When doctors manipulate, coerce and force their patients to comply with any and all of their recommendations, they should not be surprised when the parents sue over a bad outcome. If there was any kind of birth injury in my own birth experience, I would have delighted in suing my providers for everything I could get. If doctors don’t want their patients suing them, perhaps they should work with them instead of ordering them around or physically forcing them to comply.

I used to think people were kidding when I saw this question in comment threads– that they were trying to make a joke. I came to realize that people were really wondering.

Why would she sue anyone? Is that a given that someone must be sued if there is a negative birth outcome? Why?

And if you’re referring to the case above, the baby was just fine. The cesarean recommendation was totally unnecessary. The hospital has a 50 percent cesarean rate.

You raise a lot of points, and I will take them one at a time:

“Pardon my ignorance, but who will she sue if she refuses treatment and the baby is then injured and/or dies?”

First, this is a scenario that would rarely occur. Most situations in maternity care are not life or death, and most mothers, when given the risks, benefits and alternatives would choose a life saving procedure over death. If she chose to withhold a life saving treatment, the physician has the option of obtaining a legal court order. It is illegal for the physician to treat her against her will without a court order. If she is found to have the psychological capacity to choose or refuse treatment, her choice to withhold treatment may be upheld by the courts. This is her legal right because a fetus is not legally a person and therefore she has the right to refuse treatment to her own body, even if it means the fetus might die. Second, it is not required that she sue someone if her baby dies or is injured, and it would be very rare that she would do so if she had true informed consent and made her own choice not to treat.

“Should she sue the people who stood back and ignored their hypocratic oath by letting her have her way?”

Which part of the hypocratic oath are you referring to? After reading the entire oath, I do not see any section of it that a physician would be violating by offering a person treatment option and then allowing them to make a choice on how to proceed. If that were so, many physicians would be in violation of this oath, since in most areas of medicine informed consent and personal choice is standard practice. People do not always choose the course of treatment a physician recommends. That is their legal right.

“(There are reasons why abortions aren?t usually allowed after x months – why suddenly let the kid die on the insistence of non-medically trained people? YES, it?s her kid, but doesn?t she want to save it?)”

The act of seeking medical care for her birth would show us that she has a vested interest in “saving” her infant. That does not mean she must submit to any procedure recommended to her. It is rarely a life and death situation. Baby’s lives are not being saved by their mothers being forced vaginal exams, AROM, or continual fetal monitoring. In the case of this post, the recommended medical procedure, a c-section, was not necessary. That was proven when the baby was born alive and healthy vaginally. Studies show that interventions are being overused and causing harm to babies. Mothers being granted their legal rights to refuse these treatments would most often be benefiting their babies lives, not putting them in harms way.

?But Doctor, what do I do??
?Nothing – you?re not qualified? may be funny in the movie (Monty Python?s Meaning of Life), but it?s not entirely untrue, since most mothers aren?t medical trained at all.”

Most people who seek any type of medical care are not medically trained, however, they are still allowed to make decisions for themselves based on the physician’s explanation of the issues, and being presented with the risks, benefits and alternatives of treatment or non-treatment of an illness. All patients have these legal rights and make choices for their health care despite the fact that they do not hold medical degrees. Pregnancy and birth is rarely a medical event, it just happens to take place in a hospital in this country as a cultural practice. This means that most of the “treatments” or procedures a woman chooses or refuses are not life or death, they are done to augment, induce, or otherwise tamper with a normal process. She should certainly have the right to accept or reject something that doesn’t even have a medical or health benefit, and may be potentially dangerous for her or her baby.

“YES, I realise that birth is often being over-medicalised, but since one of Australia?s foremost spokeswomen on natural births, midwives, etc, etc just spent _3 days_ in labor AND lost her baby, I should have thought that some balance of ?natural? and ?sensible idea to get help when it?s standing right there waiting? should be reached.”

