Code of Ethics

INTRODUCTION

In an effort to increase understanding and, hence, use of the International Code of Ethics for Midwives (1999), the ICM Board of Management commissioned the publication of this booklet. The booklet contains the Code, the glossary of terms used in the Code, the ethical analysis of the Code, a brief history of the development of the Code, and suggestions on how the midwife can use this Code in practice, education or research.

International Code of Ethics for Midwives (1999)

PREAMBLE

The aim of the International Confederation of Midwives (ICM) is to improve the standard of care provided to women, babies and families throughout the world through the development, education, and appropriate utilization of the professional midwife. In keeping with its aim of women's health and focus on the midwife, the ICM sets forth the following code to guide the education, practice and research of the midwife. This code acknowledges women as persons with human rights, seeks justice for all people and equity in access to health care, and is based on mutual relationships of respect, trust, and the dignity of all members of society.

THE CODE

I. Midwifery Relationships

a. Midwives respect a woman's informed right of choice and promote the woman's acceptance of responsibility for the outcomes of her choices.
b. Midwives work with women, supporting their right to participate actively in decisions about their care, and empowering women to speak for themselves on issues affecting the health of women and their families in their culture/society.
c. Midwives, together with women, work with policy and funding agencies to define women's needs for health services and to ensure that resources are fairly allocated considering priorities and availability.
d. Midwives support and sustain each other in their professional roles, and actively nurture their own and others' sense of self-worth.
e. Midwives work with other health professionals, consulting and referring as necessary when the woman's need for care exceeds the competencies of the midwife.
f. Midwives recognize the human interdependence within their field of practice and actively seek to resolve inherent conflicts.
g. The midwife has responsibilities to her or himself as a person of moral worth, including duties of moral self-respect and the preservation of integrity.

II. Practice of Midwifery

a. Midwives provide care for women and childbearing families with respect for cultural diversity while also working to eliminate harmful practices within those same cultures.
b. Midwives encourage realistic expectations of childbirth by women within their own society, with the minimum expectation that no women should be harmed by conception or childbearing.
c. Midwives use their professional knowledge to ensure safe birthing practices in all environments and cultures.
d. Midwives respond to the psychological, physical, emotional and spiritual needs of women seeking health care, whatever their circumstances.
e. Midwives act as effective role models in health promotion for women throughout their life cycle, for families and for other health professionals.
f. Midwives actively seek personal, intellectual and professional growth throughout their midwifery career, integrating this growth into their practice.

III. The Professional Responsibilities of Midwives

a. Midwives hold in confidence client information in order to protect the right to privacy, and use judgement in sharing this information.
b. Midwives are responsible for their decisions and actions, and are accountable for the related outcomes in their care of women.
c. Midwives may refuse to participate in activities for which they hold deep moral opposition; however, the emphasis on individual conscience should not deprive women of essential health services.
d. Midwives understand the adverse consequences that ethical and human rights violations have on the health of women and infants, and will work to eliminate these violations.
e. Midwives participate in the development and implementation of health policies that promote the health of all women and childbearing families. Revised May 1999.

IV. Advancement of Midwifery Knowledge and Practice

a. Midwives ensure that the advancement of midwifery knowledge is based on activities that protect the rights of women as persons.
b. Midwives develop and share midwifery knowledge through a variety of processes, such as peer review and research.
c. Midwives participate in the formal education of midwifery students and midwives.

6 May 1993

Glossary of Terms used in ICM Code of Ethics

It is the goal of the ICM that this Code of Ethics be used and tested for its relevance to the practice of midwifery and for midwives. One element of understanding relates to the use of language across cultures and societies. Therefore, the following terns are defined as used in the ICM Code of Ethics.

equity in access to health care (preamble): this implies fairness in the allocation of limited resources according to need; for example, vulnerable populations/groups could receive more attention to their health needs and access to services than those who can purchase such services anywhere.

informed right of choice (I.A.): "informed" implies that complete information is given to and understood by the woman regarding the risks, benefits and probable outcomes of each choice available to her.

