One for Two: VBACs and Autonomy

Dear Millicent,

In her article “Do Pregnant Women Have The Right to Refuse Surgery,” Rebecca Spence over at RH  Reality Check highlights one of the craziest and mindwalloping aspects of motherhood. You and I have parsed shades of it before, looking at how the sacrifice of parenting is so much more than time and money or giving hugs and casseroles when you just don’t feel like it.

While both parents might gain the privilege of joint dictatorship over their kids’ lives, once pregnant, a woman is pushed into a new definition of selflessness.  Her body becomes a grounds for expectation, judgement, and social know-betterness.  And, while there are lots of glowy wonderful aspects, that other terrifying analogy exists: Mama as host and Baby as blood-pressure-spiking parasite.    Why terrifying? Because parasites usually win, and hosts are never defined by their exhilarating autonomy, are they?

Spence’s article focuses on the NIH’s Vaginal Birth After Cesearean Consensus Development panel, which last week issued a statement that had some good news (mostly that the regulations limiting VBACs needed to scrutinized), but the squirmy argument that there were circumstances where a doctor’s opinion trumped a mother’s wishes regarding surgery.

Spence  emphasizes “the panelists’ comments indicated that a conclusion regarding the ethical question was beyond their scope, yet stated to the press and to the audience that the body of law and ethics that protects the right to refuse surgery was not written for, and may not include pregnant patients.”

Spence asks “Are women who are pregnant simply a different form of person with a different set of rights?”

Obviously, and yet I had never thought of it before, this question is a big question in the field of obstetric ethics, and is simple (treat people well! ) and sticky (it’s ethics!).  Spence writes:

Much ink has been spilled refuting the two-patient model of obstetric ethics, which conceptualizes the interaction between mother and fetus as a conflict capable of being decided by an outside arbiter (be it a judge, ethicist, or doctor), rather than a conflict between the mother and the doctor. The manner in which the panel has cast the problem of obstetric ethics as a maternal-fetal conflict, as opposed to a woman-doctor conflict could lead one to the conclusion that a physician’s ethical obligation to “first do no harm” applies to fetuses, but not to women — an untenable position for a profession devoted to caring for women, and a dangerous position for public health. The panel’s failure to condemn practices such as court-ordered cesareans and child protective services intervention to coerce women’s compliance with doctor’s orders poses major questions about whether and how personal convictions may have been at play in this discussion.

I read this, and I think ack! The maternal-fetal conflict is real, but biological and strange and nobody really wants to talk about what that really means because by the time the conflict presents itself, it has to be come to terms with.  If my partner chooses to have a child, he deals with feelings of maturity, fears, finances.  If I choose to have a child, I have to decide whose body comes first in my judgment, the kid’s or mine. My freedom is probably tanked, but hopefully on my own terms.  If I choose to continue my pregnancy, I am both hijacked and hijacker’s big boss. But that problem is not one of obstetric ethics, it’s of how maternity is a strange feat.  And Spence here focuses on how doctors should support women in this moment: as individuals with full rights.

And, while the horrors of court-ordered cesareans exist, it sounds like the panel’s opinion is not the majority’s perspective.  Spence says:

The position taken by the consensus panel directly contradicts the thoughtful and comprehensive presentation given 24 hours earlier by Dr. Anne Lyerly of Duke University, the invited expert speaker on the ethics of vaginal birth after cesarean. Dr. Lyerly reminded the panel of “a lesson that we need to keep learning but should know by now.”

“In obstetrical decision making,” she said, “women retain their rights of bodily integrity, just as people do in all other situations. So when a woman declines a cesarean, even when it is absolutely indicated, she cannot be forced to undergo it, [n]or be punished for her decision not to. American jurisprudence supports that, as well as ACOG [the American Congress of Obstetricians and Gynecologists].”

I’m happy to see this opinion offered so eloquently, but what worries me is that the establishment still fumbles with the question.  And I shudder to think what a Law and Order episode would look like dealing with this topic.  We’re taught early on that if a woman is pregnant, the stakes are raised (think of any movie with a holdup at a restaurant or bank…usually there is a pregnant woman among the hostages).  A useful narrative device, yes:  two lives in one (get her off the boat first!).  But, while it usually expands her freedom in these fictional situations, she loses voice and power so often in real life.  The idea of woman as baby container/host/russian nesting doll is so scary—-Not because of the act of reproduction, but because of the transformation from person to object.   Here’s hoping, like Spence offers, that this is becoming a less standard standard in the medical field.