Editorials

Women's autonomy in childbirth

The lay and medical press have recently hosted a vigorous debate over enforced caesarean sections. At least six cases have been reported in the past six months, of which one, albeit an unusual one, is discussed in this week's BMJ (p 1183).¹ A landmark judgment from the court of appeal this March has clarified the legal position: a mentally competent patient has an absolute right to refuse medical treatment even where that decision might lead to her death or the death of her baby, for any rational or irrational reason or for no reason at all. What this means is that unless capacity to consent is at issue, the courts are unlikely to consider future applications of this kind. The capacity to consent is assumed to be present until it is shown not to be, and is quite distinct from mental health or rationality.² This still leaves some obstetricians feeling uncomfortable.

In this week's BMJ four sets of commentators discuss one of the earlier cases, where doctors' perceived ethical duty to rescue a threatened fetus came into conflict with the mother's wishes.¹ The case is unusual in that the order enabling an enforced caesarean section on a woman with schizophrenia was granted under the Mental Health Act, rather than under common law. We asked an obstetrician, a barrister, two ethicists, and two patient representatives to comment, and unusually, they are unanimous in their condemnation of the judgment. Instead of sticking to what obstetrician Susan Bewley refers to as the time honoured and legitimate weapon of "heavy duty persuasion," doctors in Tameside and Glossop sought a court order which led to an unprecedented use of the Mental Health Act.

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Forensic psychologist Bridget Dolan and Camilla Parker, legal officer of the mental health charity Mind, believe the judgment makes bad law. "The Mental Health Act was intended to provide a balance between the desire of clinicians to provide (psychiatric) treatment and the right of patients to make decisions about their treatment. It certainly was not intended to override the rights of women to decide on their obstetric care," they argue. Susan Bewley believes it was also bad medicine, contravening the Royal College of Obstetricians and Gynaecologists" guidelines, which state that a woman's wishes must be taken into account even if she is incompetent for the purposes of consent.³ There can be no trust between women and their obstetricians, she argues, if women fear coercion.

According to barrister Adrian Whitfield, clinicians faced with this type of ethical dilemma sometimes "allow their hearts to rule their heads," disregarding the fact that the unborn child has no legal status under common law, and the courts "no jurisdiction to take the interests of the fetus into account and balance them against those of the mother." That the patient had no proper legal representation is a worrying twist emphasised by patient representatives Hilda Bastian and Cathy Conroy, who argue that seeking such a ruling had as much to do with "medical paranoia" as with the woman's state of mind.

We are left wondering why obstetricians are turning to the courts to sanction compulsory treatment, and why now? Perhaps it is to do with societal change and medical reaction. Nowhere than in obstetrics is it clearer that paternalism from doctors is decreasingly acceptable to patients, yet obstetricians must struggle to square this with their role as "passionate advocates of fetal health and wellbeing."¹ The medical vigilance which has helped to reduce perinatal and maternal morbidity and mortality sometimes rests uneasily with a woman's enfranchisement in her own care. Perhaps modern women are too comfortably unaware of the dangers faced in childbirth by their great grandmothers, and the frustration this engenders in doctors sends them running to the courts for support. The distress associated with labour would appear, superficially, to justify this approach; after all, to take literally every appeal from an exhausted woman of, "I can't" or, "Just do a caesarean section" would equally be to fail her. So with fear of negligence litigation on the one hand and an increased awareness of the need for informed consent on the other, doctors (and healthcare trusts) feel impotent where they are most responsible.

But the Cumberledge report on changing childbirth has made society's mandate absolutely clear: women are to be at the centre of decisions surrounding their obstetric and midwifery care.⁴ The legal underpinning of this is now also clearer than ever. Sometimes the best obstetric care will be declined, with disastrous consequences, and nothing goes harder with an obstetrician than to listen passively to a decelerating fetal heartbeat. But our duty is to respect a woman's autonomy and obey the law. Doctors, midwives, and childbirth educators must advise fully and honestly, may persuade, but may never coerce.

Sandra Goldbeck-Wood, Assistant editor ^a

^a BMJ, London WC1H 9JR

1. Dolan B, Parker C, Bewley S, Whitfield A, Bastian H, Conroy C. Tameside and Glossop Acute Services Trust v CH (a patient) [1996] 1 FLR 762. BMJ 1997; 314:1183-7.
2. Dyer C. Appeal court rules against compulsory caesarean sections. BMJ 1997;314:993. [Free Full Text]
3. RCOG guidelines. Ethics. A consideration of the law and ethics in relation to court-authorised obstetric intervention. No 1. London: Royal College of Obstetricians and Gynaecologists, 1994. (Supplement to No 1 published in December 1996.)
4. Cumberledge J. Changing childbirth. London: HMSO, 1993