1.Consent and refusal
8. Maternal-fetal conflicts: Cesarean delivery on maternal request
Ruth Landau and Steve Yentis
Jane and Jim, successful lawyers in their mid-forties, are expecting their first child. Immediately after they learned that their 4th in-vitro fertilization attempt was successful, they decided to request a Cesarean delivery. At 36 weeks, Jane and Jim confirm again their desire to have a ‘maternal request’ Cesarean section and ask for the Cesarean delivery to be performed the following week at 37 weeks’ gestation to accommodate Jim’s busy agenda. In addition, Jane is adamant she wants to have a general anesthetic due to her fear of experiencing any kind of discomfort or pain during the Cesarean section.
Until recently, debate around the indications for and choice of Cesarean section have focused on rights of women to refuse a Cesarean section when urgent delivery is medically indicated. In terms of the “principlism” (four principles) approach to ethical analysis, this debate has highlighted the balance between the obligations of the obstetrician to both the mother and fetus and obligations of the mother to the fetus, based on beneficence and non-maleficence, and the duty to respect the mother’s autonomy. Legally, many courts recognize an absolute right of women with capacity to refuse medical treatment even when that decision may result in their death or the death of their baby. Doctors have duties to respect a woman’s autonomy and obligations to inform fully, counsel honestly, and avoid coercion.
Recently, a new phenomenon has emerged in which patients demand a cesarean section. More women are switching their birth plan from a “natural childbirth/no epidural” perspective towards a more “controlled”, medicalized or surgical childbirth. What ethical implications does this growing phenomenon have for clinicians?
Cesarean section upon maternal request
Cesarean section rates are rising in developed countries. Reasons include a decline in vaginal births after previous Cesarean delivery, a decline in vaginal breech deliveries, and a reluctance among many obstetricians to “risk” a vaginal delivery when labor is not straightforward. The number of Cesarean deliveries at maternal request (CDMR) – i.e., in the absence of any medical or obstetrical indications – has been increasing, accounting for 48–18% of all Cesarean deliveries.1 An independent panel of the National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the National Institutes of Health (NIH) reviewed CDMR in 20062 and drew the following conclusions.
(1) The incidence of cesarean delivery without medical or obstetrical indications is increasing in the US, one component of which is CDMR.
(2) There is insufficient evidence to fully evaluate the benefits and risks of CDMR compared to planned vaginal delivery. More research is needed.
(3) Until evidence becomes available, the decision to perform CDMR should be individualized and consistent with ethical principles.
(4) The risks of placenta previa and accreta rise with each Cesarean delivery, and CDMR is not recommended for women desiring several children.
(5) CDMR should not be performed before 39 weeks’ gestation or without verification of lung maturity because of the significant danger of neonatal respiratory complications.
(6) Unavailability of effective labor pain options should not influence the decision to perform CDMR.
Ethical considerations for CDMR go beyond the principles of respect for autonomy and beneficence/ non-maleficence. They include issues of resource allocation and the impact of CDMR on healthcarecosts (i.e., the principle of justice) as well as idealistic and philosophical reflections on future societal implications if Cesarean deliveries become the norm.
CDMR from the mother’s perspective
Common reasons reported by women requesting a cesarean delivery are fear of labor pain and stress; uncertainty of outcome; fear of emergency intervention such as forceps; fear of fetal distress during labor; fear of future sexual dysfunction, stress incontinence or pelvic prolapse; and convenience. Ultimately, women may invoke a right to have their autonomy respected, and to participate in all decisions related to their healthcare; in other words, if an informed woman wants a cesarean delivery, she should have the right to request a cesarean delivery regardless of any medical risk that her decision may inflict on her or her baby.
