Tag: cesarean section

Bioethics Blogs

Legal Briefing: Unwanted Cesareans and Obstetric Violence

In my latest legal briefing for the Journal of Clinical Ethics, I discuss “Legal Briefing: Unwanted Cesareans and Obstetric Violence.”


A capacitated pregnant woman has a nearly unqualified right to refuse a cesarean section. Her right to say “no” takes precedence over clinicians’ preferences and even over clinicians’ concerns about fetal health. Leading medical societies, human rights organizations, and appellate courts have all endorsed this principle. Nevertheless, clinicians continue to limit reproductive liberty by forcing and coercing women to have unwanted cesareans. This “Legal Briefing” reviews recent court cases involving this type of obstetric violence. I have organized these court cases into the following six categories:
1.   Epidemic of Unwanted Cesareans
2.   Court-Ordered Cesareans
3.   Physician-Coerced Cesareans
4.   Physician-Ordered Cesareans
5.   Cesareans for Incapacitated Patients
6.   Cesareans for Patients in a Vegetative State or Who Are Brain Dead


Legal Briefing: Unwanted Cesareans and Obstetric Violence
Thaddeus Mason Pope, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 163-73.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

In the Journals – January 2017 by Anna Zogas

Welcome to a new year of Somatosphere’s In the Journals section! Here are some of the articles available in January 2017. Enjoy!

Medical Anthropology

Chronic Subjunctivity, or, How Physicians Use Diabetes and Insomnia to Manage Futures in the United States
Matthew Wolf-Meyer & Celina Callahan-Kapoor

Prognostication has become central to medical practice, offering clinicians and patients views of particular futures enabled by biomedical expertise and technologies. Drawing on research on diabetes care and sleep medicine in the United States, in this article we suggest that subjectivity is increasingly modeled on medical understandings of chronic illness. These chronic conceptions of the self and society instill in individuals an anxiety about future health outcomes that, in turn, motivate practices oriented at self-care to avoid negative health outcomes and particular medical futures. At its most extreme, these anxieties of self-care trouble conceptions of self and social belonging, particularly in the future tense, leading patients and clinicians to consider intergenerational and public health based on the threats that individual patients pose for others.

Decoding the Type 2 Diabetes Epidemic in Rural India (open access)
Matthew Little, Sally Humphries, Kirit Patel & Cate Dewey

Type 2 diabetes mellitus is an escalating public health problem in India, associated with genetic susceptibility, dietary shift, and rapid lifestyle changes. Historically a disease of the urban elite, quantitative studies have recently confirmed rising prevalence rates among marginalized populations in rural India. To analyze the role of cultural and sociopolitical factors in diabetes onset and management, we employed in-depth interviews and focus groups within a rural community of Tamil Nadu.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Special Issues! Biomedicalization in Brazil; Life after Biopolitics by Anna Zogas

April brings many special issues! We’ve already highlighted themed issues on insurance and digitized health, and here are two more themed issues to know about: this month’s História, Ciências, Saúde-Manguinhos is on The Biomedicalization of Brazilian Bodies: Anthropological Perspectives, and the current South Atlantic Quarterly is about Life After Biopolitics. Enjoy!

História, Ciências, Saúde-Manguinhos

The Biomedicalization of Brazilian Bodies: Anthropological Perspectives (open access)
Ilana Löwy, Emilia Sanabria

This special issue brings together work on the “biomedicalization” of Brazilian bodies, examining the way biomedical techniques are taken up across the divergent structural constraints afforded by private and public health in Brazil. Biomedicalization – or “technoscientific interventions in biomedical diagnostics, treatments, practices, and health to exert more and faster transformations of bodies, selves, and lives” – forms an assemblage that is both global and highly local. Our aim is to interrogate this phenomenon from Brazil.

