Thursday, 27 September 2012

Biomedical Ethics and Peer-to-Peer Milksharing

Dr. Karleen Gribble, adjunct research fellow in the School of Nursing and Midwifery at the University of Western Sydney, has generously allowed us to adapt her PowerPoint Presentation to a blog post as part of World Milksharing Week's blog carnival. This post outlines Dr. Gribble's application of six ethical principles to health worker / patient interactions in the area of peer-to-peer milksharing. Rather than investigating the merits of milksharing itself, this piece looks at the obligations of health workers and parents to discuss the practice. Keep an eye out for Dr. Gribble's upcoming article on this topic in Clinical Lactation.

Many thanks to Jodine Chase, blogger at Human Milk News, for hosting Dr. Gribble's post in the carnival.

A large ziplock bag of filled breast milk storage bags.
Photo: Bart Everson
Health authorities in Canada, the US and France have publicly warned parents not to feed their babies peer-shared milk. Many health workers are unsure about how to respond to mothers who are considering being involved in peer-to-peer sharing of milk.Applying the principles of biomedical ethics to the problem may assist in guiding action.

Biomedical ethics can be used to explore actual or anticipated dilemmas in medicine and find reasoned, consistent, and defensible solutions to moral problems.

Principle 1: Autonomy- individuals should be supported to make health care decisions free from deceit, duress, constraint and coercion.

Health Workers are obliged to provide individuals with the information they need to make informed decisions. Limiting of information for the “good of the patient” is paternalistic and interferes with autonomy. Information should only be withheld in very limited circumstances: if the health worker believes that the sharing of information might seriously harm the physical or mental health of the individual or if the individual states that they do not want the information.

Principle 2: Veracity- patients and health workers must be honest with each other.

When parents seek information about alternatives to a mother’s own milk, health workers must discuss all alternatives including infant formula, banked donor milk, peer-to-peer shared milk and wet nursing in an unbiased and non-judgmental way.

Parents must discuss consideration or actual involvement in milk sharing with their health workers.

Policies that prohibit discussing the option of peer-shared milk with mothers could be considered as breaching the ethical principles of autonomy and veracity. They are also dangerous.

Principle 3: Beneficence- minimization of harm and risk and promotion of good outcomes.

The interpretation of “good outcome” depends upon the specifics of a situation and the beliefs and values of the individual. Individuals seeking health care are those who define “good outcome.”

In peer-to-peer milk sharing, beneficence might involve health workers providing information or directing the patient toward information on the correct way of storing and dispensing expressed breast milk or on flash heating or on medications and milk. It might also involve facilitating the sharing of medical records between milk donor and recipient.

Principle 4: Nonmaleficence- active avoidance of harm to the patient.

A health worker who dismisses, mocks, berates or derides an individual seeking advice or information about milk sharing and so humiliates or belittles them could be considered as having breached the principle of nonmaleficence.

A health professional who withdraws care from a mother or child because they wish to be involved in the peer-sharing of milk and does not ensure that appropriate alternate care is available could be considered as having breached the principles of nonmaleficence and the principle of autonomy.

Principle 5: Confidentiality- health providers must not reveal private information without consent.

While sharing of medical records may assist in reducing the risks of peer-sharing of milk, donor records cannot be shared with a potential recipient without the consent of the donor.

Principle 6: Justice- individuals must be treated fairly.

Aspects of justice to consider in the distribution of resources include: distribution equally, or according to need, effort, contribution, merit or notwithstanding ability to pay.

The application of Justice to milk sharing has proven contentious in North America where donor milk banks are experiencing shortages of milk.

Milk banks distribute according to need but payment is required.

Peer-to-peer donors distribute for free and to those who do not qualify for banked milk.

Both groups are applying justice but neither application is unproblematic. Such conflict is not uncommon in biomedical ethics and indicates that further discussion between the players involved is necessary.

Health workers cannot ignore, dismiss, discount or demonize peer-sharing without acting unethically. What then should they do?

• Educate themselves about the various options for infant feeding including the benefits, risks and costs of each option and the ways in which the risks and costs might be managed, reduced or eliminated

• Be open and honest with mothers about each option and refrain from using pejorative terminology in relation to any option

• When speaking to the media ensure that information is provided in such a way that it cannot be used to portray breastmilk as inherently dirty and dangerous and that the risks associated with other alternatives to mothers' own milk are considered.

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