Forced Caesarean Sections

drkpower

This is an issue that is very likely to arise at some point in this state. It is somewhat surprising that it hasnt already. The situation does come up in medical practice from time to time. This is the type of thing I am talking about:

A pregnant woman is advised that for whatever medical reason (and there are many), the life of her baby would be at serious risk unless a caesarean section is performed. She refuses (for whatever reason). There is no substantial threat to the mother's health or life in performing a CS. Should the doctor be entitled to over-ride that refusal and forcibly perform a caesarean section?

Looking at the legal situation, this type of case did come up a few times in the UK courts a few years ago, and after a number of cases where courts ordered forced caesarean sections, the courts in the UK have now essentially settled this area of law on the side of the mother; she is fully entitled to refuse. However, the Irish situation is likely to be very different. First, there has been no case where this has directly arisen in Ireland. Second, a court, if faced with this situation, in this country, would need to consider the constitutional framework (which the UK obviously doesnt). And if applying A. 40.3.3 (The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.) in a situation where there is a serious risk to the unborn life but no risk to the maternal life, they would be likely to be obliged to vindicate the unborn life which necessarily would involve forcible restraint and operative intervention upon the woman.

So, what do people think? Is this going too far? Is it appropriate to forcibly operate on someone to save another? Personally, in these situations, however distasteful it may be, I feel it is justified.

While it is difficult to discuss this issue without the wider 'abortion' debate coming up, lets try and stick to this particular issue, as the wider topic has been done to death.

I posted this in the Humanities forum but would be interested to hear the view of practitioners on this issue. How would you feel if this situation arose, either now, before there has been any formal decision taken, or after a court rules formally that such restraint is permissable (if it ever does)? Would you be prepared to act in such a scenario?

Chuchoter

I think that since she has made the decision to carry the child to term, she has committed herself to doing whats best for the baby if at all possible.

lonestargirl

An sole adult absolutely has the right to refuse treatment, however in the case of a pregnant women I feel the unborn child also has the right to life. As a pregnant women you are more than one person and I think the court would be correct to force a CS.

Remember this case, here it was the mother's life at risk but she was the only family the child had in the country and as such the court ordered the transfusion. As far as I understand she is appealing to the supreme court at the moment, if they find against her I can't see how they wouldn't order a CS in a case where the baby's life is at risk.

lonestargirl

metrovelvet wrote: »

However, people will argue, its her body, her choice and given how knife happy OBS have become due to fear of litigation or the 20k they get for a cesarian

While a CS may costs 20k in the US that's not what the doctor gets. I just paid my bill for the electvie CS I'm having in 8 weeks + all the prenatal visits I've had, my 20% portion is $800 thus the total doctor's bill is more like 4k and that's before he pays his nurse, receptionist etc.

metrovelvet wrote: »

I would hope very stringent protocols are put in place before a doctor and override the wish of the mother.

Remember that in the US while the child is in the mothers body, the mother remains soverign over her right to privacy.

One of my best friend's here is a ob/gyn resident. One of her scariest situations to date was a schizophrenic patient who refused to believe that she was pregnant and hence refused to push once she went into labour. Psych wouldn't declare her incompetent and hence they couldn't force a CS. Baby was eventually delived with suction and promptly taken into care.

drkpower

lonestargirl wrote: »

Remember this case, here it was the mother's life at risk but she was the only family the child had in the country and as such the court ordered the transfusion. As far as I understand she is appealing to the supreme court at the moment, if they find against her I can't see how they wouldn't order a CS in a case where the baby's life is at risk.

There is no SC appeal in that case. The HC hearing (a year after the initial injunction) found in favour of the Hospital on the basis she didnt have capacity rather than on the basis that the child had noone to look after the kid.

lonestargirl wrote: »

One of my best friend's here is a ob/gyn resident. One of her scariest situations to date was a schizophrenic patient who refused to believe that she was pregnant and hence refused to push once she went into labour. Psych wouldn't declare her incompetent and hence they couldn't force a CS. Baby was eventually delived with suction and promptly taken into care. .

