The Society of Obstetricians and Gynaecologists has issued a guideline amidst a rising amount of c-sections chosen over natural birth, emphasizing patient autonomy.
SOCG says the decision about whether to get a c-section should ultimately be up to the patient, not the doctor.
Many women are opting for c-sections, but this can create ethical dilemmas.
Dr. Jon Barrett, chief of maternal-fetal medicine at Toronto’s Sunnybrook Health Sciences Centre and one of the authors of the new guideline, said that there are competing principles that a doctor has to consider when a patient requests a c-section.
“For example, one [ethical principle] might be for a physician not doing harm to a patient, and yet we know that on balance planned c-section is probably more risky than planned vaginal birth, at least overall,” Dr. Barrett said.
This ethical principle of not doing harm to a patient has to be balanced with the principle of patient autonomy, which lets people decide for themselves if they want to take certain medical risks that affect their own bodies, Dr. Barrett said.
There is also the ethical principle of considering the community, he added.
“Here in Canada we have a funded health system, so what resource implications are there for an individual’s choice on the rest of society’s choice?”
Dr. Barrett said there is a clear order of priority to these principles.
“At the bottom line, patient autonomy almost always trumps everything else.”
But whether each hospital incorporates this new guideline is up to them.
Plenty of doctors disagree that a patient has a right to choose a c-section according to a 2009 study that SOCG cited. It found that only 42 percent of Canadian obstetricians support a person’s right to choose c-section. The figure is lower among family physicians at 19 percent.
So what if a patient and doctor disagree? What if a doctor’s medical understanding is at odds with the patient’s wishes?
The guideline suggests that the decision to have a c-section should be made over several sessions and “may also include other members of the maternal health care team.”
This can give the patient and doctors more opportunity to exchange perspectives.
“Very often, patients who come to me requesting a c-section, once you start discussing the reasons… and you talk about some of the fears of the birth, the pain, and you start discussing the birth process, most of the time the request is not completed,” said Dr. Barrett.
But if the patient is insistent about getting a c-section against doctor advice, the doctor has the responsibility to make sure the patient has access to care.
“The doctor would have to find somebody who would be willing to carry out the patient’s wishes,” said Dr. Barrett. “And make every reasonable attempt to do that. A practitioner is not compelled to do that themselves, but is compelled to make sure that the patient has access to that service.”
SOCG’s guideline will appear in July’s Journal of Obstetrics and Gynaecology Canada.