This is a completely different topic, and not one that I wrote about in this post, so I am unsure why you are bringing it up? I am not sure who you are referring to or what the circumstances of her birth was. However, I was not writing about natural birth in this article, I was writing about informed consent and refusal in maternity care. Those are two different topics. In this article, I am advocating that patients be allowed their legal rights to make their own choices, not that patients make the choice to birth naturally at all costs. I have no problem with women making informed choices for their maternity care that would include procedures or treatments that may not be considered “natural”. I do have a problem with physicians making these decisions for women and then coercing, manipulating, or forcing them to comply with what the physician feels is the best course of action without giving the mother a true choice. One does not have to be an advocate of natural birth to be an advocate of informed consent and refusal in maternity care.

(There are reasons why abortions aren’t usually allowed after x months – why suddenly let the kid die on the insistence of non-medically trained people? YES, it’s her kid, but doesn’t she want to save it?)

“But Doctor, what do I do?”
“Nothing – you’re not qualified” may be funny in the movie (Monty Python’s Meaning of Life), but it’s not entirely untrue, since most mothers aren’t medical trained at all.

YES, I realise that birth is often being over-medicalised, but since one of Australia’s foremost spokeswomen on natural births, midwives, etc, etc just spent _3 days_ in labor AND lost her baby, I should have thought that some balance of “natural” and “sensible idea to get help when it’s standing right there waiting” should be reached.

Your reply is excellent. “TheOtherSide” is an OB in Tucson, Arizona that has been making the rounds leaving anonymous comments on various blogs. Sort of anonymous… the IP address is there and searchable.

TOS said: “Are cesareans necessary, not always, but if you say never then you need to be comfortable with a higher maternal-fetal mortality rate.”

TOS (Dr. S.T. in AZ)- Is anyone saying “never” here? I haven’t seen an argument to date for no cesareans. And you’re also saying that cesareans are not always necessary, so that’s an argument for fewer cesareans. I would have to agree with you.

This comment and the other I saw this morning have the same reactive tone, which comes across as “Oh yeah, well if you guys can do this, then we should be able to do this, too.” ACOG’s Committee Opinion 385 says you *do* have the right to refuse to perform a procedure, no?

TOS said: “If you want a birth that is without risk of cesarean then you should not deliver with an OB and should opt for a home birth where you can do what you want.”

So you agree that it would be a positive if all women who wanted a home birth actually had the option to plan a home birth with a licensed midwife? I think that’s great. I didn’t realize that you were a fan of women having a range of choices in birth location. Do you cooperate with local out-of-hospital midwives? The U.S. needs more home birth friendly doctors like you.

TOS asked: “Who is being difficult here?”

I guess in your mind it is the women who don’t want to play by your rules, which are comparable to those of the Catholic Church? Well, I suppose as long as you are actively advocating for a strong out-of-hospital network of options for women who, according to your allegory, don’t want to be Catholic, then your argument is partly reasonable. There will still be those of us who push for institutional change at the same time.

See you on Twitter.

“You cannt compare an episiotomy to a cesarean with refusal. There is absolutely no medical indication for an episiotomy and it would be rare that a physician would perform one just for the heck of it.”

I’m confused, it seems like you are contradicting yourself here. If there is never a medical indication for an episiotomy, yet physicians don’t perform them “just for the heck of it”, then why are so many done? Why are so many forced on women, or done without their consent or knowledge, or done against their explicit written or verbal refusal? After they are done, we are told there was a medical reason, that the baby needed to come out ASAP. If there is never a medical reason, why are we lied to? I actually do think that many providers would disagree with you and say there can be a medical reason, as it does speed up delivery by a small amount, and if a baby is really in distress, the provider may feel that this small amount would benefit the baby.

“The cesarean section on the other hand has multiple instances, cephalopelvic disproportion, fetal distress, etc where there is definite need or baby and mother might die. Are cesareans necessary, not always, but if you say never then you need to be comfortable with a higher maternal-fetal mortality rate.”

