Currently, many women who are expecting to give birth have no option but to attempt vaginal delivery, since access to elective planned caesarean sections (PCS) in the absence of what is deemed to constitute ‘clinical need’ is variable. In this paper, we argue that PCS should be routinely offered to women who are expecting to give birth, and that the risks and benefits of PCS as compared with planned vaginal delivery should be discussed with them. Currently, discussions of elective (...) PCS arise in the context of what are called ‘Maternal Request Caesarean Sections’ (MRCS) and there is a good deal of support for the position that women who request PCS without clinical indication should be provided with them. Our argument goes further than support for acceding to requests for MRCS: we submit that healthcare practitioners caring for women with uncomplicated pregnancies have a positive duty to inform them of the option of PCS as opposed to assuming vaginal delivery as a default, and to provide (or arrange for the provision of) PCS if that is the woman's preferred manner of delivery. (shrink)

Whether it is morally permissible to compel women to undergo a caesarean section is a topic of longstanding debate. Despite plenty of arguments against the moral permissibility of a forced caesarean section, the question keeps cropping up. This paper seeks to scrutinise a particular moral argument in favour of compulsion: the appeal to parental obligation. We present what we take to be a distillation of the basic form of this argument. We then argue that, in the (...) absence of an exhaustive theory of parental obligation, the question of whether a labouring woman is morally obliged to undergo emergency surgery—and especially the further question of it is morally permissible for third parties to compel this—cannot be answered via ready-made theory. We propose that the most viable option for settling both questions is by analogy. We follow earlier writers in presenting an analogous case—that of fathers being compelled to undergo non-consensual invasive surgery to save their children—but expand the analogy by considering objections that appeal to the ownership of the fetus. We offer two lines of response: the parthood view of pregnancy and chimaera dad. We argue that it is clear in the analogous case that compulsion cannot be justified. We also offer this analogy as a useful tool for assessing whether mothers have a moral duty to undergo caesarean sections, both in general and in particular cases, even if such a duty is insufficient to warrant compulsion. (shrink)

In their paper, ‘How to reach trustworthy decisions for caesarean sections on maternal request: a call for beneficial power’, Eide and Bærøe present maternal request caesarean sections (MRCS) as a site of conflict in obstetrics because birthing people are seeking access to a treatment ‘without any anticipated medical benefit’. While I agree with the conclusions of their paper -that there is a need to reform the approach to MRCS counselling to ensure that the structural vulnerability of pregnant people (...) making birth decisions is addressed—I disagree with the framing of MRCS as having ‘no anticipated medical benefit’. I argue that MRCS is often inappropriately presented as unduly risky,without supporting empirical evidence,and that MRCS is most often sought by birthing people on the basis of a clinical need. I argue that there needs to be open conversation and frank willingness to acknowledge the values that are currently underpinning the presentation of MRCS as ‘clinically unnecessary’; specifically there needs to be more discussion of where and why the benefits of MRCS that are recognised by individual birthing people are not recognised by clinicians. This is important to ensure access to MRCS for birthing people that need it. (shrink)

Court-ordered caesarean sections against the explicit wishes of the pregnant woman have been criticised as violations of the woman's fundamental right to autonomy and to the inviolability of the person--particularly, so it is argued, because the fetus in utero is not yet a person. This paper examines the logic of this position and argues that once the fetus has passed a certain stage of neurological development it is a person, and that then the whole issue becomes one of balancing (...) of rights: the right-to-life of the fetal person against the right to autonomy and inviolability of the woman; and that the fetal right usually wins. (shrink)

Court-ordered caesarean sections against the explicit wishes of the pregnant woman have been criticised as violations of the woman's fundamental right to autonomy and to the inviolability of the person--particularly, so it is argued, because the fetus in utero is not yet a person. This paper examines the logic of this position and argues that once the fetus has passed a certain stage of neurological development it is a person, and that then the whole issue becomes one of balancing (...) of rights: the right-to-life of the fetal person against the right to autonomy and inviolability of the woman; and that the fetal right usually wins. (shrink)

