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By Alex Smith
Muriel is expecting a baby. She is reassured to know that if she decides to engage with the maternity services, because legally she may decide not to, nothing will be done to her without her consent. That is the law. For her consent to be valid, the pros and cons of all possible pathways will be outlined without any pressure on Muriel to accept one in particular. There will be time for Muriel to think things through, and her decisions will be respected and supported even if the midwife or doctor does not agree with them. Any test, examination or procedure that Muriel might allow would be as a result of her own free will; or would it?
The problem of free will – do we have it? – is one of the oldest and most important questions in Western philosophy. While an exploration of the question is beyond the scope of this article, it is safe to say that the jury is still out. Whether or not Muriel, or anyone else for that matter, can truly make free and fully informed decisions about their maternity care, or indeed about their lives, is gloriously and endlessly debatable. This is true even when we feel as if we do make our own decisions, and even when the law protects our right to do so. It may be good at this point to tease apart some of the terminology required in order for Muriel to explore this issue a little deeper.
Free will can broadly be divided into freedom of will and freedom of action. Freedom of will is very much governed by what we know. For example, it would be difficult for Muriel to have the will to give birth at home if she does not know this is possible, and has therefore never envisioned it. It would literally be unimaginable for her. With knowledge of homebirth as a possibility, Muriel can start to picture the homebirth setting. The image in her head may awaken and resonate with her deepest instincts and suddenly it just feels right. The somatic marker hypothesis suggests that feelings and emotions play a critical role in making rational decisions and so Muriel is now free to decide ‘I will have my baby at home’, but she may not feel free to act on this decision when barriers are put in her way, “I decided to have my baby at home, but I wasn’t allowed.” It would still be Muriel’s human right to stay at home, and it is her legal right to give birth without a midwife in attendance, but even with this knowledge, cultural conditioning as to who holds authority and power in this situation, combined with a cultural fear of birth, may weigh more heavily than knowledge of her rights and leave Muriel feeling as if she had no choice.
Choice is rather different from decision-making. A choice is when a person selects from a menu of options that has been put together by another person or body of people. An informed choice is self-explanatory, and a free choice suggests that no overt or covert pressure or coercion is used to ‘force’ a choice, as a magician might. There is an element of passivity and limitation in the concept of choice, whereas a decision involves a stronger element of self-determination. If I am determined to eat pasta tonight but my local restaurant does not offer me that choice, then I will try another restaurant or make dinner at home. There is a greater sense of a decision coming from within the person; of them being intrinsically motivated and confident to act. The belief that one can have control over the outcome of events in this way is sometimes referred to as having an internal locus of control. If Muriel is truly decided about having her baby at home, on hearing that the hospital has suspended their homebirth service, she may contact AIMS for support, write a stiff letter to the Head of Midwifery, make enquiries about independent midwifery and explore the idea of freebirth. On the other hand, if she has succumbed to learned helplessness and has an external locus of control, she will believe that these things are out of her hands and that there is nothing she can do.
Self-determination theory holds that if a person’s need for competence, relatedness and autonomy are met, they will be able to exercise free will or self-determination.
The only part of the conduct of anyone, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign. (John Stuart Mill on liberty)
Whether or not this limitation of autonomy should be different within the context of maternity care is debatable.
Even if Muriel usually considers herself to be an educated and self-determined woman, even if she knows that her consent is required for any procedure, withholding it may feel very uncomfortable indeed and she may find herself asking if she is ‘allowed’ to say no. This is because in our culture the subjugation of women within patriarchal institutions is still deeply entrenched; it was only 30 years ago that non-consensual sex inside marriage was made illegal. When women encounter the patriarchal authority of the now normalised medical model of maternity care, they usually and quite unconsciously adopt a submissive, even fawning position within the power hierarchy, ignoring their own needs, values, and boundaries to conform to what they believe others expect of them. They may submit to unwanted tests, examinations or procedures for fear of not being liked, creating a fuss, getting people’s backs up, or being regarded as an irresponsible mother. Rather than being respected, women who express concerns about a procedure may be considered unduly anxious. A midwife may then ‘gentle’ them into submission: ‘It’s just routine, we have to do this, try and relax, I will hold your hand until it’s over, well done’. Or they may be perceived as being difficult and challenging and will be reined in with direct or thinly veiled threats: ‘Yes, it is your decision but we don’t want anything to happen to your baby, do we?’ Either way we know that they will be talked about behind their back, and the respective midwife or doctor will be commended for gaining patient compliance.
