Colleges say no to forced caesarean sections

The Royal College of Obstetricians and Gynaecologists (RCOG) in Britain is to be asked this month to approve a paper by its ethics committee strongly opposing the use of the courts to sanction obstetric intervention against a patient's will. The committee takes the same line as the American Medical Association (AMA), which spoke out against the practice after a string of caesarean sections were ordered by courts in the US.

American courts have become more reluctant to make such orders since the District of Columbia Court of Appeals held in 1990 that women have a virtually absolute right to make choices about their health care, even when these endanger the life of the fetus. The parents of a victim of cancer, Angela Carder, brought the appeal after their daughter died in 1987 as a result of a caesarean section sanctioned by the court.

Last month the issue surfaced again when a public guardian in Chicago asked Cook County Circuit Court to order Tabita Bricci, a 22 year old Pentecostal Christian of Romanian origin to have her baby by caesarean section. Doctors at St Joseph's Hospital, Chicago, told Mrs Bricci that the fetus, in the 38th week of gestation, was being deprived of oxygen and would die or be severely brain damaged unless it was delivered early.

Mrs Bricci and her husband, Mircea, refused. The circuit court refused to order her to undergo the operation, and the decision was upheld by the Illinois Appellate Court. The Illinois Supreme Court and the US Supreme Court, after hearing argument, refused to allow further appeals.

During the case John Glasson, the chairman of the AMA's council on ethical and judicial affairs, issued a statement affirming the association's opposition to forced caesarean sections. “It is a fundamental ethical and legal principle that patients cannot be forced to accept a risk to health to benefit another, whether the other is a person or a fetus. Even if a person is dying of leukemia, we do not force someone else to donate potentially lifesaving bone marrow,” he said. “The risk of death for the pregnant woman from a caesarean section is two to four times higher than that from a vaginal delivery.” The baby was born at full term, weighing 1.36 kg less than the average newborn baby but apparently healthy.

In Britain the High Court approved a forced caesarean section in 1992 on a Nigerian woman whose fetus was full term, in transverse lie, with an elbow projecting through the cervix. The court was told that an immediate caesarean section was the only means of saving the life of mother and baby, and the case was dealt with in only 23 minutes. The baby died but the woman survived. Medicolegal experts have criticised the decision as English law allows competent adults to refuse treatment that would save their lives, gives a fetus no individual rights, and will not compel a person to undergo surgery for the benefit of another.

John Friend, an obstetrician in Plymouth and chairman of the RCOG's ethics committee, said: “It would be in exceptional circumstances - and we can't really think of any exceptional circumstances - that an obstetrician could go to law to justify a caesarean section or any other obstetric intervention. It's very difficult to see a situation where you should counteract the autonomy of the woman concerned.”