Obstetricians face difficult decisions when the interests of fetus and mother conflict. An example is the problem of choosing the delivery method when labour begins prematurely and the fetus is breech. Vaginal delivery involves risks for the breech fetus of brain damage or death caused by umbilical cord compression and head entrapment. Caesarean section might avoid these dangers but involves risks for the mother, including infection, haemorrhage and even death in a small percentage of cases. If a (...) class='Hi'>caesarean section is performed the infant might die anyway, due to complications of prematurity. Thus, decisions about delivery method involve balancing the risks to mother and fetus. Uncertainty about the frequency of fetal injuries in vaginal breech deliveries adds to the difficulty of these decisions. (shrink)

Caesarean delivery is a common and life-saving intervention. However, it involves an overall increased risk for short-term and long-term complications for both mother and child compared with vaginal delivery. From a medical point of view, healthcare professionals should, therefore, not recommend caesarean sections without any anticipated medical benefit. Consequently, caesarean sections requested by women for maternal reasons can cause conflict between professional recommendations and maternal autonomy. How can we assure ethically justified decisions in the case of (...) class='Hi'>caesarean sections on maternal request in healthcare systems that also respect patients’ autonomy and aspire for shared decisions? In the maternal–professional relationship, which can be characterised in terms of reciprocal obligations and rights, women may not be entitled to demand a C-section. Nevertheless, women have a right to respect for their deliberative capacity in the decision-making process. How should we deal with a situation of non-agreement between a woman and healthcare professional when the woman requests a caesarean section in the absence of obvious medical indications? In this paper, we illustrate how the maternal–professional relationship is embedded in a nexus of power, trust and risk that reinforces a structural inferiority for women. To accommodate for beneficial use of power, these decision processes need to be trustworthy. We propose a framework, inspired by Lukes’ three-dimensional notion of power, which serves to facilitate trust and allows for beneficial power in shared processes of decision-making about the delivery mode for women requesting planned C-sections. (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)

ObjectiveInformed consent is a prerequisite for caesarean section, the commonest surgical procedure in low- and middle-income settings, but not always acquired to an appropriate extent. Exploring perceptions of health care workers may aid in improving clinical practice around informed consent. We aim to explore health workers’ beliefs and experiences related to principles and practice of informed consent.MethodsQualitative study conducted between January and June 2018 in a rural 150-bed mission hospital in Southern Malawi. Clinical observations, semi-structured interviews and a (...) focus group discussion were used to collect data. Participants were 22 clinical officers, nurse-midwives and midwifery students involved in maternity care. Data were analysed to identify themes and construct an analytical framework.ResultsDefinition and purpose of informed consent revolved around providing information, respecting women’s autonomy and achieving legal protection. Due to fear of blame and litigation, health workers preferred written consent. Written consent requires active participation by the consenting individual and was perceived to transfer liability to that person. A woman’s refusal to provide written informed consent may pose a dilemma for the health worker between doing good and respecting autonomy. To prevent such refusal, health workers said to only partially disclose surgical risks in order to minimize women's anxiety. Commonly perceived barriers to obtain a fully informed consent were labour pains, language barriers, women’s lack of education and their dependency on others to make decisions.ConclusionsHealth workers are familiar with the principles around informed consent and aware of its advantages, but fear of blame and litigation, partial disclosure of risks and barriers to communication hamper the process of obtaining informed consent. Findings can be used to develop interventions to improve the informed consent process. (shrink)

Although a pregnant woman can now refuse any medical treatment needed by the fetus, the Court of Appeal has acknowledged that ethical dilemmas remain, adverting to the inappropriateness of legal compulsion of presumed moral duties in this context. This leaves the impression of an uncomfortable split between the ethics and the law. The notion of a pregnant woman refusing medical treatment needed by the fetus is troubling and it helps little simply to assert that she has a legal right to (...) do so. At the same time, the idea that a pregnant woman fails in her moral duty unless she accepts any recommended treatment or surgery—however great the burdens—is also not without difficulty. This article seeks to find a way between these two somewhat polarized positions by arguing that, instead of being a question primarily about whether legally to enforce moral obligations, the «maternal—fetal conflict» begins with previously unrecognized difficulties in determining when a woman's prima facie moral rights invoked in the treatment context should «give way» to the interests of the fetus. This difficulty is mirrored within the law. Thus, how can we tell when a pregnant woman has the moral or legal duty to submit to a caesarean section? Seen in this way, the conflict is a problem which lies at the interface between moral and legal rights and duties, showing that there are important conceptual links between the ethics and the law. Against this background, this article explores the limits of a pregnant woman's right to bodily integrity by focusing upon the idea of her moral duty to aid the fetus through her body. Here we find difficulties in determining the existence and extent of this somewhat extraordinary duty. Such a duty is contrasted with both negative and positive duties toward others in the course of «general conduct». Attention to the social context of pregnancy and the refusal of treatment within this is also instructive. Overall, the purpose is to foster understanding and acceptance of the current legal position. (shrink)