Respect for patient autonomy requires that a patient be fully informed about the benefits and the risks of a recommended treatment, and then has the right either to consent to the treatment or refuse it. But broadening this principle to create an obligation to respect a patient request for treatment that is not recommended and might even be harmful stretches the concept of patient autonomy to a point that many ethicists and lawyers believe goes beyond what is reasonably acceptable within the usual doctor–patient relationship. In the UK, non-obstetrical patient treatment requests have been tested in the courts, which have confirmed that doctors are not legally or ethically obliged to provide treatment requested by a patient if they consider it not in his/her best interests.3
With CDMR, the situation is further complicated by the involvement of a third party – the fetus. A woman may desire CDMR to avoid a complicated vaginal delivery that may be harmful not only to herself but also to her baby. Furthermore, the risk of a primigravidae requiring an urgent unplanned cesarean delivery during labor are significant – approximately 10%–20%. Cesarean section following a prolonged trial of labor involves higher maternal morbidity than a scheduled Cesarean, due to increased risk of uterine atony and hemorrhage. For the baby, a scheduled Cesarean delivery may reduce risks, such as reduced availability of neonatal resuscitative measures, associated with a possible “out of office hours” delivery. Indeed, concern for the baby is one of the most common motivations cited by women requesting CDMR.4
Autonomy of decision-making implies that the benefits and risks are known, disclosed and discussed. In the case of CDMR, this may not be entirely possible. Evidence on the risks and benefits of CDMR in low risk pregnant women has never been entirely assessed, leading the NIH to call for more randomized clinical trials.
CDMR from the fetus’s perspective
The concept of “fetal rights” contributes to a notion that the pregnant woman and her fetus are potential adversaries. Much of the debate around “fetal rights” has been in the context of abortion, an area of great political, ethical, and legal controversy. The fetus is in an intermediate ethical, and legal position. Lacking capacity, it cannot have autonomy. Furthermore, the fetus is dependent for its well-being on the choices made by the mother. In UK and Canadian common law “the fetus does not have legal rights until it is born alive and with complete delivery from the body of the pregnant woman.”5 If a competent woman refuses medical advice, her decision must be respected even if the doctor believes that her fetus will suffer as a result. According to the ACOG Committee on Ethics6:
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.
Regarding CDMR, the fetus’s best interests are usually considered in terms of the risks of prematurity and trauma if delivered by elective cesarean section, weighed against the risks of injury arising from difficult delivery, emergency intervention, or post-maturity.
In the case of Jane and Jim, CDMR is particularly controversial because they request it at 37 weeks’ gestation. Compelling evidence concludes that neonatal outcomes are improved if Cesarean delivery is delayed until 39 weeks.7 The risks should clearly be presented to Jane and Jim as well as the option to perform fetal lung tests prior to scheduling the surgery.
CDMR from the doctor’s perspective
Do doctors have the choice whether or not to perform a CDMR ?
Principles of beneficence and nonmaleficence are particularly challenging with CDMR, since they must balance benefits and harms for both mother and baby in a situation where (1) there is a lack of reliable authoritative data, (2) physicians’ own personal views may vary widely, and (3) there is heated political as well as medical debate.
The most compelling arguments against performing an elective Cesarean section relate to complications. To reduce fetal morbidity, CDMR should at least not be performed before fetal lung maturation has been established, and therefore should not be scheduled before 39 weeks’ gestation. Data regarding maternal morbidity are generally based on nonscheduled procedures in women with medical and obstetrical conditions that both increase risks and may require general rather than regional anesthesia. Data for maternal morbidity following scheduled procedures are few. In addition, maternal risks are known to increase with successive Cesarean sections. From a nonmaleficence perspective, therefore, CDMR risks to future pregnancies must be thoroughly examined and discussed.
Should obstetricians ever be compelled to provide a Cesarean delivery they do not believe to be medically necessary? Most doctors believe that professional autonomy protects them from providing such therapy, and ensures their “clinical freedom.” There are cases (e.g., abortion) in which doctors are excused from obligations to provide treatment to which they have a moral or religious objection. Obstetricians might argue it is against their moral integrity to perform a nonindicated surgical procedure such as a CDMR. However, as reinforced in the UK by the Burke ruling,8 a much stronger argument may be one based on risks and benefits and the interests of the patient(s), rather than one based on physicians’ personal morals. In the UK, National Institute for Health and Clinical Excellence (NICE) guidelines suggest that doctors have the right to “decline a request for a caesarean section in the absence of an identifiable reason.”9
What do obstetricians believe?
