Introduction

Ethics provides essential guidance to obstetricians for offering, recommending, recommending against, and performing cesarean delivery, which is the most common and important intervention in obstetric practice. Drawing on our previous work, we present the professional responsibility model of obstetric ethics . We will deploy this model to address two especially ethically challenging clinical topics in cesarean delivery: patient-choice cesarean delivery and trial of labor after cesarean delivery .

A distinctive of this chapter will be its emphasis on a preventive ethics approach . Preventive ethics, a concept pioneered by the authors , is designed to prevent ethical conflict in clinical practice. To achieve this goal, a preventive ethics approach uses the informed consent process to offer cesarean delivery as a medically reasonable alternative to vaginal delivery, to recommend cesarean delivery when it is justified to do so, to recommend against cesarean delivery when it is justified to do so, and to engage in shared decision making when it is justified to do so . The professional responsibility model of obstetric ethics guides this multi-faceted preventive ethics approach.

Professional responsibility model of obstetric ethics

In our chapter on “Ethical Dimensions of the Fetus as a Patient,” we have defined ethics and medical ethics, the ethical principles of beneficence and respect for autonomy, and the ethical concept of the fetus as a patient. The professional responsibility model of obstetric ethics incorporates these concepts and principles . This model provides an antidote to the rights-based reductionism that characterizes much of the literature on perinatal ethics . This oversimplification in the context of cesarean delivery occurs when the only or overriding ethical consideration is the unlimited rights of the pregnant woman . This is woman’s-rights-based reductionism in obstetric ethics, which the professional responsibility model rejects .

We do not deny that appeal to the pregnant woman’s unlimited rights has an initial appeal, largely because of its simplicity: a pregnant woman has the unconditional right to control what happens to her body. This initial simplicity, however, does not withstand close scrutiny. Asserting the pregnant woman’s unlimited rights is not just simple but simplistic, because it ignores professional integrity, which can set justified limits on the preferences of pregnant women . For example, a distraught woman who is thirty-four weeks pregnant reports that her husband has deserted her and insists on induced abortion immediately. The professional responsibility model creates an ethical obligation of her obstetrician not to implement her request because feticide is ruled out by the obstetrician’s beneficence-based obligation to protect the life of this fetal patient. The obstetrician should therefore recommend against feticide and explain that no conscientious obstetrician should implement her request. There are many such circumstances in which a pregnant woman’s request for an induced abortion should not be implemented unquestioningly.

The woman’s-rights-based reductionism approach has been advocated in the obstetric ethics literature. This approach asserts an unconditional right of the pregnant woman to control her body in all aspects of the management of pregnancy, including the performance of cesarean delivery: “ … the moral and legal primacy of the competent, informed pregnant woman in decision making is overwhelming” . Another expression of this approach seems to be non-reductionist, but only at first. Its authors state that patient safety as a “first-order issue” and support what they call “restrictive guidelines” based on protecting the life and health of pregnant women . This seemingly more nuanced approach, however, is then abandoned in favor of the woman’s-rights-based reductionist model when the authors go on to assert: “Crucially, even when restrictive guidelines are warranted the rights of pregnant women to bodily integrity must be maintained” . Some express this approach explicitly, e.g., that “women have fully endowed rights that do not diminish with conception, nor progressively degrade as pregnancy advances to viability and birth” . The woman’s-rights reductionism approach has been used to claim the right of pregnant women to have a clinically non-indicated cesarean delivery . Another example is the assertion of the pregnant woman’s autonomy as an “unrestricted negative right,” i.e., an unconditional right to non-interference with refusal of cesarean delivery: “autonomy is an inter-relational right – ultimately there is no circumstance in which someone should be brought to an operating room against their will” .

Womens-rights-based reductionism in obstetric ethics undermines the professional nature of the relationship of an obstetrician to his or her patients . The professional obligations of the obstetrician originate in the ethical concept of medicine as a profession. This concept was introduced into the history of medicine by Drs. John Gregory (1724–1773) of Scotland and Thomas Percival (1740–1804) of England. This concept is based on three commitments of physicians: (1) becoming and remaining scientifically and clinically competent; (2) protecting and promoting the health-related and other interests of the patient as the physician’s primary concern and motivation; and (3) preserving and strengthening medicine as what Percival called a “public trust,” a social institution that exists primarily for the benefit of society not its members (in contrast to the concept of medicine as a merchant guild) .

In the professional responsibility model obstetricians have beneficence-based an autonomy-based obligations to the pregnant patient and beneficence-based obligations to the fetal patient . Beneficence-based obligations are a direct function of evidence-based clinical judgment about diagnostic and therapeutic measures that are reliably expected to result in a greater balance of clinical goods over clinical harms for patients. The pregnant woman’s autonomy is empowered by offering or recommending medically reasonable alternatives, i.e., clinical management that is technically possible and supported in beneficence-based clinical judgment. That a form of clinical management is technically possible does not, by itself, make that form of clinical management medically reasonable. As a beneficence-based concept, medical reasonableness is not based on the preferences of the pregnant woman, especially when they are poorly informed or uninformed.

The contrast of the professional responsibility model with women’s-rights-based reductionism is stark. Women’s-rights-based reductionism is a failure, because it requires the obstetrician without question or objection to implement birth plans that unconditionally exclude cesarean delivery or the unconditional right to planned home birth. Women’s-rights-based reductionism eliminates the obstetrician’s beneficence-based obligations to the pregnant patient and therefore reduces the obstetrician to a mere technician or even automaton. This reductionist approach also has absurd implications, e.g., ruling out, as potential paternalism, strongly and repeatedly recommending that pregnant women who abuse tobacco and alcohol seek help and be supported in doing so. Respect for the pregnant woman’s rights allows simply accepting such clinically choices by patients because they have made autonomous choices. Once such choices have been made, that they are clinically unnecessarily risky is of no concern on the reductionist approach. This is abandonment from the perspective of professional responsibility for patients. Women’s-rights-based reductionism, despite its initial simplicity and powerful appeal for many, is unacceptable because it leads obstetric ethics to conceptual and clinical failure. This reductionism therefore should be abandoned in obstetric ethics and practice.

