Sunday, March 29, 2009

Ethics of refusing to perform elective cesareans

A few recent posts by Mom's Tinfoil Hat--Reply turned post, three way mirror style and
Reply turned post, tired-of-pushing style--got me thinking about the ethics of refusing to do a non-medically indicated cesarean section. If a woman requests to have a c-section with no medical reason, are physicians justified in refusing to perform one? Does refusal or promotion of elective cesarean section (ECS) have ethical implications for other birth choices, such as VBAC or homebirth? Is ECS a "choice" that is an essential part of women's reproductive rights? If a physician defends a woman's right to choose ECS, should he/she also be obliged to defend her right to choose homebirth, waterbirth, etc? Is it ethically/morally justifiable to refuse a woman an ECS but to argue that VBACs should not be banned?

Here's how I see the issue: Refusing to perform a non-medically indicated cesarean is ethically justifiable. Refusing to allow VBAC is not. What's the difference between the two situations?

1) Elective cesarean section is a medical procedure that cannot happen without the physicians and staff to perform it. On the other hand, a vaginal birth after cesarean is not a medical procedure, but rather the spontaneous and inevitable conclusion of pregnancy. It will occur whether or not there is someone doing something.

2) As I understand it, patients have the legal right to informed consent, which includes the right to decline/refuse medical treatment and to bodily autonomy* (provided they are in a state to make competent decisions). Patients do not have the legal right to demand medically unnecessary procedures; they only have the right to decline procedures that are offered/indicated. Refusing to perform an ECS does not violate a patient's right to informed consent and refusal. If a physician feels that there is no good reason to perform a cesarean section (or any other medical procedure), they can refuse to do it and/or refer the patient to another care provider. However, banning VBACs does violate a woman's legal rights, in that it does not allow the woman to refuse a repeat cesarean section.

What are your thoughts on this issue?

* For additional reading on this topic, see:
The Right to Refuse Treatment: Ethical Considerations for the Competent Patient in the Canadian Medical Association Journal
The NHS' explanantion of the right to refuse treatment
Informed Consent and the Right to Refuse Treatment by Valerie Goodwin Larcombe, Esq.


  1. Hmmm, that's an interesting take on it. It's a tricky sticky situation, that's for sure. I've always been of the "support ALL birth choices" camp, because what is "best" or "safe" is so subjective and like you said, taking away a woman's right to ECS is not going to do anything to further our rights to homebirth or VBAC. But I like this new spin on the topic. I'm going to have to keep these points in mind next time this discussion comes up.

  2. I believe that a physician has a an absolute right to refuse to perform any procedure that he believes is morally wrong or unethical. It can get sticky, but a doctor who will do anything for money regardless of any ethical standards is a scary proposition as well.

  3. I left this over at MomTFH...

    Based on the fallacious argument that c/s and vaginal birth are simply two equal ends to pregnancy that both result in a live baby (usually) and live mother (usually), then it would seem to me to be ethical to offer or recommend either. However, as you stated and as I stated in my original comment, they are not apples for apples. If an end to pregnancy can occur in the car on the way to a c/s appt, they are not in the same category even if they both result in a separated mother and baby.

    I do believe it is ethically justifiable to refuse to perform elective procedures, especially major abdominal surgery, in the absence of evidence. So does ACOG.

    ACOG’s stance on the ethics of maternal request c-section is the following:

    In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery. In this case, a referral to another health care provider would be appropriate if physician and patient cannot agree on a method of delivery.

    So as long as you BELIEVE that what you are doing has some benefit to the woman and fetus, you’re behaving ethically. So what if you BELIEVE that c/s is not a negative outcome but simply an equal or superior alternative? Then it’s ethical (according to ACOG’s opinion). It seems then that if you DO NOT BELIEVE that VBAC is safe or that vaginal birth of a suspected macrosomic fetus is safe, then you can refuse to participate in the birth. A doctor could refuse to catch the baby, which will exit vaginally and spontaneously within 43 weeks whether a c/s is on the calendar or not. The total absence of medical intervention does not, of course, guarantee perfect outcomes for everyone. Then again, neither does a c-section. There are no guarantees.

