Archives for posts with tag: ethics

Rinat Dray was forced to have a cesarean in 2011 at Staten Island University Hospital.  Dray had two previous cesareans and chose a doctor who said he supported her desire for a VBAC and a hospital with (by American standards) a low cesarean rate and a good VBAC rate.  But once she arrived at the hospital in labor, according to Dray (as reported by the New York Times),

The doctor told her the baby would be in peril and her uterus would rupture if she did not [have a cesarean]; he told her that she would be committing the equivalent of child abuse and that her baby would be taken away from her.

She still refused the cesarean, and she was supported in her refusal by her husband and her mother.  The hospital strapped her down and wheeled her into surgery as she begged them to stop.  A note in her medical record by Dr. James Ducey says, “I have decided to override her refusal to have a C-section.”  During the surgery, the doctor punctured her bladder.  You can hear a podcast on RH Reality Check in which Dray discusses her case along with professionals in obstetrics, law, and ethics.

Dray is a Hasidic Jew, which likely means that she wants a large family.  While there are risks to vaginal birth after cesarean, in most cases there are even greater risks to having many cesareans.

In the podcast, Dr. Katharine Morrison, MD, FACOG (Director of Buffalo WomenServices, which I wrote about here) says that she reviewed the record and it did not appear that there was an emergency situation or that a cesarean was needed at all.  But even if a cesarean has appeared necessary to preserve the life or health of Dray or her baby, as Dr. Howard Minkoff, chairman of obstetrics at Maimonides Medical Center in Brooklyn, said in the NYT article, “I don’t have a right to put a knife in your belly ever.”

One would think that a case in which a psychologically stable woman refused surgery and was then strapped down, sliced open, and had her bladder perforated would be apparent to anyone as a horrendous breach of human rights.  (And actually, she was asking them to wait a little longer, not saying she would not agree if she felt a cesarean was truly necessary).

All one has to do to see where a woman falls in the human rights spectrum of many is to read the comments on the New York Times piece.

The comments fall into a number of categories, including some that unequivocally support Dray.

Many, however, unequivocally support the the doctors or the profession of obstetrics.  Here is Northstar5:

If this woman had 2 prior C-sections then the doctors are absolutely right that vaginal delivery was exceedingly risky. I almost laughed when I read that the woman is charging the doctors and hospital for “improperly substituting their judgment for that of the mother.” What?? That’s what they are supposed to do. They are doctors, she is not.

Some defend the doctors doing whatever they like to avoid risks of malpractice:

Attempting a vaginal birth after two c-sections is extremely dangerous and reckless. The physicians involved would likely have been sued regardless of the method of delivery, so I applaud them for at least saving a life in this case.

I’m not sure where the commenters get their medical information, but the doctor agreed in advance to attend Dray at a vaginal birth.  You can read the entire American College of Obstetricans and Gynecologists’ practice statement “Vaginal Birth After Previous Cesarean Delivery,” which specifically says, “women with two previous low transverse cesarean deliveries may be candidates for TOLAC [trial of labor after cesarean].”  I highly recommend that you visit Jennifer Kamel’s website and read “13 Myths about VBAC.”  Repeat cesarean and VBAC both have risks.  The newest ACOG obstetric care consensus statement on cesarean points out the risks of cesarean over vaginal birth.  Cesarean nearly quadruples the risk of maternal death, and risks of maternal morbidity and mortality go up with every cesarean.  This would be a particular concern for a woman who wanted a very large family, as many Hasidic women do.  Here is a consent form that clearly lays out the risks and benefits of repeat cesarean and VBAC.

Some commenters are completely on the side of the fetus–if the mother’s status is reduced to that of a container, so be it.  Here’s NYC Commuter:

In this case, the hospital and doctors have not one patient, but two. One is an adult who appears competent to make medical decisions. The other is a fetus, at term, who has no voice. The courts have repeatedly affirmed that the state has a duty to protect citizens that cannot protect themselves. If a fetus is believed to be “alive,” then an argument can be made that it must be protected as well. Pregnant women have been forced to receive imprisoned to prevent them from harming their fetuses (e.g. drug abusers), take medication (e.g. for treatable diseases), and even receive c-sections if the baby’s life is judged to be in direct jeopardy.

I have written about the ethics of privileging the well-being of a fetus over an adult woman many times, including here, here, and here.  ACOG also agrees that a woman should have the right to make her own decisions, even if it may negatively impact the fetus.  One recommendation from ACOG’s Committee Opinion, “Maternal Decision Making, Ethics, and the Law” says,

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

In addition to wanting to protect the rights of physicians and fetuses over those of pregnant women, many commenters simply condemn Dray as selfish, selfish, selfish.  Here’s Beth Green:

What an incredibly selfish woman putting her unborn child in harms way. She got her several hours of trial-labor and no baby, so according to the standard of care she got a C-section and a healthy baby.

Some also posit that Dray is not only selfish but also psychologically compromised.  Here’s Dave:

This case is not about the “debate over C-sections.” This case is mostly about psychopathology, but there is a larger point. Rinat Dray’s actions harm us all. In her narcissism, she was willing to sacrifice her child to maintain her sense of control. This bears repeating – we are dealing with someone who would rather her child suffer than allow a section. So I’m sure she cannot put herself in the place of others, and she will not understand this, but she makes it all the more difficult to deliver babies in the US. Once all the OB/GYNs suffer these indignities and these lawsuits from those with personality disorders, who will deliver babies safely?

And here’s Reader:

A mother in labor who focuses more on her joy of delivery rather than trying to ensure that she delivers a healthy child who could be stuck with birth defects for up to an average of 7-8 decades thereafter is not rational, is selfish and needs to have her head examined.