If Muriel stands her ground by declining to follow the hospital protocol, she is very likely to experience efforts to put her back ‘in her place’. She may be hounded with repeated talk of risk; pressured, coerced or forced into accepting unwanted treatment; threatened with referral to social services; or even held against her will and not allowed to leave until the doctor says so. Some women say that they were literally ‘held captive’ by locked doors and security guards. These things constitute obstetric violence and can cause long-term physical and psychological injury to the mother and her family. To cope psychologically in this sort of situation, Muriel might experience:
It may seem as if I am demonising the midwife and doctor and perpetrating the ‘them and us’ relationship, but I absolutely am not. Free will is an ‘I and I’ situation, with the midwife and doctor subject to the same hegemonic forces as the mother. Just as the law supports Muriel’s autonomy, the same law not only compels but (in theory) frees the midwife and doctor to honour and respect her decisions, even when those decisions are leading towards a door unsanctioned by hospital protocol. The law is intended to protect all three. Yet as that portal is approached, those forces bear in and all three start to feel a sense of fear. This isn’t so much the fear of death, though this will be part of it, but more the deeply enculturated fear of social or professional opprobrium or condemnation that would be experienced should that death happen outside of the hospital, even when the hospital setting may increase the chance of that outcome. Muriel is likely to seek approval and permission for her decision, which although not legally required, will absolve her from responsibility in the eyes of society. The midwife or doctor, if they cannot bring her back into the fold, are likely to take steps to cover their backs. Of course they will, they are only human. They equally feel that they have no choice. Their behaviours naturally reflect those of the medical model of birth in which they were educated, and strongly reflect the culture of their workplace. When midwives and doctors step out of line by challenging the status quo, they too experience censure. This is endemic within the system, and is written about as horizontal bullying or violence. It is explored by Shapiro in her 2018 article ‘“Violence” in medicine: necessary and unnecessary, intentional and unintentional’ and in relation to midwives in particular, by Kirkham in her 2007 article, ‘Traumatised Midwives’.
It seems, then, that to de-traumatise birth for everyone, we have a complex Gordian knot to unravel, and unfortunately there is no simple linear logic to hand that helps.
Chaos theory says that outcomes from a non-linear dynamic process such as pregnancy and birth would be predictable if all the factors could be taken into account. This would greatly aid decision-making, but the factors are so numerous, complex and changing that it is impossible to identify or map them all. The smallest change in just one factor early in the process can change everything. Sensing this complexity and uncertainty, everyone concerned seeks other ways of making decisions. Heuristics are shortcuts to making quick decisions without all the information. This is the ‘as a rule of thumb’ method. Muriel, her midwife and the doctor are all likely to employ this method. As a rule of thumb, Muriel takes the midwife’s advice, the midwife refers to the doctor, and the doctor sticks to the protocol. Alternatively, the different parties involved may believe in shared decision-making and seek a group consensus, but Muriel may be very swayed by the views of others and end up making an unnecessary compromise. Worse still, the group decision process can descend into group think (remember the Asch experiment) where people agree with things they know to be wrong simply to maintain group harmony; they conform. This is particularly dangerous when dissent is frowned upon. If Muriel isn’t seeing the same group or team of people throughout, but a chain of different individuals, their decisions may form an information cascade in which the midwife or doctor she sees this week will look in the notes and just go along with what has been written at earlier appointments, sometimes ignoring their own judgement. This apparent concurrence between the midwives and doctors will sway Muriel’s decisions, and if she has any remaining doubts she may utilise her own information cascade by finding out what most other women do in that situation, and following suit. Following suit is a very common heuristic decision-making strategy when the complexity of the situation makes it hard to decide.
So, when AIMS confirms to Muriel that she is indeed free to make her own decisions in so much as her own body is concerned, and that her midwife and doctor are free to support her – this is both true and not true. On the face of it, this legal fact is the solution that easily unties the Gordian knot and frees everyone from its oppressive bind, but freedom is complicated and this is where it gets philosophical. Muriel might want to look away.