This paper argues that cyborg perspectives offer real possibilities for the debate around enforced caesareans and the search for a language to encompass embodied maternal subjectivity. It is suggested, with reference to the fictional narrative of Star Trek, that cyborg figures have the power to disrupt the liberal subject and the body in legal discourse, not least because the plethora of cyborgs challenges simple conceptions of connections/disconnections between bodies. Feminist readings of case law relating to enforced caesarean sections have (...) raised questions about the notion of autonomy at the heart of liberal legalism, have argued that law is complicit with white male techno-medicine's approach to childbirth and focused upon the pregnant woman's lived experience of pregnancy. The recent Court of Appeal decision in St George's Healthcare N.H.S Trust v. S., Regina v. Collins and Others, ex parte S., where the pregnant woman's self-determination was upheld, provides a good opportunity to confront both the liberal story and the idea of connectedness between mother and unborn child. (shrink)

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people’s health and autonomy in childbirth and argue that this remains crucial (...) during the current emergency. We consider some potential arguments—based on pregnant people’s health and resource allocation—that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital’s ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances. (shrink)

As obstetric medicine has become more sophisticated, so Caesarean section (CS) has become safer. It is now seen as equally safe or, in some circumstances, safer than vaginal birth. Under the new National Institute for Clinical Excellence (NICE) guidelines on CS that were published in November 2011, requests for CS are to be given more weight. Women requesting CS can no longer be seen as compromising their control over birth. Rather, they are merely exercising their power, with the (...) new guidelines offering them an increasing role in the decision-making process regarding how they give birth. However, these new guidelines also present new problems, bringing the rights of patients and obstetricians into conflict. In order to mediate these tensions, a virtue-based approach to obstetric ethics is needed as a supplement to the rule- and right-based guidance provided by NICE. (shrink)

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)

This paper describes the meaning of a father’s presence with a full-term healthy child delivered by caesarean section, as observed during the routine post-operative separation of mother and child. Videotaped observations recorded at a maternity clinic located in the metropolitan area of Stockholm, Sweden formed the basis for the study, in which fifteen fathers with their infants participated within two hours of elective caesarean delivery in the 37th - 40th week of pregnancy. A phenomenological analysis based on (...) Giorgi’s method was conducted on the data. The description of the new father’s experiences that emerged pointed to a process of being and becoming in taking the child to himself. Fatherhood developed gradually as a result of recurrent experiences of the child’s expressions. There was an ebb and flow between taking on the role of being a father and physical withdrawal from the role. The findings of this study not only confirm previous accounts of new fathers’ experiences, but go further in revealing an ebb and flow variation in the fathers’ involvement. What this indicates is that the process of transition to fatherhood requires not only presence but time. The period required for this process thus must not be disturbed, but supported, trusting in the father’s ability to assume his role as a father. It is suggested that, in addition to their relevance in guiding the attitudes and expectations of those professionally involved in postnatal care and community health, these findings could be useful in antenatal courses for parents, and especially in instances when caesarean birth is planned, to highlight the meaning of the role of fathers as caregivers. Indo-Pacific Journal of Phenomenology , Volume 6, Edition 2 August 2006. (shrink)

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion (...) between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

The culture of giving birth in Brazil has changed drastically since 1970. The caesarean section, once known as a life-saving medical procedure to be used under extraordinary circumstances, is now perceived by the medical profession and their female patients as a safe, painless, modern, and ideal form of birth for any pregnant woman. Brazil has the world's highest percentage of caesarean deliveries. The widespread use of C-sections has become a cultural phenomenon whose boundaries extend far beyond the (...) medical arena. Medical practitioners have appropriated cultural values regarding the female body and sexuality, rein-forced a blind fascination with technology, and medicalized women's fear of labor to justify their preference for surgical births. By narrowing ethical concerns to the doctor-patient relationship and drawing on the notion of the patient's best Interest, physicians defend their practice as appropriate and even desirable. (shrink)

