Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma in patient care, you vote, and then we present an expert's judgment.
Last week, you voted on the ethics of compelling a woman to have a cesarean section to save her baby otherwise likely to die. Here are the results from over 1,200 votes:
Would you seek a court order forcing the woman to have the C-section?
Yes: 31.12%
No: 68.88%
If not allowed to perform the procedure, would you withdraw from the woman's care?
Yes: 38.42%
No: 61.58%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
Questions regarding reproductive ethics are among the most challenging in medicine and prone to generate disagreement and impassioned arguments among people of goodwill. While competent adults are generally permitted to make medical decisions for themselves, including turning down life-sustaining care, pregnancy cases are more complicated in that they also involve the welfare of a fetus. Some philosophers view either birth or even postnatal "sentience" as the point at which there is an ethical imperative to preserve life -- making this case for them no different than any other medical decision.
However, for much of society, fetal life beyond a certain point of pregnancy acquires inherent value -- although that point is a source of much political conflict. One might frame this case as a question of how we balance the life of a prospective baby against the right of the mother to make choices about her own body. After all, cesarean section is a major surgical procedure with a mortality rate more than three times higher than that of vaginal delivery. Not surprisingly, mothers who happen to be physicians have lower rates of C-sections when controlled for other factors, suggesting they appreciate this risk and avoid it when possible.
Historically, some religious and cultural traditions favored saving the life of a baby over a pregnant mother (an Arizona hospital even had its Catholic status revoked in 2010 for allowing an abortion to save a mother's life), but most ethicists and physicians now reject such a blanket approach.
But how much risk should a mother be forced to endure? And for how much likelihood of preserving a fetal life?
Once we accept the premise of such a forced trade-off, it is hard to draw a line. Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics oppose forced C-sections and the American Medical Association generally looks unfavorably upon them. However, state judges continue to grant physicians the authority to perform such procedures. New York courts ruled in favor of Staten Island University Hospital doctors when they performed a C-section on Rinat Dray against her express wishes, while a Utah woman, Melissa Ann Rowland, was even charged with murder in 2004 for refusing the procedure. Women averse to C-sections in such jurisdictions should be careful to choose hospitals and obstetricians committed to honoring their wishes.
Complicating this case is the question of whether the expecting mother has the capacity to make her own medical decisions. We must explore why this mother believes the baby will be fine. Is this merely optimism in the face of bad odds, or does she not fully comprehend the danger to the fetus? Ethics may favor honoring an informed refusal: for instance, that of a woman who accepts the probability that her baby will die but whose religion opposes surgery and favors letting nature take its course. In contrast, a woman who does not appreciate these risks lacks the capacity to render such a high-stakes decision, and pursuing a court order may prove appropriate.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College. Appel is the author of the recent book, .
And check out some of our past Ethics Consult cases: Give COVID-19 Vax to Yourself Before Patients?, Walk Out Over Mask Reuse?, Take Elderly COVID-19 Patient Off Ventilator?