The authors, writing from Brazil, Europe, and North America, share a long-standing commitment to analyzing the specific local biologies – and local politics – of Brazilian approaches to health and the body. They probe the incursion of biomedical technologies within richly depicted social worlds, revealing quotidian violence (particularly where women’s bodies are concerned), exceptional forms of care within conditions of precarity, and the intersections of kinship, class, work, and the symbolic capital afforded by biomedical consumption in Brazil. They share a commitment to critically engaging with biomedical conceptions of disease and illness, destabilizing the body as a stable referent (implicitly grounded in a biomedical ontology), analyzing health as a deeply relational, situated, and political process.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

The influence of Reality TV on medical breakthroughs


The recent
story of the failed uterine transplant had a decidedly American flavor. Let me
explain.


In Sweden
there have been 9 successful uterine transplants. The first recipient delivered
a healthy baby boy, by cesarean section, in September 2014. Three more babies
have been born since then. Not one of the families have been identified
publicly. In Sweden the surgery and blessed
event are personal, no media splash.


  
Not so here in the states. A 26 year old woman named Lindsey, last name not
provided, underwent the uterine transplant at Cleveland Clinic on February 24,
2016. On March 7 she was literally, rolled out, for the TV cameras to celebrate
the surgery. Sadly, a day later the transplant failed due to some, as of this
writing, undisclosed complication. Within 24 hours
Lindsey went from the bright lights to the darkness of despair when her hope
for carrying a baby was dashed.


    But in the American way every
accomplishment is displayed for the public,
playing out like a made for TV movie or any other reality program. I’m sure
Lindsey had to sign a stack of papers to have the surgery attesting to her
understanding of the risks. Her informed consent was
probably scrutinized line by line by the IRB.
But was her appearance for the media part of that? And if so, did
anyone take the time to help her understand the ramifications of sharing this
part of her life? Sure,
she
chose not to share her last name. Laughable, frankly. Did she really
think that by not sharing her full name her privacy would be protected despite
having her face, clear as a bell, appear on 50 inch, HD television screens
across the country?

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

OB Potpourri

This month’s issue of the medical journal Obstetrics & Gynecology (O&G) has a review of the four best ethics articles that appeared in their journal in the last year. Here are my comments (in italics) on their review (in quotes).

Article title: “Clinical, Ethical, and Legal Considerations in Pregnant Women With Opioid Abuse.” O&G‘s bottom line: “Opioid abuse is a chronic medical illness, not a moral failing. Obstetricians should advocate for pregnant women’s access to opioid maintenance therapy and social services that support healthy outcomes for these women and their fetuses.” Some will quibble about whether the slavery that is opioid addiction should be defined as a chronic medical illness (and remember that some opioid addiction comes courtesy of us physicians who misprescribe opioid medications). However, whether you believe that these women are unable to stop their substance abuse (illness model) or somehow unwilling (moral failure model), from a medical standpoint, treating these women as criminals isn’t helpful for either them or their babies to achieve the best outcomes. We’re doctors, not the police, so acting judgmentally has no role; we should be helping these patients and their babies in any ethical way possible.

Article title: “Evaluation of Ethics Education in Obstetrics and Gynecology Residency Programs.” In this study, 57% of OB residencies had 0-5 hours of ethics training, and 64% of residency directors said their graduates are unprepared or only somewhat prepared to handle ethically challenging situations. O&G‘s bottom line: “Obstetrics and gynecology residencies are behind in creating and evaluating formal ethics education programs.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Losing Informed Consent

A couple of weeks ago I was I was the faculty attending on Labor and Delivery. We were inducing a woman with severe pre-eclampsia and an IUGR fetus. Things went well until she was five centimeters dilated, at which point the fetal tracing went rapidly from category one to category three (reassuring to really bad). I quickly explained the situation to the patient with a resident and a nurse in the room. She heard the reasons I was recommending a cesarean section, a brief discussion of its risks, and an even briefer discussion of the alternatives (continue labor placing the fetus at risk of permanent injury or death). She had no questions, and since she had already signed a cesarean consent at the beginning of the induction, we proceeded to the operating room to perform a cesarean.  She needed general anesthesia because her platelets were low, so it was too risky to give her a spinal anesthetic. During the induction but before intubation, the circulating nurse announced that she couldn’t find the “informed consent” and that we could not proceed. My response involved a reference to male cattle manure, and the comment that informed consent had just happened and that she had witnessed it herself. The anesthesiologist agreed, and the cesarean section occurred without delay.