    Whether it’s ethical to perpetuate VBAC bans, gross overuse of inductions and gratuitous cesareans is, in my opinion, subject to the provider’s core beliefs about birth in general. If enough physicians feel that a c/s is the safer, more controlled and more humane alternative to vaginal birth, the ethics of banning vaginal birth in hospitals will probably never be challenged on a systemic level.

  4. You know what? I take part of that back. ACOG says nothing about evidence, period. Only beliefs.

    So when I said this: "I do believe it is ethically justifiable to refuse to perform elective procedures, especially major abdominal surgery, in the absence of evidence. So does ACOG."

    Nothing about actual evidence... just one's (highly subjective) belief.

    Here's the press release and short version of ACOG's opinion on ethics of elective c/s:

  5. Is ECS a "choice" that is an essential part of women's reproductive rights?

    Counter question: if ECS isn't a choice that is an essential part of women's reproductive rights, then how do you argue that a woman has a right to an abortion?

    Abortion is also "a medical procedure that cannot happen without the physicians and staff to perform it". Its purpose is to prevent the "spontaneous and inevitable conclusion of pregnancy". And it is often a medically unnecessary procedure.

    Restricting women's reproductive choices-- ANY choices, even the ones you don't agree with or wouldn't choose for yourself-- is bad for ALL of our reproductive rights.

    I personally would never opt for an ECS myself, but I don't believe in forcing a woman to have a vaginal birth if she really doesn't want one.

  6. Actually, there are spontaneous abortions. There will never be a spontaneous cesarean. I know what you mean, though.

    I have always been reluctant to put abortion and cesarean in the same category, although I've heard it done before. One is a procedure that ends a pregnancy with a dead fetus. One is a procedure that ends a pregnancy with a live baby. The more accurate comparison for the sake of any argument would be live birth to live birth.

    I don't think cesareans should be offered or promoted to healthy women, as there's no evidence that they spare mother or baby from increased morbidity—in fact, they have more complications. If a woman requests one, I believe it would be ethical to kindly and sensitively refer her to another provider if one is not comfortable with performing unnecessary major surgery, as MomTFH says she will most likely do.

    However, I tend to agree with you. There’s that *something* that you just can’t mess with when it comes to reproductive freedom. I hate to dismiss all maternal req cesarean rhetoric as a straw man argument because for the handful of women that actually request one in the absence of medical indication, it is very important. I’m curious to see how it would all pan out… would loads and loads of women really be banging on the doors of the hospital for their c-sections? I only know one woman who requested one.

    I have to say that I resent all of the time the NIH and ACOG have spent discussing the ethics of maternal req c/s, especially when they could be tackling unwanted and unnecessary c-sections and educating stubborn physicians on their evidence-based practice guidelines.

  7. I agree with you. I wouldn't go as far as to say ECS should be illegal (I know you didn't say that either), for the same reasons I don't believe abortion should be illegal--because whether or not I think those thigs are ethical, when people start taking things like that into their own hands, or when doctors start doing things like that under the table, horrible mistakes will get made.

    But, as you said, a doctor should have the right to refuse any procedure they find ethically questionable because, especially in ECS cases, the patient can just as easliy get a new doctor who will do what they want.

    I know some women who are terrified of birth and who refuse to do the mental work to overcome that fear. Should their babies suffer as a result...technically no, but rights of the unborn have always been a really tough topic, there's just too many variables. Especially since the mother is still a seperate entity in some sense...she still has her thoughts, fear, and emotions regardless of the pregnancy.

    I suppose I would like to see ECS only being done at a minimum of 40 weeks pregnant, and for those that go into labour before 40 weeks, an ECS would be performed as soon as labour started. That obviously wouldn't remove all the negative aspects of c-section, but it would hopefully improve outcomes for babies, at least in some way.

