A major theme throughout the book, What to Expect When You’re Expecting, seems to be the idea that “Doctor knows best”. While I have great respect for the knowledge and experience of the physicians I have known, I certainly would never be prepared to simply hand over my care unquestioningly. I’ve written before about being mystified by the birth apathy that some of my clients seem to be afflicted with. They want me to make all the decisions and tell them what to do. While I am happy to offer recommendations and advice, I cannot tell a client what to do, because it is not my body.
Jacob Appel, a bioethicist and medical historian wrote eloquently on this topic in a recent article for The Huffington Post online, Medical Kidnapping: Rogue Obstetricians Against Pregnant Women. Speaking of the Samantha Burton case, where a 25-weeks pregnant woman was detained in the hospital on bed rest by court order, he writes:
“Preventing a competent pregnant woman from leaving the hospital under these circumstances is no less egregious than compelling her to have an abortion. Forcing additional intrusive care upon her, such as unwanted vaginal exams or cervical assessments, is legally-sanctioned digital rape.”¹
Compounding the problem of a woman’s right to make choices for her pregnancy and birth is the fact that medical opinion tends to sway back and forth like the proverbial pendulum. Case in point: witness the recommended changes in VBAC policy as outlined at the NIH VBAC conference. So now, the NIH is recommending that the requirement for the physician to be in the hospital for the entirety of a VBAC labor be relaxed. While this is good news, how will it be received by all the women who in very recent years have been denied the option to VBAC, because it was “too dangerous” without the capability for immediate surgery? Did the risks change, or did medical opinion and interpretation of the evidence change?
A woman trying to obtain a “second opinion” often runs into the brick wall of the “good ol’ boys” network, where few physicians will run the risk of ostracism by their peers in order to offer a different opinion. Health care providers become proficient at telling the truth about risks in such a way as to sway the patient’s decision to comply with provider preferences. Informed consent given in this way is not truly informed, even if the risks have been stated.
No doctor is God, nor can s/he know the future or guarantee an outcome. As a pregnant woman, you should NOT expect to have such total trust in your physician or midwife that you stop thinking and asking questions and examining the evidence for what you are told.
A recent situation at a nearby hospital illustrated perfectly for me this principle. An immigrant woman from a culture who shuns surgery for religious and cultural reasons was in labor. Her membranes were artificially ruptured (I wonder if anyone explained to her the potential risks of this procedure and obtained her consent?). Her baby immediately began to show signs of distress, and it was determined that the umbilical cord had prolapsed into the vagina. Birth was not imminent, and the woman refused the provider’s entreaties to have emergency surgery to save the life of her baby. Because of this woman’s beliefs, she could not in good conscience agree to surgery. She was under tremendous pressure and coercion from the staff to consent to surgery–even to the point that her bed was wheeled into the operating room, although she was indicating through a translator her refusal and signed an “Against Medical Advice” form. For the next two hours, heart tones varied from 60 - 120 beats per minutes. Ignoring instructions to remain still, the woman followed her instincts and moved around, even getting up to use the toilet twice.
Amazingly–at least to the medical mind–the baby was born with apgar scores of 7 and 9 and was discharged the next day, with the mother, in good condition.
Had I been in this woman’s position, I would have chosen the c-section, as most of us would; but what a clear picture this is for us that even the best advice of multiple physicians is not necessarily a guarantee of outcome. Only the mother can decide what is best for her body.
1. Retrieved 03/11/2010 from http://www.huffingtonpost.com/jacob-m-appel/medical-kidnapping-rogue_b_434497.html
Booooo. I have retained a mother against her will for the legal 72 hours and then had her committed as the only way to stop her from OD’ing on cocaine again, while she already had a partial abruption, at 25 weeks. Not every mother makes the right decision of what’s best for her body. Also, the provider in the prolapsed cord had a duty to the fetus for a safe delivery. Not watch a potential murder. We cannot bend to every religious rule and you certainly would not approve of female circs by the Taliban as an example. Ignorance of proper care is not a viable reason. There is no difference in this womans religious/cultural declining of a c/section then the scientologist that faces jail for prayer over (not with) antibiotics, praying away the gay, or sacrificing your child as indicated in the old testament. If she wanted the horrid outcomes of a third world country then she should have devlivered there. Why did she even go to the hospital? And just because the horrbly fallible apgars were in the “normal” range there is no guarantee this child slipped by anoxic brain damage. No blood gases? No long term follow up? Seizures at 48 hours? Trust me this once, in a heart beat she can find an attorney that would ask these questions. I have to do what is correct by the child while never sacrificing the mother. Even if it is against her wishes, balancing this with always heeding them. Would you have let the addict go? I am on your side. I just don’t like the ancedotal outcomes without full background held out as a vindication. Treat breast ca at home. Every so often someone might win. Should we trumpet it? Sorry, just a little sensitive on this one.
