Bioethics Case Study: A 28-year-old Woman Presents in Active Labor

A 28-year-old Somali woman, G2P1, full term, presents in active labor. After several hours of labor, the fetal monitor indicates increasing fetal distress. The obstetrician recommends Cesarean section. The patient refuses a Cesarean, stating that her first baby was delivered Cesarean because her obstetrician estimated the baby was too large to safely deliver via vaginal birth. The surgery was very traumatic for the patient, and her baby was normal weight, so she does not believe the doctors when they advise her she needs another Cesarean. She repeatedly verbalizes, “My baby will be fine. I trust God.” Her husband is present, but he defers to his wife’s wishes. She continues in active labor for another 17 hours, with the fetal monitor continuing to show evidence of severe fetal distress.

Can the physician force the patient to have a Cesarean section in order to protect the baby?

Once a patient has refused a Cesarean section despite the physician’s best efforts to clearly explain the situation, the obstetrician has three options:

1. Respect the patient’s autonomy and not proceed, regardless of the outcome;
2. Offer the patient the option of seeking her care from a different provider (except in an emergency situation);
3. Request the involvement of the court.

Rarely, physicians have resorted to obtaining a court order to proceed with a Cesarean section when the mother is refusing. A landmark case, In re A.C., the D.C. Court of Appeals overturned a previous court ordered authorization of Cesarean delivery, saying that if a competent pregnant woman makes an informed decision, “her wishes will control in virtually all cases.” In this case, the parents sought the appeal after their daughter, Angela Carter, died as a result of a Cesarean section mandated by court order in 1987. The courts made this determination based on the fact that medical judgment is fallible. There is no certainty in predicting a bad outcome. Fetal monitors are fallible, and the physician cannot guarantee that performing a Cesarean will result in a good outcome with no harm to the mother.

Historically, forcing a mother to have a cesarean without her consent occurred with much greater frequency among low-income, African American patients. This lead to suspicion that decisions to force Cesareans were carried out in an unjust, biased manner. This practice became ethically and legally unacceptable.

The ethical values at conflict in this case are respect for the mother’s autonomy vs. beneficence for the fetus, as well as the value of justice, or equal treatment. Physicians must respect a patient’s right to refuse treatment regardless of how likely it is that the treatment would benefit the patient or another individual. This respect for autonomy is extended to pregnant women just as it is to any non-pregnant person. This also exemplifies the ethical value of justice, or equal and fair treatment. Physicians cannot force a treatment or procedure on one person in order to benefit another person. For example, a physician cannot force a person to be a kidney donor, even if the donation would benefit that person’s own child.

In this case, the mother was determined to have decision-making capacity. After the additional 17 hours of labor, she was very reluctantly persuaded to consent to the Cesarean section. Unfortunately, her baby did not survive.