That seems like a slightly bizarre decision by the psych doctors. Capacity, on any legal definition, would be absent if the person denied the very fact of being pregnant!!

But in any case, the situation I am raising in the OP is in situations where the pregnant woman is very much capable of making a decision not to have a CS.

SleepDoc

A competent adult has the right to consent to or refuse medical or surgical intervention.

End of story.

drkpower

SleepDoc wrote: »

A competent adult has the right to consent to or refuse medical or surgical intervention.

End of story.

Well, it may not be actually!

Rightly or wrongly, the state (including the courts) has an obligation to vindicate the unborns right to life, and that is only subject to the maternal right to life. It is not subject to her right to bodily integrity, so on the face if it, a court, if presented with the situation in the OP, are likely (although not certain) to order a forced CS.

SleepDoc

drkpower wrote: »

Well, it may not be actually!

Rightly or wrongly, the state (including the courts) has an obligation to vindicate the unborns right to life, and that is only subject to the maternal right to life. It is not subject to her right to bodily integrity, so on the face if it, a court, if presented with the situation in the OP, are likely (although not certain) to order a forced CS.

Maybe. However a caesarian section, like all surgical procedures carries a certain (small admittedly) risk of death.

Wonder how many doctors would agree to be involved in such a case.

Not me.

drkpower

SleepDoc wrote: »

Maybe. However a caesarian section, like all surgical procedures carries a certain (small admittedly) risk of death.

Wonder how many doctors would agree to be involved in such a case.

Not me.

I dont think the risk of death attaching to a CS (surely far less than 1%) would be sufficient to consitute a sufficient risk to maternal life within the the terms of A. 40.3.3.

I agree with your latter point though; i suspect that the number of doctors willing to engage in physical/chemical restraint of women and then forced operative intervention would be few. And if a court orders such intervention, it would put such doctors in an impossible situation.

sam34

lonestargirl wrote: »

One of my best friend's here is a ob/gyn resident. One of her scariest situations to date was a schizophrenic patient who refused to believe that she was pregnant and hence refused to push once she went into labour. Psych wouldn't declare her incompetent and hence they couldn't force a CS. Baby was eventually delived with suction and promptly taken into care.

drkpower wrote: »

That seems like a slightly bizarre decision by the psych doctors. Capacity, on any legal definition, would be absent if the person denied the very fact of being pregnant!!

why didnt the obs team do a capacity assessment then? capacity assessments dont have to be done by psych, they can be done by any doctor.

drkpower

sam34 wrote: »

why didnt the obs team do a capacity assessment then? capacity assessments dont have to be done by psych, they can be done by any doctor.

+1
In fact, the initial assessment of capacity should be done by the patient's treating doc (particularly if they have prior dealings with the patient). Of course, if doubt still remains following that assessment, or if mental illness is suspected, a psychiatrist/clinical psychologist should be asked to consult also.

Batiste

Just to address the thread starter..The life of the carrier (the pregnant female) should be paramount.
And if there is a risk to the life of the pregnant female,and a CS is the only alternative,then what is the problem?

drkpower

Batiste wrote: »

Just to address the thread starter..The life of the carrier (the pregnant female) should be paramount.
And if there is a risk to the life of the pregnant female,and a CS is the only alternative,then what is the problem?

The OP concerns a situation where there is no real risk to the life of the mother but there is an almost certainty of death to the unborn.

Manach

Slightly off topic but perhaps relevant. AFAIR, a British House of Lords ruling stated that an intentional assault to cause harm to a foteus/child in the womb which results in death whilst not murder, could be considered manslaughter. So in theory this could be a legal sanction in this theoricial case?

drkpower

Manach wrote: »

Slightly off topic but perhaps relevant. AFAIR, a British House of Lords ruling stated that an intentional assault to cause harm to a foteus/child in the womb which results in death whilst not murder, could be considered manslaughter. So in theory this could be a legal sanction in this theoricial case?