  8. I get the actual question, does the doctor have a RIGHT to refuse to do something, but I just cant help but throw in the reality that I have seen and heard which is that there seems to be no shortage of reasons/excuses/justifications to do a cesarean. Ever.

    I am sure there are some really cool and natural OBs out there who, (especially on the record) would say oh, no, we would never do an unecessary c-section. But when almost every part of being a pregnant woman can be considered a high risk, (and in the absence of evidence they will use thier faulty machinery to tell you the 7 pound baby is suspected macrosomia, etc etc etc)....I just dont see anyone who wants a c section getting denied one or at least being able to get one around town.

    Do I think that's right? Yeah. theres so much involved to sexuality birth reproduction mothering that who knows what someone is going through to get to that point where they want to get cut open and suffer such a debilitating recovery just to avoid vaginal I have always had as my personal agenda, I only wish that all women and girls were truly informed as to the benefits and risks, and that is something we really cant guarantee, but we can try.

    There is also the mothers' friends and family and what they are telling her about birth, etc.

    We have a long way to go. I have no answers I guess. But great topic. I think in general, with the malpractice situation and beliefs in this country, many doctors like the control and ceertainty that they PERCIEVE cesarean delivery to be.

  9. Yarg. Comment didn't work.

    With the evidence that c-sections are inherently more risky than a spontaneous vaginal (or even an assisted) delivery, I would think that refusing an ECS would be well within a doctor's right and would be well justified. In fact, I think many would be fulfilling their oath - to first do no harm. I think the same can be said for medically unnecessary inductions, too, given their risks.

  10. My opinion runs sort of along the same lines as anon's 'abortion' comment and Jill's 'freedom' comment -

    Choice is important. Governance of any sort that limits my right to choose is not to be preferred, in my opinion.

    Paired with informed decision making, having the opportunity to make one's own decision supports a cultural mindset of personal responsibility.

    I don't mean to sound like an idealist. Of course I realize there will probably always be those for whom personal investment and responsibility aren't of importance. We cannot control others; we can only set positive examples through self-confident and -reliant action. We can change the world by first changing ourselves and sharing the outcome of our actions with others.

  11. I think this issue of truly elective cesareans is a very tricky one. On the one hand, I think doctors (including myself of course)should be able to decline performing procedures that have no medical reason, especially when there are as many attendant risks as there are with something as major as cesarean section. You can't request to have your gallbladder out just because you want it out, for instance. I also think doctors should have the right to decline to perform procedures which they don't feel comfortable doing (such as abortions, or elective cosmetic procedures) Of course doctors declining these types of things does then limit women's ability to access them, and it's hard for me to figure out where my rights end and the lack of access begins.

    In personal experience, women who request elective cesareans have a lot of complex reasons for doing so. Some have family or personal histories of bad birthing experiences (I know a woman, for example, who requested a cesarean under general for her 2nd child after her first child had been stillborn and she'd had a long induced labor after finding out the baby had died - she just could not face being any part of the birth experience. To me, this seems personally the wrong way to go, but she was very satisfied with just waking up in recovery and finding out her baby was alive.) Some are terrified of labor and birth, and often have so many horror stories floating around in their brains. Some are very frightened of the lack of control pregnacy and birth bring (and parenting for that matter!)

    The odd thing I've found, though, is that although usually I can intellectually convince someone that it's in their best medical interest to pursue a vaginal birth, changing their beliefs and emotions and worries is so much harder. Virtually every woman I've ever cared for who wanted an elective cesarean ended up with a cesarean in the end - often for "failure to progress" or another medical reason. It has made me wonder if I should give up explaining and empathizing and planning with folks and just call up my OB back up and schedule an elective cesarean.

    I agree very strongly, though, that rather than focus so much on the availabilty of elective cesarean, there ought to be much more discussion about the availability of other birth choices, and the increasing medicalization of birth!

