Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
In the United Kingdom the law and medical guidance is supportive of women making choices in childbirth. NICE guidelines are explicit that a competent woman’s informed request for MRCS (elective caesarean in the absence of any clinical indications) should be respected. However, in reality pregnant women are routinely denied MRCS. In this paper I consider whether there is sufficient justification for restricting MRCS. The physical and emotive significance of childbirth as an event in a woman’s life cannot be understated. It is, therefore, concerning that women are having their wishes ignored, and we must ascertain whether the denial of agency is justifiable. To answer this question I first demonstrate that access to MRCS is a lottery in the UK. Second, I argue that there is nothing unique about pregnancy that displaces the ethical norm of respecting patents’ sufficiently autonomous choices. Thus, the starting presumption is that all informed choices regarding MRCS should be respected. To ascertain whether any restriction of MRCS is justifiable the burden of proof must be placed on those who argue that MRCS is ethically impermissible. I argue that the most common justifications in the literature against MRCS are insufficient to displace the presumption in favour of autonomous choice in childbirth. I conclude that MRCS should be available to pregnant women, and we must strive to reduce the lottery in access to choice.
Abortion Act 1967.
Al-Mufti, R., McCarthy, A., & Fisk, N. M. (1997). Survey of obstetricians’ personal preference and discretionary practice. European Journal of Obstetrics and Gynecology and Reproductive Biology, 73(1), 1–4. PubMed
Amu, O., Rajendran, S., & Bolaji, I. I. (1998). Maternal choice alone should not determine method of delivery. British Medical Journal, 317(7156), 463–465. PubMed
Bastian, H. (1999). Commentary: “Health has become secondary to a sexually attractive body”. British Medical Journal, 319(7222), 1402. PubMed
Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics. Oxford: Oxford University Press.
Betran, A. P., Temmerman, M., Kingon, C., Mohiddin, A., Opiyo, N., Torloni, M. R., et al. (2018). Interventions to reduce unnecessary caesarean sections in health women and babies. The Lancet, 392(10155), 1358–1368.
Bewley, S., & Cockburn, J. (2002). The unfacts of ‘request’ caesarean section. An International Journal of Obstetrics and Gynaecology, 109(1), 597–605.
Birch v University College Hospitals NHS Trust (2008) EWHC 2237.
Birthrights (2018). Maternal Request Caesarean. http://www.birthrights.org.uk/wordpress/wp-content/uploads/2018/08/Final-Birthrights-MRCS-Rep. Accessed September 20, 2018.
Brione, R. (2015). To what extent does or should a woman’s autonomy overrule the interests of her baby? A study of autonomy related issues in the context of caesarean section. The New Bioethics, 21(2), 71–86. PubMed
Burcher, P., Gabriel, J. L., Campo-Engelstein, L., & Kiley, K. C. (2013). The case against cesarean delivery on maternal request in labour. Obstetrics and Gynecology, 122(3), 684–687. PubMed
Burrow, S. (2012). Reproductive autonomy and reproductive technology. Teche: Research in Philosophy and Technology, 16(1), 31–44.
Burrow, S. (2012). On the cutting edge: Ethical responsiveness to cesarean rates. American Journal of Bioethics, 12(7), 44–52. PubMed
Callahan, D. (1992). When self-determination runs amok. The Hasting Center Report, 22(2), 52–55.
Chester v Afshar (2004) UKHL 4.
Ching, R. (2006). Should women be able to choose caesarean section? South African Journal of Obstetrics and Gynaecology, 12(2), 84–87.
Cotzias, C. S., Paterson-Brown, S., & Fisk, N. M. (2001). Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. European Journal of Obstetrics and Gynecology and Reproductive Biology, 97(1), 15–16. PubMed
Feinmann, J. (2002). How to limit caesareans on demand—Too NICE to push? The Lancet, 359(9308), 774.
Habiba, M., Kaminski, M., Da Fré, M., Marsal, K., Bleker, O., Libero, J., et al. (2006). Caesarean section on request: a comparison of obstetricians’ attitudes in eight European countries. An International Journal of Obstetrics and Gynaecology, 113(6), 647–656.
Hall, M. H. (1994). Maternal mortality higher after cesarean section. British Medical Journal 308(6929), 654–655. PubMed
Hall, M. H., & Bewley, S. (1999). Maternal mortality and mode of delivery. The Lancet, 354(9180), 776.
Herring, J. (1997). Caesarean sections, phobias and foetal rights. The Cambridge Law Journal, 56(03), 509.
Heywood, R. (2009). Medical disclosure of alternative treatments. The Cambridge Law Journal, 68(1), 30–32.
Jackson, E. (2000). Abortion, autonomy and prenatal diagnosis. Social & Legal Studies, 9(4), 467–494.
Jones, M. A. (1999). Informed consent and other fairy stories. Medical Law Review, 7(2), 103–134. PubMed
Kapfhamer, J. D., Menon, S., & Spellecy, R. (2012). The importance of risk tolerance in maternal autonomy. The American Journal of Bioethics, 12(7), 53–54. PubMed
Keag, O. E., Norman, J. E., & Stock, S. J. (2018). Long term risks and benefits associated with caesarean delivery for mother, baby and subsequent pregnancies: Systematic review and meta-analysis. PLOS Medicine. https://doi.org/10.1371/journal.pmed.1002494. PubMedPubMedCentral
Kurapati, R. (2018). Physician: How science transformed the art of medicine. Austin, TX: River Grove Books.
