{"id":4557,"date":"2024-02-23T16:22:20","date_gmt":"2024-02-23T15:22:20","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=4557"},"modified":"2024-02-23T16:22:20","modified_gmt":"2024-02-23T15:22:20","slug":"trumping-rights","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2024\/02\/23\/trumping-rights\/","title":{"rendered":"Trumping rights?"},"content":{"rendered":"

By Ezio Di Nucci.<\/p>\n

Our team just finished another round of the ethics course at Copenhagen\u2019s medical school<\/a>, and we are now grading exams, which this semester included the following case study:<\/p>\n

A 32-year-old woman is in early labor. Tests indicate fetal hypoxia, i.e., that the fetus lacks sufficient oxygen. Various attempts are made to improve the situation\u2014positional changes, oxygen, an IV\u2014but none succeed.\u00a0 The obstetrician explains to the patient the nature of fetal hypoxia, and informs her that, if it persists, it can progress to acidosis and possible long-term neonatal organ failure. On this basis, the obstetrician recommends an immediate cesarean delivery. The patient, however, states that she strongly desires a natural birth, and declines the recommendation. The patient\u2019s husband is concerned, but he has left the decision to his wife.<\/em><\/p>\n

This case has generated quite a bit of discussion within our research group, which started by noticing \u2013 with surprise \u2013 that a few of our students suggested the patient\u2019s husband should decide (reminding one of our local colleagues that when she was herself born in \u201870s Denmark with an emergency C-section, the doctor left the room to ask her mother\u2019s husband for permission\u2026 times have changed; or have they?).<\/p>\n

So let us start there. The description of the case makes no suggestion towards the idea that the patient might be incapacitated, so the obvious argument for guardianship or delegated decision-making does not apply. By the way, guardianship could be exercised by the husband but need not to be \u2013 apart from the fact that there is no mention of the husband being the prospective father either.<\/p>\n

Any guardianship or proxy decision-making arrangements would have to be with the patient\u2019s next of kin, who might neither be the unborn\u2019s prospective father nor the patient\u2019s partner but, say, a friend, parent or other relative. This is an important clarification because it stresses that even in cases where we might not be sure of the pregnant woman\u2019s decision-making capacity (never miss a chance not to trust a woman\u2019s word, right?), it is her<\/em> interests that the system would have to guarantee through guardianship arrangements.<\/p>\n

This also complicates the path towards a coercive medical intervention. The patient has been given medical advice and has been informed of the risks attached to refusing to follow medical advice, after which the patient has declined the emergency C-section. This seems to be the most natural interpretation of this case study. So the question, then, is whether the patient\u2019s right to bodily autonomy, which in this case is exercised by refusing treatment, trumps any rights the unborn might have or, indeed, any duties medical professionals might have towards either the pregnant woman or the unborn.<\/p>\n

One possible version of the case would be where the pregnant woman refuses the C-section and her partner \u2013 who is both her next of kin and the prospective co-parent \u2013 supports her refusing treatment (whether or not she is incapacitated would not matter here because if she is, the next of kin declines; if she is not, she declines herself). Here we might be tempted to argue for coercive medical intervention and for the physician to be the adult in the room but, again, there is no grounds for such a judgement in a consent-based healthcare system.<\/p>\n

Before concluding that guardianship is not relevant to this case, we should compare it to refusal of life-saving blood transfusions for religious reasons. Many jurisdictions distinguish between adults and minors in these kinds of cases: adults might refuse on their own behalf but might not refuse on behalf of their dependents, so that in many jurisdictions healthcare professionals are either allowed or in fact even required to paternalistically disregard parental consent requirements when it comes to life-saving blood transfusions.<\/p>\n

Could this model be applied to our case? The problem is that even if we equated the unborn with the minor (itself a controversial move); and then took the C-section to be life-saving like the blood transfusions in the other case (this latter comparison being less controversial if we interpret organ failure to be likely fatal, which seems fair \u2013 but obviously we can imagine more complex cases where the probability of death s less than 1); there would still be the following crucial difference: the pregnant woman in our case is not refusing treatment on behalf of her dependent, she is refusing treatment on her own body. So here again the more fitting comparison would have to be to the adult refusing her own blood transfusion rather than refusing her child\u2019s blood transfusion.<\/p>\n

What\u2019s left is the question of whether medical professionals would have the right \u2013 or indeed a professional duty \u2013 to try to talk the pregnant woman out of declining treatment with the result that the unborn will die of organ failure. The question is not how far the power of persuasion goes \u2013 because we are confident that in most cases persuasion would not even be necessary. The relevant normative question is whether trying to convince a patient \u2013 especially if they are a pregnant woman \u2013 might itself be a form of epistemic injustice.<\/p>\n

There seems no way, basically, to work around the hard question, which was always going to be whether the pregnant woman\u2019s right to refuse treatment can trump either the unborn\u2019s right to life or the physician\u2019s duty of beneficence towards the unborn. And even though whether the emergency C-section happens at, say, week 25 as opposed to week 41 (intentionally picking uneven numbers, here, to mess with the Donald\u2019s brain<\/a>), the answer to the question of whether a woman\u2019s bodily autonomy rights should trump the supposed right to life of an unborn child is the same one we are familiar with from the abortion debate<\/a>: obviously.<\/p>\n

Author<\/strong>: Ezio Di Nucci<\/p>\n

Affiliation:<\/strong> University of Copenhagen<\/p>\n

Competing interests<\/strong>: None declared<\/p>\n","protected":false},"excerpt":{"rendered":"

By Ezio Di Nucci. Our team just finished another round of the ethics course at Copenhagen\u2019s medical school, and we are now grading exams, which this semester included the following case study: A 32-year-old woman is in early labor. Tests indicate fetal hypoxia, i.e., that the fetus lacks sufficient oxygen. Various attempts are made to […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":354,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8059,8057],"tags":[],"class_list":["post-4557","post","type-post","status-publish","format-standard","hentry","category-abortion","category-medical-ethics"],"yoast_head":"\nTrumping rights? - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2024\/02\/23\/trumping-rights\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Trumping rights? - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Ezio Di Nucci. Our team just finished another round of the ethics course at Copenhagen\u2019s medical school, and we are now grading exams, which this semester included the following case study: A 32-year-old woman is in early labor. Tests indicate fetal hypoxia, i.e., that the fetus lacks sufficient oxygen. 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