Pregnant women have the right to refuse treatment and obstetricians should respect that right, even if the lack of treatment could potentially harm her or her fetus, said a committee opinion from the (ACOG).
While the ob/gyn may feel compelled to try to balance a pregnant woman's autonomy with an ethical desire to optimize the health of the fetus, the woman is the primary patient of the ob/gyn, and the patient has the right to refuse any medical or surgical interventions, reported the Committee on Ethics, writing in .
The authors drew the distinction between the two, saying "the obstetrician-gynecologist [has] beneficence-based motivations towards the fetus of a woman who presents for obstetric care and a beneficence-based obligation to the pregnant woman who is the patient," they wrote.
They cite the potential example of a woman with severe cardiopulmonary disease, where a potential pregnancy may make the condition life-threatening. In that case, an ob/gyn may recommend pregnancy termination, which would be in the best interest of the woman, not the fetus.
"This reinforces ACOG's longstanding support of a patient's right to consent to or refuse medical treatment, and the principle that pregnancy is not an exception to this fundamental right," said co-author , in a statement. "Respecting this right is vital to the patient's relationship with her physician, and prevents coercive interventions and incursions against bodily integrity, which are always ethically impermissible."
Moreover, ob/gyns should not coerce medical interventions for pregnant patients, and should refuse to participate in court-ordered interventions that "violate their professional norms of consciences."
Court-ordered interventions, such as court-ordered cesareans, are to be applied to women of color, low socioeconomic status, or women who do not speak English as a first language. They note that in nearly a third of cases where court orders were sought, medical judgment . Also women with court-ordered interventions were less likely to seek prenatal care.
"Forced compliance -- the alternative to respecting a patient's refusal of treatment -- raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality," the authors wrote.
Instead of coercion, they recommend "directive counseling," where the ob/gyn offers advice, recommendations, or guidance, but stops short of force or threats.
When speaking to the patient, the authors suggest a team-based approach. In addition to the ob/gyn, the team may include ethics consultants, as well as colleagues from other disciplines, such as nursing, social work, chaplains, and members of the pregnant woman's personal support network. In the event of adverse outcomes after refusing recommended treatment, ob/gyns should continue to support the patient and offer counseling services, if necessary.
"While such situations can cause distress to both the patient and her physician, it is imperative that the pregnant woman be supported and that her wishes be respected," said , chair of ACOG's Committee on Ethics, which developed the Committee Opinion, in a statement. "As ob-gyns, we have a vital role in recognizing the interconnectedness of the pregnant woman and her fetus while also maintaining respect for the pregnant woman's autonomy and decision-making capacity."
This committee opinion does not address any professional liability or legal issues a clinician may encounter when pregnant women refuse medically indicated treatment, but these resources are available on the .
Primary Source
Obstetrics and Gynecology
Committee on Ethics "Refusal of medically recommended treatment during pregnancy" Obstet Gynecol 2016; Number 664.