Later
I would be interested in what other readers think about retaining mothers against their will.
The blood gasses on this baby were obtained and were normal.
I think a very important difference to be noted between circumcision (of females OR males) for religious reasons and refusing surgery for religious reasons is that in the first case, the religion is being imposed soley on another person.
In the case of cesarean surgery, the person who holds to the religion–the mother–is the one is going to be impacted the hardest. Do not be fooled–a woman who looses her baby to death suffers, and suffers HARD, so don’t think that a woman refuses cesarean on religious grounds “easily.”
A father would NEVER be legally compelled to give his kidney to his dying child in order to save the child’s life…and yet women are compelled to submit to surgery in order to save their child. Something is really wrong with that.
I do agree that there are issues that need to be addressed with tort reform. If an individual refuses medical care after having the potential negative outcomes explained, and one of those outcomes occurs, the individual should not be able to sue…period. I don’t agree with all of the “I didn’t really realize it truly could happen to me, my Dr. didn’t make me understand that enough” nonsense.
That said…I do wonder what percentage of malpractice cases really are of that type, as compared to true malpractice? I’ve read that even estimates within the medical community are that only 1 in 6 true victims of malpractice sue–I know a few that haven’t. I also know a woman who is suing because her attending OB rushed her to a cesarean for failure to progress while the resident said that she was 3 cm more dialated than the attending said, the attending was heard to remark to a nurse “lets make this a quick one so that I can make it to my daughter’s recital,” and after removing the baby, the attending left the OR, calling in another OB who did not show up to do the closure for FORTY FIVE minutes.
Regardless of if a patient is pregnant or not – anyone that comes in that has overdosed is going to be held. I have worked in an ER and those are automatic and have nothing to do with the child other then making their situation more tragic and perhaps a more aggressive approach to helping the mother in an attempt to help her unborn child.
What I find in your response though is a rather large amount of arrogance. In the US there is a little something called the Bill of Rights and the First Amendment (note: this was written first and therefore was important to our founders) that says:
“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”
If a person would like to forgo the right to medical care because of their religious views then they are guaranteed that right. If a person believes their prayers will save them then who are you to tell them differently? Is it hard to stand on the sidelines and you know that you can help them? Of course it is. It is hard on ANYONE to watch someone suffer, knowing you could help them and not being allowed to.
Your right, I do not believe in female circumcision. Or male circumcision for that matter. But then again I am not Muslim and do not believe in what the Taliban believes. I find that argument weak. In some Pagan religions it is customary to eat the placenta, or how about in some African cultures they ostracize a woman if any of her privates become injured… or how about… does it really matter? All religions have their own beliefs and who are you to tell us which ones we can and can not follow? Oh right – you are a ‘doctor’ and therefore your opinions on religion should be held higher then ones own religious beliefs.
I find your argument about fetal rights to be on the ridiculous side. Mostly because while the fetus has rights, the mother also the right to choose the best course of action for her and her child. As long as she is competent and has been fully briefed about her options – if she at that point still refuses medical care then she has the right to do that.
There is no law that says I have to receive care, I have a right to seek care and I can not be turned away for any reason. I also have the right to leave a hospital against medical advice. I would fight for that right until the day I die.
In Canada, at least, it’s illegal to detain a mother for the rights of the fetus – the fetus has no legal right until birth. Detain a woman to help her get off cocaine for her own health and safety but don’t bring her fetus into it, sad though we may be for the potential life of that child.