Surveys show disagreement among obstetricians regarding CDMR, and that a significant proportion of obstetricians would either choose CDMR for themselves or their partners and/or would comply with women’s requests. Their reasons include fears of complications of vaginal delivery, desires to avoid medicolegal consequences if such complications develop after refusing to perform CDMR, and desires to respect women’s autonomy. In a survey involving eight European countries and over 1500 obstetricians, wide differences in culture and case law appeared to account for variation in compliance with a woman’s request for CDMR, which ranged from 15% (Spain) to 79% (UK).10 A survey of ACOG members found that of 699 respondents, just over half believed that women had the right to CDMR and a similar proportion had complied with such a request.11
CDMR from a public health perspective
In a world of finite resources, we might question the ethics (distributive justice) of promoting CDMR as a standard of care to endorse women’s autonomy when millions of citizens do not have access to even basic health coverage. If healthcare resources are diverted to increased Cesarean deliveries, theoretically such resources will not be available to others. Should individual women therefore bear financial responsibility for their CDMR just as they do for other “non-medically” indicated procedures such as cosmetic surgery? Limiting CDMR to women able to afford the extra cost of surgery, however, creates another inequality in healthcare access. How would this model take into account the percentage of women who ended up with an urgent, complicated, and costly unplanned Cesarean delivery after a failed trial of labor and delivery?
Finally, how do we anticipate the true cost of CDMR when most studies assessing such costs compare vaginal deliveries with all cesarean sections, including those with sicker women and/or babies? Taken to an extreme, if all women who wanted CDMR obtained it, the need for labor and delivery rooms, and the incidence of lengthy failed labors, urgent instrumental or cesarean deliveries would significantly decline, potentially being replaced by a less costly obstetrical practice. Although cesarean section without labor would seem to be more expensive than uncomplicated vaginal delivery, studies attempting to compare such costs are often methodologically flawed, involve few randomized trials, are plagued by inadequate power, and often omit important considerations including costs accruing to patients.
Other societal issues not directly related to costs include the medicalization of childbirth and a paradoxical transfer of power from women to the medical profession if CDMR becomes the norm.
CDMR from the anesthesiologist’s perspective
The anesthesiologist probably would not have been directly involved in the patient’s and obstetrician’s decisions regarding mode of delivery. However, one of the reasons cited by women choosing CDMR is fear of pain during labor and delivery, and adequate information and access to optimal labor analgesia may be crucial in shaping this discussion. Anesthesiologists are obliged to inform women that early neuraxial analgesia is safe and available. For women who fear loss of control, access to low-dose neuraxial labor analgesics with patient-controlled epidural analgesia (PCEA) may be one way to “avoid” a CDMR. Pain during and after Cesarean section is a major concern for women, and these issues also need to be addressed.
At minimum, the following information regarding general anesthesia should be discussed with Jane and Jim:
Maternal risks of general anesthesia
Anesthesia-related maternal mortality, though low, has been associated with difficult airway management and aspiration during induction of anesthesia and recovery.12 However, these risks are clearly increased when patients are obese and surgery is unplanned and urgent, mitigating this concern when it is applied to elective surgery.
Risk of pain after Cesarean delivery
A woman who requests a general anesthetic to avoid all pain and discomfort during Cesarean section should be informed that the gold standard for post-Cesarean analgesia, neuraxial opioids, cannot be administered. The clear association of severe acute post-delivery pain, post-partum depression, and chronic pain must also be disclosed.
Risk of awareness during general anesthesia
Although the risk of awareness is low, this potentially traumatic and devastating outcome must be disclosed to women who are seeking the utmost comfort and stress-free experience when choosing a CDMR under general anesthesia.
