Barry DeCoster

The birth plan has become an increasingly institutionalized tool of Western birth practices, used both in medicalized and midwifery settings. Limited empirical research has been done on the efficacy of birth plans in achieving a commonly-ascribed goal: empowering women in their birth experiences. Still, less work has been done on the ethical dimensions of birth plans. As such, this tool has become nearly ubiquitous in birthing practices, yet they warrant further reflection. In this paper, I articulate the ethical goals of writing birth plans. I frame the birth plan as a narrative project: one that women are encouraged to write out, after careful consideration, as a kind of story that articulates the values, experiences, and relationships that are most important to shaping their experience of a “good birth.” Given the importance of the birth experience for many women, birth plans are ethical projects that the attempt to reframe and improve the deeper political dimensions of birth and patient choice. Birth plans are meant to structure the experience, guide women’s understanding of the process, and foster important clinical relationships. In this way, they are similar to advance directives, which are written to shape successful end-of-life care. Yet, the success of birth plans as tool for this ethical work is questionable. This tool aiming at women’s empowerment and ethical self-reflection often sets women up for a kind of ethical injury, in the attempt to avoid unwanted physical harms of labor and delivery. Birth plans are not legally binding, despite how they are framed as pseudo-contracts. Instead of resisting the challenges of a medicalized birth and to be empowered agreements, birth plans often set women up to fail, often aiming at unreasonable expectations. In my argument, I ask to identify for whom the birth plan works, and in which ways the birth plan experience can be improved. Finally, I address how the failure to give birth plans uptake during emergencies often undermines the patient-physician relationship, working against the primary goal of empowerment.

Bien que les minorités sexuelles et de genre courent un risque accru de problèmes de santé, on dispose de peu de données sur les interactions patient-prestataire de soins. Dans cette étude, nous avons exploré les perspectives des patients LGBTQ et leurs rencontres avec les médecins afin d’améliorer notre compréhension des expériences patient-médecin. À l’aide d’une sélection ciblée de patients LGBTQ auto-identifiés, nous avons réalisé quatorze entrevues semi-structurées en profondeur sur des sujets comme l’orientation sexuelle et l’identité de genre, ainsi que leur rôle perçu dans la relation patient-fournisseur. Un codage utilisant une approche modifiée de la théorie ancrée a été effectuée pour générer des thèmes. Nous avons identifié trois grands thèmes qui démontrent la complexité des expériences vécues par les patients LGBTQ. La première, le manque de confiance, identifie la méfiance et la perte de la relation médecin-patient résultant d’une mauvaise communication des médecins ou d’un jugement porté sur eux, ou du fait que les médecins font des suppositions sur le genre, utilisent des pronoms incorrects et ne reconnaissent pas l’hétérogénéité dans la communauté transgenre. Un deuxième thème, être vulnérable, décrit les défis et les craintes liés au réconfort des patients face à la divulgation de leur orientation sexuelle ou de leur identité de genre. Un dernier thème, la discrimination sélective, met en relief la discrimination raciale ou ethnique qui crée un fardeau supplémentaire en plus de la maladie et de l’identité stigmatisée. Nos résultats révèlent les besoins complexes des personnes aux multiples identités stigmatisées lorsqu’il s’agit d’établir des relations avec les prestataires. En utilisant une perspective intersectionnelle qui tient compte de la pluralité des identités des patients, les prestataires peuvent aider à améliorer leurs relations avec les patients LGBTQ. L’intégration d’une formation intersectionnelle pour les étudiants en médecine et les résidents pourrait grandement profiter aux patients LGBTQ et à leurs médecins.

The flu has an interesting history with respect to health care rationing in the United States. Consider that just about two years ago, the American public faced a shortage of influenza vaccine. Dire predictions were made about how many people might perish, and rationing protocols were created. However, many of the rationing protocols were ignored. Luckily, that flu season did not result in the horrible fatalities that were predicted. For these reasons, problems of health care rationing around issues of the flu were postponed, rather than resolved.Over the last year, the public has focused its anxious attention on the possible avian influenza pandemic. Last week I noticed that at least once each day I heard mention in some discussion or another of the threat of this disease becoming easily transmissible from human to human.