Should a father dive into a flowing stream to aid his daughter, struggling to keep her head above water? Should a mother donate a kidney to her child with renal failure? Is it ethical for a parent to work two or three jobs so that they can pay private health insurance or school fees for their children? In all of these situations most of us would think that it is commendable for a parent to take these actions. We applaud and approve of a parent who decides to take on some personal risk, who sacrifices his or her own wellbeing and health in order to prevent a risk of serious harm to their child. It is one of the duties of a parent to do whatever they reasonably can to avoid risks and secure benefits to their children. How morally important it is for parents to make these sacrifices depends on the balance between the risks to the child and those to the parent. But it is appropriate for a parent to give greater weight to the risks to their child than to themselves. Indeed we might well be critical of a parent who failed to do so.
What then, of a mother who decides to undergo abdominal surgery in order to reduce the risk of her child suffering brain injury, or being admitted to intensive care? Shouldn’t we also applaud this decision?
Not according to the public responses to a new guideline on caesarean section recently released by the National Institute of Clinical Effectiveness (NICE) . NICE have recommended that women who request caesarean section at term should be permitted this choice after counseling about the risks and benefits of this mode of delivery. Previously, at least in the UK, doctors would often decline requests for an elective section unless there was a ‘medical indication’. NICE now recommends that if doctors are unwilling to perform a caesarean at maternal request they should refer the mother to another physician. The new NICE guideline has been criticized as madness, and an example of ‘gynophobia’.
The change in advice by NICE reflects a shift over time in the risks of caesarean section. Caesarean section was once thought to impose significant (even if small) risks of maternal death. However, the evidence reviewed by NICE suggests that with current anaesthetic practice the risks to the mother are extremely small. (One possibility that is difficult to tease out from the data is that mothers may have an increased risk with subsequent pregnancies because of the surgical scar in their uterus.)
In essence, decisions about the mode of delivery weigh up risks and benefits to the mother, and risks and benefits to the baby. There are definite downsides to elective caesarean section – mostly for the mother. It is associated with longer hospital stay, and small increases in the risk of hysterectomy and cardiac arrest. But there are also potential benefits, and these are particularly for the baby –reduced risks of the baby being admitted to neonatal intensive care, and probable (but hard to prove) small reductions in the risk of very serious complications for the baby including bleeding in the brain, death in the womb, and brain damage from lack of blood supply during labour.
The NICE report quotes evidence that most mothers requesting elective caesarean section are motivated by the perceived safety benefits to the baby. Most mothers don’t make such choices for cosmetic reasons, nor because they are ‘too posh to push’. Sometimes mothers have had bad experiences with previous deliveries, or they may have been influenced by the experiences of friends or family members.
It is not clear whether overall the benefits of elective caesarean section outweigh the risks, or justify the additional expense of delivery by caesarean section. There will doubtless continue to be debate about the interpretation of epidemiological studies, and the relative risks to both mother and child. But, the cases mentioned at the start of this article suggest that it is rational and ethically appropriate for mothers to weigh the risks to their child more heavily than the risks to themselves.It is entirely reasonable for a mother to accept some personal risk in order to reduce a potentially devastating harm to her child.
Elective caesarean section can be a morally commendable choice.
Further reading
Elective primary caesarean section NEJM 2003
Thank you for writing such a well-balanced post on this subject. Unlike some commentators this week, you have attempted to look at both sides of the argument without resorting to a knee-jerk ideological reaction about the superiority of natural birth.
The only other thing I would add which may be of interest is that in terms of the moral argument, some years ago (before the evidence on the safety for babies was as clear as it is today), women who chose a cesarean were accused of being 'selfish' for wanting to protect their pelvic floor. They were accused of putting their babies at unnecessary risk. Of course this case can no longer be made – as long as the mother and her doctor follow the advice given of waiting until 39+ weeks' gestation before scheduling surgery. Protection of her pelvic floor is now fast becoming the prophylactic medical benefit that some women perceive as outweighing the intrapartum risks of a planned cesarean birth.
There is always the question of perception / view.
When transplants were first introduced it raised similar moral issues.
By now it had become a standard procedure.
Good post, and it's also good to see NICE make such a sensible recommendation. I'd like to draw your attention to <a href="http://j.mp/tnibLZ">this post by Claire Gallop defending the woman's right to choose elective caesarean</a>, which supports and expands on some of what you say here. (Note that the article incorrectly states that Claire is a lecturer at the Bioethics Centre – sadly, she is not, but happily she <a href="https://twitter.com/#!/otagogrs">still works at the University of Otago.</a>)
Sorry – it seems my html tags didn't work properly!
The post by Claire Gallop is here: http://j.mp/tnibLZ
And the link to her work is here: https://twitter.com/#!/otagogrs
I hope that works.
The first sensible, evidenced based article I have read on this subject after hours of upsetting 'opinion'. I am so pleased they have reviewed this policy. I had been saving for private ecs. A history of mental illness following years of abuse made a 'natural' birth and thus children impossible.
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