The American College of Obstetricians and Gynecologist Committee on Ethics just published Refusal of Medically Recommended Treatment During Pregnancy. The update to the 2005 Committee Opinion Number 321 reaffirms in no uncertain terms that a woman has the right to refuse any recommended treatment or intervention despite the fact that it may create an ethical dilemma for her obstetrician–gynecologist.
With regard to pregnancy and childbirth, a physician may feel strongly that not following through with his or her recommendation may put the expectant mother or her baby at risk but, ACOG emphasizes that it is the caregiver’s ethical obligation to “safeguard the pregnant woman’s autonomy.”
A U.S. national survey of healthy, low-risk pregnant women with a prior cesarean reported that almost 9 out of 10 physicians strongly recommended a routine repeat cesarean to their patients rather than laboring for a VBAC. Many women felt they had no choice but to comply. Healthy pregnant women’s informed decisions to refuse routine hospital policies such as continuous fetal monitoring and restricting a woman’s movement to the hospital bed have often been denied.
Evidence in the California Maternal Quality Care Collaborative Toolkit to Support Vaginal Birth and Reduce Primary Cesareans indicates that when used routinely, without evidence of improved outcomes, both labor and delivery policies can increase the risk of an avoidable cesarean.
The following are highlights of the Committee on Ethics recommendations:
Informed refusal is the corollary of the doctrine of informed consent; it is an ongoing process of mutual communication between the patient and the physician and enables a patient to make an informed and voluntary decision about accepting or declining medical care.
Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.
Obstetrician–gynecologist’s actions should be guided by the ethical principle that adult patients who are capable decision makers have the right to refuse recommended medical treatment.
Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.
Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.
Intervention on behalf of the fetus must be undertaken through the pregnant woman’s body. Thus, questions of how to care for the fetus cannot be viewed as a simple ratio of maternal and fetal risks but should account for the need to respect fundamental values, such as the pregnant woman’s autonomy and control over her body.
(The) patient should be reassured that her wishes will be respected when treatment recommendations are refused.
ACOG’s document also outlines various recommendations to improve physician/patient relationship, develop patient trust and communicate effectively. Refusal of Medically Recommended Treatment During Pregnancy reinforces existing national and international policies and human rights protections to include all patients in the decision-making process and respect their individual values and cultural beliefs.
The concepts of respectful maternity care, and childbirth rights specifically are two of the most prominent issues that expectant women and birth advocates are currently talking about.