Refusal of C-Section: Where Does Your Moral Compass Lead You?

[[{"type":"media","view_mode":"media_crop","fid":"25468","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2845987046603","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2324","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Paul Burcher, MD, PhD","typeof":"foaf:Image"}}]]I was recently surprised to read in the New York Times that a woman had undergone a cesarean section despite her refusal to consent to the procedure.¹ The details of the case are not entirely clear from the article, so what follows is not a specific comment on this case. That said, what surprised me was my assumption that the ethics of “refusal of consent” were not in dispute.

The American Congress of Obstetricians and Gynecologists (ACOG) has taken a clear position on this: It is not permissible to perform surgery on a patient with decisional capacity without her consent. In a committee opinion, ACOG strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section and concludes with the following statement²:

“Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy.”

This committee opinion gives six strong and compelling arguments for these conclusions, which I won’t repeat here, but I encourage readers to review them. What I want to address is the thinking that may lead some physicians to believe it’s ethically permissible to override a patient’s autonomous choice.

Respecting Patient Choice

We teach cesarean section refusal as an ethical case during the third-year clerkship in Obstetrics and Gynecology for medical students. We present a hypothetical case of a young woman with pre-eclampsia and a non-reassuring fetal tracing who refuses a cesarean section on the grounds that she had hoped to have an abortion but presented to a clinic too late for a termination. So, she was carrying a pregnancy that she did not intend and did not desire.

A consistent response from at least one medical student in every group is that the pregnant patient is behaving unethically by refusing to make choices in the best interests of her fetus and, therefore, we are justified in overriding her wishes. Leaving aside the excellent arguments that ACOG makes about the limitations of our own knowledge in predicting fetal outcomes and the arrogance of believing that the physician can address the interests of the fetus better than the pregnant woman herself, there is a simple logical flaw in this reasoning. It is easier to see if you present it as a series of propositions, which are:

1. A woman carrying a fetus beyond viability has a duty to the fetus, including acting to best ensure its well-being.

2. If she is acting against medical advice or refuses a recommended procedure, she is not fulfilling this duty.

3. Therefore, physicians are justified in overriding her autonomous choice in order to ensure fetal well-being.

The ACOG committee opinion on maternal decision making calls into question the second proposition. My issue is actually with the third proposition-the conclusion. There is a logical fallacy here. Namely, it does not necessarily follow that because we believe the woman is acting unethically that we are then justified in violating her right to autonomy and bodily integrity. Put differently, we can agree that pregnant women beyond fetal viability bear some responsibility to their fetuses without leaping to the conclusion that we have the right or duty to compel it.

Slippery Slopes

But isn’t the potential harm of a fetal death a greater harm than the loss of autonomy suffered by the patient? Again, I would refer readers to ACOG’s committee opinion on maternal decision making for an extensive argument against this point, but I will reiterate and amplify one of their responses. The logic that justifies this also justifies the incarceration of pregnant women who have behaviors that jeopardize their fetuses, and it isn’t hard to see where this logic ultimately takes us.

Smoking during pregnancy, by this argument, should be illegal. Maybe even inadequate prenatal care and choosing a home birth could lead to laws or actions that restrict a pregnant woman’s liberty. When critics of this logic argue that it transforms women from moral agents into powerless “baby vessels,” they are only following the argument to its logical but unjust conclusions. This logic isn’t just a theoretical concern; women in several states have been incarcerated for drug use during pregnancy.³

It is important to note that it is not drug use per se that got them arrested, it was the state of pregnancy combined with drug addiction (and poverty, and lack of good legal counsel) that resulted in their loss of freedom. Furthermore, it is evidence of our historical prejudices that illegal drug use results in incarceration while tobacco addiction does not. I would suggest that the evidence does not support this demarcation.

It is neither logically necessary nor wise public policy to empower physicians in this way. History is replete with examples of those so empowered abusing it with tragic consequences, and always the victims seem to be the vulnerable. While we may experience moral regret if we are the physician on call when a woman refuses a cesarean section for fetal indication and the fetus ultimately dies or suffers harm, I would rather see this than a woman forcefully sedated or restrained while I deliver her fetus against her will by cesarean section. No concern regarding fetal well-being can justify this act of aggression against a patient. This flagrant violation of “first, do no harm” has no place in the healing arts.

References:

1. Hartocollis A. Mother accuses doctors of forcing a C-section and files suit. New York Times. May 16, 2014. Available at: http://www.nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html?module=Search&mabReward=relbias%3Ar&_r=0.

2. ACOG Committee Opinion no. 321. Maternal decision making, ethics, and the law. Obstet Gynecol. 2005;106:1127-1137. Available at:
 http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Ethics/Maternal_Decision_Making_Ethics_and_the_Law.

3. Ehrlich JB, Paltrow LM. Jailing pregnant women raises health risks. Septemer 20, 2006. Available at: http://womensenews.org/story/health/060920/jailing-pregnant-women-raises-health-risks#.U6NomiiwkgY.