Despite having the freedom not to, the Milgram experiments in the 1960s showed (and still do) that a majority of people will obey someone they see as an authority figure, even when asked to do something they believe will harm someone else and even when this is not aligned with values they hold dear. It appears that the illusion of authority is a force of oppression that could rival the fundamental forces of nature. It is the social equivalent of the electromagnetic force bonding us together and keeping us in shape through conformity and compliance. To overcome this oppressive force, it feels as if you would have to do battle. In fact, the educator and philosopher Paulo Friere warned that, in seeking freedom from oppression, “The oppressed, instead of striving for liberation, tend themselves to become oppressors.” We condemn the system and expect all the change to happen there, without exercising the freedoms we do have. Freedom walks hand-in-hand with responsibility. It is a contentious and often unpopular thing to say, but the clue is in the word ‘own’. Muriel must own her decisions if they are to be her own decisions. Midwives and doctors must own their behaviours if they are to practice with integrity and in an ethical way, even if this comes at a cost. We cannot say that we did not have a choice, when we did. The price of freedom in this context is the exercise of free will – of being the change you want to see in the world – and it is the willingness to take responsibility for the consequences, which is not always easy. Friere said, “Liberation is thus a childbirth, and a painful one”, but like childbirth, it can also be transformative.
We but mirror the world. All the tendencies present in the outer world are to be found in the world of our body. If we could change our-selves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. This is the divine mystery supreme. A wonderful thing it is and the source of our happiness. We need not wait to see what others do. (Gandhi 1913)
So, where does that leave Muriel? She is probably asking herself the same question. The theory can take us round in circles and tie us in knots, but happily the ethics committees and lawyers have stepped in and I refer her to the opening paragraph. Muriel is free to do what she feels is best and she should expect our wholehearted support!
 Nursing Times (2018). Informed consent 1: legal basis and implications for practice. www.nursingtimes.net/roles/nurse-educators/informed-consent-1-legal-basis-and-implications-for-practice-21-05-2018. Also see this issue's article on the Montgomery Ruling by Emma Ashworth.
 O'Connor, Timothy and Christopher Franklin, "Free Will", The Stanford Encyclopedia of Philosophy (Spring 2021 Edition), Edward N. Zalta (ed.) Available at: plato.stanford.edu/archives/spr2021/entries/freewill
 Somatic Marker Hypothesis - psychology.wikia.org/wiki/Somatic_marker_hypothesis
 Lopez-Garrido (2021) Self-Determination Theory and Motivation. Simply Psychology. Available at: www.simplypsychology.org/self-determination-theory.html
 Mary Nolan AIMS Journal 2021 Vol 33, No 1 'Self Efficacy: What is it? Why is it important? And what can we do about it?' - www.aims.org.uk/journal/item/self-efficacy-pregnancy-birth
 Romanis EC, Nelson A. Homebirthing in the United Kingdom during COVID-19. Medical Law International. 2020;20(3):183-200. doi:10.1177/0968533220955224
 Fahy K. (2002) Reflecting on practice to theorise empowerment for women: Using Foucault's concepts. The Australian Journal of Midwifery February 15(1):5-13
 Enculturation: the process by which an individual learns the traditional content of a culture and assimilates its practices and values
 Hastie C. (2006) Horizontal Violence in the Workplace. Birth International. Available at: birthinternational.com/horizontal-violence-in-the-workplace
 Determined to conform: Disbelief in free will increases conformity. www.sciencedirect.com/science/article/abs/pii/S0022103112001825?via%3Dihub
 The Gordian knot is a Greek legend often used as a metaphor for an apparently intractable problem that can be solved easily by finding a solution that renders the perceived constraints of the problem moot.
 Muoni, Tambu. (2012). Decision-making, intuition, and the midwife: Understanding heuristics. British Journal of Midwifery. 20. 52-56. 10.12968/bjom.2012.20.1.52.
 Asch Conformity Replication - ahp.apps01.yorku.ca/2008/06/asch-conformity-replication
 Electromagnetic force. energyeducation.ca/encyclopedia/Electromagnetic_force
 A proviso: On occasion women are forcibly examined, treated, restrained or threatened and this should be reported to the police as assault. On occasion midwives and doctors are pressured into giving inadequate, negligent care or non-consensual care, and this should be reported to their supervisors, regulatory bodies and to their unions.
 These words are attributed to Gandhi but are actually a summarised paraphrasing of the quote that follows.
 Collected Works of Mahatma Gandhi, Vol. 13, Ch. 153, page 241. www.gandhiashramsevagram.org/gandhi-literature/collected-works-of-mahatma-gandhi-volume-1-to-98.php
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services. From the beginning of 2018, the journal has been published online and is freely available to anyone with an interest in pregnancy and birth issues. Membership of AIMS continues to support and fund our ability to create the online journal, as well as supporting our other work, including campaigning and our Helpline. To contact the editors, please email: firstname.lastname@example.org
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