Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a doctor should perform a C-section without the patient's consent.
Should the doctor perform the C-section without the patient's consent?
Yes: 37%
No: 63%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Cases of women refusing medically indicated Cesarean sections are relatively rare. Most cognitively intact mothers want their babies to survive -- and are usually willing to make sacrifices, such as undergoing surgery, to do so. Yet C-sections are not benign procedures: even in otherwise healthy women, the mortality rate (13.3 maternal deaths per 100,000 births) for such surgical deliveries is more than three times that for vaginal deliveries. In addition to cosmetic concerns, such as Amber's, a prospective mother might have legitimate medical worries about what amounts to a major potentially life-threatening operation.
Although forced C-section cases raise issues similar to those that arise when discussing elective abortion, many commentators have noted several distinctions between the two. While the burden of carrying a fetus to term may be significant, it is arguably not nearly as weighty as undergoing major surgery against one's wishes. In cases like Roe v. Wade, the mother's intent is generally to terminate fetal life. In contrast, many involuntary C-section disputes involve mothers who very much want their babies to survive -- they just disagree with medical opinions or have a more elevated threshold for risk.
In fact, in several high-profile cases during which doctors fought in court for C-sections and lost, the mothers eventually delivered healthy babies. In Amber's case, one might ask whether "the fetus will likely die" means a 60% chance or a 99% chance of demise. Assuming one believes society has some stake in fetal life beyond a certain point of development, one must decide at what point the risk to the full-term fetus becomes elevated enough that the decision-making power should be transferred from the mother to the state. One might also ask whether Amber's motivation matters. If she objected on medical or religious grounds, rather than cosmetic ones, would that change the case?
Many bioethicists are uncomfortable with the idea of forcing a competent patient to undergo surgery, no matter how compelling the reason. Howard Minkoff, MD, ob/gyn chair at Maimonides Medical Center in Brooklyn, gave voice to these concerns regarding the case of Rinat Dray, who claimed that doctors at Staten Island University Hospital forced her into a C-section. Minkoff told the New York Times, "In my world view, the right to refuse is uncircumscribed. I don't have a right to put a knife in your belly ever."
Major professional organizations, including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, generally discourage forced surgery, except under extraordinary conditions. No legal consensus yet exists regarding how to handle these challenging cases, and courts in different states have reached highly divergent opinions. For example, judges in Georgia and Florida have upheld forced C-sections, while Illinois's courts have proven unwilling to do so.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the 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.
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