The Ethics of Refusing a Caesarean Section April 2004 e -Cases in Ethics * In January of 2004, Melissa Ann Rowland—a young woman with a long history of mental illness—refused to undergo a Caesarean section that doctors said was necessary to protect the lives of her unborn twins. Doctors told her that low amniotic fluid and poor growth placed the twins in danger, but she refused the surgery until too late, reportedly on cosmetic grounds—she is alleged not to have wanted the resulting vertical scar. * In 1987, Angela Carter, who was dying of cancer, also refused a C-section.
She sought to remain pregnant until the 28th week of pregnancy, the point at which doctors had once told her her baby would have the best chance to survive. At 26 weeks, however, physicians felt that the child had a 50% chance of surviving outside Angela’s dying body, and virtually none if the surgery was not performed. Angela’s condition had deteriorated to the point that her understanding of the implications of refusing the surgery was unclear, but she seemed to refuse the operation. Her distraught husband and mother would not consent to the surgery.
It is hard to imagine anyone reading either of these stories and not having a strong reaction. Reactions are radically different, however, depending on the ethical principles on which they are grounded. For example, there are those whose arguments stem from the belief that there is an ethical duty, rooted in beneficence, to save innocent human life—even if unborn, and especially when as close to term as the ones discussed here. On the other hand, there are those whose arguments are grounded in the belief that the paramount ethical duty in these cases is to respect the autonomy of the mother.
They echo Supreme Court Justice Benjamin Cardoza, who established in 1912 that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body. ” To force a woman to undergo surgery against her will violates the critical ethical requirement for informed consent. When balancing ethical questions regarding the protection of human life against respect for personal autonomy, it is obvious that cases involving pregnant women present uniquely thorny challenges.
Is a pregnant woman a person who carries within her body a human with fewer rights than she, or is she carrying a person with the same rights and human dignity that she herself possesses? Even for those who believe—as the Catholic Church clearly and unequivocally teaches—that an unborn child is from the moment of conception a person with all the human dignity of one who has been born, the answers are not simply “either/or” matters. That is, we cannot settle for respecting either the rights of the mother or those of the fetus; the rights of both must be both honored and carefully balanced.
There are many questions that deserve critical consideration regarding the extent to which society can intervene to keep an unborn child from harm’s way. Should we (or could we), for example, physically confine all mothers who smoke, use drugs, or consume alcohol? What about busy expectant mothers who disregard doctor’s orders to rest? More pressing, and more relevant to health care, are questions that ask the extent to which a pregnant woman might be obliged to put herself at risk by consenting to fetal surgery.
These issues hover in the background throughout the discussion here of cases in which C-sections are believed necessary to save a viable fetus from what is believed to be certain death. In Angela’s case, medical professionals believed such surgery to be the only real hope of survival for her child, despite the fact that surgery would probably hasten the end of Angela’s own exceedingly tenuous grasp on life. In Melissa’s case, doctors also argued that a C-section was required for the sake of her unborn twins, while accepting that it placed Melissa herself at minimally greater risk than would a vaginal delivery.
When the court- ordered surgery was performed on Angela, the infant lived for only two hours, and Angela herself died two days later. When Melissa finally agreed to surgery, weeks after it was first encouraged, one of the twins was stillborn. (A factor in Melissa’s case that cannot be ignored is the lack of timely action on the part of the medical profession, when her mental illness was clearly apparent. Why did they not intervene, when they clearly believed the lives of both twins to be in jeopardy? The central ethical questions in these two cases, from the perspectives of the two sides of this controversy, are whether a mother’s autonomy rights can be trampled by cutting open her body against her will, versus whether a mother has the right to allow her child to die within her when the child’s rescue is easily attainable. Both sides ask if and when the State should be involved in such cases. Nevertheless, such intervention is often sought, with inconsistent results.
In Angela’s case, for example, a judge ordered the C-section, but an appellate court later decided that the refusal of Angela and her surrogates should have ended the discussion. Melissa, on the other hand, has been arrested and charged with criminal homicide for allowing her son to die; she later pleaded guilty to two counts of third-degree felony child endangerment. A number of ethical theories have been developed over the centuries to offer guidance on the issue of intervention by higher authority. One of these is the Just War Theory, which seeks to establish when war can ethically be entered into, despite the harms that may be involved.
Perhaps that theory can be used to consider the cases discussed here, by reframing some of its considerations. First, for example, we can ask in these and similar cases if there is sufficient reason for the intervention of higher authority. In other words, is it conclusive that mother, family, physicians, and hospital are unable to reach an agreement before the State is involved? Second, are they confronted with a situation in which a C-section has become, or is expected to become, the last and only resort to save human life?
Third, does a real threat to human life already exist, as in these cases, and opposed to circumstances when there is only possible or potential risk? Fourth, does surgery offer a reasonable chance of saving human life? Fifth, is the good to be gained—saving the life of the unborn child—equal to or greater than the harms involved, i. e. , violating the mother’s personal autonomy and cutting into her body against her will, thus putting her life at some risk? Finally, is the possible harm to the mother only risked in order to achieve the greater good of saving the life of the unborn child?
These cases may seem isolated and unusual incidents, but they are, in reality, quite relevant, especially in view of the advances being made in fetal surgery. What is the answer to the question of whether a mother can ethically refuse such surgery when it is clearly felt to be in the best interest of her child—or is perhaps even the child’s only chance at life? The cases of Melissa and Angela thus have significant ethical importance not only in and of themselves, but in regard to a greater debate as well.
Published by the Ethics Department of Catholic Health East, 14 Campus Blvd, Suite 300, Newtown Square, PA 19073 (610) 355-2065 www. che. org Calendar of Events Conference Calls April 2004 e-Cases in Ethics March 2003 Ethics Champions Education Program Module 14 Decision Making at the End of Life ACUTE CARE (Section A) Monday, 5/3/04 12:00-1:30 pm (Section B) Wednesday, 5/5/04 12:00-1:30 pm CONTINUING CARE Tuesday, 5/4/04 12:00-1:30 pm ORGANIZATIONAL ETHICS Module 2 Conflicts of Interest and Vendor Relations Friday, 5/7/04 12:00-1:30 pm
BEHAVIORAL HEALTH ETHICS CASE CONFERENCE Thursday, 5/6/04 12:00-1:30 pm Conference Calls Dial in phone number for ALL calls: 610-355-2070, ID 2063 Contact Us Philip Boyle, Ph. D. 610-355-2063 [email protected] org Margy Bott Administrative Assistant 610-355-2065 [email protected] org Educational considerations are not to be construed as policy recommendations. To download and print additional copies of this publication in color, go to: http://www. che. org/ethics Educational considerations are not to be construed as policy recommendations.