This paper presents a relational account of autonomy showing that a technological imperative impedes autonomy through undermining women’s capacity to resist use of technology in the context of labor and birth. A technological imperative encourages dependence on technology for reassurance whenever possible through creating a (i) separation of maternal and fetal interests; and (ii) perceived need to use technology whenever possible. In response I offer an account of how women might promote autonomy through cultivating self-trust and self-confidence. Autonomy is not (...) simply a matter of choosing freely and acting on our choices, it is also a matter of possessing the ability to resist social contexts undermining choice and action. An important implication of this view is that respecting autonomy requires more than simply respecting persons’ ability to make and act on choices. Respecting patient autonomy requires a recognition of patients’ need to resist factors impeding autonomy and support for that resistance. (shrink)

The emergence of new forms of reproductive technology raise an increasingly complex array of social and ethical issues. Nevertheless, this paper focuses on commonplace reproductive technologies used during labor and birth such as ultrasound, fetal monitoring, episiotomy, epidurals, labor induction, amniotomy, and cesarean section. This paper maintains that social pressures increase women’s perceived need to such reproductive technologies and thus undermine women’s capacity to choose an elective cesarean or avoid an emergency cesarean. Routine, normalized use of technology interferes with the (...) possibility of choosing use of technology where best suited through misdirecting laboring women to use technological resources whenever possible. This normalized use of technology decreases risk tolerance and increases dependence on technology for reassurance, which bears significant implications for self-trust and self-confidence. My account encourages women’s cultivation of autonomy as a capacity interconnected with our own attitudes and those of other persons; and as a function of cultivating trust and confidence in one’s body. (shrink)

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. Reproductive autonomy is at (...) stake since a technological imperative undermines patients’ ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates. (shrink)

Approaches to supporting autonomy in medicine need to be able to support complex and sensitive decision-making, incorporating reflection on the patient's values and goals. This should involve deliberation in partnership between physician and patient, allowing the patient to take responsibility for her decision. Nowhere is this truer than in decisions around pregnancy and Caesarean section where maternal autonomy can seem to directly conflict with foetal interests. Medical and societal expectations and norms such as the expectations of a ‘mother’, constraints of (...) making decisions in an emergency, and the role of technology in viewing the foetus as a separate patient and surgery as a guarantor of results can all act to limit a woman's autonomy. In considering decisions about Caesarean section, maternal interests in bodily integrity can be dismissed as being less important than the foetus's own interests and the mother's duties to it, despite the inherent risks and impacts of such a major surgical procedure... (shrink)

Wilkinson’s discussion of the individual and family consent to organ and tissue donation is to be welcomed because it draws attention to the “incoherent hybrid” of the current position.1 I wish to highlight some areas of his discussion and propose that, in a situation of posthumous organ and tissue donation, the cadaver has no individual rights and family rights should under no circumstances automatically outweigh the potential transplant recipients’ right to a life-saving treatment.Transplant immunobiology and clinical transplantation is a revolutionary (...) area of medicine and has saved thousands of lives. In the UK, between 1 April 2004 and 31 March 2005, organs from 752 people who died were used to save or dramatically improve many people’s lives through 2242 transplants.2 In the US, 23 506 transplants were performed between January and October 2005 from 12 084 donors.3 Information from available databases shows that demand for organs, cells and tissues has outstripped the supply. As of 18 January 2006, 6553 people are still waiting for transplants in the UK and there are 90 636 waiting list transplant candidates in the US.2,3 As of 01 January 2006, there are 15 977 people active on the Eurotransplant waiting list.4 It is likely that non-compulsory posthumous donation of organs has resulted in the loss of many thousands, possibly many …. (shrink)

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)

In this paper, I argue that the conscience clause around abortion provision in England, Scotland and Wales is inadequate for two reasons. First, the patient and doctor are differently situated with respect to social power. Doctors occupy a position of significant moral and epistemic authority with respect to their patients, who are vulnerable and relatively disempowered. Doctors are rightly required to disclose their conscientious objection, but given the positioning of the patient and doctor, the act of doing so exploits the (...) authority of the medical establishment in asserting the legitimacy of a particular moral view. Second, the conscientious objector plays an unusual and self-defeating moral role. Since she must immediately refer the patient on to another doctor who does not hold a conscientious objection, she becomes complicit, via her necessary causal role, in the implementation of the procedure. This means that doctors are not able to prevent abortions, rather, they are required to ensure that they... (shrink)

Savulescu has recently introduced the "rational non-interventional paternalist" model of the patient-doctor relationship. This paper addresses objections to such a model from the perspective of an anaesthetist. Patients need to make their own decisions if they are to be fully autonomous. Rational non-interventional paternalism undermines the importance of patient choice and so threatens autonomy. Doctors should provide an evaluative judgment of the best medical course of action, but ought to restrict themselves to helping patients to make their own choices rather (...) than making such choices for them. (shrink)

Over the last several years, as cesarean deliveries have grown increasingly common, there has been a great deal of public and professional interest in the phenomenon of women 'choosing' to deliver by cesarean section in the absence of any specific medical indication. The issue has sparked intense conversation, as it raises questions about the nature of autonomy in birth. Whereas mainstream bioethical discourse is used to associating autonomy with having a large array of choices, this conception of autonomy does not (...) seem adequate to capture concerns and intuitions that have a strong grip outside this discourse. An empirical and conceptual exploration of how delivery decisions ought to be negotiated must be guided by a rich understanding of women's agency and its placement within a complicated set of cultural meanings and pressures surrounding birth. It is too early to be 'for' or 'against' women's access to cesarean delivery in the absence of traditional medical indications – and indeed, a simple pro- or con- position is never going to do justice to the subtlety of the issue. The right question is not whether women ought to be allowed to choose their delivery approach but, rather, taking the value of women's autonomy in decision-making around birth as a given, what sorts of guidelines, practices, and social conditions will best promote and protect women's full inclusion in a safe and positive birth process. (shrink)

The American Journal of Bioethics, Volume 12, Issue 7, Page 53-54, July 2012.

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

In the UK in October 1992, Mrs S was forced to have a caesarean section despite her objections to such a procedure on religious grounds. The case once again called into question the obligations of women to the unborn, and also whether one person can be forced to undergo a medical procedure for the benefit of someone else. Re S, like the case of Angela Carder, is often discussed in terms of the conflict between maternal and fetal rights. This paper (...) looks instead at our obligations to save life in general-whether or not we are pregnant- and at the obligations of mothers to their children-whether they are born or unborn. Drawing on Judith Jarvis Thomson's distinction, it argues that minimal decency informs the duties which are owed to strangers, but that parents can be expected to behave as Good Samaritans towards their children. Finally, it is argued that even if mothers are ethically obliged to consent to caesarean sections which will save the lives of their babies, this does not necessarily mean that others are at liberty, or even obliged, to proceed with such operations without their consent. (shrink)