Manslaughter in the type of case you refer to is only applicable where the foetus is born alive and then subsequently dies (.ie Mr X intentionally stabs mother (M); foetus (F) is born and sometime thereafter dies as a consequence of the injuries F suffered in utero). The key is that intention to assault a foetus is not 'illegal' as it is not a life in being. What attracts a manslaughter verdict is that there must be an intention to asssault a life in being (the mother) and that results in the death of another life (the foetus, which has since been born).

In the scenario in the OP, even if the foetus survived and then subsequently died, the act of the mother is not an an intentional assault of any life in being.

kelle

I was in a situation described in the OP nearly 10 years ago. My baby's heartbeat had fallen dangerously low, and I was told I needed a CS immediately. I was frantic, as the maternity books and magazines I had read were very negative in their attitudes towards Caesareans!
Such attitudes described were :
1. The muscles in my abdomen would sag and never tighten again as some of the muscles would be cut (OK, that's vanity!) My experience: Rubbish, I have a nice neat abdo - not quite 6-pack but working on it
2. I would be in severe pain and unable to hold the baby or breastfeed. My experience: Morphine helped the pain for the first 2 days, didn't need it after that - right as rain. Was able to hold baby and BF no problem.
3. I would be more likely to haemorrage afterwards and maybe die! (The only 2 people I know who haemorraged had natural births!)
4. Less likely to bond with my baby, and more likely to suffer PND. My experience: Bonded with baby. Had PND, but the same as anybody I know that had a natural birth.

OK, I know that's to discourage women looking for elective CS's because they are too posh to push, but it is frightening to an ordinary mother-to-be who is faced with no other choice!

Had I been very stubborn, I probably would have questioned the decision.
As it was, I was frantic but I just wanted a baby that was alive. I went ahead with it and, while he needed resuscitation when born (he was blue!) he recovered and is now a football-loving schoolboy. I've since had 2 further CS's with no problems.

I just feel there shouldn't be as much negativity about CS's, that's all - then the patient is less likely to refuse.

Batiste

drkpower wrote: »

The OP concerns a situation where there is no real risk to the life of the mother but there is an almost certainty of death to the unborn.

Okay,im trying to understand then why would there be anybody trying to force a caesarean if the situation was not a breach birth let's say or in anyway life endangering?

drkpower

Batiste wrote: »

Okay,im trying to understand then why would there be anybody trying to force a caesarean if the situation was not a breach birth let's say or in anyway life endangering?

There are a number of situations where a CS is required to avoid a high risk of death to the foetus but where the mother's life is not in danger (whether vaginal birth or CS is chosen).

It is exceedingly rare for a mother to refuse CS in such circumstances but it certainly has happened in the UK, and i would be surprised if it hasnt happened here.

lonestargirl

sam34 wrote: »

why didnt the obs team do a capacity assessment then? capacity assessments dont have to be done by psych, they can be done by any doctor.

1) Bear in mind this was not a situation I was personally involved in, just recounting what my friend told me. My friend in a junior resident and was not in charge in the situation.
2) In the US although a doctor may be fully licensed and qualified the procedures they can do as an employee of a hospital are limited by the priviledges the hospital affords them, i.e. hospital policy may be that only surgeons who did 200+ colonoscopies in their training can have colonoscopy priviledges. As result services are limited to practicing within the narrow scope of their training and must consult for everything else.

Regarding the OP scenario I think when a woman makes a choice to have a baby then they also have to accept that the baby has some rights too. They've already made a decision to put their own life at increased risk simply by getting pregnant.