Introduction US data reveal a Caesarean rate discrepancy between insured and uninsured patients, with the C-section rate highest among the privately insured. The data have prompted concern that financial incentives associated with insurance status might influence American physicians' decisions to perform Caesarean deliveries. Objective To determine whether differences in medical risk factors account for the apparent Caesarean rate discrepancy between Medicaid and privately insured patients in Michigan, USA. Method A retrospective review was performed of 617 269 (...) live birth deliveries in Michigan hospitals during 2004–8. All live birth records that were able to be linked to their mothers' hospital discharge records were utilised. Diagnosis-related group codes from the hospitalisation records were used to identify Caesarean deliveries. Regression models determined Caesarean probability for the time period under study, adjusted for insurance type, maternal age, race, maternal medical conditions, multiple births, prematurity and birth weight. Results From 2004 to 2008, Caesarean rates were 33% for privately insured patients and 29% for Medicaid patients. The probability of Caesarean delivery was significantly greater for privately insured than Medicaid patients on univariate analysis (OR 1.2, 95% CI 1.19 to 1.22) but not on multivariate analysis (adjusted OR 1.01, 95% CI 0.99 to 1.02). Conclusion No significant disparity was found in the odds of Caesarean delivery between privately insured and Medicaid patients in Michigan after adjusting for other Caesarean risk factors. A positive disparity would have provided de facto evidence that financial incentives play a role in physician decision-making regarding Caesarean delivery. (shrink)

During the French Revolution, obstetrics underwent substantial transformations in practice, teaching, and the physical spaces where it was conducted. The revolutionary authorities implemented reforms in French medical institutions that promoted an instrument-centred style and the dissemination of novel surgical techniques in obstetrics. The selection of professors for the obstetrics chair at the newly established École de santé and the appointment of chiefs for the new maternity ward in Paris favoured proponents of a mechanistic approach to labour assistance. This essay explores (...) the theoretical principles and societal pressures that guided these transformative reforms and the remarkable changes they introduced in healthcare and in the practise of medicine and surgery. Furthermore, it examines the consolidation of new epistemological, ethical, and professional boundaries within the context of late eighteenth-century French obstetrics. A critical section of this study focuses on the debate ignited by the contemporaries who voiced concerns that the rise of surgical interventions on pregnant women's bodies might result in unwarranted violence, in a diminishing of midwives’ roles, and in a departure from the tradition of natural childbirth. These controversies among obstetricians highlight significant contradictions within the Revolutionary medical reforms. (shrink)

Unconsented episiotomies and other procedures during labour are commonly reported by women in several countries, and often highlighted in birth activism. Yet, forced caesarean sections aside, the ethics of consent during labour has received little attention. Focusing on episiotomies, this paper addresses whether and how consent in labour should be obtained. We briefly review the rationale for informed consent, distinguishing its intrinsic and instrumental relevance for respecting autonomy. We also emphasise two non-explicit ways of giving consent: implied and opt-out (...) consent. We then discuss challenges and opportunities for obtaining consent in labour and birth, given its unique position in medicine.We argue that consent for procedures in labour is always necessary, but this consent does not always have to be fully informed or explicit. We recommend an individualised approach where the antenatal period is used to exchange information and explore values and preferences with respect to the relevant procedures. Explicit consent should always be sought at the point of intervening, unless women antenatally insist otherwise. We caution against implied consent. However, if a woman does not give a conclusive response during labour and the stakes are high, care providers can move to clearly communicated opt-out consent. Our discussion is focused on episiotomies, but also provides a useful starting point for addressing the ethics of consent for other procedures during labour, as well as general time-critical medical procedures. (shrink)

I was recently invited to talk about ethics with the staff of a level‐three neonatal intensive care unit. They presented a case featuring a full‐term baby born by emergency caesarean‐section after a cord prolapse that caused prolonged anoxia. Her initial pH was 6.7. She was intubated and resuscitated in the delivery room. Her Apgar score remained at 1 for ten minutes. Further evaluation over the next two days revealed severe brain damage. Her prognosis was dismal.The doctors recommended a (...) do‐not‐resuscitate order. The parents agreed. The doctors suggested a gastrostomy tube. The parents disagreed. Instead, they requested that fluid and nutrition be discontinued. The emotions in the room, as we started to discuss the case, were strong and discordant. Eventually, the conversation wound down. They turned, expectantly, to the visiting bioethicist. (shrink)