Whether cesareans are necessary or not, or how often, is actually irrelevant to this discussion. The point is that women need to be informed of the risks, benefits and alternatives to each procedure and be allowed to decide or refuse it, including cesareans. The WHO recommends a 15% cesarean rate and ours is over 30% and climbing. Anything beyond 15% is no longer healthy for mothers and babies and will start to affect the maternal-infant mortality rate. There is no doubt that at least 15% of cesareans are unnecessary, and women should definitely be informed of the increased risks of a cesarean to her and baby, and the alternatives to having one, and then be allowed to make the choice for herself free of coercion or manipulation or outright force.

“If the patient has a right to refuse a procedure (which I agree with) then the physician also has the right to refuse a procedure.”

No, actually, it is not the physicians job to refuse or accept procedures for a patient. It is also illegal. The physician’s job is to present the patient with their options, explain the risks, benefits and alternatives, and then allow the patient to decide which course of treatment or non-treatment they think is best for themselves.

“If you want a birth that is without risk of cesarean then you should not deliver with an OB and should opt for a home birth where you can do what you want.”

There is no such thing as a birth without the risk of cesarean. Every homebirth midwife has a certain percentage of transfers for c-section, which is generally around 4 to 5%. This percentage is lower then the WHO’s recommended 15% because, first, homebirth midwives only take on low risk women, and second, homebirthing women are not exposed to the iatrogenic risks of the hospital (e.g. epidural, narcotics, immobility, lack of food and water, induction, augmentation, etc.). Also, women don’t expect to have a birth without risks of intervention, and even homebirthing women know that a transfer to the hospital may be needed if the expertise of an OB is warranted. The point of my post was to say that women should have their legal rights to informed consent and refusal upheld, whether birthing at home or at the hospital. When an intervention is needed, the woman should be informed and allowed to make a choice without pressure. Also, most women are given the impression from their hospital based childbirth classes and from their providers prenatally that they will have choices and options and be allowed to refuse certain interventions or treatments. If physicians and hospitals do not intend to allow women their legal rights to informed consent, then they should inform the women of this prenatally so that women can choose a provider that will uphold their legal rights to informed consent. Most women though do not expect to be coerced, manipulated, or forced into things they did not want or need.

“It?s like the Catholics saying they are going to quit because they will not let women be priests. You don?t have to be a Catholic to believe in Jesus. They have rules and they abide by the rules they have, you don?t have to abide by them if you don?t want to, but why do people insist on going somewhere they know their ?way? is different when they can go somewhere they will be embraced. Who is being difficult here?”

Women have a legal right to informed consent, they have parental rights to make decisions for their child, and a fetus is legally not a person, so they have personal rights to make decisions for their own bodies before the baby is born. If the “rules” in a hospital infringe on the personal, parental, and civil rights of an individual, then those “rules” are in contempt of the law. Also, your illustration is not valid. Catholics are upfront about the fact that they do not allow women to be priests, thus people are free to make an informed choice about whether or not they want to belong to that religion. Hospitals and many providers are not upfront about the fact that they do not allow women to have personal autonomy, parental rights, or have the ability to make informed decisions for themselves about their own health care. In fact, many women are mislead to believe they will have these choices, and then when they arrive to give birth, they are not allowed to make them. Had the hospitals and providers been as upfront and honest as the Catholics, then perhaps many women would not be choosing this setting to give birth in.

If the patient has a right to refuse a procedure (which I agree with) then the physician also has the right to refuse a procedure. If you want a birth that is without risk of cesarean then you should not deliver with an OB and should opt for a home birth where you can do what you want. It’s like the Catholics saying they are going to quit because they will not let women be priests. You don’t have to be a Catholic to believe in Jesus. They have rules and they abide by the rules they have, you don’t have to abide by them if you don’t want to, but why do people insist on going somewhere they know their “way” is different when they can go somewhere they will be embraced. Who is being difficult here?