Cesarean delivery on maternal request: Can the ethical problem be solved by the principlist approach?

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Abstract

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.

We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).

Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.

Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

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Most cited references 59

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Maternal morbidity associated with multiple repeat cesarean deliveries.

Robert M Silver, Mark Landon, Dwight J Rouse … (2006)

Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. II-2.

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International ethical guidelines for biomedical research involving human subjects.

(2002)

The CIOMS guidelines have been developed and revised with the problems of conducting medical research in less developed countries particularly in mind. The proposed guidelines were first published in 1982, revised in 1993, and have now been published in a third version after a revision process lasting three years. Last month the Bulletin published just one guideline and accompanying commentary. There now follow all the guidelines, without commentary, but with an appendix detailing what should be in a protocol.

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End-of-life practices in European intensive care units: the Ethicus Study.

Charles Sprung, Simon Cohen, Peter Sjokvist … (2003)

While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. A prospective, observational study of European ICUs. Consecutive patients who died or had any limitation of therapy. Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001). The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Med Ethics

Title: BMC Medical Ethics

Publisher: BioMed Central

ISSN (Electronic): 1472-6939

Publication date Collection: 2008

Publication date (Electronic): 17 June 2008

Volume: 9

Page: 11

Affiliations

[1 ]Department of Medical Ethics, University of Lund, BMC C13, SE-221 84 Lund, Sweden

[2 ]Reproductive Science Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Robert Kilpatrick Building, Leicester Royal Infirmary – PO Box 65, Leicester LE2 7LX, UK

[3 ]Department of Obstetrics and Gynaecology, Lund University, SE-223 85 Lund, Sweden

[4 ]IFC-National Research Council, via Trieste 41, 56100 Pisa, Italy

[5 ]Unit of Epidemiology, Regional Health Agency of Tuscany, Viale Milton 7, IT-50129, Florence, Italy

[6 ]Unit of Epidemiology, Ospedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4, IT-00165 Rome, Italy

Article

Publisher ID: 1472-6939-9-11

DOI: 10.1186/1472-6939-9-11

PMC ID: 2446392

PubMed ID: 18559083

SO-VID: 177c5501-ebf7-43fa-a60e-3f2f617e89b1

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cesarean delivery on maternal request: Can the ethical problem be solved by the principlist approach?

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Most cited references 59

Maternal morbidity associated with multiple repeat cesarean deliveries.

International ethical guidelines for biomedical research involving human subjects.

End-of-life practices in European intensive care units: the Ethicus Study.

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