EDITOR—Paterson-Brown seems to assume that an autonomous patient has an unconditional right to have her wishes fulfilled.1 The (negative) right to decline treatment needs to be distinguished from the supposed (positive) right to demand it. In English law, the principle of autonomy allows, for example, competent people the right to refuse life saving treatment, and doctors have a correlative duty to respect this right.2 A dying patient, however, does not have the right to impose a duty on a healthcare professional to end his or her life.

With respect to medical and surgical interventions, the law is also clear. A patient, however competent, cannot invariably impose his or her demands and force a practitioner to act in a way which he or she believes to be contrary to the patient's best interests. This prerogative would be viewed by the courts as “an abuse of power as directly or indirectly requiring the practitioner to act contrary to the fundamental duty which he owes to his patient” (per Lord Donaldson).3

Healthcare professionals could not preserve their professional integrity, self respect, or credibility if they were to act as mere instruments to the “foolish” or “irrational” demands of patients, particularly if this ran contrary to good medical practice or violated their deeply held values.4 Decision making should be a collaborative enterprise based on mutual respect with the shared goal of the good of the patient.

Distributive justice also deserves consideration here. If patients demand expensive treatments such as caesarean sections, in circumstances for which there is little or no evidence of benefit—and, indeed, there may be evidence of harm—the costs should be considered.

The profession and the public, in the interest of patient welfare, should consider setting limits to personal autonomy and to professional self effacement.

EDITOR—We agree with Paterson-Brown that obstetricians should perform an elective caesarean section if a fully informed woman requests it.1 Obstetric anaesthetists are faced with a similar dilemma. A woman who is to have a caesarean section may have the procedure performed under regional or general anaesthesia. Once she has been fully informed of the relative risks of anaesthesia, her right to choose the type of anaesthesia is accepted by anaesthetists. In practice, it is uncommon for women not to choose the anaesthetic technique recommended. While some obstetricians argue that vaginal and abdominal delivery may be equally safe, in contrast, regional anaesthesia is regarded as considerably safer than general anaesthesia with respect to maternal mortality.2

The position of Amu et al, that maternal choice alone should not determine the method of delivery, seems less tenable.1 Various risks of caesarean section are quoted, including hysterectomy because of haemorrhage, increased risk of maternal death, and Mendelson's syndrome. Mendelson's syndrome, however, which is most commonly associated with general anaesthesia, is extremely rare nowadays. Only one instance is cited in a 1991-3report on confidential inquiries into maternal deaths in the United Kingdom,2 while the increased risks of hysterectomy, haemorrhage, and maternal death associated with caesarean section are almost certainly due to the fact that it is often the method of delivery chosen for patients at high risk. All types of anaesthesia carry risks, however, particularly increased morbidity, a point not mentioned by Amu et al.

Amu et al conclude by stating that active participation by patients should be encouraged to arrive at a safe and logical informed decision about the method of delivery. The implication is that to choose caesarean section for an uncomplicated pregnancy is illogical. We do not believe that the 31% of female obstetricians in London who would choose caesarean section for themselves in those circumstances are making an illogical choice.3 This population of women really is without doubt fully informed of all risks and hazards. Pregnant women must be made aware that they all are potential candidates for anaesthesia, and potential risk factors should be sought and assessed during pregnancy.4 In obstetric practice in the 1990s, most women who give birth, irrespective of the mode of delivery, receive regional analgesia or anaesthesia.

EDITOR—Paterson-Brown thinks that doctors should perform elective caesarean sections on request as long as the woman is fully informed.1 We consider such advice to be irresponsible. How can a mother be properly informed when there is an almost total lack of reliable information on mortality related to the procedure and on the short and long term morbidity of caesarean section compared with vaginal delivery in normal women at term? Existing evidence suggests that vaginal delivery is generally safer for the mother. Nor should we forget the baby. The need for resuscitation at birth and the incidence of both transient tachypnoea and respiratory distress are considerably higher after caesarean delivery. In addition, caesarean section leaves a scar on the uterus, which not only has implications for future pregnancies but will complicate any subsequent pelvic surgery. It is true that the pelvic floor may be damaged during vaginal delivery. Rather than stimulate ever more ready recourse to caesarean section, however, our first concern should surely be to review aspects of the modern management of labour that may contribute to it—for example, maternal posture and mobility, the use of epidural anaesthesia, the length of the second stage of labour, and the liberal use of episiotomy.

Informed maternal choice is fundamental to the practice of midwifery and obstetrics today. Maternal autonomy is, however, only one element in ethical clinical practice: another is not doing harm. To carry out a caesarean section on a woman when, in the opinion of the obstetrician, it is not in the best interests of her and her baby is, therefore, unethical. Here, the autonomy of the doctor not to act unethically must be exercised. Unfortunately, maternal autonomy is often assumed as doing what the woman requests at a particular moment. It is far more complex than that. Doctors should help the mother in the process of exercising her autonomy in the best interests of herself and her child. Despite her assertion to the contrary Paterson-Brown consigns the obstetrician to being little more than a technician in the matter. Our patients expect and professional standards require more of us than that.

EDITOR—The debate about elective caesarean on request will continue.1 Maternal and fetal mortality have been reduced to a point that allows us to shift the focus to reduction of morbidity, but we caution against dismissing the mortality associated with caesarean section.

Elective caesarean section is now regarded as safe, but we believe that the relevant comparison of mortality is between elective caesarean and trial of labour resulting in a number of emergency caesarean sections and vaginal deliveries. The mortality ratio in healthy women between caesarean and vaginal delivery has been estimated at 5:1.2 If the attributable mortality ratio of elective versus emergency caesarean is 1:1.5 as has been suggested,2 then a success rate of vaginal delivery of approximately 40% would lead to a maternal death rate equal to that for elective caesarean. Thus for healthy women without complications a trial of labour with an emergency caesarean rate of less than 60% provides a safer alternative to elective caesarean.

