Legal and ethical aspects in maternal and child health nursing


·         Negligence - failure to do something
·         Malpractice- failure to maintain accepted ethical standard.
·         Plaintiff- a person bringing a case against another in a court of law.
·         Commission — duty.
·         Omission — fail to do.
·         Ethics: Refers to the consideration of standards of conduct or the study of philosophical ideas of right and wrong Behavior.
·         Bioethics: The branch of ethics within the field of health care —clinical settings, clinical research, and education.
·         Medico legal problems in obstetrics practice are rising both in developed and in the developing world. When the nurse fails to exercise the duty properly, she/he found to be negligent. The failure to perform the proper duty to patient care may be due to her incompetence or malpractice or mere negligence. The failure to provide a standard care may be either by acts of omission or commission.
Adverse outcomes of medical care often due to -
(i)                 System errors (inadequate staff, physician or operating room etc.)
(ii)               Health care personnel's error.
Once the act of substandard care due to system error, negligence, malpractice or incompetence is  proved in the court of law, the plaintiff to be compensated.
Common areas of legal threat:
l . Perinatal injury — Still birth, Neonatal death, Neonatal injury.
2.  Maternal injury — Maternal trauma, Maternal death, forgotten packs in abdominal cavity Or with in the vagina.
3.  Both — Instrumental delivery, operative delivery, Anaesthesia.

Measures to minimize medico legal problem
·         Communication- must be made in a clear and understandable way to the client and the relatives about the management decision.
·         Informed and written consent- must be taken before any agreed management decision.
·         Proper documentation of facts in the patients file clearly and legibly in respect of date and time.
·         Strict adherence to established management protocol (evidenced based) is essential, when there is any deviation, it must be documented showing sufficient reasons.
·         Careful record maintenance in institution as it may be required later on.
·         Adequate training and supervision of juniors, especially involved in labor ward patient care. Seniors must be available for consultation or direct involvement as and when asked for.
·         Regular audit and meetings - should be done to update the knowledge of all the staff involved in patient care. Audit will help to improve the quality of care.

Ethical issues: Abortion, Maternal fetal conflict, Intra uterine fetal surgery, Reproductive assistance, Embryonic stem cell research, Human genome project, Cord blood banking, Makin  treatment decision for children, Terminating life sustaining treatment, Organ transplantation issues, Adolescent pregnancies.
Abortion: Abortion is the extraction or the expulsion of products of conception less than 20 weeks and of weight less than 500 grams from the mother.
Legal status of abortion:
Summary of the decision is as follows:
l) First trimester - Abortion decision and its implementation should be left to the judgment of women and her physician
2)  Second trimester - state promote its interest in the health of the pregnant mother, and rnay choose to regulate abortion in the ways that are reasonably related to health.
3)  Third trimester - crossed the viability period. The state is promoting its interest in the potentiality of human life, but it can prescribe abortion to preserve the life or health of pregnant women.
In India: Medical termination of pregnancy act (MTP). Abortion was legalized in 1971 and enforced on 1st April 1972.
It consisted of 3 components:
-    Conditions where the pregnancy can be terminated?
-    Who can do it?
-    The place where it can be performed?
The purpose of this act was to: define the situations and circumstances in which safe abortion could be legally performed and to empower medical practitioners and institutions delivering this service.
Nurses ethical decision making: Nurse has the right to refuse to assist abortion procedures. ( moral and ethical beliefs). Written agreement during the time of entry. Ensure that someone with similar qualification is there to care the client.
Maternal fetal conflict
Previously mother and fetus were considered as two different unit. Both of them deserve
respect and treatment. It was designed to promote perinatal care to bring about a healthy baby. Attempts have been made to criminalize the behavior of women who failed to follow physicians order or advice or who engage in behavior such as substance abuse.
Legal implications: Such cases are best resolved by internal hospital mechanism including: Counseling, Consultation with institutional ethical committee, Court intervention, Public awareness, mandatory rehabilitation.

