Healthcare professionals often have to deal with ethical dilemmas in their practice. This paper will consider an ethical dilemma faced by specialists in the field of obstetrics and gynecology regarding elective cesarean section (CS). The number of deliveries through CS has increased throughout the world, with the number of CS on maternal request ranging from 1 to 9% of all CS deliveries (Olieman et al., 2017). The increasing number of CS, especially elective CS, raises healthcare professionals’ concern as to whether they should grant women’s wish to deliver a child through CS when there are no medical indications to this operation. Even though CS has certain benefits for women and newborn children, this procedure is also associated with many risks that may influence the health of a woman and a child, as well as future pregnancies (Olieman et al., 2017). Therefore, healthcare professionals should weigh all possible risks to decide whether elective CS should be permitted. Although it is important to consider women’s autonomy in deciding how they should treat their bodies, healthcare professionals should pay more attention to the ethical principle of beneficence.
Issues with Elective Cesarean Section
Although unassisted vaginal delivery is the safest way of delivering a child, some women oppose it and request CS. A frequent reason for this is a fear of childbirth, which is experienced by about 20% of all pregnant women and is sometimes quite severe (Olieman et al., 2017). Another reason is a wish to avoid potential adverse effects of vaginal delivery, such as “third-degree perineal tears, subsequent urinary and/or fecal incontinence, and future prolapse” (Van de Wiel et al., 2017, p. 434). Hence, women’s tendency to choose CS over vaginal delivery is mostly related to health concerns.
Although vaginal delivery indeed poses some health risks, women requesting CS often are not aware of the risks of CS, which are more numerous. For example, CS has negative psychological consequences, such as a woman’s feeling of guilt for not delivering a child by herself or regretting her decision in the case of complications (Van de Wiel et al., 2017). Other cons include a higher risk of wound infection, endometritis, and uterine rupture in the next pregnancy compared to vaginal delivery (Van de Wiel et al., 2017). Although CS significantly decreases maternal and infant mortality in case it is undertaken when it is medically necessary, the benefits of this operation performed on patients’ demand are not sufficiently studied (Chervenak & McCullough, 2017; Van de Wiel et al., 2017). Thus, the drawbacks of elective CS are evident, while its benefits are still unproven.
Ethical Principles Involved in the Issue
Ethics has a great significance in medical practice because healthcare professionals constantly have to make decisions that influence their patients’ lives. Medical ethics is based on the following major principles: respect for autonomy, nonmaleficence, beneficence, and justice (Van de Wiel et al., 2017). Although all these ethical principles apply to the issue of elective CS, the principles of autonomy and beneficence have the primary importance.
According to the principle of autonomy, people should be able to make decisions regarding their bodies. Even though healthcare professionals should respect patients’ autonomy, it becomes difficult in the case of pregnant women because their decisions affect not only themselves but also their unborn children. Here, the principles of autonomy and beneficence come into conflict. Healthcare professionals have a beneficence-based obligation to provide patients with treatment that will do more good than harm (Chervenak & McCullough, 2017). In the case of a pregnant woman, the medical staff deals with two patients at once, a woman and a fetus, and is obliged to make medically reasonable decisions to exercise the beneficence principle. However, a medically reasonable decision is not the one based on women’s preference, which is particularly true when women are poorly informed of the risks (Chervenak & McCullough, 2017). Thus, the principle of beneficence advises healthcare professionals against granting women’s wish to undergo elective CS.
Yet, there is still a need to respect women’s autonomy. This could be done by shared decision-making between a healthcare professional and a patient (Chervenak & McCullough, 2017). However, this approach is limited to situations when two or more medically reasonable alternatives exist (Chervenak & McCullough, 2017). In this case, patients should be given autonomy in choosing the option that appeals to them most. Otherwise, if there is only one medically reasonable decision, healthcare professionals should act according to this decision and convince the patient of its necessity.
According to the ethical principles described above, the solution to the ethical dilemma related to elective CS is to recommend against CS on maternal request. Healthcare professionals should inform pregnant women of the risks associated with non-indicated CS since women requesting CS are often unfamiliar with them. Patients with a severe fear of childbirth should be provided with counseling and psychiatric care for depressive disorders or anxiety (Olieman et al., 2017). These measures should be directed toward persuading women to choose vaginal delivery because it is more beneficial for both a woman and a fetus.
However, if a woman is highly persistent in her wish to undergo elective CS even after she was informed of the risks, healthcare professionals should consider granting this wish. Teng et al. (2016) present a case of a pregnant woman diagnosed with “severe borderline personality disorder and depression” who demanded CS in order to save her child since she was likely to commit suicide (p. 168). After lengthy discussions and observations, the healthcare team granted her wish by undertaking CS at 31 weeks of gestation (Teng et al., 2016). In challenging cases like this, when a woman is highly persistent, and her behavior may harm the fetus, elective CS may be the right choice.
Chervenak, F. A., & McCullough, L. B. (2017). Ethical issues in cesarean delivery. Best Practice & Research Clinical Obstetrics & Gynaecology, 43, 68-75.
Olieman, R. M., Siemonsma, F., Bartens, M.A., Garthus-Niegel, S., Scheele, F., & Honig, A. (2017). The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: A systematic review. BMC Pregnancy and Childbirth, 17(195), 1-8.
Teng, J. Y., Yin Ing Chee, C., Chong, Y.-S., Lee, L. Y., Yong, E. L., Chi, C., & Broekman, B. (2016). A suicidal pregnant patient’s request for premature Cesarean section: Clinical and ethical challenges. Journal of Affective Disorders, 194, 168-170.
Van de Wiel, H. B. M., Paarlberg, K. M., & Dermout, S. M. (2017). Health advocate: An obstetrician in doubt—coping with ethical dilemmas and moral decisions. In K. Paarlberg & H. van de Wiel (Eds.), Bio-psycho-social obstetrics and gynecology (pp. 433-454). Springer.