  12. First thing - doctorjen: PLEASE DON'T GIVE UP ON US!!!! So, so, soooo many women all over this country think cesareans are the way to go because this culture scares the socks off them with "horrifying" birth stories - then when we end up with our car accidents, er, I mean c-sections, THEN, and only THEN do we understand how having something cut out of us is horribly traumatic and unnatural, and leaves a hole that nothing (except a vaginal birth) can fill. Some women really just don't know. If they're ending up with c-sections that could have otherwise been avoided, then they're NOT getting all the information. Our minds can be changed.

    Second. I think it is 100% ethical to refuse to perform any procedure. The reason VBAC doesn't fit under this is because VBAC is NOT a "Procedure." A VBAC is nothing more than NOT doing something. It's letting nature take it's course. It is UNethical to force a woman to have a c-section. I think doctors refuse VBACs, perform C-sections against will (which actually happens!) or even talk a woman into unnecessary c/s, should not be doctors anymore. It goes against everything that medicine is supposed to be.

    Doctors have the right to refuse to perform abortions. But many doctors still do them - in fact, they set up clinics geared toward it.

    I really wish the c-section-happy doctors would set up their own clinics and stop masquerading as caring doctors who "want" you to go vaginal, that is, until your vaginal birth interrupts their dinner plans, or takes more than 12 hours. Then, off to the OR!

    If they had their own "Come-here for-your-elective-C-section!" clinics, I'd know how to avoid them.

  13. I didn't mean to imply that I have clients having totally medically unnecessary cesareans. My overall cesarean rate in the nearly 8 years I've been practicing is 11% - so maybe not ideal, but far lower than the national average and our local average (my hospital has an overal rate around 23%.) What I mean, is that no matter how much education and discussing I do with women, the few months they spend having prenatal care can not always overcome the years of cultural conditioning about birth some women have.
    Just as women talk about how hard it is to labor in the hospital with hostile providers if they have been preparing for a homebirth in a supportive environment, women who are terrified of labor and don't really care to have a vaginal birth often seem to have long difficult labors. Also, they make choices that don't optimize their chances for vaginal birth, such as early epidurals, limited movement in labor, and if it comes to decision times between maybe trying to push in an upright position vs surgery, they choose surgery. Just somehow, most of the women I've met who initially wanted a cesarean birth and I thought we'd finally agreed on trying for a vaginal birth, end up with cesareans ultimately.
    It's not a universal thing - I've had the pleasure of catching a baby vaginally that was the first baby since great-grandmother's generation born vaginally. Just recently, I had a young woman who'd originally adamently wanted an elective cesarean birth her baby vaginally, squatting on the bed with her partner holding her - and she had a lot of things going against her, from family who were amazingly negative all during her pregnancy and the labor, she was quite obese, had elevated blood sugars, and pregnancy induced hypertension at the very end - but she did beautifully and was thrilled in the end with her birth.
    I'm a family doc, and I don't do surgeries anyway, but do continue to advise against elective cesareans, but it's not as simple as just refusing and then the client has a vaginal birth. Some of the cultural factors involved are far more complicated (and of course medicine as a whole deserves a lot of the blame!)

  14. Great comments, Dr. Jen.

  15. You all need to understand something...if there is a choice between an elective CS or suicide, I am going to choose the CS. The only other choice for me is abortion. There is NO OTHER alternative. I totally understand what DoctorJen stated. I would do anything to avoid a vaginal birth, up to and including abortion or suicide. It's gross, disgusting, and not something I am going to be browbeaten into considering. I would only put myself through one pregnancy because I want a child, because I find the whole process gross. If you want to condemn some of us to either abortion or suicide, block off elective CS. How vicious is that? And no, I don't want anymore so-called "education". It just makes the anxiety worse. I have a choice between abortion, suicide or CS. I don't tell you how to birth--leave those of us who can't handle anything else alone. We don't want your feedback or sympathy or condemnation. Just let us have what we need in peace.

  16. I don't think that the insurance provider should have to pay for a surgery that is not medically needed. So if a woman wants an elective c-section, and wants to pay for it out of pocket and finds a doctor willing to do it, then go for it.


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