MacKenzie, I. (1999). Should women who elect to have cesarean sections pay for them? British Medical Journal, 318(7190), 1070. PubMed
Miesnik, S. R., & Reale, B. J. (2007). A review of issues surrounding medically elective caesarean delivery. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(6), 605–615. PubMed
Mill, J. S. (2008). On liberty. New York: Oxford University Press.
Molina, G., Weiser, T. G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Azad, T., et al. (2015). Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA, 314(21), 2263.
Montgomery v Lanarkshire Health Board (2015) UKSC 11.
National Institute for Health and Care Excellence (2011). Caesarean Section: Clinical Guideline [CG132]. https://www.nice.org.uk/guidance/cg132/chapter/1-Guidance#planned-cs. Accessed October 15, 2018.
National Institute for Health and Care Excellence (2011). Information for the public; caesarean section. https://www.nice.org.uk/guidance/cg132. Accessed October 15, 2018.
NHS Digital (2017). NHS Maternity Statistics 2016-2017. https://files.digital.nhs.uk/pdf/l/1/hosp-epis-stat-mat-repo-2016-17.pdf. Accessed December 17, 2018.
Nygaard, I., & Cruikshank, D. P. (2003). Should all women be offered elective caesarean delivery? Obstetrics and Gynecology, 102(2), 217–219. PubMed
Paterson-Brown, S. (1998). Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. British Medical Journal, 317(7156), 462–463. PubMed
Penna, L., & Arulkumaran, S. (2003). Cesarean section for non-medical reasons. International Journal of Gynecology & Obstetrics, 82(3), 399–409.
Plante, L. A. (2006). Public health implications of cesarean on demand. Obstetrical & Gynecological Survey, 61(12), 807–815.
Purdy, L. M. (1976). Abortion and the husband’s rights: A reply to Wesley Teo. Ethics, 86(3), 247–251. PubMed
Purdy, L. M. (1990). Are pregnant women fetal containers? Bioethics, 4(4), 273–291. PubMed
R (Burke) v General Medical Council (2005) EWCA Civ 1003.
Re MB (Medical Treatment) (1997) 2 FLR 426.
Re T (Adult: Refusal of Medical Treatment) (1993) Fam 95.
Redden, M. (2018). A third of people get major surgery to be born. Why are C-sections routine in the US? The guardian. https://www.theguardian.com/lifeandstyle/2017/oct/04/one-in-three-us-births-happen-by-c-section-caesarean-births. Accessed October 01, 2018.
Schiller R. (2018). Instead of judging women who want C-sections, why not listen? The guardian. https://www.theguardian.com/commentisfree/2018/aug/21/women-c-section-birth-planning-caesarean. Accessed October 01, 2018.
Schuitemaker, N., Roosmalen, J., Dekker, G., Dongen, P., Geijn, H., & Gravenhorst, J. B. (1997). Maternal mortality after cesarean section in The Netherlands. Acta Obstetricia et Gynecologica Scandinavica, 76(4), 332–334. PubMed
Shahvisi, A. (2018). Conscientious objection: A morally insupportable misuse of authority. Clinical Ethics, 13(2), 82–87.
Sheldon, S. (1997). Beyond control: Medical power and abortion law (1st ed.). Chicago: Pluto Press.
Showalter, E., & Griffin, A. (1999). Commentary: All women should have a choice. British Medical Journal, 319(7222), 1401.
Siddique, H. (2018). One in six NHS trusts do not offer caesareans on request – charity. The Guardian. https://www.theguardian.com/society/2018/aug/21/one-in-six-nhs-trusts-do-not-offer-maternal-request-caesarians. Accessed August 21, 2018.
Symonds, I., Baker, P., & Kean, L. (2002). Problem orientated obstetrics and gynaecology. London: Arnold Publishers.
Torres, J. M., & De Vries, R. G. (2009). Birthing ethics: What mothers, families, childbirth educators, nurses and physicians should know about the ethics of childbirth. Journal of Perinatal Education, 18(1), 12–24. PubMed
Visco, A. G., Viswanathan, M., Lohr, K., Wechter, M. E., Gartlehner, G., Wu, J. M., et al. (2006). Cesarean delivery on maternal request: Maternal and neonatal outcomes. Obstetrics and Gynecology, 108(6), 1517–1529. PubMed
Wagner, M. (2000). Choosing caesarean section. The Lancet, 356(9242), 1677–1680.
Wax, J. R., Cartin, A., Pinette, M., & Blackstone, J. (2004). Patient choice cesarean: An evidence-based review. Obstetrical & Gynecological Survey, 59(8), 601–616.
Wax, J. R., Cartin, A., Pinette, M. G., Blackstone, J., et al. (2005). Patient choice cesarean—The maine experience. Birth, 32(3), 203–206. PubMed
Wittwer, H. (2013). The problem of the possible rationality of suicide and the ethics of physician-assisted suicide. International Journal of Law and Psychiatry, 36(5–6), 419–426. PubMed
Wolf, A. B., & Charles, S. (2018). Childbirth is not an emergency: Informed consent in labor and delivery. International Journal of Feminist Approaches to Bioethics, 11(1), 23–43.
Yamamoto, S. L. (2011). Recognizing cesarean delivery on maternal request as a social problem: utilizing the public arenas model. Policy, Politics and Nursing Practice, 12(3), 168–174. PubMed
- Why the Elective Caesarean Lottery is Ethically Impermissible
Elizabeth Chloe Romanis
- Springer US
Health Care Analysis
An International Journal of Health, Philosophy and Policy
Print ISSN: 1065-3058
Elektronische ISSN: 1573-3394