Definition of the problem: The rapid pace of medical progress has drawn renewed attention to the various possible ways of treating dead or brain-dead pregnant women since the 1980's. The discussion today revolves around medical, social, legal and economic aspects. The historical areas of conflict which surrounded deliveries carried out on dead mothers (usually by means of a Sectio in mortua, nowadays known as a perimortem Caesarean section) and their significance in today's debate are, for the most part, (...) regarded as being of little relevance.Arguments: The history of the Sectio in mortua was, for a long time, influenced by the difficulty in establishing whether the mother and foetus were actually dead, by the degree of autonomy of the foetus in the womb, by religious issues, by the lack of acceptance among the people because of their irrational fears concerning the operation and by legal regulations and constraints especially in relation to operations carried out on the dying. Each of these areas shows remarkable parallels to the present-day medical and ethical discussion.Conclusion: The value of such considerations does not lie in the uncritical application of experience gained in the past, but rather in a growing awareness of the wide spectrum of parameters and in a deeper understanding of the various possible approaches to a given situation. The tradition in the Western world of carrying out a delivery on a dead mother, in spite of the conflict of interests between the mother and the foetus, is of particular importance. In practice, the many non-medical factors should be taken more into consideration, with special emphasis being placed on the informed consent of the relatives. (shrink)

Is it lawful for a doctor to give a patient life-shortening pain relief? Can treatment be lawfully provided to a child under 16 on the basis of her consent alone? Is it lawful to remove food and water provided by tube to a patient in a vegetative state? Is a woman's refusal of a caesarean section recommended for the benefit of the fetus legally decisive? These questions were central to the four focal cases revisited in this book. This (...) book revisits nine landmark cases. For each, a new leading judgment is attributed to an imagined judge, Athena, who operates within the constraints of the legal system of England and Wales. Her judgments accord with an innovative legal theory, referred to as 'modified law as integrity', and are linked as a line of precedent. The result is a re-spinning of extant judicial threads into a web of legal principles with a greater claim to coherence and defensibility than those in the original cases. The book will be of great interest to scholars and students of medical law, criminal law, bioethics, legal theory and moral philosophy. (shrink)

Practically, causation matters. Juries must decide, for example, whether a pregnant mother’s refusal to give birth by caesarean section was the cause of one of her twins death. Policy makers must decide whether violence on TV causes violence in life. Neither question can be coherently debated without some theory of causation. Fortunately (or not, depending on where one sits), a virtual plethora of theories of causation have been championed in the third of a century between 1970 and 2004.

This article presents the findings of qualitative research which explored, from the mothers’ perspective, the process of decision-making about mode of delivery for a subsequent birth after a previous Caesarean Section. In contradiction to the clinical literature, the majority of mothers in this study were strongly of the opinion that a vaginal birth after caesarean (VBAC) posed a higher risk than an elective caesarean (EC). From the mothers’ perspective, risk discussions were primarily valuable for gaining support (...) for their pre-determined choice, rather than obtaining information. The findings posit ethical concerns with regards to informed consent and professional obstetric practice at a time when there is a documented and worrying trend towards an increase in births by caesarean section (CS). (shrink)

Suppose a woman chooses to carry a pregnancy to term. What duties should she be understood to have with respect to the fetus? If she is informed that a vaginal delivery will pose significant risks to its life or health, for example, is she obligated to submit to a caesarean section procedure on its behalf?

