From MIDWIFERY MATTERS, Issue No. 112 - Spring 2007
Caroline J Hollins Martin
Ask yourself the following questions. Have I ever avoided offering the option of 'home birth' simply to avoid the bureaucratic hassles that may be involved? Have I ever ruptured a woman's membranes when I knew it was completely unnecessary to do so? Have I ever commenced syntocinon when I knew that given time the woman's labour would progress normally? Have I ever persuaded a woman to have cardiotocography in order to sidestep the consequences of breaking with protocol?
THIS PAPER IS ABOUT DENIAL of our own obedience. Denial is a feature that reduces the psychological stress incurred when a midwife takes an action or inaction that results in consequences that he/she does not like. Refusing to accept responsibility for one's behaviour removes the uneasiness experienced when carrying out an instruction that is considered by that person to be inappropriate.
In contrast, dissent refers to a verbalised disagreement with the course of action prescribed, with such dissent running the risk of possibly rupturing hierarchical bonds between that person and the senior member of staff. Like other institutions, maternity units have chains of command with incumbent expectations. Within such hierarchies, dissent from complying with senior people is likely to be labelled as disobedient behaviour. What is more, insubordination may be branded a disciplinary offence. In the main, subordinates respect a senior person's right to overrule their opinion. If a subordinate decides to articulate a differing opinion, this does not mean that they intend to be disobedient. In many ways, voicing an objection and then proceeding to undertake the task anyway reduces any strain that may be experienced by the subordinate. In fact, voicing a contradictory opinion may provide psychological consolation for the moral conflict that may be experienced. For instance, a midwife may publicly declare herself opposed to refusing a 'home birth', conducting an amniotomy, commencing syntocinon or undertaking cardiotocography. This public declaration of disapproval enables the midwife to establish a desirable self-image whilst maintaining a submissive relationship with the senior person. For example:
She won't benefit from that (cardiotocography). It's pointless. Why does he want it? (midwife)
He wants it to be done (senior midwife).
Well, I would have to agree then! (midwife).
Midwives may experience disobedience as an extreme and radical response, which means they are more likely to obey and deal with the psychological strain involved instead of disrupting the social etiquette. Once strain starts, a number of psychological mechanisms may be implemented to reduce the severity. For example: denial, dissent, avoidance, circumvention, minimal compliance, blaming and projecting responsibility on to others. The intellectual litheness of the human mind and its capacity to dissipate strain allows processes such as denial to come into play. It works through the intellectual mechanism of rejecting apparent evidence in order to arrive at a more consoling interpretation of events. Observers of the Nazi epoch (see Bettleheim, 1960; Blass, 1993; Churchill, 1997) point out how persuasive denial was among both victims and persecutors. Jews who faced imminent death could not accept the clear and obvious evidence of what was going on and even today, some people deny (illegally) that innocent people were annihilated on a massive scale by their government.
Denying accountability and projecting responsibility for a decision on to the senior person permits the individual to impersonalise the event. Unfortunately there is nothing more obstructive to 'woman-centred care' than disinterested authority combined with the midwife's buffering effects of denying responsibility. There is a distinction between what is logical and what is psychological. On a purely quantitative basis, it could be perceived as worse to deny all women a 'home birth', than it is to deny one woman the experience. Yet the latter is psychologically the more difficult act. In relation to numbers, diffusion of responsibility and the physical barrier of protocols and patterns of care neutralise the moral sense. There is virtually no personal psychological culpability involved in a remote refusal based on instruction from authority.
Disobedience is not an act that is seen as available to most midwives. They are tightly bound to the institution and a rigid hierarchy makes non-compliance very difficult. When points of disagreement arise, midwives often acquiesce with what has been suggested in order to avoid retribution that might result from their resistance. Acquiescence of this kind could be interpreted as necessary agreement, which was a finding of Brehm and Cohen (1962), Festinger (1954, 1957) and Wickland and Brehm (1976), who found that public compliance without private acceptance can be forced when there is a threat of punishment for non-compliance.
Results of these observations have important implications for events that happen in hospitals. Within midwifery, values are not just dissimilar to those held by the German regime when the Holocaust occurred; they are in fact diametrically opposite. Nevertheless, people use the same psychological processes to deal with the stress resulting from carrying out a task that otherwise they would prefer not to. Unfortunately, obedience sometimes causes midwives to obstruct choice and deny the anguish caused to the childbearing woman. Most frequently among the obedient, we find not a denial of events but a denial of responsibility for them (Krackow and Blass, 1995).
In a recent study, I found a large disparity between midwives' private responses to work related decisions, when compared with answers they gave when influenced to respond in a particular way by a senior midwife. What these midwives perceived was an obligation to obey the senior midwife when the postal results clearly showed that many disagreed with her point of view. A full report of these studies has been reported by Hollins Martin and Bull (2004, 2005, 2006 in press) and Hollins Martin, Bull and Martin (2004).
Many of these midwives recognised that their focus shifted from giving preferential consideration to the choice of the childbearing woman, to instead fulfilling a perceived obligation to follow the direction given by the senior midwife, for example, carrying out an unnecessary cardio-tocography just because the senior midwife has asked you to do so (obedience to authority). Some of the midwives in the Hollins Martin and Bull study overtly denied responsibility for decisions that they made, for example, instead they attributed responsibility to the senior midwife for not permitting the woman to have a water birth (denial of responsibility). Other midwives presented excuses for why they would not accommodate a homebirth - for example, it was the doctor who said that the homebirth was not a good idea.
