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ethical aspects of cesarean section
Current Obslerrics & Gynoecology (1999) 9, 53-54
0 1999 Harcourt Brace & Co. Ltd
Medico-legal/education
Medical/legal/ethical aspects of Cesarean.section
C. C. Coulson and J. M. Cain No single topic in obstetrics is more controversial these days than that of Cesarean delivery. Although much of the discussion centers around the issues of vaginal birth after Cesarean section and the associated informed consent, there are other significant medical/legal aspects to consider. Both women who refuse medically-recommended Cesarean delivery as well as those who demand seemingly unwarranted Cesarean section, are the primary subjects of this review. The court systems in the USA, Canada, and the UK are reticent about overriding decisions made by competent mothers who have refused Cesarean delivery.’ Similarly, practitioners hesitate when asked to perform Cesarean section purely at patients’ requests. The judicial system should be the last venue for answers to medical dilemmas.
INTRODUCTION The medical/legal issues surrounding Cesarean section are manifold. In some respectsthey do not differ from the principals governing any provider-patient relationship. In other ways, however, the obstetric patient is unique because of the presenceof a fetus. Any action committed or omitted on the part of the mother has the potential to help or harm the baby, with some dependence on gestational age. At times the mother, health care provider(s) and hospital may have different stances on the advisability of Cesarean section. Although many of these dilemmas can be settled long before labor and delivery, some arise emergently and the judicial system must intervene. COURT ORDERED CESAREAN SECTION Court-ordered Cesarean sections have been performed for fetal distress, prior Cesarean delivery, placenta previa, arrest of labor, and mental health. MD, Joanna M. Cain MD, Department of Obstetrics and Gynecology, The Penn State Geisinger Health System, The Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
Carol C. Co&on
Correspondence to: CCC.
Many different models of the maternal-fetal relationship have been proposed to address the dilemma of applying existing medical ethics and law to obstetric cases. Justin and Rosner suggest that the failure to fully disclose management alternatives to a patient creates clinical paternalism, diminishes the patient’s empowerment, and restricts her autonomy.2 Indeed, 8.7% of 326 patients undergoing non-elective Cesareandelivery in a recent study felt they had inadequate input into the decision, although all ultimately accepted the recommendation for Cesarean.’The
status of the fetus as a person, legal entity, or voting power, notwithstanding, it appears unjust to force sacrifices on the mother which are not required of the father. Of course, the unique housing of the fetus within the mother’s body makes this a spirited argument. Even if all pregnant women are good Samaritans,ethically obligated to consent to Cesarean delivery when thought to be in the best interest of their fetuses,some wilI fail to uphold this obligation.” The care provider is obligated to respect the considered choice of a woman and not perform the operation in the absence of consent. Informed consent implies that the patient considers the information in light of her values, that she comprehends the facts and opinions presented, and is able to communicate her choices. The use of court-ordered Cesarean section disregards this autonomous choice, and directly
54
Current Obstekcs & Gynaecology
damages the trust relationship between patient and physician. In addition, care must be taken not to advertise interventions of uncertain (if any) benefit as ‘doing everything possible’.sThis is particularly true of the extremely premature neonate where scientific evidencehas failed to demonstrate a proven benefit of Cesareandelivery. Disagreement between health care provider and patient can be uncomfortable and frustrating. The use of an uninvolved health care colleague to render a second opinion may be helpful to all parties. This might take the form of a medical opinion from another obstetric provider or discussion with ministry, social work, or a patient representative as appropriate for the area of conflict. The hospital ethics committee can also be consulted. Legal judgement should be sought only as a last resort. Compelling reasonsto override a mother’s autonomy must be present in those rare and exceptional circumstances where court intervention might be considered. The following criteria for intervention may provide guidance for practitioners, as well as the legal system:” l l l l
maternal risk and side effects are low fetal benefit is substantial the intervention will probably be effective the intervention is minimally invasive.
