Whose Values? Whose Risk? Exploring Decision Making About Trial of Labor After Cesarean.

In this article, we discuss decision making during labor and delivery, specifically focusing on decision making around offering women a trial of labor after cesarean section (TOLAC). Many have discussed how humans are notoriously bad at assessing risks and how we often distort the nature of various risks surrounding childbirth. We will build on this discussion by showing that physicians make decisions around TOLAC not only based on distortions of risk, but also based on personal values (i.e. what level of risk are you comfortable with or what types of risks are you willing to take) rather than medical data (or at least medical data alone). As a result of this, we will further suggest that the party who is best epistemically situated to make decisions about TOLAC is the woman herself.

The moral agency of institutions: effectively using expert nurses to support patient autonomy.

Patient autonomy-with an emphasis on informed consent and the right to refuse treatment-is a cornerstone of modern bioethics. Within discussions about patient autonomy, feminist bioethicists have argued for a relational approach to autonomy. Under a relational framework, we must look beyond the individual moment of choice to include the role relationships and specific contexts can play in supporting or undermining autonomy. Given the day-to-day interactions they have with patients, nurses play a significant role in helping patients understand the nature of their illnesses and make truly informed decisions. However, the skills of expert nurses also support patient autonomy in more subtle ways. Specifically, nurses develop skills of attunement that help them to find subtle ways to support patient autonomy. However, in order to effectively do this, nurses need institutions that support their professional autonomy. In this paper, I look at the ways nurses have been inhibited in their professional autonomy both as a profession and as individual practitioners. I argue that turning our attention to institutions and the role they play in supporting or undermining nurses' autonomy can help promote nurses' professional autonomy and thereby enhance patient autonomy.

Obstetricians and violence against women.

I argue that the American Congress of Obstetricians and Gynecologists (ACOG), as an organization and through its individual members, can and should be a far greater ally in the prevention of violence against women. Specifically, I argue that we need to pay attention to obstetrical practices that inadvertently contribute to the problem of violence against women. While intimate partner violence is a complex phenomenon, I focus on the coercive control of women and adherence to oppressive gender norms. Using physician response to alcohol use during pregnancy and court-ordered medical treatment as examples, I show how some obstetrical practices mirror the attitudes of abusive men insofar as they try to coercively control women's behavior through manipulation and violence. To be greater allies in the prevention of violence against women, obstetricians should stop participating in practices that inadvertently perpetuate violence against women.

The mammography screening controversy: who and what is heard in the press?

The objective of this project was to analyze newspaper coverage of the January 2000 meta-analysis by Gotzsche and Olsen, "Is screening for breast cancer with mammography justified?" [Lancet 355 (2000) 129]. A content analysis was performed on a comprehensive set of newspaper clippings from the UK during the 2 weeks following publication of the Lancet article. The original authors were most quoted in Wave 1 (the first weekend); the screening programme was most quoted in Wave 2 (week 2). Screening programme description, and the "quality" of the Lancet article dominated Wave 1; patient testimonials increased in Wave 2. Newspaper articles were structured as debates between experts and advocates, thereby enhancing polarisation of opinion. We suggest this is counter-productive to evidence-based patient choice and public involvement in decision-making. Medical journals' and charities' press releases that begin to include discussion of uncertainty inherent in medical technologies can contribute to evidence-based public deliberation.

Mothers in the media: blamed and celebrated--an examination of drug abuse and multiple births.

The media has always had a profound interest in mothers and birth stories. This study examined the difference between media portrayal of "good" mothers and "bad" mothers. Did the media cover potential harm to fetuses and would-be children in the same way for two groups of mothers: (a) pregnant women addicted to illicit drugs and (b) women who chose to continue a high-order, multiple birth pregnancy? Two searches were conducted on Lexis-Nexis, one with keywords "McCaughey and birth" and another with the keywords "pregnancy and illegal drugs." A total of 210 articles were coded for the McCaughey search, and 90 articles were coded for the pregnancy and illegal drugs search. The media did not address potential harm in the same way in both cases. The harm from illegal drugs was exaggerated, while the harm from multiple births was downplayed. Consequently, the media response towards the two cases was dramatically different. In conclusion, the communal and regulatory responses to both drug-addicted pregnant women and large multiple births caused by infertility treatments needs to be rethought.