Abstract
In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.
Highlights
Cesarean delivery on maternal request (CDMR), patient choice cesarean, or cesarean on demand all refer to elective caesarean section (CS) for singleton term pregnancy carried out on maternal request in the absence of maternal or fetal indications [1]
Concerns about legal consequences linked to complications of vaginal delivery were mentioned in all countries, less often in the Netherlands (30%) and Sweden (31%)
The view that vaginal birth is preferable in the absence of medical indications for CS is evidence of the weight given to medical utility, a concept encompassing calculations of risk and benefit as well as concerns for optimising the use of resources
Summary
Cesarean delivery on maternal request (CDMR), patient choice cesarean, or cesarean on demand all refer to elective caesarean section (CS) for singleton term pregnancy carried out on maternal request in the absence of maternal or fetal indications [1]. According to recent reviews [1,10,12], conclusive evidence on the risks and benefits of CDMR compared to vaginal birth is lacking. A case has been made for a standardized definition of CDMR and for research to validly compare CDMR with planned, rather than actual, vaginal birth [12,13,18]
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