Medical practice has many issues around informed consent, with many procedures being routinely performed with no shared decision making process, no informed consent, or no permission at all. Rebecca Dekker of Evidence Based Birth wrote than in her training as a nurse,
I was taught to say, ‘I am going to listen to your lung sounds now.’ My instructors told me that the patient would be less likely to refuse if I simply stated what I was doing, instead of asking permission. I practiced that way– and even taught nursing students that way– for several years. (emphasis mine)
This seems relatively innocuous when it involves listening to lung sounds, but has more onerous implications for pregnancy and childbirth. Training to make statements is training for practitioners to say, “I am going to cut an episiotomy now” or “I need to do a cesarean.” It may be true that the procedure is a good idea, but it is not acceptable to tell a woman that you are going to do something to her body. A woman needs to have to opportunity not only to consent to a procedure, but also to refuse it.
Sometimes practitioners do not even say what they are going to do–they just do it. Sometimes they tell the woman after it has been done, as in this case from My OB Said What?:
‘I gave you an episiotomy.’ – OB to mother after birth. Nothing was mentioned about an episiotomy being needed during the birth, and when the mother screamed in pain when the OB touched her, both the OB and the L&D nurse insisted the OB was just ‘stretching’ her.
Or this one
‘We will go ahead and schedule your cesarean section now.’ —OB to mother with two prior cesareans, at the mother’s 10 week prenatal appointment, after the mother indicated that she wanted to have a VBAC.
Sometimes the practitioner doesn’t tell tell woman anything, and she finds out what happened by reading her chart or talking about her case with a different practitioner, as in this report from Cookieparty at Community Baby Center:
I remember my OB saying he was stitching me and I was like oh I must have torn. He didn’t even tell me he did [an episiotomy], I found out later that day or the next day I think, when one of the nurses was tending to it. [It] pissed me off!
Instruction on “Patient Rights” from The Birth Place of UCLA Medical Center make it sound that their belief is that women do not have the right to refuse what health practitioners want to do in any case. Their responsibility is to follow the rules and cooperate (emphasis mine):
As a patient, you have the responsibility to:
- Treat those who are treating you with respect and courtesy.
- Be considerate of the rights of other patients and hospital personnel.
- Observe the medical center’s rules and regulations, including the Visitor and No Smoking policies.
- Be as accurate and complete as possible when providing information about your medical history and present condition, including your level of pain.
- Cooperate fully with the instructions given to you by those providing your care.
- Fulfill the financial obligations of your health care, know your insurance benefits and eligibility requirements, and inform the hospital of changes in your benefits.
- Provide a copy of your Advance Directive (Durable Power of Attorney for Healthcare) if you have one.
In their Committee Opinion “Elective Surgery and Patient Choice,” the American College of Obstetricians and Gynecologists (ACOG) says that OBGYNs may perform unnecessary surgeries upon a woman’s request, including cesareans, as long as the woman is adequately informed of the risks and alternatives and the OBGYN believes the surgery is not an undue health threat:
Performing cesarean delivery on maternal request should be limited to cases in which the physician judges that it is sufficiently safe, given the specifics of the woman’s pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.
In their Committee Opinion “Maternal Decision Making, Ethics, and the Law,” ACOG points out
- Appellate courts have held…that a pregnant woman’s decisions regarding medical treatment should take precedence regardless of the presumed fetal consequences of those decisions.
- [M]ost ethicists also agree that a pregnant woman’s informed refusal of medical intervention ought to prevail as long as she has the ability to make medical decisions
- [I]n the vast majority of cases, the interests of the pregnant woman and fetus actually converge.
- Because an intervention on a fetus must be performed through the body of a pregnant woman, an assertion of fetal rights must be reconciled with the ethical and legal obligations toward pregnant women as women, persons in their own right….Regardless of what is believed about fetal personhood, claims about fetal rights require an assessment of the rights of pregnant women, whose personhood within the legal and moral community is indisputable.
Two of the main conclusions of this committee opinion are
- Coercive and punitive legal approaches to pregnant women who refuse medical advice fail to recognize that all competent adults are entitled to informed consent and bodily integrity.
- Court-ordered interventions in cases of informed refusal, as well as punishment of pregnant women for their behavior that may put a fetus at risk, neglect the fact that medical knowledge and predictions of outcomes in obstetrics have limitations.
However, the obstetric community continues to bully women into acquiescing to procedures that the obstetric team wishes to perform, and women are still persecuted for refusing procedures both legally and socially, even when these procedures are not evidence based.
Even when medical professionals do explain risks and benefits to a procedure, they often expect a woman to draw the same conclusion that they do regarding what should be done. The flip side of informed consent, however, is informed refusal. Women not only have the right to know what their options are, they have the right to choose the option they believe is right, regardless of what their health practitioner believes.