As for the woman who refused a c/s for a prolapsed cord. She has every right to bodily integrity for whatever reason she sees fit. Again, the fetus does not have a legal right to supersede that until the moment of birth. She an her family are the ones who will forever live with the outcome of her decision and only she knows what is best for her. One of my very wise teachers during my midwifery training has told me “it’s not your baby, it’s not your birth, it’s not your choice”, and I always try to hold that in my heart when I’m with a woman.
This makes me think of the women from the Canadian north who are forced to fly south to give birth. I don’t know if this is really true, but I had heard that babies who are not born on their ancestral lands are not considered Inuit by their communities. Can you imagine the heartache and the shattering of a person’s identity, family, community and long-held beliefs that this inflicts. And, lets face it, the results of such policies are very evident in these damaged communities. We do not know what damage we will inflict when we take a paternalistic attitude to women and stop respecting their autonomous choices.
I truly don’t understand what happens in our culture when a woman gets pregnant. It’s as if she becomes invisible, a vessel for a fetus and no-one cares any longer about her except in regard to the health of the fetus. It speaks volumes about the real value of women in the twenty-first century!
I think retaining a mother against her will when she is doing something ILLEGAL is a completely different thing than retaining a mother against her will when she is doing something that isn’t necessarily the ‘norm’, but still within her legal rights to do. If a women is doing an illegal drug during pregnancy, why the heck shouldn’t we be able to take LEGAL action against an ILLEGAL act? But if a women doesn’t want a c-section, induction, drugs etc, its her right as a consenting/non consenting adult and biological parent and legal guardian of the baby. Parents have the right to refuse medical treatment on a two year old, and only in the most egregious of situations is that right overcome by societies role to protect children from neglect/abuse. There is no reason why the rules should change just because the baby isn’t visible to the rest of society quite yet!
I would just like to correct the female circumcision-Taliban comment. The taliban may have done a lot of terrible things but female circumcision was never one of them. Female circumcision is a PRE-Islamic practice in parts of Africa. In those parts where it is still practiced today it is practiced by individuals as due to their culture not their religion, as much as they themselves may confuse the two. In places where it is practiced it will be practiced by groups that have adopted Islam, but also by those that retain traditional beliefs and even those that have adopted Christianity. The same goes for honor killing, also not an Islamic practice, but a cultural one pre-dating Islam in parts of the middle east. Both of these things are forbidden in Islam.
I apologize for my comment being irrelevant to the actual discussion about detaining patients, but I hate to see ignorance spread, especially regarding my own religion which is so poorly understood as is these days in the West.
Thanks.
Thank you for the response. Even the most absurd patient action can result in a good outcome occassionally. I have seen lung cancer treated (not-treated) and it resolved but I still do not recommend it.
Gigi: I have checked with the ER at the hospital across the street from where I now sit in my office. It is a 700 bed facility that I have been on staff at for 21 years. I have been assured that patients are not held for an accidental overdose whether it is tylenol or crystal meth. They are encouraged to stay for medical reasons (detox included) but they cannot be held. I am informed this is federal and not state law. I am the opposite of arrogant and ask that you please check my other comments on this blog. There is no voice inflection to typing and I do not know how to use a webcam. I too grew up with the bill of rights. A viable fetus is considered viable for a reason and is afforded protection under the law. IF this mother in question had given her child cocaine 5 seconds after delivery she would face jail. Not caring if she does so to a viable fetus in the womb is different? Lets say she shot a pistol into her abdomen to kill her fetus at 37 weeks. Is this late term abortion legal? In my state I have recently followed a trial where this occured but it was a boyfriend shooter. The mother lived. The killer was sent to prison for 25 years. I am going to be careful with my next statement as this could be used against me (yeh, I know, they already have). I agree that people have the right to forgo there own medical care. I have said nothing to the contrary. A viable fetus is not just your medical care anymore, it is theirs too. Not my opinion. It is the law. You want to pray away your own bacterial meningitis, go for it. Your childs – now that is where the BIll of Rights comes into play. That is called murder and it is not my opinion. It is the law and this case happened in Florida. Incidentally, both parents who did not believe in medical intervention, prayer only, had both had dental work recently under local anesthesia. Situational healing I guess. And I do not ever know that I can help someone. I am trained to try though. How is my argument weak? I cannot control what Muslim women will have happen and stay muslim. I can report their butchers to the police if it occurs here as I do not care what they “believe”. I have never dealt with a woman that has undergone religious clitorectomy with or without infibulation that elected to have it done. I do not appreciate your “doctor” higher level reference. My discussion is not about religion but the law and viable fetus rights. You have turned this to to a religious attack when it started as an insight about religions/cultural difference in the original blog. I cannot control anything about refusing care but I can uphold the law and I can keep a woman who has sought medical care by showing up in a hospital from her own idiocy as defined by the anti-abortionists that have established the rights of the viable fetus. I totally agree with your last paragraph. A rational person, making a rational decision, and absolutely nothing to do with the case I am defending. I wish we could meet. I do not disagree with all of your arguments but please do not attack me as some arrogant being just because I took the time to go to med school. My opinions are no better than yours. My training puts me in a more precarious position that’s all.