The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women9s Health advises against tubal occlusion (TO) performed at the time of caesarean section (CS/TO) or following a vaginal delivery (VD/TO) if this sterilisation has not been discussed with the woman in an earlier phase of her pregnancy. This advice is neither in accordance with existing medical custom nor evidence based. Particularly in less-resourced locations, adherence to it would deny much wanted (...) one-off sterilisation opportunities to hundreds of thousands of women, many of whom have no reliable contraceptive alternative. To be sure, a well-timed discussion in pregnancy about a potential peripartum TO is preferable and, if conducted as a matter of course (as the Committee appears to promote), would represent an enormous improvement on current practice. Earlier counselling has the advantage that it results in fewer women who regret having rejected the CS/TO or VD/TO option. However, there is no evidence that earlier counselling leads to a smaller proportion of regretted sterilisations. Consequently, where early TO counselling has been impossible, forgotten or deliberately omitted on pronatalist, traditional, financial, cultural or religious grounds, offering a perinatal sterilisation belatedly and in an unbiased, culturally sensitive manner is often verifiably better than not presenting that option at all, notably where high parity and uterine scars are particularly dangerous. Belated counselling, as will be demonstrated in this paper, saves many lives. The Committee9s blanket rejection of belated counselling on perinatal sterilisation is therefore unjustified. (shrink)

Many first-time mothers (primiparous) within UK National Health Service (NHS) settings require an obstetric intervention to deliver their babies safely. While the antepartum period allows time for conversations about consent for planned interventions, such as elective caesarean section, current practice is that, in emergencies, consent is addressed in the moments before the intervention takes place. This paper explores whether there are limitations on the validity of consent offered in time-pressured and emotionally charged circumstances, specifically concerning emergency obstetric interventions. (...) Using the legal framework of the Mental Capacity Act,Montgomery v. Lanarkshire Health Board(2015) andMcCulloch v Forth Valley Health Board(2023), we argue that while women have the capacity to consent during labour, their autonomy is best supported by providing more information about instrumental delivery (ID) during the antepartum period. This conclusion is supported by some national guidelines, including those developed by the Royal College of Obstetricians and Gynaecologists, but not all. Further, we examine the extent to which these principles are upheld in modern-day practice. Data suggest there is relatively little antepartum information provision regarding ID within NHS settings, and that primiparous women do not report a thorough understanding of ID before labour. Based on these results, and bearing in mind the pressures under which NHS obstetric services currently operate, we recommend further research into patient and clinician perceptions of the consent process for ID. Pending these results, we discuss possible modes of information delivery in future practice. (shrink)

Postpartum depression is a major maternal health problem after childbirth. It can start at any time within the first year after delivery and continue for several years. It is characterized by an inability to experience pleasure, anxiety symptoms, panic attacks, spontaneous crying and depressed mood. Some women with postpartum depression even have thoughts of harming their child and self-harm. This study aims to find out the status of postpartum depression and the associated factors among postnatal mothers at the first, fourth (...) and sixth month. This study is a prospective descriptive study, carried out in three major health facilities in Misurata. This study consists of a three-part questionnaire. Part 1 covers the demographic characteristics of the participants, while Part 2 explores the associated risk factors according to the variables used. Part 3 consists of the psychological evaluation of the participants. A hundred mothers (ages between 15 and 43 years) were enrolled in this study. The findings revealed that the prevalence of depression is 60.0% and 22.0% are suffering from borderline depression. Development of depression was strongly correlated with sleeping disturbances, the state of the neonate after birth, excess consumption of stimulants, less weight acceptance by mothers during pregnancy and infant illness. There was a weak relation between depression and delivery state, maternal admission to the hospital during the current pregnancy, and infant gender dissatisfaction. No correlation was found with the development of depression regarding miscarriage, maternal medical problems after delivery, previous child sex, maternal age, education, parity or neonate weight. Thus, this study shows that the chance of having a miscarriage and an unhealthy neonate increases with advanced maternal age. It also shows that caesarean section is associated with bad neonatal outcomes, more weight gain and having gestational diabetes or preeclampsia during pregnancy. Maternal sleeping problems are more pronounced in the first month, attributed to the baby's care, compared with the fourth and sixth months. The study indicates that depression is a common state of psychiatric disorders among Libyan women and should have appropriate attention by physicians and gynecologists. (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)