Obviously few clinical situations will fit all four principals ideally. The Royal College of Obstetricians and Gynaecologists, the American College of Obstetrics and Gynecology, and The American Medical Association have all publicly opposed the use of the courts to sanction obstetric intervention, particularly compulsory Cesarean section, against the will of a competent patient. In several landmark judgments in the USA and the UK, appeals courts have upheld the absolute right of a pregnant woman to make her own health care choices, even if these choices endanger the fetus.’
a fetus with a known lethal anomaly may not find medical support for her decision easily. Honest communication and participation of paediatric providers in the dialogue prior to labour and delivery may be helpful. Generally, a patient with a prior Cesarean may choose another, but a primi gravida may not electively choose the first Cesarean for non-medical reasons becauseof the potential hazards of surgery.R Based on the increasing safety of Cesarean delivery, as well as the increasing awarenessof pelvic damage with vaginal delivery, opinion may shift to closely parallel the patient-centered autonomy model previously described.” A 1986 survey of 112 respondents detailed 19 different clinical scenarios in which a patient requested Cesarean section. Responses were highly variable despite the provider’s recommendation for continued labor or vaginal delivery.“’The authors concluded the patient choice must play a large role, especially where medical knowledge is unclear. Again, the issue of extreme prematurity warrants special consideration, as providers many construe Cesarean section as obligatory under the guise of ‘doing everything possible’. In all cases,referral to another obstetric provider after outlining the conflict may be necessaryif resolution cannot be reached. In conclusion, providers and patients may weigh the risks and benefits of Cesarean section differently. Social workers, clergy, patient advocates, hospital ethics committees and, in rare instances, the courts may be needed as arbiters on medical, legal, ethical, moral and religious grounds. In the end, patient autonomy is critical to any decision. Primum non nocere. REFERENCES I. Tatter CA. Lives at stake! How to respond to a woman’s 2. 3.
PATIENT
REQUESTED
CESAREAN
SECTION
In contrast to court-ordered Cesarean section, which often follows a pregnant patient’s refusal of a provider’s suggestion that Cesareandelivery is medically appropriate, circumstancesalso exist where a provider refuses a patient’s request for Cesarean delivery. A Cesarean delivery which is not medically necessary raises issues of acceptability on the basis of autonomy. Some would argue that such a request has more validity if the patient’s argument for Cesarean delivery is internally consistent.’ For example, a request for Cesareanowing to fear of pain in labour is not consistent with medical facts. Labour pain can be controlled with medication and, postoperatively, pain will certainly be worse after major abdominal surgery than after successful labour and vaginal delivery. Likewise, a mother who requestsCesareandelivery for
4. 5.
6. 7. 8. 9. IO.
refusal or Ccsarcan Surgery when she risks losing her child or her life. Health Progress 1992; 73(3); 18: 20--27 Justin RG, Rosncr F. Matcrnallfctal rights: IWOviews. J Am Mcd Worn Assoc 1989; 44(3): 90. 95 Lcscalc KB, lnglis SR, Eddlcman KA, Peeper EQ. Chervcna KFA, McCullough LB. Conflicts bctwccn physicians and patients in non-elective Ccsarcan delivery: incidcncc and the adequacy of informed consent. Am J Pcrinatology 1996; 73(3): I71 I76 Draper H. Women, forced Caesareansand antcnatal responsibilities. J Med Ethics 1996; 22(6): 327-333 American Academy of Pediatrics Committee on Fetus and Newborn, American College of Obstetrics and Gynecology, Committee on Obstetric Practice. Pcrinatal cart at the threshold of viability. Pediatrics 1995; 96(5), Part I): 974-976 Strong C. Court-ordered treatment in obstetrics: the ethical news and legal framework. Obstct Gynccol 1991: 78(5,Pt I): 861-868 Dyer C. Colleges say no to forced Caesarean sections. BMJ 1994; 308(6923): 224 FIG0 Commillec for the Ethical Aspects of Human Reproduction and WornenS Health, September 1998, prcpublication communication Paterson-Brown S, Fisk NM. Caesarean section: every women’s right to choose?Curr Opin Obstct Gynccol 1997; 9: 351-355 Johnson SR, Elkins TE, Strong C, Phelan JP Obstetric decision-making: responsesto patients who request Ccsarcan delivery. Obstct Gynccol 1986; 67(6): 847-850
0 1999 Harcourt Brace & Co. Ltd
Medico-legal/education
Medical/legal/ethical aspects of Cesarean.section
C. C. Coulson and J. M. Cain No single topic in obstetrics is more controversial these days than that of Cesarean delivery. Although much of the discussion centers around the issues of vaginal birth after Cesarean section and the associated informed consent, there are other significant medical/legal aspects to consider. Both women who refuse medically-recommended Cesarean delivery as well as those who demand seemingly unwarranted Cesarean section, are the primary subjects of this review. The court systems in the USA, Canada, and the UK are reticent about overriding decisions made by competent mothers who have refused Cesarean delivery.’ Similarly, practitioners hesitate when asked to perform Cesarean section purely at patients’ requests. The judicial system should be the last venue for answers to medical dilemmas.