What we get above all else if the “all that matters is a healthy baby” trope.  Here is NMY:

I have absolutely no sympathy for this woman at all. Her sense of entitlement is simply galling. She’s having a baby. The most important thing here is to ensure the delivery of a healthy baby, not to satisfy some preconceived notion that she should have a vaginal delivery.

Here’s Jen:

The OBGYNs can’t win. Now they are going to get sued for performing c-sections. It used to be they got sued for not doing the section soon enough. This lawsuit is absolutely ridiculous and I hope the physicians win. Do you want a c-section and a healthy baby or a VBAC and a dead baby? How can any mother refuse a c-section when the physician is telling you the health of your baby is at risk?

Here’s Stephen:

Sorry, but the health of the fetus should trump the intellectual desires of the mother….There are too many C-sections performed to be sure, but isn’t the point of labor and birth to deliver a healthy baby?

Here’s Lynn in DC:

She had this child in 2011 and all of her children are healthy so what’s the big harm here?

Aside from the fallacy of believing that Ms. Dray could not have both a respectful vaginal birth AND a healthy baby, a healthy baby is not all that matters.  A healthy mother matters too.  As in Ms. Dray’s case, having a perforated bladder and the trauma of being strapped down for a surgery that she actively refused did not result in a healthy mother.  Not being dead is not good enough.





Note: there is follow-up to this post with a response from Dr. Paul Burcher.  You can read it here.

Obstetrician Paul Burcher has a column called The Ethical ObGyn at in which he instructs his fellow OBs, “Don’t Dread the Birth Plan.”  The best thing I can say about it is that not everything he says in this column is offensive.

He starts off citing Frank Chervenak and Laurence McCullough’s concept of “preventive ethics.”  For those of you not familiar with Chervenak, he is an OB, an expert in ultrasonography, and an anti-homebirth crusader.  He is perhaps most famous among homebirth supporters for a clinical opinion he published in AJOG in which he discussed midwife-supported homebirth in terms of “recrudescence” (which basically means resurgence or revival, except it tends to refer to something really bad, like guerilla warfare).  Chervenak also presented an anti-homebirth screed in the IOM Birth Settings Workshop in the Spring of 2013 in which he used vital records (birth certificate) data to make the case that homebirth led to a an enormous increase in stillbirth.  The statistician representing the National Center for Vital Statistics, Marian MacDorman, responded after his presentation that vital records were not a reliable source for making such claims, but he went on to publish the data anyway.  He also wrote the following in response to the ACOG Committee Opinion against homebirth (which he did not feel went far enough):

Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with respectful persuasion.

Note that he is not suggesting that there be a full explanation of the benefit-risk analysis, a shared decision making process, or a consideration of the woman’s values.  There should just be information (that has been questioned by numerous experts) that neonatal mortality increases (and as I have posted before, even with the increase cited by Chervenak, the absolute risk of such a grim outcome is very, very small).  In other words, women should make the choice that he deems to be ethical.  At the time he wrote this recommendation, the hospital where he practices had one of the highest cesarean rates in New York.

But back to Burcher.  Burcher makes a private assessment of birth plans, dividing maternal requests into “of course,” “probably,” and “nonstarter.”  He suggests beginning by placating women with the “of course” items, such as not shaving because the hospital never does that anyway (do any hospitals still do routine shaves?  Even 20 years ago in the middle-of-nowhere hospital where I delivered, it never came up).

Regarding the “nonstarters,” his approach is reasonably respectful.  he suggests asking the woman about why she made the request and seeing if it can be fully or partially accommodated in some other way.  For instance, if a woman planning a VBAC wants to avoid continuous electronic fetal monitoring, but it is not the monitoring she objects to, but rather the restriction of movement, telemetric monitoring could work.  While I still think that women should have the ultimate choice about what is done to their bodies, I also understand that outside forces on physicians could jeopardize their careers if they agreed to processes that went against hospital or practice guidelines.  However, that does not mean that a woman cannot refuse against medical advice (AMA), and if she does, her wishes should be respected.  He does not address this very important ethical issue.

This biggest issue I have with Burcher are the “maybes.”  First of all, if it’s a maybe, it seems like what it should really be is “yes.”  If it is possible, and the woman wants it, what is the debate?  Of course, he is referring to the possibility of complications that would tip a “maybe” to a “nonstarter”–however, he indicates that this is already the case with the “of courses”:

I always tell my patients that my comfort zones may be different than the limits that my partners may have, so I cannot guarantee that the decisions made during prenatal care will all be carried out during labor. As circumstances change, so may our determinations of what is safe and appropriate.

This strikes me as bait and switch.  I read stories from so many women saying that their provider said s/he would support a VBAC, only to insert so many caveats along the way (you must go into spontaneous labor by x date, you must consent to y while in labor, you must deliver in z way) that their support for VBAC revealed itself to be a sham.  So what he is saying is that he cannot guarantee that he will attend the birth, and if one of his partners is there, what has already been determined by him to be perfectly acceptable might be outside the other practitioner’s “comfort zone,”  and therefore the agreed-upon birth plan would be meaningless.  I don’t understand why the doctor’s comfort zone is under consideration, as he is not birthing the baby.  How does the new doctor get the woman to change her informed consent?  By telling her that Dr. Burcher misinformed her?

The woman must have the autonomy to make the final decisions regarding her own care even if the doctor would personally make a different choice.  That is ethical, and that is the  point that Dr. Burcher (and many of his colleagues) seems to miss.

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