I've been thinking a lot about ethics lately. I'm not an expert in this topic, but I was inspired to learn more and to think more deeply by Sylvia Wood's article, which appears in this issue of MCN. Sylvia is asking all of us who care for women and infants to reassess how we provide intrapartum care. Not a small request, and not made frivolously, I'm sure. We've all been talking about evidence-based practice for the past few years. It's clear that we need to base our practice on something concrete, be it research evidence, practice protocols, standards of practice, laws, or regulations. We talk a good game, but when it comes right down to it, do we live it? Can we live it? Do we question ourselves enough? Do we question what we do every day, and why we do it? If we practice ethically, then we are obligated to do so, aren't we?

Sylvia has taken the issue of electronic fetal monitoring (EFM) and written a provocative article about the ethics of routinely using EFM without first assessing whether our patients understand the implications of using this technology. I urge you to take the time to read her article thoroughly, and debate it with your colleagues. It's neither a simple read nor a simple concept, but it's definitely worth the challenge to follow her logic through the steps of ethical decision-making and draw a conclusion for how we should be practicing. After spending considerable time reading, rereading, and editing Sylvia's article, I am left feeling concerned. I am concerned that there are many, many issues in prenatal care and intrapartum care that our patients simply do not understand, and that we might not have worked hard enough at teaching them. EFM is but one of these topics. We go on, every single day, connecting women to EFM despite the evidence from the literature that is very clear on the issue: when EFM is used routinely, cesarean birth rates increase.

I know cesarean birth is an important intervention for a number of fetuses who are in trouble, or for a number of women who are sick or unable to birth vaginally. But I doubt that anyone truly believes that 25%, 30%, or even more women actually require cesarean birth. Yet the women we care for know none of this. What if women were asked to give informed consent before EFM was applied, as Sylvia Wood wonders? What if we had to show women the evidence from the literature, which demonstrates that their chances of a cesarean birth are higher with EFM? Would they care? Would they opt for a different method of fetal surveillance? We don't know the answers because we've never before asked the question.

Ethical dilemmas exist in the care we give women throughout pregnancy. For example, triple screening (also called MSAFP testing in some parts of the United States), has grave consequences. I was once so concerned about how little it seemed women knew about this topic that I conducted a study on it, trying to find out what women really understood about the test after they had been told about it. It wasn't a big surprise to me that the women didn't understand very much (Freda, DeVore, Valentine-Adams, Bombard, Merkatz, 1998), yet they overwhelmingly agreed to the test. We know that the test is not benign, for a positive screen can result in further testing such as amniocentesis, followed by agonizing decisions about what to do next. Yet we continue to assume that women understand what we tell them about this testing. Is it ethical practice to do such tests without assuring that the women understand the implications?

I know that each of us tries his or her best to be ethical practitioners. People don't become nurses just to disregard their patients' rights. But sometimes we need to sit up and take notice of something we haven't thought of before. Sometimes we need to read something provocative and then discuss it. In doing so, one becomes a thinking, feeling, analytical, wise, scientific, and intelligent nurse. We can't do things because we've always done them in the past. Read Sylvia's article. You might agree or disagree with her. What's important is that you think about this, and make a decision for yourself, and for your patients. We can't be ethical nurses without thinking hard about the difficult topics.

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