INTRODUCTION The medical/legal issues surrounding Cesarean section are manifold. In some respectsthey do not differ from the principals governing any provider-patient relationship. In other ways, however, the obstetric patient is unique because of the presenceof a fetus. Any action committed or omitted on the part of the mother has the potential to help or harm the baby, with some dependence on gestational age. At times the mother, health care provider(s) and hospital may have different stances on the advisability of Cesarean section. Although many of these dilemmas can be settled long before labor and delivery, some arise emergently and the judicial system must intervene. COURT ORDERED CESAREAN SECTION Court-ordered Cesarean sections have been performed for fetal distress, prior Cesarean delivery, placenta previa, arrest of labor, and mental health. MD, Joanna M. Cain MD, Department of Obstetrics and Gynecology, The Penn State Geisinger Health System, The Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
Carol C. Co&on
Correspondence to: CCC.
Many different models of the maternal-fetal relationship have been proposed to address the dilemma of applying existing medical ethics and law to obstetric cases. Justin and Rosner suggest that the failure to fully disclose management alternatives to a patient creates clinical paternalism, diminishes the patient’s empowerment, and restricts her autonomy.2 Indeed, 8.7% of 326 patients undergoing non-elective Cesareandelivery in a recent study felt they had inadequate input into the decision, although all ultimately accepted the recommendation for Cesarean.’The
status of the fetus as a person, legal entity, or voting power, notwithstanding, it appears unjust to force sacrifices on the mother which are not required of the father. Of course, the unique housing of the fetus within the mother’s body makes this a spirited argument. Even if all pregnant women are good Samaritans,ethically obligated to consent to Cesarean delivery when thought to be in the best interest of their fetuses,some wilI fail to uphold this obligation.” The care provider is obligated to respect the considered choice of a woman and not perform the operation in the absence of consent. Informed consent implies that the patient considers the information in light of her values, that she comprehends the facts and opinions presented, and is able to communicate her choices. The use of court-ordered Cesarean section disregards this autonomous choice, and directly
54
Current Obstekcs & Gynaecology
damages the trust relationship between patient and physician. In addition, care must be taken not to advertise interventions of uncertain (if any) benefit as ‘doing everything possible’.sThis is particularly true of the extremely premature neonate where scientific evidencehas failed to demonstrate a proven benefit of Cesareandelivery. Disagreement between health care provider and patient can be uncomfortable and frustrating. The use of an uninvolved health care colleague to render a second opinion may be helpful to all parties. This might take the form of a medical opinion from another obstetric provider or discussion with ministry, social work, or a patient representative as appropriate for the area of conflict. The hospital ethics committee can also be consulted. Legal judgement should be sought only as a last resort. Compelling reasonsto override a mother’s autonomy must be present in those rare and exceptional circumstances where court intervention might be considered. The following criteria for intervention may provide guidance for practitioners, as well as the legal system:” l l l l
maternal risk and side effects are low fetal benefit is substantial the intervention will probably be effective the intervention is minimally invasive.
