giving up the right to practice. Look at the NY midwives and what happened to them and what they have been through to stop it. Can't we learn anything?

You won't be able to chose an independent midwife at all in the near future. With 7500 dollars for insurance, fees, travelling, registration, 40 cpd points to get, mid review to undertake and only a small rebate WHO will be able to afford this and then still be beholden to the medical model. The program has always been to get rid of independent midwives and this is something the college have wanted too, so the last bastien of birthing outside the system the way you may want will be gone unless you have an unregistered provider or you free birth. This is not about homebirth this is about the right to chose as a woman and the right to practice as the international definition says we can. We have been practicing with the freedom of the UK and NZ, in fact with more freedom. Santa gives you the red bike and says don't worry you can change it later. Later Santa says sorry but you are managing just fine on the red bike I decided that all the other bikes are now ban.

If you don't want medicare then you still have to either have a signed agreement OR have an acknowledged transfer plan(signed agreement with the hospital) where in that do you see choice for women and midwives?

I believe that if determination falls over the college of midwives will be out of pocket, I feel this is far more of a driving force that what is right.

How will group practices who are at the moment bending the rules be able to continue with a veto over their practice written into legislation? The ramifications are massive and not a simple conundrum of wording.

Oh and the woman has to be referred to you if you have medicare to access the payment. Mmm that's a thing in itself. Their body are against homebirth so how many women will be referred for antenatal and postnatal care to a midwife when the doctor himself could do it and get the payment. Will GPs and Obs do all of this for free?
No more self referral if you want a medicare rebate.

Lisa Barrett said...

"Does not mean you need acknowledgment in writing - we have been told by the Minister’s advisers that a midwife writing in her own clinical notes that results etc have been sent to the hospital/doctor where they have a collaborative arrangement meets this requirement. "

So you already have to have an arrangement (not available at the moment) and you HAVE to inform the hospital. What is the control for the woman? What happens when the midwife doesn't comply because the woman says no?

Thinking of the moment is too shortsighted. Thinking of the big picture and how it will benefit everyone is good. How will it benefit anyone I'd like to know. Oh maybe one or two midwives who are happy to sell out the women to make an extra 1000 dollars. I can now see why determination is good.

InfoMidwife said...

interesting view on the bike, I have thought of that concept myself; at the end of the day I believe that a midwives role is only in the 'normal' and collaborative care for all the rest.....this is the first instance I have followed the utilitarian you know there are no guarantee's in this line of work.... we will just have to wait and see.... we do have a divided view....

InfoMidwife said...

the bike comment was meant for you midwifethinking.... just goes to show when you are not well... it catches up with you....thanks for the comment.

InfoMidwife said...

Thanks Debbie for your comment I particularly liked your concept of "Having Medicare provider numbers - it can be argued - provides more of a levelling: two autonomous practioners working together." that has a good ring to will be interesting to watch how it all pans out....

InfoMidwife said...

Always nice to hear your point of view Lisa even if I don't is good to let people read two sides to an argument, thanks.

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