Court-authorised caesarean section.

Abstract

Competent adults have the right to make their own decisions regarding treatment. A competent adult has the ability to understand the relevant information, retain it, weigh it up and communicate the decision. Every adult is presumed to be competent, but this presumption can be rebutted. An adult may lack capacity as a result of neurodevelopmental handicap, mental illness or unconsciousness. In these cases, it is clear that the health professional has to act in the patient's ‘best interests’. The difficulty arises in other cases in which capacity is temporarily absent because of confusion, fatigue, pain, drugs or panic induced by fear. The issue here is that, although a decision made by a competent adult does not have to be rational, irrationality could indicate incompetence. Further, doctors and lawyers could hasten to declare a patient incompetent if any of the aforesaid factors is present. Doctors’ concern for fetal wellbeing may conflict with a woman's right to self-determination. These issues are illustrated by USA and UK caesarean section (CS) cases. In the US case Doe v Doe 1994, the Illinois Appellate Court upheld the right of a woman who declined CS on religious grounds. The court discountenanced the argument that concern for fetal wellbeing should override the woman's right. Prior to this case, however, there had been cases of court-authorised caesarean delivery for fetal indication – such as Jefferson v Griffin Spalding County Hospital Authority 1981. Both the American College of Obstetricians and Gynecologists and the American Medical Association state that the woman has the final decision on CS. Nevertheless, a Florida court took a contrary view in Pemberton v Tallahassee Memorial Regional Medical Center 1999 – a case of previous classical CS. The position of the UK courts has evolved. In Re S (adult: refusal of treatment) 1992, the mother declined CS for religious reasons. At a lunchtime hearing, the court authorised delivery. This sparked an animated debate among legal and social commentators. Nevertheless, CS was imposed on non-consenting women in further cases: Norfolk and Norwich Healthcare NHS Trust v W 1997; Tameside and Glossop Acute Services Trust v CH 1996. In the latter, it was held that CS on a schizophrenic woman could be regarded as ‘treatment’ under the Mental Health Act 1983. The issue was revisited in Re MB (an adult: medical treatment) 1997. The Court of Appeal affirmed the unqualified right of a competent woman to decide whether or not to accept CS, regardless of the risk to her baby or herself. It declared, however, that this woman was incompetent because of a fear of needles (her reason for refusing the operation). In St George's Healthcare NHS Trust v S 1998, the woman was detained under s.2 of the Mental Health Act and CS was performed under a court order, but she appealed against this decision. Her appeal was upheld and the use of mental health legislation to enforce obstetric treatment was deplored. The court reaffirmed the position that a competent pregnant woman has the right to refuse medical intervention. The author declares there are no conflicts of interests.