Obviously few clinical situations will fit all four principals ideally. The Royal College of Obstetricians and Gynaecologists, the American College of Obstetrics and Gynecology, and The American Medical Association have all publicly opposed the use of the courts to sanction obstetric intervention, particularly compulsory Cesarean section, against the will of a competent patient. In several landmark judgments in the USA and the UK, appeals courts have upheld the absolute right of a pregnant woman to make her own health care choices, even if these choices endanger the fetus.’
a fetus with a known lethal anomaly may not find medical support for her decision easily. Honest communication and participation of paediatric providers in the dialogue prior to labour and delivery may be helpful. Generally, a patient with a prior Cesarean may choose another, but a primi gravida may not electively choose the first Cesarean for non-medical reasons becauseof the potential hazards of surgery.R Based on the increasing safety of Cesarean delivery, as well as the increasing awarenessof pelvic damage with vaginal delivery, opinion may shift to closely parallel the patient-centered autonomy model previously described.” A 1986 survey of 112 respondents detailed 19 different clinical scenarios in which a patient requested Cesarean section. Responses were highly variable despite the provider’s recommendation for continued labor or vaginal delivery.“’The authors concluded the patient choice must play a large role, especially where medical knowledge is unclear. Again, the issue of extreme prematurity warrants special consideration, as providers many construe Cesarean section as obligatory under the guise of ‘doing everything possible’. In all cases,referral to another obstetric provider after outlining the conflict may be necessaryif resolution cannot be reached. In conclusion, providers and patients may weigh the risks and benefits of Cesarean section differently. Social workers, clergy, patient advocates, hospital ethics committees and, in rare instances, the courts may be needed as arbiters on medical, legal, ethical, moral and religious grounds. In the end, patient autonomy is critical to any decision. Primum non nocere. REFERENCES I. Tatter CA. Lives at stake! How to respond to a woman’s 2. 3.
PATIENT
REQUESTED
CESAREAN
SECTION
In contrast to court-ordered Cesarean section, which often follows a pregnant patient’s refusal of a provider’s suggestion that Cesareandelivery is medically appropriate, circumstancesalso exist where a provider refuses a patient’s request for Cesarean delivery. A Cesarean delivery which is not medically necessary raises issues of acceptability on the basis of autonomy. Some would argue that such a request has more validity if the patient’s argument for Cesarean delivery is internally consistent.’ For example, a request for Cesareanowing to fear of pain in labour is not consistent with medical facts. Labour pain can be controlled with medication and, postoperatively, pain will certainly be worse after major abdominal surgery than after successful labour and vaginal delivery. Likewise, a mother who requestsCesareandelivery for
4. 5.
6. 7. 8. 9. IO.
refusal or Ccsarcan Surgery when she risks losing her child or her life. Health Progress 1992; 73(3); 18: 20--27 Justin RG, Rosncr F. Matcrnallfctal rights: IWOviews. J Am Mcd Worn Assoc 1989; 44(3): 90. 95 Lcscalc KB, lnglis SR, Eddlcman KA, Peeper EQ. Chervcna KFA, McCullough LB. Conflicts bctwccn physicians and patients in non-elective Ccsarcan delivery: incidcncc and the adequacy of informed consent. Am J Pcrinatology 1996; 73(3): I71 I76 Draper H. Women, forced Caesareansand antcnatal responsibilities. J Med Ethics 1996; 22(6): 327-333 American Academy of Pediatrics Committee on Fetus and Newborn, American College of Obstetrics and Gynecology, Committee on Obstetric Practice. Pcrinatal cart at the threshold of viability. Pediatrics 1995; 96(5), Part I): 974-976 Strong C. Court-ordered treatment in obstetrics: the ethical news and legal framework. Obstct Gynccol 1991: 78(5,Pt I): 861-868 Dyer C. Colleges say no to forced Caesarean sections. BMJ 1994; 308(6923): 224 FIG0 Commillec for the Ethical Aspects of Human Reproduction and WornenS Health, September 1998, prcpublication communication Paterson-Brown S, Fisk NM. Caesarean section: every women’s right to choose?Curr Opin Obstct Gynccol 1997; 9: 351-355 Johnson SR, Elkins TE, Strong C, Phelan JP Obstetric decision-making: responsesto patients who request Ccsarcan delivery. Obstct Gynccol 1986; 67(6): 847-850