Professional responsibility model of obstetric ethics

In our chapter on “Ethical Dimensions of the Fetus as a Patient,” we have defined ethics and medical ethics, the ethical principles of beneficence and respect for autonomy, and the ethical concept of the fetus as a patient. The professional responsibility model of obstetric ethics incorporates these concepts and principles . This model provides an antidote to the rights-based reductionism that characterizes much of the literature on perinatal ethics . This oversimplification in the context of cesarean delivery occurs when the only or overriding ethical consideration is the unlimited rights of the pregnant woman . This is woman’s-rights-based reductionism in obstetric ethics, which the professional responsibility model rejects .

We do not deny that appeal to the pregnant woman’s unlimited rights has an initial appeal, largely because of its simplicity: a pregnant woman has the unconditional right to control what happens to her body. This initial simplicity, however, does not withstand close scrutiny. Asserting the pregnant woman’s unlimited rights is not just simple but simplistic, because it ignores professional integrity, which can set justified limits on the preferences of pregnant women . For example, a distraught woman who is thirty-four weeks pregnant reports that her husband has deserted her and insists on induced abortion immediately. The professional responsibility model creates an ethical obligation of her obstetrician not to implement her request because feticide is ruled out by the obstetrician’s beneficence-based obligation to protect the life of this fetal patient. The obstetrician should therefore recommend against feticide and explain that no conscientious obstetrician should implement her request. There are many such circumstances in which a pregnant woman’s request for an induced abortion should not be implemented unquestioningly.

The woman’s-rights-based reductionism approach has been advocated in the obstetric ethics literature. This approach asserts an unconditional right of the pregnant woman to control her body in all aspects of the management of pregnancy, including the performance of cesarean delivery: “ … the moral and legal primacy of the competent, informed pregnant woman in decision making is overwhelming” . Another expression of this approach seems to be non-reductionist, but only at first. Its authors state that patient safety as a “first-order issue” and support what they call “restrictive guidelines” based on protecting the life and health of pregnant women . This seemingly more nuanced approach, however, is then abandoned in favor of the woman’s-rights-based reductionist model when the authors go on to assert: “Crucially, even when restrictive guidelines are warranted the rights of pregnant women to bodily integrity must be maintained” . Some express this approach explicitly, e.g., that “women have fully endowed rights that do not diminish with conception, nor progressively degrade as pregnancy advances to viability and birth” . The woman’s-rights reductionism approach has been used to claim the right of pregnant women to have a clinically non-indicated cesarean delivery . Another example is the assertion of the pregnant woman’s autonomy as an “unrestricted negative right,” i.e., an unconditional right to non-interference with refusal of cesarean delivery: “autonomy is an inter-relational right – ultimately there is no circumstance in which someone should be brought to an operating room against their will” .

Womens-rights-based reductionism in obstetric ethics undermines the professional nature of the relationship of an obstetrician to his or her patients . The professional obligations of the obstetrician originate in the ethical concept of medicine as a profession. This concept was introduced into the history of medicine by Drs. John Gregory (1724–1773) of Scotland and Thomas Percival (1740–1804) of England. This concept is based on three commitments of physicians: (1) becoming and remaining scientifically and clinically competent; (2) protecting and promoting the health-related and other interests of the patient as the physician’s primary concern and motivation; and (3) preserving and strengthening medicine as what Percival called a “public trust,” a social institution that exists primarily for the benefit of society not its members (in contrast to the concept of medicine as a merchant guild) .

In the professional responsibility model obstetricians have beneficence-based an autonomy-based obligations to the pregnant patient and beneficence-based obligations to the fetal patient . Beneficence-based obligations are a direct function of evidence-based clinical judgment about diagnostic and therapeutic measures that are reliably expected to result in a greater balance of clinical goods over clinical harms for patients. The pregnant woman’s autonomy is empowered by offering or recommending medically reasonable alternatives, i.e., clinical management that is technically possible and supported in beneficence-based clinical judgment. That a form of clinical management is technically possible does not, by itself, make that form of clinical management medically reasonable. As a beneficence-based concept, medical reasonableness is not based on the preferences of the pregnant woman, especially when they are poorly informed or uninformed.

The contrast of the professional responsibility model with women’s-rights-based reductionism is stark. Women’s-rights-based reductionism is a failure, because it requires the obstetrician without question or objection to implement birth plans that unconditionally exclude cesarean delivery or the unconditional right to planned home birth. Women’s-rights-based reductionism eliminates the obstetrician’s beneficence-based obligations to the pregnant patient and therefore reduces the obstetrician to a mere technician or even automaton. This reductionist approach also has absurd implications, e.g., ruling out, as potential paternalism, strongly and repeatedly recommending that pregnant women who abuse tobacco and alcohol seek help and be supported in doing so. Respect for the pregnant woman’s rights allows simply accepting such clinically choices by patients because they have made autonomous choices. Once such choices have been made, that they are clinically unnecessarily risky is of no concern on the reductionist approach. This is abandonment from the perspective of professional responsibility for patients. Women’s-rights-based reductionism, despite its initial simplicity and powerful appeal for many, is unacceptable because it leads obstetric ethics to conceptual and clinical failure. This reductionism therefore should be abandoned in obstetric ethics and practice.