Refusing Interventions and Demanding Alternatives: Ethical Professional responses to ‘Risky’ Birth Choices Seminar

Abstract

There is a fair bit of literature discussing that pregnant women – like any other competent adults – have the right to refuse medical treatments, even when that leaves their fetus at risk. But that raises a second question, to which much less, if any, attention has been given: to what extent can, and should, birth attendants go along with resulting requests for alternative modes of assistance? For a woman refusing a medically indicated hospital birth is still likely to ask for a midwifery assisted home-birth. And the woman refusing caesarean section still wishes for help for herself and her baby during the rest of her attempt at vaginal delivery. The mere fact that the woman’s refusal should be accepted does not clinch what, if any, such alternative assistance should be provided. To the treating health care professional, this second question is where the real dilemma resides, as illustrated by a recent spate of Dutch court cases. 

I discuss such cases and shall argue: (1) that it is a key feature of these cases that a request is accompanied by, or follows from, a refusal. This changes the nature of the professional norms applicable; (2) that the professional and moral response to such cases in first instance ought to be: search for the next best alternative acceptable treatment; and (3) that the boundaries of ethically acceptable professional alternatives on these cases can be arrived at by judicious application of bioethical principles. Finally I will point out that, although the gist of this analysis applies throughout medicine, there are particular features of birth care which means that the boundary is stretched much further beyond normal practice, then in normal, interventionist, curative medicine.