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  • Moral/Ethical/Legal Dilemma. Patient refusing C-section.



    Had a lovely little experience this weekend. Called in for an emergent c-section for a breach baby. Arrive to hear MDs engaged in a lively conversation with the patient and husband via interpreter. Patient is 35 weeks, G8 P6. No prenatal care. She is new to the U.S. from Guatemala. She is complete but membranes have not ruptured. One leg of the baby is protruding down into pelvis while other is up by babies head. The MDs are explaining to the patient that it will be impossible for the baby to be delivered because of it's position and a c-section is the only option. The patient goes on to explain that while in Guatemala she had two pregnancies that were breach. One of the babies lived and the other one did not survive delivery. The doctors went on explaining that this baby would also die if a c-section was not performed. The patient calmly stated that her sister had a c-section 5 years ago and still had abdominal pain. She didn't want this to happen to her so she was fine with attempting a vaginal delivery and acknowledged the risk to the baby. She went on that she believed this was God's will and whatever happens is what God wants. The doctors again repeated that the baby would not survive and she needed a c-section. This back and forth went on for over an hour. At this time one of the MDs came out of the room to talk to me. She told me that I needed to be ready to take the patient back for a c-section regardless of what the patient says. Luckily during this entire time the baby is looking great. I began to make some calls to other providers to see if they had ever been in this situation and that there thoughts were. My initial thoughts were that I had to follow the patient's wishes as trying to anesthetize her against her wishes would be assault and battery, but at the same time I couldn't imagine sitting back and watching a 35 week old baby die (in my state you get 2 counts of murder for killing a pregnant woman). Other providers echoed these thoughts but encouraged attempting to get a court order to over rule the patient such as can be used in blood transfusions for Jehovah Witnesses. This entire time I am just picturing the baby crashing and them trying to bring the mother back to the OR while fighting off the husband. Then holding her down with multiple people while trying to induce anesthesia to save a baby and incur a lawsuit and jeopardize my license. Fortunately, out of the blue she decided to sign the consent and we had an uneventful c-section with a spinal.

    There are so many ethical, moral, legal, and emotional aspects to this case. I've talked to our CEO to review this case with the hospitals legal team and risk management team to clarify exactly what appropriate actions would have been if baby would have started to show distress. I'm curious as to what everyone else thinks of this situation and what you would have done if FHTs would have dipped and baby started looking bad.

    I did call my liability insurance provider today and they told me that the only way I would have been able to legally anesthetize this patient would be if there was a court order over-riding her wishes.
    This article was originally published in forum thread: Moral/Ethical/Legal Dilemma. Patient refusing C-section. started by HuskerCRNA View original post
    Comments 110 Comments
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by MmacFN View Post
      totally agree. If the mom is competent and refuses after being properly informed then thats how the cookie crumbles. There is NO place for others to try and force anything upon the mother based on ANY of their personal religious beliefs.

      To even VAGUELY sanction that idea means it would also be ok for other religious beliefs to be forced upon YOU whenever that provider felt differently. Its wrong, plain and simple.
      You are always quick to blame religion for anything you don't agree with....religion doesn't necessarily factor in to this at all.....do you not place any value on human life? Are you torturing kittens for fun in the desert?
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by MmacFN View Post
      totally agree. If the mom is competent and refuses after being properly informed then thats how the cookie crumbles. There is NO place for others to try and force anything upon the mother based on ANY of their personal religious beliefs.

      To even VAGUELY sanction that idea means it would also be ok for other religious beliefs to be forced upon YOU whenever that provider felt differently. Its wrong, plain and simple.
      I am not sure how this became a religious issue. I don't see it as one. It certainly isn't for me. I just cannot believe you would let a near term, fully viable baby possibly die just because it is the moms wishes. A lot of us just don't want a dead baby, having nothing to do with religious convictions. It is certainly not as black and white for many.

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. bettermj's Avatar
      bettermj -
      Quote Originally Posted by RAYMAN View Post
      You are always quick to blame religion for anything you don't agree with....religion doesn't necessarily factor in to this at all.....do you not place any value on human life? Are you torturing kittens for fun in the desert?
      That was kinda funny. Kittens.
    1. MmacFN's Avatar
      MmacFN -
      That is correct, as an atheist i bring exactly ZERO biased to the table.