Results of the Hollins Martin and Bull study showed that midwives' levels of obedience are similar to most other social groups, such as college students (Meeus and Raaijmakers, 1995), ordinary men (Milgram, 1963, 1965, 1974) and soldiers (Shalala, 1974). Stanley Milgram showed that 65% of ordinary people provide maximum levels of obedience, even when the request made is morally wrong. He designed an experiment with the pretext that he was studying the effects of punishment on memory. The participant was told to play the role of 'teacher' who measured a confederate 'learner's' ability to remember a list of word pairs. The 'learner' was strapped into a chair and attached to electrical connections. The subject 'teacher' was shown into a separate room where a shock generator was placed on a table. They were told that each time the 'learner' made a mistake in recall of the list of word pairs, they were to administer a shock by pressing one of the thirty switches on the shock generator. The first switch was labelled '15 volts-mild shock' the next '30 volts' and so on up to '450 volts' and the 'teacher' was told to press the 15 volt switch first and then move one switch up the scale each time the 'learner' made a mistake. Milgram wanted to know how far up the scale of shocks participants would go when told to continue by the experimenter. This was despite the sound of cries and pounding on the wall from the 'learner' asking the participant to stop giving the shocks and, later, the 'learner's' complete silence. The results were unexpected and dramatic, with 65% of people proceeding up to the 450 volt level. No shocks were in fact delivered to the 'learner'.
Milgram (1974, p 100) describes how Elinor Rosenblum denied responsibility for shocking the confederate learner and deferred responsibility to the experimenter:
MRS ROSENBLUM: I kept saying, "For what reason am I hurting this poor man?"
INTERVIEWER: Why did you go on?
MRS ROSENBLUM: It is an experiment. I'm here for a reason. So I had to do it. You said so.
Like other ordinary people, midwives similarly sometimes inaccurately predict how they will behave in a particular situation. Hollins Martin and Bull (2005) issued a postal questionnaire to midwives, which assessed their views on the following issues:
(1) I believe that guidelines are unnecessary when labour is progressing normally.
(2) I would argue with the consultant if he refused to support a home confinement when a mother with a healthy pregnancy is keen to have one.
(3) I would follow a senior member of staff's request to rupture a woman's membranes if this was the decided course of action.
(4) I would administer oxytocin to a woman desiring a normal labour if it was a requisite of the guidelines for routine labour.
(5) I believe that it is acceptable for a women to have more than one 'birth partner' present during labour when the unit policy states only one person at a time.
(6) I would automatically commence cardiotocography if it was requested by a senior member of staff.
(7) In general I would challenge a senior member of staff if they decided to override a decision I made regarding normal labour.
(8) I would conceal my opinion from a consultant obstetrician when my stance about carrying out elective section for social reasons differs.
(9) I would allow a women to have her two friends and husband present during labour and delivery if this is what she wanted.
(10) Informed choice for women is an idealised dream. when the reality is that we know what is best for women in labour.
A disparity was evident between what these midwives said they would do in a private postal questionnaire and what they said they would do when socially influenced by a senior midwife during an interview (see Table 1).
Milgram (1974, p 45) discussed disparities between how people expect to behave and what actually happens when they are placed in the countenance of a senior person. In a survey regarding the aforementioned Milgram (1974) study, 110 respondents reported that they would have disobeyed the experimenter at some point in the shock series. According to Milgram's findings, approximately 65% (72) of these participants would have proceeded in the shock series to the 450 volt level. The survey respondents saw their refusal as flowing from empathy, compassion, and a sense of justice. The following excerpt illustrates this:
"I can't stand to see people suffer. If a learner wanted to get out, I would free him so as not to make him suffer pain. I couldn't deliberately hurt a perfect stranger" (Milgram, 1974, p 45)
These people, "enunciated a conception of what is desirable and assumed that action follows accordingly" (Milgram, 1974, p 47). They showed little insight into the web of forces that operate in real social situations. Several assumptions underlie these respondents' predictions. First, that people are by and large decent and do not readily want to hurt innocent people; second that, unless coerced by a physical force or threat, individuals are pre-eminently the source of their own behaviour.
The Hollins Martin and Bull (2005) postal questionnaires also revealed that most midwives begin with presuppositions when asked to think about their own responses to the given questions. Many believed they would argue with the consultant who refused a healthy childbearing woman's request for a home birth. Others believed they would refuse to carry out an unnecessary amniotomy. On answering the questions, these midwives focused on their own thoughts and denied the constraints of the actual situation, e.g., protocols, rules, punishments and the attendant hierarchy.
As midwives, it is important to gain insight into what is deemed normal human behaviour. If we can acknowledge our own human limitations, we are then in a position to understand and design a system that optimises choice provision for childbearing women. Denial of obedient propensities extends to all people. I sent a paper from the Hollins Martin and Bull study to a professional journal and received the following review: I remain unconvinced of the extrapolations. My view is a midwife lecturer is a peer, not a senior. This reviewer denied the findings of the experiment, instead preferring to believe that those who are higher in the hierarchy are disempowered to influence decisions.
As midwives it is important that we are made aware of characteristics that affect our perception of direction given. It is helpful to understand the results of obedience experiments since they inform us about how people perceive and react to authority. It is important that we are taught to view our communication, not just from the standpoint of sender or receiver, but to step outside the communication process and examine it within its broader context. We may then notice that perception of various elements of the communication process differ between individuals. How a senior midwife perceives herself and how she thinks her subordinates see her, may in fact differ. This is important, since consequences have profound effects on our midwifery practice. Understanding the psychology of obedience and its denial may help us address the difficulties that we (midwives) have with supporting choices of childbearing women.
*Address for correspondence: Caroline Hollins Martin, Room 528, Gateway House, Piccadilly, Manchester; E-mail: Caroline.Hollins-martin@manchester.ac.uk
This article was originally published in Midwifery Matters ISSUE 112 - Spring 2007
AH updated 16 October 2008