Caesarean section should be available on request: FOR: Responding professionally to requests for non‐indicated caesarean delivery

Abstract

Obstetricians should respond professionally to requests for non-indicated cesarean delivery (CD). The professional responsibility model of obstetric ethics provides guidance for doing so (Chervenak et al. Am J Obstet Gynecol 2011;205:315.e1–5). This approach to obstetric ethics avoids the gridlock that results when obstetric ethics based primarily on fetal rights collides with obstetric ethics based primarily on maternal rights. The professional responsibility model is based on the ethical concept of medicine as a profession, introduced into the history of medicine by two British physician-ethicists, John Gregory (1724–1773) of Scotland and Thomas Percival (1740–1804) of England. This concept requires physicians to become and remain scientifically and clinically competent, to use their knowledge and skills primarily for the benefit of the patient, and to keep individual and guild self-interest systematically secondary. The ethical principles of beneficence (undertake clinical management, the outcomes of which are reliably expected to be clinically beneficial) and respect for autonomy (empower the pregnant woman to make informed decisions about the clinical management of her pregnancy) translate this concept into clinical practice. The obstetrician has beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetus when it is a patient (McCullough and Chervenak, Ethics in Obstetrics and Gynaecology, New York: OUP; 1994). Because the viable fetus is a patient, the ethics of CD requires balancing of obligations the pregnant and fetal patient (Chervenak and McCullough, Best Pract Res Clin Obstet Gynaecol 2013;27:153–64). In the professional responsibility model of obstetric ethics, the pregnant woman is ethically obligated to take reasonable risks to her life and health for fetal benefit, when there is a reliable evidence base for such benefit. Requests by patients for clinical intervention do not, in themselves, create an ethical obligation to fulfill such requests without careful evaluation of them, to ensure that acting on them is consistent with professional integrity (Brett and McCullough, JAMA 2012;307:149–50). Professional integrity requires that implementing such requests will result in net clinical benefit to the patient. There is no net clinical benefit from non-indicated CD (Minkoff and Chervenak, New Engl J Med 2003;348:946–50). The beneficence-based and integrity-based professional responsibility of the obstetrician is to respond to requests for non-indicated CD with a recommendation against it and for vaginal delivery. Non-directive counselling, i.e., offering both modes of delivery as if both passed muster in beneficence-based clinical judgment, is ruled out by the professional responsibility model. These recommendations should be explained to the pregnant woman and discussed with her in the informed consent process. Obstetricians should take a preventive ethics approach to decision-making, raising it as a possibility and making decisions about it well in advance of the intrapartum period (Chervenak and McCullough, Am J Obstet Gynecol 2013;209:166–7). In rare cases, the pregnant woman will not accept the recommendation of vaginal delivery when CD is not indicated and will reiterate her request for the latter. It is ethically permissible to implement an informed, reflective decision for non-indicated CD. None declared. ■