      Quote Originally Posted by jwk View Post
      So is his point of view, whatever it may be, any less valid than yours, an unwavering atheist? You don't think you bring any bias to the table?
    1. MmacFN's Avatar
      MmacFN -
      Im not blaming religion, its a simple fact ray. His deep seated personal beliefs as a FATHER cannot be dismissed in a discussion about an unborn child. Its like asking a parent if they think their kid is good looking or smart, THEY ALL DO.

      Quote Originally Posted by RAYMAN View Post
      You are always quick to blame religion for anything you don't agree with....religion doesn't necessarily factor in to this at all.....do you not place any value on human life? Are you torturing kittens for fun in the desert?
    1. MmacFN's Avatar
      MmacFN -
      I agree gass

      I also would not want it to happen, however, that isnt the question. The question is who has the legal rights here and the answer is the mother not us. Just like you dont get to kill a patient who comes into the OR that is a child molestor (as much as we might want to) you cant circumvent this womans rights because of your own personal beliefs, guilt or feelings on what is right.

      Quote Originally Posted by gaspass3 View Post
      I am not sure how this became a religious issue. I don't see it as one. It certainly isn't for me. I just cannot believe you would let a near term, fully viable baby possibly die just because it is the moms wishes. A lot of us just don't want a dead baby, having nothing to do with religious convictions. It is certainly not as black and white for many.

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by MmacFN View Post
      I agree gass

      I also would not want it to happen, however, that isnt the question. The question is who has the legal rights here and the answer is the mother not us. Just like you dont get to kill a patient who comes into the OR that is a child molestor (as much as we might want to) you cant circumvent this womans rights because of your own personal beliefs, guilt or feelings on what is right.

      I fell that this falls much into a gray area in a legal sense. The courts have not spoken clearly on this issue, but a term fetus certainly enjoys some protection (for example, the courts have consistently ok'd charging women who abuse drugs during pregnancy).
    1. MmacFN's Avatar
      MmacFN -
      Yah but this is different, you are talking about circumventing a constitutional right to self determine which has been held up in courts over and over again. This isnt an individual trying to kill a baby with illegal drugs, or doing anything illegal. In fact many clearly delivered without difficulty EVEN in this situation (we had one a month ago exactly the same story).

      Its totally different.

      Quote Originally Posted by J-Dubya View Post
      I fell that this falls much into a gray area in a legal sense. The courts have not spoken clearly on this issue, but a term fetus certainly enjoys some protection (for example, the courts have consistently ok'd charging women who abuse drugs during pregnancy).
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by MmacFN View Post
      That is correct, as an atheist i bring exactly ZERO biased to the table.
      0.o lol

      i hope that was one of those moments where a sarcastic inflection was lost in the written form.
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by MmacFN View Post
      Yah but this is different, you are talking about circumventing a constitutional right to self determine which has been held up in courts over and over again. This isnt an individual trying to kill a baby with illegal drugs, or doing anything illegal. In fact many clearly delivered without difficulty EVEN in this situation (we had one a month ago exactly the same story).

      Its totally different.
      Again I disagree and the courts certainly afford protection to unborn fetuses. Causing harm to a fetus may be illegal, just as denying an infant care for religious reasons has been ruled illegal. As I posted earlier, women have been charged with murder for refusing c-sections (in the case I posted the woman took a plea). It's gray area and it's unclear how higher courts would rule on this exact case.

      Again, the woman's rights take a back seat IF the fetus is seen as an infant. In the case of a term fetus, legally, I think you are going to find it's not a free-for all.
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by MmacFN View Post
      That is correct, as an atheist i bring exactly ZERO biased to the table.
      Puhleaze! You're human, I think, so you have bias....esp against conservatives and religion....the fact that you don't want a priest involved shows your bias. As for your other comment regarding constitutional self determination....SCOTUS pretty much threw that baby out with aca...
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by RAYMAN View Post
      Puhleaze! You're human, I think, so you have bias....esp against conservatives and religion....the fact that you don't want a priest involved shows your bias...
      He's just biased against people biased against his bias
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by J-Dubya View Post
      Again I disagree and the courts certainly afford protection to unborn fetuses. Causing harm to a fetus may be illegal, just as denying an infant care for religious reasons has been ruled illegal. As I posted earlier, women have been charged with murder for refusing c-sections (in the case I posted the woman took a plea). It's gray area and it's unclear how higher courts would rule on this exact case.