CathyMoran

I had a c-section with my son. They had problems putting in the spinal block (the interns were not trained enough to do it properly) and in the end the consultant put it in - it was a painful and horrific experience. I am facing this again and I must admit that I am petrified and am considering to be knocked out for the procedure. I would understand why a mother would not want to have one, especially if they had a bad experience with a previous birth. You are dealing with women who may be in a highly traumantised state who may potentially be in great pain. Having said that if the option of being asleep for the procedure is made clearly avaivable it might be easier. Yes the mother should be made have a c-section but her comfort should also be paramount.

metrovelvet

CathyMoran wrote: »

I had a c-section with my son. They had problems putting in the spinal block (the interns were not trained enough to do it properly) and in the end the consultant put it in - it was a painful and horrific experience. I am facing this again and I must admit that I am petrified and am considering to be knocked out for the procedure. I would understand why a mother would not want to have one, especially if they had a bad experience with a previous birth. You are dealing with women who may be in a highly traumantised state who may potentially be in great pain. Having said that if the option of being asleep for the procedure is made clearly avaivable it might be easier. Yes the mother should be made have a c-section but her comfort should also be paramount.

Ok that is all true. But frankly if your childs life is threatened then fears of the procedure would be overridden by fears for your child's life. My son had the threat of cerebral palsy because his head got stuck mid contraction during a failed induction [which I should have never agreed to in retrospect.] and I took the surgeons' [all Harvard graduates - I checked!] advice without hesitation and I was knocked out for it - but not hard to to because I had been awake for 26 hours at that stage.

CathyMoran

metrovelvet wrote: »

Ok that is all true. But frankly if your childs life is threatened then fears of the procedure would be overridden by fears for your child's life. My son had the threat of cerebral palsy because his head got stuck mid contraction during a failed induction [which I should have never agreed to in retrospect.] and I took the surgeons' [all Harvard graduates - I checked!] advice without hesitation and I was knocked out for it - but not hard to to because I had been awake for 26 hours at that stage.

I agree, my child was the main person on my mind. The fact that I am willing to go through this all again while the memory is still very fresh in my mind (May/June next year, my son was born this April).

When they did get the spinal block in sucessfully I was able to see my son take his first breaths (am crying as I write this, it was wonderful)...I have and would do anything for my children (born and unborn).

metrovelvet

CathyMoran wrote: »

I agree, my child was the main person on my mind. The fact that I am willing to go through this all again while the memory is still very fresh in my mind (May/June next year, my son was born this April).

When they did get the spinal block in sucessfully I was able to see my son take his first breaths (am crying as I write this, it was wonderful)...I have and would do anything for my children (born and unborn).

I had the epi during the induction. I dont know if they would have given me one if I had gone in straight for the section. I had GA for the section and I didnt see anything, not even my son. I saw him a few hours later.

But as I said in Humanities, I was so exhausted and drugged and sick with a fever that I would hope that someone would have over ridden my protest if I had refused one. I honestly dont know how compus mentus you can be under these circumstances. At the same time, if someone is going to slice you open, they should have your consent. Very tricky area.

lonestargirl

http://breakingnews.ie/ireland/hse-applies-to-have-hiv-drugs-administered-to-newborn-482486.html

The outcome to this case could have relevance here, as well as administering the drugs the HSE want to carry out an early C Section.

SomeDose

lonestargirl wrote: »

http://breakingnews.ie/ireland/hse-applies-to-have-hiv-drugs-administered-to-newborn-482486.html

The outcome to this case could have relevance here, as well as administering the drugs the HSE want to carry out an early C Section.

I cannot possibly see the High Court ruling in favour of the mother here, the benefits of using anti-retrovirals in newborns to prevent transmission from HIV+ mothers has been established for some time now, and far outweigh any potential toxicity. I'm certain there's bucketloads of case law to refer to where court injunctions have been obtained to allow such treatment.

I've no legal training, but I'd imagine that compelling a woman to accept a zidovudine infusion is no different in principle to forcing a CS on them in the interests of her unborn child.

metrovelvet

SomeDose wrote: »

I cannot possibly see the High Court ruling in favour of the mother here, the benefits of using anti-retrovirals in newborns to prevent transmission from HIV+ mothers has been established for some time now, and far outweigh any potential toxicity. I'm certain there's bucketloads of case law to refer to where court injunctions have been obtained to allow such treatment.