How shall we decide for others who cannot decide for themselves? And who—or what, in the case of artificial intelligence — should make the decision? The present issue of the journal tackles several interrelated topics, many of them having to do with surrogate decision making. For example, the feature article by Jardas et al 1 explores the potential use of artificial intelligence to predict incapacitated patients’ likely treatment preferences based on their sociodemographic characteristics, raising questions about the means by which (...) we come to decide for others. And a clinical ethics round table led by Wilkinson and Pillay2 examines the case of a premature baby on life support whose primary surrogate is herself incapacitated. Together, these examples force us to think more deeply about the meaning and significance of taken-for-granted concepts: respect for autonomy, substituted judgement, best interests. We’ll consider the baby first and then turn to AI. “Baby T” is a critically ill newborn delivered prematurely by emergency caesarean section. The mother had entered into a surrogacy arrangement with a same-sex male couple, the intended parents, who were to take over the baby’s care after birth—just as soon as a formal parental order could be obtained through the court. Until then, the birth mother, who had used her own eggs to conceive Baby T along with sperm from an unidentified donor, would have legal and ethical responsibility to decide about the baby’s care. Unfortunately, she too was in critical condition, having fallen unconscious prior to delivery due to a sudden brain haemorrhage. She remained unconscious, and thus incapacitated, during a crucial period in which time-sensitive decisions about Baby T’s care needed to be made, including whether to continue life support. Given the mother’s incapacity, who should …. (shrink)

Sterilisation is the most desired method of contraception worldwide. In 1996, the Brazilian Congress approved a family planning law that legitimised female and male sterilisation, but forbade sterilisation during childbirth. As a result of this law, procedures currently occur in a clandestine nature upon payment. Despite the law, sterilisations continue to be performed during caesarean sections. The permanence of the method is an important consideration; therefore, information about other methods must be made available. Tubal sterilisation must not be the (...) only choice. We argue that review of this restriction will not contribute to the increase in caesarean sections but will allow for greater sterilisation choice for men and women. (shrink)

Ethical medical care of pregnant women in Australia should include the real provision of information regarding the risks and benefits of vaginal birth. Routinely obtaining consent for the different ways in which childbirth is commonly intervened on and the assistance involved (such as midwife-led care or a planned caesarean section) and providing sufficient information for women to evaluate the harms and benefits of the care on offer, would not only enable the empowerment of women but would align with (...) the current standard of care as established by Rogers v Whittaker. (shrink)

Postpartum depression is a major maternal health problem after childbirth. It can start at any time within the first year after delivery and continue for several years. It is characterized by an inability to experience pleasure, anxiety symptoms, panic attacks, spontaneous crying and depressed mood. Some women with postpartum depression even have thoughts of harming their child and self-harm. This study aims to find out the status of postpartum depression and the associated factors among postnatal mothers at the first, fourth (...) and sixth month. This study is a prospective descriptive study, carried out in three major health facilities in Misurata. This study consists of a three-part questionnaire. Part 1 covers the demographic characteristics of the participants, while Part 2 explores the associated risk factors according to the variables used. Part 3 consists of the psychological evaluation of the participants. A hundred mothers (ages between 15 and 43 years) were enrolled in this study. The findings revealed that the prevalence of depression is 60.0% and 22.0% are suffering from borderline depression. Development of depression was strongly correlated with sleeping disturbances, the state of the neonate after birth, excess consumption of stimulants, less weight acceptance by mothers during pregnancy and infant illness. There was a weak relation between depression and delivery state, maternal admission to the hospital during the current pregnancy, and infant gender dissatisfaction. No correlation was found with the development of depression regarding miscarriage, maternal medical problems after delivery, previous child sex, maternal age, education, parity or neonate weight. Thus, this study shows that the chance of having a miscarriage and an unhealthy neonate increases with advanced maternal age. It also shows that caesarean section is associated with bad neonatal outcomes, more weight gain and having gestational diabetes or preeclampsia during pregnancy. Maternal sleeping problems are more pronounced in the first month, attributed to the baby's care, compared with the fourth and sixth months. The study indicates that depression is a common state of psychiatric disorders among Libyan women and should have appropriate attention by physicians and gynecologists. (shrink)

