Designer Obstetrics: Cesarean Section on Demand

Should women be able to request a cesarean section to deliver their baby just because they can?

Cesarean Section on demand is defined as a primary or first cesarean section at the request of the mother in the absence of any medical or obstetrical indication. A cesarean section is usually done for maternal or fetal reasons in accordance with accepted medical practice and guidelines set forth by the American College of OB/GYN (ACOG). An electively requested cesarean section in an uncomplicated pregnancy has traditionally been considered inappropriate and not done by most obstetricians. However, in recent years this belief has been challenged and more obstetricians are honoring their patients decisions. ACOG, in their committee opinion No. 394, December 2007, outlines the most recent guidelines when confronted with cesarean delivery on maternal request.

There are risks and benefits for both planned a vaginal birth and for cesarean section. Some mothers requesting cesarean section rather than proceeding with a planned vaginal birth do so because they believe that a vaginal birth will cause damage to the pelvic floor. Later in life this could contribute to urinary/fecal incontinence and pelvic organ prolapse. Others opt for cesarean section because they fear the pain of labor and delivery. While others prefer the convenience of a scheduled delivery. The strongest argument against a cesarean section are problems that can arise in future pregnancies. Subsequent pregnancies following a primary cesarean section have increased rates of placental abnormalities (placenta previa, accreta and increta), uterine rupture, hemorrhage and gravid hysterectomy. Nationwide because of the overall increasing rates of primary cesarean sections and the repeat cesarean sections the rates of these life threatening complications have been on the rise.

Ethically, the question we obstetricians face is "which ethical principle should triumph - patient autonomy or non-maleficence?" Should the patient's right to autonomy be respected, after being advised and explained all the risks, benefits and alternatives, that is after informed consent is obtained? On the other hand should the physician as healer respect the principle of non-maleficence, "first do no harm" and so, refuse to accede to a patient's demand?

[Aycan Turkmen, MD, is an obstetrician/gynecologist and a guest blogger for the Women's Bioethics Blog.]

NYS Supreme Court Case Stirs Ethical Debate

As is being being reported in numerous outlets, the NYS Supreme Court will be hearing a civil case filed against NewYork-Presbyterian Hospital by a construction worker who underwent an involuntary rectal examination as part of his trauma assessment. The plaintiff is claiming assault, battery, and false imprisonment for being restrained, sedated, and examined against his wishes. The hospital's response, of course limited due to HIPAA requirements, is that the plaintiff was brought to the ER with head trauma, was combative, and needed to have severe head trauma ruled out. (Apparently a rapid way to assess injury to the nerves of the spinal cord is to check rectal sphincter tone.) The plaintiff resisted, was sedated, and when brought out of sedated, punched a doctor in anger, and was arrested for assault.

None of this in itself is particularly new or newsworthy; it is a continuing debate of what constitutes emergency care, standard care, informed consent, and what it means to have decision making capacity. These debates have been going on for years, and will likely continue for as long as any of us can envision.



No, the interesting thing actually comes from the commentary at City Room, the NYTimes local blog. Reading through the comments gives an eye-opening view into the way the general public perceives medicine, emergency medical care, and doctors. The most fascinating, and oft-repeated claim, is that if the patient (plaintiff) could be be arrested for assault, then he was obviously competent to decide his medical care - that, as one commenter put it,

if the patient’s competence is questioned regarding his ability to make an informed decision, then it’s inconsistent to charge that same incompetent person with assault.

Of course, the best retort to that (also brought up in comments) is that a drunk person is not competent to make decisions - yet is still responsible for the actions they take while drunk. (Also of note is that no one claiming specific background and training in medical ethics has spoken up in the thread. For those of you reading this, with the limited information available, what's your take on the situation?)

Obviously the message of personal autonomy and the basic idea of informed consent has permeated our society, but at a very simplistic level that might actually cause more misunderstanding and difficulty when treating emergency medical cases than potential good. The question becomes then, how do we increase the general knowledge level of the lay person while still emphasizing autonomy, while simultaneously acknowledging the education and superior knowledge of the physician without falling back on paternalism?

For anyone interested in this line of thought, the comments in that thread are well worth the read, and the contemplation.
-Kelly