Almost a midwife: I am not going to discuss Canadian health care. I have too many Canadian doctors that have moved to the US that discuss the problems in your system at length. I admire the positives, however, I have never heard of a doctor moving north, or US ob patients choosing to deliver there. I can be totally wrong on this and admit that I am quite ignorant of exactly how your system works. Our laws are different on fetal rights. And what happens when the child does not get to live with the mothers decision but gets to die by it? As far as your ancestoral lands, my question backs up to WHY are these women flying south to give birth and what difference does your place of birth make concerning your ancestry? These would fall under the ignorance and arrogance catagories. I again state that my whole discussion involved women that had sought medical care. Not those that chose against it. And if you believe your last statement you have serious esteem issues. I can think of no one more important or that has more power than the woman growing with her fetus. She is doing what no man will ever do, including me.
Jespren: Yes but we have to be careful. There is a horrible trend afloat that mothers can be forced into a c/section rather than a VBAC. One of the hospitals that I now rarely use has “outlawed” VBAC’s. The mother cannot be forced into a section but can be ignored because she is laboring ama. My own insurer has threatened to drop me because I am one of only two MD,s in a city of 68, that offer vbacs. I have had two ruptures and both had perfectly healthy children by c/s’s in less than 8 minutes from diagnosis. Also, even though I would love to, we cannot arrest/retain a mother from doing legal acts that can asuredly harm her fetus. Smoking and drinking come to mind. There is a very steep and slippery slope here that must be watched carefully.
Kristina: I have dealt with 9 patients that have had female circumsion. 4 with infibulation. By request I surgically corrected these 4. All nine patients were middle eastern and all were operated on while being retained by family members and the surgeon in every case was an Islamic leader (I would say priest but I may have that wrong). I cannot speak for your ideas that these circs predate islamic beliefs in there homeland regions. I can say that what I see in the US is a separation of church and state so that religous and cultural differences do exsist. In the Islamic dominated lands it seems to me that there is no separation of church and state and there is no provision for it, ergo religious and cultural beliefs appear to be the same. I am by no means an expert on Islamic beliefs or practices. I like Hummus. Ok, that was a weak attempt at humor at the end of probably the longest thing I have ever typed. Gigi and the Midwife, I really do try hard. If you want me to stay off the board I will. I have to go and attend a delivery. A breech in the land of no breech deliveries.
Yes, it is well established in medicine that the occasional case of breast cancer will spontaneously go into remission, just as this baby did well despite the dire predictions. I am not by any means suggesting that women ignore the best evidence and advice we have to offer them. That is why I stated in my post that I would not have made the same choice, were I in this woman’s position, and if I had a patient in this position, I would have been strongly recommending cesarean delivery.
What I am saying is that doctors and midwives are not God and because we cannot guarantee a specific outcome, I do not believe we have the right to force a woman to agree to a recommended course of management. I recently read an article posted at the hospital where I work, discussing the dilemma of maternal-fetal rights and provider responsibilities. One question struck me: the author reminded the reader that late-term abortion is legal in several states. Should physician be able to retain a pregnant woman with a viable fetus in custody, so that she cannot cross states lines in order to obtain a late-term abortion? This may seem like an absurd scenario, but really–what is the difference?