human interdependence (I.F.): since midwives work in relationship with women and others and may not always agree about what is right or should be done in a given situation, it is important that midwives seek to understand the reasons for the disagreements with clients or colleagues. Midwives do not stop with understanding, however. They also work to resolve those conflicts that need to be resolved in order for ethical care to continue.

individual conscience (III.B.): defined as thoughtful reflection on, analysis, and ownership of deeply held moral positions; in this context, the midwife can refuse to provide care only if someone else is available to provide the needed care.

professional (Preamble): this term is used to recognize the concept that to be ethical is to be professional, to be unethical is to be unprofessional.

professional knowledge (II.C.): this implies midwifery knowledge gained from both formal and informal educational opportunities that lead to competence in practice.

professional responsibilities (III.): this refers to the broad ethical duties/obligations of the midwife that are not practice, education or research specific.

related outcomes (III.C): midwives are responsible for the results of their own decisions and actions; they cannot be held responsible for outcomes over which they have no control (e.g. genetics). There may be situations in which the midwife is ordered by someone in power to practice in an unethical manner. We appreciate the difficulty of this situation, but the action remains unethical if the midwife chooses to follow such an order. The midwife must be aware of the risks in choosing not to follow such an order, however.

rights of women as persons (IV.A.): human rights related to any research involvement include privacy, respect, truth-telling, doing good and not harming autonomy and informed consent.

throughout the life cycle (II.E.); midwifery care is more than care related to childbearing; midwives care for women of all ages, many of whom never conceive or bear children; use of this phrase is an attempt to cover both the reproductive and gynaecological health care for women.

women as persons (preamble); women will be treated with respect for human dignity (not as objects). Principles of truth-telling, privacy, autonomy and informed consent, doing good and not harming will direct any interaction between women and midwives.

ETHICAL ANALYSIS OF THE CODE OF ETHICS

INTRODUCTION

Ethics codes are often a mix of universal ethical principles and strongly held values specific to the "professional group". Below is a brief analysis of the major ethical principles and concepts that form the basis for each of the statements of the ICM International Code of Ethics for Midwives.

I. Midwifery Relationships

a. Autonomy and accountability of women
b. Autonomy and "human equalities" of women
c. Justice/fairness in the allocation of resources
d. Respect for human dignity
e. Competence. Interdependence of health professionals, safety
f. Respect for one another

II. Practice of Midwifery

a. Respect for others, do good, do not harm
b. Client accountability for decisions, do not harm, safety
c. Safety
d. Respect for human dignity, treat women as whole persons
e. Health promotion: attain/maintain autonomy, good/no harm, allocation of resources
f. Competence in practice

III. Professional Responsibilities of Midwives

a. Confidentiality
b. Midwife accountability
c. Midwife conscience clause: autonomy and respect of human qualities of the midwife
d. Health policy development: justice, do good

IV. Advancement of Midwifery Knowledge and Practice

a. Protect rights of women as persons
b. Midwife accountability, safety, competence
c. Professional responsibility: enhance competence of all professionals to do good, do not harm

The Process of Development of the ICM Code

The charge to develop a code of ethics that defined the moral context of midwifery in meeting the needs of women came from the ICM Board of Management. A brief history of the process of development of the ICM code of ethics may help the reader to understand more fully how specific principles and concepts were included and why others were not. The Code was drafted in a series of workshops, beginning in May 1986 in Vancouver, and continuing in 1987 in the Hague and in 1991 in Spain.

The final draft, the consensus document of the Executive Committee in Madrid, was presented to the ICM Council in Vancouver, British Columbia, and adopted on 6 May 1993.

Code development began with a review of systems of ethics, an understanding of how individuals develop morally, and a brief review of the history of code development in medicine and nursing. This was followed by an analysis of the values inherent in the ICM Constitution's statements on the aim and objectives of the Confederation, the ICM/WHO/FIGO definition of a midwife, and accepted ICM position statements as of 1992.