I've no legal training, but I'd imagine that compelling a woman to accept a zidovudine infusion is no different in principle to forcing a CS on them in the interests of her unborn child.

You know what. That link annoys me. It annoys me because it is the HSE, an extension of the government trying to medicate an infant against the parents will. While I see their point, I also see that medicine in this country is an extension of the state. I am very creepily getting the feeling in this country our children are not ours, they are the states and the mothers are just kept at home [in the constitution ] to baby sit and the dads are sent out to work because the state knows it can collect more revenue via taxes from the higher paid men.

If it were not the HSE it mightn't bother me as much.

There has to be a point where the state has to stop interfering. It does NOT always know better.

drkpower

SomeDose wrote: »

I've no legal training, but I'd imagine that compelling a woman to accept a zidovudine infusion is no different in principle to forcing a CS on them in the interests of her unborn child.

The only circumstance where a CS could be forced or a mother could be forced or an infusion could be enforced is where it is required to vindicate the right to life of the unborn. Not where it is merely beneficial to the baby, or in the interests of the baby.

My understanding of the present case is that such an infusion to the mother (or delivery by CS) is certainly the preferred option for the baby, but neither option is required to save the unborn baby's life. In the hypothetical i cited in the OP, a CS is required, it is the only way, to save the life of the baby.

drkpower

metrovelvet wrote: »

While I see their point, I also see that medicine in this country is an extension of the state. I am very creepily getting the feeling in this country our children are not ours, they are the states .....

No, they are not yours, and they are not the state's. They are individual citizens with individual rights. And where the most fundamental of those rights are breached by anyone, the state, as the protector of those rights, has a duty and responsibility to intervene.

tallaght01

drkpower wrote: »

The only circumstance where a CS could be forced or a mother could be forced or an infusion could be enforced is where it is required to vindicate the right to life of the unborn. Not where it is merely beneficial to the baby, or in the interests of the baby.

My understanding of the present case is that such an infusion to the mother (or delivery by CS) is certainly the preferred option for the baby, but neither option is required to save the unborn baby's life. In the hypothetical i cited in the OP, a CS is required, it is the only way, to save the life of the baby.

It's a huge difference in risk, though. Depending on how the delivery goes, risk of transmission is up to 25-30%. With proper care it's about a quarter of a percent.

drkpower

tallaght01 wrote: »

It's a huge difference in risk, though. Depending on how the delivery goes, risk of transmission is up to 25-30%. With proper care it's about a quarter of a percent.

It is; but in order to justify a fairly massive breach of maternal rights, the intervention must be required to save the unborn baby's life, i would suggest to a point that it is almost certain that the unborn will die without that treatment.

metrovelvet

drkpower wrote: »

No, they are not yours, and they are not the state's. They are individual citizens with individual rights. And where the most fundamental of those rights are breached by anyone, the state, as the protector of those rights, has a duty and responsibility to intervene.

They are not individual citizens of the state until they are born and the registrar sends you a birth cert.

I could not get my son a passport while I was pregnant.:rolleyes:

No. As long as that psychopath Mary Hearney is compromising the nations health and lives, the state can butt out.

tallaght01

drkpower wrote: »

It is; but in order to justify a fairly massive breach of maternal rights, the intervention must be required to save the unborn baby's life, i would suggest to a point that it is almost certain that the unborn will die without that treatment.

And it could be argued that HIV isn't even terminal these days.

But, from my experience with these things overseas, judges have been less than sympathetic to these parents, or it doesn't reach court before the parent gives in. Will be interesting to see how the Irish courts react.

It's a terribly sad story either way, as post-delivery treatment is important for a few months, and you'd have to wonder whether the mother is going to give the kiddy the meds at home anyway if she feels so strongly about them.