This case exemplifies the ambiguity around “informed consent.”  The nurse was referring to a document, a signed piece of paper; I was referencing a conversation, a process involving sharing information and answering questions. From a legal perspective, informed consent would seem to represent the document, whereas from an ethical perspective it is the process, not the paper that embodies informed consent.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Surrogate Mothers in India Unaware of Risks

(Business Insider) – Renting out their wombs may ease financial problems for poor women in India, but new research suggests surrogate mothers there are unaware of the risks and often left out of key medical decisions about their pregnancy. “Of the 14 surrogate mothers I interviewed, not a single one could explain the risks from having multiple embryos placed in their uterus, or having a fetal reduction or a Cesarean section,” said Dr. Malene Tanderup from Aarhus University in Denmark.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Ruby Graupera-Cassimiro Survives 45 Minutes without Pulse

Ruby Graupera-Cassimiro, 40, went to Boca Raton Regional Hospital in Florida for a cesarean section on September 23.

The surgery was uneventful and the baby was healthy, but Graupera-Cassimiro started to experience shortness of breath and doctors had to call a code when she stopped breathing. They tried for three hours to revive her but it was no use. She had no pulse for 45 minutes. (Sun Sentinel)  


Then, her heart started beating again on its own.  “She essentially spontaneously resuscitated when we were about to call the time of death,” said Thomas Chakurda, the hospital spokesman told the Associated Press. A day later, Graupera-Cassimiro was taken off life support. And today she is “the picture of health.”


The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

International Surrogacy, Global Consumerism, Harms to Women and Children

Pattaramon Chanbua, Thai surrogate mother to Baby Gammy.
Pattaramon Chanbua, Thai surrogate mother to Baby Gammy.

This summer two separate incidents highlighted the deeply troubling problems that can arise in inter-country surrogacy arrangements. In the most extensively covered situation, the “Baby Gammy” case, an Australian couple left their infant son who has Down syndrome with his Thai surrogate mother and returned home with his twin sister. The husband was then discovered to have been convicted of multiple child sex offenses that took place between the early 1980s and early 1990s against girls as young as 5.

In the second incident, a young Japanese businessman fathered 16 children with multiple Thai surrogate mothers, only weeks or months apart, and then told Thai police that he simply wanted a large family.

The New York Times covered these stories in an article titled “Thailand’s Business in Paid Surrogates May Be Foundering in a Moral Quagmire.

What should we make of these disturbing stories? Should we see them as revealing the ingenuity of consumers (commissioning parents and particularly fathers) in devising ways to exploit women as breeders in the unregulated global market of medically assisted reproduction? Is Baby Gammy’s story best understood as a tale of eugenics by a man convicted of abusing children (his words: “I don’t think any parent wants a son with a disability”)?  What does the story of the Japanese man who fathered (perhaps “sired” is the better term) all those infants share with Theresa Erickson’s international baby-selling fraud, which also involved the horrendous abuse of unknowing women?  

Both stories raise policy questions about inter-country medically assisted reproduction, including the screening of intended parents, the parentage and citizenship status of children born of international commercial surrogacy, and these children’s welfare and interests in knowing their bio-social origins as a matter of identity.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Refusal of Cesarean Section

I was recently surprised to read in the New York Times that a woman had undergone a cesarean section despite her refusal to consent to the procedure. The details of the case are not entirely clear from the article, so I do not want what follows to be understood as a specific comment on this case. However, the source of my surprise was my assumption that the ethics of refusal of consent were not in dispute.  The American College of Obstetrics and Gynecology has taken a clear position on this: it is not permissible to perform surgery on a patient with decisional capacity without her consent. ACOG’s committee opinion, “Maternal Decision Making, Ethics, and the Law,” strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section, and concludes with the following statement:

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy. 

This committee opinion gives six strong and compelling arguments for these conclusions, and I will not repeat them here, but I encourage readers to review them.  What I would like to now focus on is the thinking that may lead some physicians to believe it is ethically permissible to override a patient’s autonomous choice.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.