Fetal risks of general anesthesia
A recent study in a cohort of very preterm infants comparing neonatal mortality after epidural, spinal and general anesthesia for cesarean reported no increased risk after general anesthesia when controlling for gestational age.13 However, a large population-based study reported higher neonatal risks with general anesthesia even in scheduled cesarean sections.14 Women therefore need to be informed that the risk for neonatal resuscitation and intubation are potentially higher after general anesthesia than after regional anesthesia.
Long-term effects of general anesthesia on the developing brain have been of growing concern,15 but further studies are necessary before firm conclusions can be drawn regarding the adverse effect of short perinatal exposure to general anesthetics.
Alternative regional anesthesia
In order to make an informed choice the risks of alternatives, including regional anesthesia must also be discussed, including hypotension, inadequate anesthesia requiring conversion to general anesthesia, severe headache, nerve damage, epidural abscess or meningitis, epidural hematoma, and severe injury including paralysis. Benefits such as being awake to bond with the baby, and the opportunity for postoperative neuraxial analgesia should also be presented.
Can the anesthesiologist refuse to participate in CDMR?
Examples of refusal by physicians to provide anesthesia when it conflicts with their personal beliefs include abortions and care of Jehovah’s Witnesses undergoing scheduled surgery. The NICE guidelines give doctors the right to decline a request for a Cesarean section in the absence of an identifiable reason. However, Camman argues that unlike terminations of pregnancies or refusal of blood transfusion by Jehovah’s witnesses, elective Cesarean sections do not have a religious or moral component, since Cesarean section is an accepted medical intervention that does not intentionally result in harm or loss of life.16 Refusal to provide anesthesia based on beneficence and nonmaleficence arguments are therefore stronger than those based on moral objection, although Gass, in a counter to Camman, has argued that there are moral grounds for refusal to participate in CDMR based on the utilitarian need to maximize societal benefit.17
Conscientious objections could be applied to any treatment where the doctor might have personal beliefs that conflict with the patient’s. But rights of physicians to invoke conscientious objection is limited by the (usually) overriding duties to provide patient care. In the UK, the General Medical Council has stated the following18:
You must make the care of your patient your first concern.
You must treat your patients with respect, whatever their life choices and beliefs.
You must not unfairly discriminate against patients by allowing your personal views to affect adversely your professional relationship with them or the treatment you provide or arrange.
If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role.
You must not express to your patients your personal beliefs, including political, religious or moral beliefs, in ways that exploit their vulnerability or that are likely to cause them distress.
(For more on physician conscientious objection, see Chapter 43.)
With regards to the choice of anesthetic, there is no difference between CDMR and any other Cesarean section. It is generally accepted that regional anesthesia is safer and better than general anesthesia. However, there may be cases, such as when the parturient’s anxiety and fear are so great – even if irrational – that her interests are best served by undergoing a general anesthetic.
The authors would personally be agreeable to Jane and Jim’s request to perform a Cesarean section as soon as fetal lung maturity has been established (or at 39 weeks), preferably under regional anesthesia. When the desires of a pregnant woman are in conflict with usual medical indications for treatment or with the best interests of the baby, the following key points should be kept in mind:
• The principle of respect for patient autonomy supports a pregnant woman’s rights to refuse recommended medical treatments, even if such refusal may be detrimental to her or to her fetus. Physicians generally are ethically obliged to honor these rights.
• The obligations of physicians to accede to requests for nonrecommended treatments are less straight forward.
• Principles of beneficence and nonmaleficence require that consideration be given to the maternal benefits against the maternal harms, as well as benefits and harms for the fetus.
• When patients request unnecessary interventions, additional ethical considerations include issues of distributive justice (does CDMR divert healthcare resources away from more basic needs to fulfill the wishes of a few privileged persons, or does it have the potential to reduce health care costs overall by avoiding the costs of complications of more traditional care?).
• Some patient care situations allow physicians to withdraw out of conscientious objection based in personal religious or moral beliefs, but refusing to provide requested and accepted (albeit unnecessary) therapies are better supported by arguments using principles of beneficence and nonmaleficence.
• When a physician objects to providing medical services that are acceptable within the standard of care, they have obligations to transfer the care of such patients to a suitably qualified colleague who can provide such care.
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