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Caesareans without consent authorised

In the two cases, heard coincidentally on the same day in June, Norfolk and Norwich NHS Trust and Rochdale Healthcare NHS Trust made emergency court applications while the patients were in labour. Mr Justice Johnson authorised the operations, in the Rochdale case after hearing only a two minute outline of the facts.

The woman in the first case, W, had gone into the accident and emergency unit of a Norwich hospital at 9 am, already in labour but denying that she was pregnant. She had had three previous caesarean sections, and the judge was told that the consultant looking after her thought that the scars would reopen or the fetus would die unless it was delivered by 6 pm. W had a history of psychiatric treatment but did not have a mental disorder, though a psychiatrist who interviewed her thought that she could not make an informed choice.

The second woman, C, had had a previous caesarean section and had told the consultant trying to deliver her baby that she would rather die than have another. There had not been time for a psychiatrist to see her, but the obstetrician thought that there was no question about her mental competence. Mr Leigh told the judge at 5 15 pm that the consultant believed that C and the fetus would die unless the operation was performed by 5 30. The judge made the order, which Mr Leigh relayed to the hospital by mobile phone. However, C had changed her mind while he was in court and agreed to the operation. In both cases the judge concluded that the pain and emotional stress of labour had prevented the women from weighing up all the considerations and making a choice--one of the three tests of competence laid down in an earlier case.

The president of the court's family division, Sir Stephen Brown, was widely criticised by legal experts when he made the first compulsory order for a caesarean section three years ago. After that case the Royal College of Obstetricians and Gynaecologists issued a paper from its ethics committee stating that mentally competent women who refused a caesarean section should not have the operation imposed on them.

Barbara Hewson, a barrister and one of the most vociferous critics of the 1993 ruling, is offering free legal advice to women in similar situations after learning of the latest cases. She said: "I'm dismayed that judges are imposing interventions like caesareans, which have their own risks." The cases seem to contradict the well established legal principle that mentally competent patients may not be forced to undergo operations against their will, even if the result of refusing is certain death, however irrational their reasons may seem.

View larger version (100K): [in this window] [in a new window]   Legal principle states that operations should not be imposed on patients who are mentally competent

Wendy Savage, consultant obstetrician at the Royal London Hospital, said: "I think it's a very sinister development. The idea that just because you're in labour, you're incapable of making a competent decision is ridiculous. If I had a woman in this situation, I would do my utmost to persuade her to have a caesarean section, but I wouldn't force her by going to the High Court."

The BMA called for clear legal advice for doctors about whether they are expected to take future cases to court when the woman refusing a caesarean section is competent and informed.--CLARE DYER, legal correspondent, BMJ

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