Intrauterine fetal surgery
Therapeutic procedure, opening of the uterus performing the surgery and replace the fetus into the uterus, A multidisciplinary approach.
Legal implications: Parents should be informed about the experimental nature of treatment, risk and alternatives, Mother has the autonomy to refuse, informed consent.

Reproductive Assistance
Assisted reproductive technology are high technological approaches used to treat infertility which includes: Invitro fertilization and embryo transfer, Surrogate mothers. One third of the pregnancy that result from ART are multiple pregnancy and à miscarriage and preterm. So American society for reproductive medicine has issued guidelines to limit the number of embryo transferred à ethical Issues for carrying unused embryos.
Legal obligations: These are satisfied by informed consent by all parties husband, wife and the donor. All of them should remain anonymous and physician has the right to select the donor. If child is born with abnormalities, the question of legitimacy can be solved by abortion.
Embryonic stem cell research
Stem cells can be found in embryonic tissues and in primitive germ cell of the fetus. Research had proven that by tissue culture of these cells can be differentiated it into other cells such as heart cells, nerve cells and it can be used to solve the problem such as Alzheimer’s, parkinsonism, spinal cord injury etc.
Ethical issues:
l) What moral status should be attached to the embryo?
2)  How an embryo is viewed as a full person or a cluster of undifferentiated cells?
3)  What sources of embryonic tissues are acceptable for research?
4) Is it ethical to produce embryo solely for research?

Cord blood banking
Cord blood taken from the newborns umbilical cord at birth are stored. It has a combating role in leukemia, immune blood disorders because of the presence of stem cells (regenerative cells)
Ethical questions:
Who owns the blood (donor, parent)?
How will the informed consent will be obtained and from whom?
How to notify the family if the blood reveals an infectious disease or genetic disorder.

Making treatment decision for children
It is more complex because of their lack of capacity to participate in decision making. Health care professionals need to determine whether their responsibility is limited for the child or it includes the interest of the parents.
Ethical obligations:
- inform the treatment modalities to the parents.
-Institutions ethical committee. 
-Court decision
l . What if parents are unavailable and a child needs medical treatment?
2.  Should children be involved in medical decisions even though their parents have final authority to make those decisions?
3.  What happens when an older child disagrees with her parents about a medical treatment?
4.  Under what circumstances can minors make medical decisions for themselves?

Terminating life sustaining treatment
Parents are the decision makers (social, emotional and financial burden).
·         Pain relief is never denied
·         Never starting is much easier than withdrawing. but there is no moral difference   Autonomy of parents
Legal obligations:
Is it justifiable to withhold or withdraw care because of costs?
Is it justifiable to withhold or withdraw food or fluids?
Justification for withholding, withdrawing and limiting therapy includes; treatrnent has poor rate if Success, Burden of treatment outweighs the benefit or the quality of life, The burden of disease outweigh the benefit of the continued survival.

Organ transplantation issues:
Death of the child can benefit other child, through organ transplantation. It will help the, survival of the child.
Ethical issues:
-Which individual on the waiting list should receive the organ available?
 -Should the families be permitted to pay the donor families for organ?
 -What are the brain death and non heart beating criteria that enable organ collection to proceed?

Adolescent pregnancy
An adolescent can be said as a emancipated when the they are self supporting, and living away from home, married, pregnant etc.
Legal obligations:
They have the right and responsibility to consent the health care. Entitled to get confidentiality.
Only with her consent or agreement other adults including her parents be included in communications.

Human genome project
Multidisciplinary approach to explore and map all human genetic material. Bring about a safer future. It helps to detect any genetic problem, To improve the quality of life. This information can be used in clinical decisions about surveillance and prevention or treatment of disease.
Ethical questions:
l . Question for the payment of genetic testing?
2.  Confidentiality
3.  Counseling and interventions

4.  Right to refuse and receive the information's



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item Legal and ethical aspects in maternal and child health nursing
Legal and ethical aspects in maternal and child health nursing
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