      Again, the woman's rights take a back seat IF the fetus is seen as an infant. In the case of a term fetus, legally, I think you are going to find it's not a free-for all.
      I'm no expert, but... isn't an infant roughly one who can't walk, estimated at age one month to twelve months? to me, fetus is stomach to air. then, newborn.. then..
      so.. I'm not sure I see this argument.
    1. MmacFN's Avatar
      MmacFN -
      No it was not.

      I have no religious code which pushes me in one director or another with the threat of going to hell. I simply take the facts and the law into account and proceed. No bias AT ALL.

      Quote Originally Posted by Burnt2 View Post
      0.o lol

      i hope that was one of those moments where a sarcastic inflection was lost in the written form.
    1. MmacFN's Avatar
      MmacFN -
      Not at all.

      I have NO bias in this case. I dont have the magical fear of being sent to hell so i have no reason to be pushed in one direction or the other. I simply am follwoing the facts and the law, which is exactly what we did at my facility when we let the lady deliver in exactly the same scenario.

      Quote Originally Posted by RAYMAN View Post
      Puhleaze! You're human, I think, so you have bias....esp against conservatives and religion....the fact that you don't want a priest involved shows your bias. As for your other comment regarding constitutional self determination....SCOTUS pretty much threw that baby out with aca...
    1. MmacFN's Avatar
      MmacFN -
      Also just so we are clear

      The LAST time a court forced someone to have a c-section was in the 1980's. The majority of decision since then has gone the other way. However at the end of the day its a crap shoot. What is relevant to us is our role as anesthesia as it will all fall on the OB or the hospital if legal recourse is sought. In my role it is right to follow the wishes of an individual who understands the consequences of their decision. We do it ALL the time. If a legal order to have the c-section came i would likely recuse myself from the case and have someone else who was willing do it.

      Later court decisions, however, increasingly recognized a pregnant woman's right to refuse medical treatment. In a 1990 case, In re A. C., 573 A.2d 1235, the District of Columbia Court of Appeals ruled that a physician must honor the wishes of a competent woman regarding a cesarean section. The court's opinion was written after the woman involved in the case, Angela Carder, and her fetus died following a cesarean section forced by a lower court.
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by MmacFN View Post
      Not at all.

      I have NO bias in this case. I dont have the magical fear of being sent to hell so i have no reason to be pushed in one direction or the other.
      Me neither. 😁
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by MmacFN View Post
      Not at all.

      I have NO bias in this case. I dont have the magical fear of being sent to hell

      neither do i, lol...i don't follow a salvation-for-works based religion

      i will say though, ethics questions aside, it really does depend what state you're practicing in. The Alabama judicial system may not see your totally unbiased decisions as favorably as one in New York.
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by MmacFN View Post
      Also just so we are clear

      The LAST time a court forced someone to have a c-section was in the 1980's. The majority of decision since then has gone the other way. However at the end of the day its a crap shoot. What is relevant to us is our role as anesthesia as it will all fall on the OB or the hospital if legal recourse is sought. In my role it is right to follow the wishes of an individual who understands the consequences of their decision. We do it ALL the time. If a legal order to have the c-section came i would likely recuse myself from the case and have someone else who was willing do it.

      Later court decisions, however, increasingly recognized a pregnant woman's right to refuse medical treatment. In a 1990 case, In re A. C., 573 A.2d 1235, the District of Columbia Court of Appeals ruled that a physician must honor the wishes of a competent woman regarding a cesarean section. The court's opinion was written after the woman involved in the case, Angela Carder, and her fetus died following a cesarean section forced by a lower court.

      Mike, this is a case from 2004, the court issued an order for a woman to have a c-section.


      http://www.freerepublic.com/focus/f-news/1059276/posts
    1. LouisiAnimal's Avatar
      LouisiAnimal -
      Quote Originally Posted by J-Dubya View Post
      Mike, this is a case from 2004, the court issued an order for a woman to have a c-section.


      http://www.freerepublic.com/focus/f-news/1059276/posts
      But she delivered vaginally at home and the baby and mom are fine. Could be used as evidence that the docs don't always know what's "best" for mom.
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