Despite the fact that the requirement to obtain informed consent for medical procedures is deeply enshrined in both U.S. moral and legal doctrine, empirical studies and anecdotal accounts show that women's rights to informed consent and refusal of treatment are routinely undermined and ignored during childbirth. For example, citing the most recent Listening to Mothers survey, Marianne Nieuwenhuijze and Lisa Kane Low state that "a significant number of women said they felt pressure from a caregiver to agree to having an (...) intervention that they did not want during birth". Specifically, Nieuwenhuijze and Low cite that "19% of women who did not have epidural analgesia felt... (shrink)

I argue that the American Congress of Obstetricians and Gynecologists (ACOG), as an organization and through its individual members, can and should be a far greater ally in the prevention of violence against women. Specifically, I argue that we need to pay attention to obstetrical practices that inadvertently contribute to the problem of violence against women. While intimate partner violence is a complex phenomenon, I focus on the coercive control of women and adherence to oppressive gender norms. Using physician response (...) to alcohol use during pregnancy and court-ordered medical treatment as examples, I show how some obstetrical practices mirror the attitudes of abusive men insofar as they try to coercively control women's behavior through manipulation and violence. To be greater allies in the prevention of violence against women, obstetricians should stop participating in practices that inadvertently perpetuate violence against women. (shrink)

In the UK, it has been proposed that alongside the current advice to abstain from alcohol completely in pregnancy, there should be increased screening of pregnant women for alcohol consumption in order to prevent instances of fetal alcohol spectrum disorder. The Scottish Intercollegiate Guidelines Network published guidelines in 2019 recommending that standardised screening questionnaires and associated use of biomarkers should be considered to identify alcohol exposure in pregnancy. This was followed in 2020 by the National Institute for Health and Care (...) Excellence Draft Quality Standard, which recommended that pregnant women should have information on their alcohol consumption recorded throughout their pregnancy and this information transferred to the child’s health records. Most recently, Public Health England has stated that the alcohol intake of all women should be recorded throughout pregnancy, not just at the initial booking appointment and that tools such as blood biomarkers and meconium testing should be researched in order to determine true prevalence rates of alcohol in pregnancy. We argue that this proposed enhanced screening undermines women’s autonomy and their legal right to be sufficiently informed to consent to screening. We argue that there is no evidence that this kind of screening will result in a reduction of fetal harm and there is a danger that undermining the autonomy of women and the trust relationship between women and healthcare professionals may even increase harm to future children. (shrink)

Contexte : L’ensemble des troubles causés par l’alcoolisation fœtale (ETCAF), un diagnostic complexe qui comprend une vaste gamme de troubles neurodéveloppementaux, résulte de l’exposition à l’alcool dans l’utérus. L’ETCAF demeure mal compris par les Canadiens, ce qui pourrait contribuer à la stigmatisation dont souffrent les personnes atteintes d’ETCAF et les femmes qui consomment de l’alcool pendant leur grossesse. Méthodes : Pour mieux comprendre comment l’information sur l’ETCAF est présentée dans la sphère publique, nous avons analysé le contenu de 286 articles (...) tirés de dix grands journaux canadiens de langue anglaise (2002-2015). Nous avons utilisé le codage inductif pour établir une grille de codage à partir des données, puis nous avons appliqué de façon itérative des codes identifiés sur l’échantillon, en vérifiant la fiabilité intercodeurs. Résultats : Nous avons identifié six grands thèmes liés au contenu cliniques et scientifiques des médias : 1) prévalence de l‘ETCAF et de la consommation d’alcool chez les femmes ; 2) recherche en lien avec l’ETCAF ; 3) diagnostic d’ETCAF ; 4) traitement de l’ETCAF et de l’abus de substances par les mères ; 5) incapacités primaires associés à l’ETCAF ; et 6) effets de l’alcool pendant la grossesse. Discussion : Dans le cadre de ces six thèmes, nous examinons trois types d’exagération et de fausse représentation qui ont des conséquences sur le plan éthique : 1) l’exagération des taux d’ETCAF dans les communautés autochtones ; 2) la contradiction entre les articles sur les effets de l’exposition prénatale à l’alcool ; et 3) l’information scientifiquement exacte qui néglige le contexte social de la consommation et de l’abus d’alcool par les femmes. Respectivement, ces représentations pourraient mener à des croyances stéréotypées préjudiciables au sujet des peuples autochtones, pourraient créer de la confusion quant aux choix sains pendant la grossesse et risqueraient d’enflammer inutilement les débats sur des questions délicates concernant les choix des femmes. (shrink)

A diagnosis of Fetal Alcohol Spectrum Disorder ascribes cause to developmental disability; however, there are logical issues in causation with ethical implications. This article focuses on the use of fallacious logic in FASD, focusing on the Canadian Guidelines for diagnosis, and knowledge translation issues from science to practice. The clinician’s logical fallacy is an ethical issue of veracity in the clinician–patient relationship; this then leads to issues of nonmaleficence, because the diagnosis in turn blames the mother for her child’s difficulties. (...) Suggestions for revised diagnostic practices that avoid allusions to causation and responsibility are discussed. (shrink)

In this article, we discuss decision making during labor and delivery, specifically focusing on decision making around offering women a trial of labor after cesarean section. Many have discussed how humans are notoriously bad at assessing risks and how we often distort the nature of various risks surrounding childbirth. We will build on this discussion by showing that physicians make decisions around TOLAC not only based on distortions of risk, but also based on personal values rather than medical data. As (...) a result of this, we will further suggest that the party who is best epistemically situated to make decisions about TOLAC is the woman herself. (shrink)

In this issue of the JME, age-old questions around how to balance the interests of mother and fetus are revisited in two separate contexts: alcohol consumption during pregnancy, and maternal request caesarean sections. Both have been the subject of recent controversy in the UK, with March 2022 seeing the introduction of new National Institute for Clinical Excellence Quality Standards on combatting foetal alcohol spectrum disorder 1; and the publication of the long-awaited Ockenden Review into a series of failures in NHS (...) maternity care.2 Both raise important questions about the role of healthcare professionals in policing women’s choices during pregnancy and childbirth, and of the importance of deference to and trust in those choices. In this issue’s Feature Article, Rebecca Bennett and Catherine Bowden explore recent proposals to enhance the screening of pregnant women in order to prevent instances of fetal alcohol spectrum disorder through more accurately determining the true prevalence of alcohol consumption during pregnancy.3 Public Health England has suggested research into tools such as blood biomarkers and meconium testing,4 which could better identify those women who are consuming alcohol ‘covertly’ and so make FASD diagnoses more straightforward. As Bennett and Bowden rightly suggest, such a move is unlikely to realise the kind of public health or welfare gains which would justify this level of interference with the women’s autonomy, and may even result in more harm through discouraging engagement with antenatal care. However even absent these very intrusive methods of surveillance, the precautionary principle which underpins such policies — namely that in the absence of evidence that any alcohol is safe, women should be instructed to avoid it altogether — is itself difficult to justify. The evidence on alcohol consumption during pregnancy is mixed. While it is widely accepted that heavy …. (shrink)