This paper illustrates the importance of monitoring health facility-level information to monitor changes in maternal mortality risks. The annual facility-level maternal mortality ratios (MMRs), complications to live births ratios and case fatality ratios (CFRs) were computed from data recorded during 2007 and 2009 in 31 upgraded public sector health facilities across Pakistan. The facility-level MMR declined by about 18%; both the number of Caesarean sections and the episodes of complications as a percentage of live births increased; and CFR based (...) on Caesarean sections and episodes of complications declined by 29% and 37%, respectively. The observed increases in the proportion of women with complications among those who come to these facilities point to a reduction in the delay in reaching facilities (first and second delays; Thaddeus & Maine, 1994); the decrease in CFRs points to improvements in treating obstetric complications and a reduction in the delay in receiving treatment once at facilities (the third delay). These findings point to a decline in maternal mortality risks among communities served by these facilities. A system of woman-level data collection instituted at health facilities with comprehensive emergency obstetric care is essential to monitor changes in the effects of any reduction in the three delays and any improvement in quality of care or the effectiveness of treating pregnancy-related complications among women reaching these facilities. Such a system of information gathering at these health facilities would also help policymakers and programme mangers to measure and improve the effectiveness of safe-motherhood initiatives and to monitor progress being made toward achieving the fifth Millennium Development Goal. (shrink)

Scholars have generally underestimated the level of Roman involvement in Africa in the period between the annexation of Carthage in 146 b.c. and Caesar's victory at Thapsus in 46 b.c., and the land in Africa which the Romans annexed has been conventionally called public land (ager publicus). This paper analyses the surviving text of the African provisions of the epigraphic lex agraria of 111 b.c. and notes that the term ager publicus is not attested in the provincial section of (...) the law. The land in Africa appears simply as ager in Africa and the term ager publicus is confined exclusively to Italy in the law of 111. However, Cicero's references to Rullus’ agrarian proposal in 64/3 b.c. in the De lege agraria suggest that the term ager publicus was used to qualify land existing outside Italy in Rullus’ proposal. This paper argues that the concept of ager publicus as opposed to private land developed in Africa between 111 and 63 b.c., and that this was linked to privatization of ager in Africa in this period. The results of this study suggest a high degree of Roman exploitation of African land prior to the Caesarean and Augustan colonies in the 40s b.c. (shrink)

A textbook designed for the mandatory semester ethics course at the United States Naval Academy by USNA Ethics Section, with contributions by the Distinguished Chair in Ethics.

Is it morally justifiable to force non-consenting pregnant women to submit to caesarean surgery to save their fetus in distress? Even though proponents and opponents largely agree on the interests at stake, such as the health and life of the fetus and the respect for bodily integrity and autonomy of pregnant women, they disagree on which moral weight to attach to these interests. This is why disagreements about the justifiability of forced caesareans tend to be pervasive and intractable. To (...) sidestep this deadlock, we will focus on conditions that give rise to the ‘caesarean dilemma’ in the first place, namely the conflict between inherent norms and values medical professionals are committed to by virtue of being a medical professional. Using the reflective equilibrium, we will test the opponents’ and proponents’ considered judgments about forced caesareans against the norms and values they—as medical professionals—are committed to and determine whether they are coherent. Subsequently we will identify the proponents’ incoherencies between the considered judgments and norms and values they are committed to and conclude that as long as these incoherencies are in place, forced caesareans are morally impermissible. (shrink)

The objective of this editorial is to help authors better understand how to contribute to discourse on corporate sustainability and business ethics. We do this in two ways. First, we clarify our expectations for publication in the “Corporate Sustainability and Business Ethics” section at the Journal of Business Ethics (JBE). As section editors at the journal, we want to make explicit the criteria we apply in our decisions to accept or reject a submission. We argue that authors should (...) explicitly reflect upon what corporate sustainability means in the context of their research. We also stress that publishing in JBE requires an explicit central focus on ethics. We do not take a position on how authors must do either of these two, only that it should be done. In short, there are good business ethics papers that do not add to corporate sustainability theory building or practice, and there are good corporate sustainability papers that are not framed in a business ethics discourse. For the “Corporate Sustainability and Business Ethics” section, we expect authors to strive for both. Second, we provide several illustrations of how corporate sustainability research can be framed from a business ethics perspective around three central sustainability constructs: objective function, carrying capacity, and generational sustainability. These examples are not intended to be comprehensive or to bound the range of acceptable research for JBE’s “Corporate Sustainability and Business Ethics” section. Rather, we aim to provide representative examples of potentially publishable research on business ethics and corporate sustainability to spur innovative thinking and constructive discussion. We hope this editorial will help authors better understand what we expect from submissions to the “Corporate Sustainability and Business Ethics” at JBE. (shrink)