The poxy internet and the shyte people write about meds causes so much more problems than these gobshytes ever realise.

drkpower

metrovelvet wrote: »

They are not individual citizens of the state until they are born and the registrar sends you a birth cert.

No; but once born they are. And pre-birth, the state also has responsibilities to them.

Harney is responsible for a lot, but she isnt responsible for the state owing born and the unborn certain duties.

drkpower

tallaght01 wrote: »

And it could be argued that HIV isn't even terminal these days.

But, from my experience with these things overseas, judges have been less than sympathetic to these parents, or it doesn't reach court before the parent gives in. Will be interesting to see how the Irish courts react.

It is very unlikely, in this case, that the courts will force the mother into any treatment.

As for the child, when born, there is a strong likelihood they will intervene. It will depend on the evidence given as to whether there is a substantial risk to the health of the baby if treatment isnt given. Parents are entitled to withhold treatment even if the treatment is in the childs interests. But not if to withold treatment would constitute a substantial risk to the health of the baby.

It is interesting alright; and its incredibly sad that the mother has chosen to put their child at risk in this way.

tallaght01

drkpower wrote: »

It is very unlikely, in this case, that the courts will force the mother into any treatment.

As for the child, when born, there is a strong likelihood they will intervene. It will depend on the evidence given as to whether there is a substantial risk to the health of the baby if treatment isnt given. Parents are entitled to withhold treatment even if the treatment is in the childs interests. But not if to withold treatment would constitute a substantial risk to the health of the baby.

It is interesting alright; and its incredibly sad that the mother has chosen to put their child at risk in this way.

I only base this on experience in the UK and Oz, but I'd be surprised if they allowed the mother to have a normal delivery.

I wouldn't like to give details, as I suppose they'd potentially be identifiable, but I've been in 2 situations where the risk has been lower than the above case, and the parent were advised in both cases by their own counsel that they were unlikely to win.

Will be interesting to see, though.

drkpower

tallaght01 wrote: »

Will be interesting to see, though.

Well as it happens, the mother agreed to a CS 'within days' and they ordered the baby, when born, gets the drugs.

tallaght01 wrote: »

I only base this on experience in the UK and Oz, but I'd be surprised if they allowed the mother to have a normal delivery.

I wouldn't like to give details, as I suppose they'd potentially be identifiable, but I've been in 2 situations where the risk has been lower than the above case, and the parent were advised in both cases by their own counsel that they were unlikely to win.

Ar you sure about that? Since the mid-90s, i think, the position in UK law has been settled. The mother can refuse a CS even if to do so would absolutely definitely certainly result in the death of the baby. I suspect the Aussie situation is the same.

The only reason why Ireland may be different is because of Article 40.3.3 and even then, a court is unlikely to intervene on the basis of a risk to the baby short of almost certain death.

tallaght01

Yes I'm sure. The cases I was involved in had nothing to do with CS. they related to parents making dodge decisions about their kids' treatment. But the risks were lower than in this case.

Didn't know this case had been settled, btw. Good news.

I still wonder how they'll enforce the use of ARVs.

drkpower

tallaght01 wrote: »

Yes I'm sue. The cases I was involved in had nothing to do with CS. they related to parents making dodge decisions about their kids' treatment. But the risks were lower than in this case..

When you said that you'd be surprised if they allowed the mother to have a normal delivery, i thought you meant that the legal advice given was that a court would order a forced CS. As I said, that option is not legally permissable in the UK (and OZ i think).

The situation with a born child is very different, though, and courts are very ready to intervene to protect their rights when the threat is sufficiently serious.

tallaght01 wrote: »

I still wonder how they'll enforce the use of ARVs.

Are they usually given on an outpatient basis? If so, yes, they will have to make sure they keep track of where the kid is, and if the parents dont bring him in for treatment, the HSE would get onto the Gardai pronto and have him brought into care for the duration of his treatment.