Of course, I hurt for the babies that are being damaged by their mother’s smoking, drinking, or decisions that I believe pose harm to her or the baby. But I fear that we are starting down a slippery slope if we start to control women’s bodies because of their religious convictions, philosophical convictions, etc. Where does it end? When it is you who is being controlled because your doctor doesn’t agree with your choice, will the picture look different?
I love the comment by medical ethicist Anne Lyerly, M.D., assistant professor of obstetrics and gynecology at Duke University in Durham, North Carolina, which I quoted in an earlier blog post. This, for me, sums up my convictions on this issue and explains why I posted the story of the woman with the prolapsed cord, who refused c-section:
“We can make dire predictions and think patients are too irrational to weigh the risks for themselves, but we’re not infallible. And since doctors and moms can both be wrong, and if they can’t agree on the best way to give birth, ultimately it has to be the woman’s choice.”
Dr. Im-por-tan-te’
If you don’t want to be perceived as arrogant, a good first start might be to choose a different screen name. As soon as I read your name–without reading a word of your post–my reaction was “oh boy, here we go with someone who is way too full of himself.”
Ya know, I had decided to stay off this board because instead of hoping to be a resource I am the enemy. I told a doula friend of it and she just emailed me about this comment. The screen name is a result of my MSRN setting up a blog and using my staffs pet/sarcastic name for me. As I am a busy solo obstetrician I am perpetually late. Imagine, I spend extraordinary amounts of time with vbac’s, breeches, pushing with my patients (yes a doctor who does) and the nurses and the nurse praticioner laugh and call me this name and tell my patients of it. It has to do with the idea that I have any importance in my own office. It seems to run just fine, if not better, without me. I signed into this board after signing into the RN setup blog and it carried my name over which is weird becuse it would not save as a favorite to begin with. I guess I could erase the box and start over but I like the story behind it. It is just funny if only to me. It is better to ask then assume. Kathy, in the eyes of the law it does not matter whose choice it was. It is still illegal, just like suicide. I otherwise agree. My decisions and actions are reality based. I do this mess, not talk about it in some etheral sense. Midwife, good luck. Keep teaching. I will now in disgrace permanently bow out.
I support and thank you for this response However, I can only agree to a point. I see the law supporting the conviction of someone that has killed a viable fetus by shooting the mother. Are we to say he is innocent of murdering that viable life? And if he is guilty would not the mother that deliberatly causes the same death (shoots herself, uses cocaine, late term abortion) also be? I have no idea where to draw this line. Where is Solomon when needed? I have to uphold the standards imposed by my profession and in 25 years have not been able to figure these out. The breech did fine.
I will sign off.
The difference between someone else causing the death of a viable fetus and a mother causing the death of a viable fetus is quite simply that it was “someone other than the mother” who did it. I’m pro-life, but I understand the position of those who support “feticide” laws while still supporting the right of a woman to have an abortion (I just disagree with it). Basically, the unborn baby is looked at as the woman’s property. If the woman wants to have a baby, then anyone who takes that baby away from her (by shooting her in the stomach, or whatever) has killed her baby; but if she doesn’t want the baby, then she can dispose of her property the way she wants. Much as a person can push his own car off a cliff, but if someone else does it against the owner’s will, then he’s guilty of destruction of property.
I don’t think that fetuses are merely the property of pregnant women, to be disposed of at will — that is the position taken by slave owners in regards to slaves. So, what I see is the counter-balancing of the mother’s right to choose what is best for herself *and* her baby (since they are joined, with the baby inside her), much as she has a right to choose medical care for the baby after birth. It does get fuzzy when women are abusing illegal drugs and causing the baby to suffer harm — if “society” has the right to take the child away from his mother immediately after birth (which is typically what happens), why can society not intervene before birth and prevent the harm to the child? Thorny questions indeed.
Absolutely thorny questions. The major problem I see with the distinction between the mother wanting the pregnancy vs. not wanting the pregnancy, and that determining whether a situation constitutes infanticide or abortion, is that the reason that obstetricians face dilemmas over maternal/fetal rights is that the mother DOES want the baby (presumably). Thus, any action or lack of action that could possibly contribute to the demise of the wanted fetus could be cause for legal action.