Although deaths from elective caesarean in the United Kingdom have decreased, they still accounted for 16.5% of all deaths from caesarean section in the most recent confidential inquiry.3 In the most recent confidential inquiry into stillbirths and deaths in infancy there were 42deaths after ruptured uterus.4 Three quarters concerned women with pre-existing uterine scars, highlighting one of the long term implications of a caesarean section.

One of the main reasons driving this “fashion” for elective caesarean seems to be a desire to avoid damage to the pelvic floor during childbirth. The evidence for this is incomplete, and it has been suggested that many of the studies in this field of research are subject to criticisms such as small numbers, case selection, lack of long term follow up, and failure to consider the impact of other possible risk factors for pelvic floor dysfunction, such as family history, connective tissue disorders, and lifestyle.5

So while we concede that obstetric care should seek to minimise the risk of injury to the pelvic floor, we believe that for now the safest option should still be to aim for a vaginal delivery in an uncomplicated pregnancy but the woman should participate fully in the decision making process.

EDITOR—The fact that 31% of 85London based female obstetricians with an uncomplicated singleton pregnancy at term would choose an elective caesarean section for themselves1 is presented as a changing view and interpreted to mean that the concept of a prophylactic caesarean section is not outrageous because almost a third of female obstetricians would choose it for themselves.

This does not mean, however, that almost a third of female obstetricians worldwide would make this choice—>these obstetricians are far less than 1% of all female obstetricians worldwide. In our anonymous postal survey of all obstetricians in the Netherlands (response rate 67%) only 8out of 567obstetricians (1.4%) opted for caesarean section in an uncomplicated singleton pregnancy.

Prophylactic caesarean section must still be considered clinically unjustifiable because of its excess maternal mortality and morbidity (including infertility) and its excess neonatal and respiratory morbidity in comparison with vaginal birth.2 Financial costs are much higher. Women are denied the experience of giving birth themselves, instead becoming victims of medicalisation.

The paper states that vaginal delivery of a fetus in breech presentation is becoming a rare obstetric art. In our survey 60-79% of obstetricians would opt for vaginal delivery of a breech fetus in primigravidas and 86-94% for such a delivery in multigravidas compared with 43% and 60% of our London colleagues.

Although caesarean section is comparatively safe in some parts of the world, short and long term maternal mortality and morbidity are serious problems elsewhere.3 If Paterson-Brown's suggestion is taken up lightly by obstetricians in other places it will definitely lead to more maternal deaths and misery for women who already have a disproportionate share of ill health in this world. As part of a confidential inquiry into maternal deaths in the Netherlands, we stated: “If the caesarean birth rate in the United States of America was similar to the rate in the Netherlands (9%), approximately half a million more births would occur annually by the vaginal route. At present, these births occur by caesarean section and would be associated with approximately 130extra maternal deaths, if the reported Dutch death rates after caesarean section were applied in the United States.”2

Demanding unnecessary intervention in some cases implies denying that service in other cases. “Developed” countries have unnecessarily high rates of caesarean section, while “developing” countries have a high unmet need for caesarean section.4 The suggestion that a valid reason is not needed to perform caesarean section will worsen this unacceptable gap.

EDITOR—Paterson-Brown et al argue against open access for caesarean section in the absence of a medical indication.1 I take issue with their assertion, however, that maternal age does not influence vaginal delivery rates. A wealth of data show increased incidence of instrumental and caesarean deliveries in older women. 23 I recently examined this issue at Queen Charlotte's and Chelsea Hospital in London and found that this effect is incremental—the older the woman the lower her chances of having a spontaneous vaginal delivery.4

In the Queen Charlotte's series of over 6000nulliparous women, those aged 35had only a 49% chance of a spontaneous vaginal delivery compared with a 71% chance in women aged 20.By the time a woman was 40or older, her risk of an instrumental delivery in labour was 42%. It could be argued that older women or their obstetricians may be more anxious, which may prompt higher rates of intervention, but the incremental increase in operative delivery rates, and the fact that there was also an incremental increase in failure to progress as a cause of instrumental delivery, point to a genuine biological effect. Older women have a right to know that their chances of a spontaneous vaginal delivery decreases with each year they delay childbirth. If they then request an elective caesarean section to avoid the high risk of emergency operative delivery (and its proved long term sequelae), then shouldn't obstetricians grant them that wish?

EDITOR—Paterson-Brown et al are incorrect when they say that there is no relation between maternal age and increased risk of caesarean section.1 Studies have shown that there is,2 and this point is increasingly important as women leave childbirth to a later age.

Two further issues have not been evaluated in this debate. Firstly, estimates suggest that a caesarean section costs £760 more than a vaginal delivery, and therefore every 1% increase in the rate of caesarean sections nationally costs £5m.3 Secondly, with the onset of clinical governance it is important that we give women correct advice when recommending a delivery route when the evidence for benefit is still uncertain. Women are routinely counselled, however, and given choices regarding regarding other surgical interventions (for example, different surgical treatments for menorrhagia) and such choices should therefore be available to pregnant women when the delivery route is discussed. Some women do not wish to experience natural childbirth, and professionals should support these women as well as those who wish to achieve a normal vaginal delivery.

Senior midwives have participated in this debate, and I have heard the argument that maternal choice should be discouraged as with “proper explanation and support” women would not choose an elective caesarean delivery without a clear obstetric indication. I hope that this debate in the pages of the BMJ will generate a response from midwives.