In order to provide a world-wide (global) focus to the ICM code, the group aimed at statements that were often broader in their meaning than individual association codes so that cultural/societal or ethnic variations could be respected. Seven midwifery association codes of ethics received at ICM headquarters during 1991 were analysed, revealing the following ethical concerns:

Safety, competence, accountability, confidentiality, appropriate consultation and referral, respect for human dignity, client involvement in decisions, participation in knowledge development in midwifery and de design of maternal-child health policies, respectful interaction with other team members, health promotion, justice/fairness, non-discrimination, and the education of future midwives.

At all times, the concern for understandability, culturally sensitive wording, and the global nature of the ICM code were kept in mind. Two other important features were agreed: first, that whenever possible, the ICM code would promote a global (universal) level of ethical principles, with reasonable consideration for personal and/or consciously to exclude reference to the law or legal entities within the code. While ethics and law are related, the law varies from country to country. Normally, ethics or ethical systems respect the law, but at times ethics may go beyond the law.

As noted during the introduction to this booklet, the Code of Ethics for Midwives is intended to be a "living" document, and the ICM welcomes comments and suggestions for enhancing the understanding and usefulness of this document over the years.

SOME QUESTIONS ABOUT A CODE OF ETHICS

1) What is a Code of Ethics?
A code of ethics is a public declaration of the beliefs and values of a profession and the members of that profession. This code makes public the goals, values and morals of those who call themselves "midwives" - a statement to the public about what the profession of midwifery defines as moral behaviour for its practitioners.

2) Why have a code?
A code of ethics acts as a specific, identifying feature for a particular professional group, both for the professionals themselves and for the general public. In addition, the need for an explicit code has become more urgent in recent years, as an accelerated pace of social and technological change has produced situations that demand an ethical response. Finally, the increased speed and frequency of global communications have made the development of a formal statement of shared beliefs and values vital as an agreed point of departure or common language for the profession worldwide.

3) What can't a code do?
A code of ethics cannot assure ethical practice or "good" decisions in midwifery care; it cannot "tell" one how to make ethical decisions or what to do in every situation; it cannot prevent its misuse; and the code cannot offer specific issues for discussion or resolution. Finally, a code cannot remove from midwives the responsibility and pain of living and acting, at times, in situations of ambiguity or "not knowing", of having no in-built guarantees about what, in a given case, constitutes "right action".

Suggestions on how to use the Code of Ethics

The value of a statement of one's professional code of ethics lies in its usefulness in all spheres of professional practice. For the midwife, these spheres of practice may include direct care-giving, teaching others, administration and research. The following are suggestions of how the International Code of Ethics for Midwives may be used:

In daily practice, the Code can be an important tool or reference point (yardstick) when facing decisions on what one "should" do in caring for women and childbearing families. While the statements of the Code may not give absolute direction to your decision making, they can (or the ethical principles they are based upon can) offer a framework for action; eg. selecting and option that promotes good or prevents harm to women.

Practitioners could use criteria within the code when negotiating with others in an effort to obtain the best outcomes for women and their families. The code can be shared with the public by the posting of printed copies.

In education, the midwife teacher has an obligation to help students understand what it means to be a moral agent, to practice ethically, and to identify, understand and accept the dominant values of the profession of midwifery. Teaching methods include a value analysis of each statement of the Code, using the Code in the ethical analysis of critical incidents from midwifery practice, and comparing the basic tenets of the Code for Midwives with those of codes from other professional groups. Critical incident analysis can be a powerful teaching instrument at any level, illuminating practice decisions with the code's principles as well as with personally identified values.

In administration, midwives can use the Code to establish a working environment for ethical practice. Administrators can use the tenets of the Code to define expectations of how midwives will relate to clients, as a framework for ethics rounds and for establishing an ethical environment in which employees can function.

In research, the Code explicitly defines the ethical approach of the midwives in Statement III.A and Statement IV. in its entirety. Researchers, whether midwives or others, should adhere to these basic principles.

ICM 5/1999