AJOG anti-phb position paper ~ section on Respect for Women’s Rights

by faithgibson on January 5, 2013

Respect for women’s rights

There are 2 ways in which respect for women’s rights can be understood. The first starts with the right of the woman to make decisions and control what happens to her body. The physician is bound to acknowledge and implement the patient’s preferences, without constraint. This is a purely contractual model of the physician-patient relationship in which the woman protects herself by the exercise of her autonomy-based rights. “In a democratic society, a woman has the right to choose where she might undergo one of the most important experiences of her life, and where she will begin to bond with a child she will raise lovingly.”48 This is rights-based reductionism, in which the patient’s rights systematically override professional responsibility. In the resulting contractual relationship the physician’s obligation to protect the pregnant woman, much less the fetal and neonatal patient is completely subordinated to the woman’s rights.29

In a professional relationship the physician and other obstetric providers do have an independent obligation, as a matter of professional integrity, to protect pregnant, fetal, and neonatal patients.29, 49 These beneficence-based obligations must in all cases be balanced against autonomy-based obligations to the pregnant patient. Beneficence-based and autonomy-based obligations combine to create the professional responsibility to empower the pregnant woman to make informed decisions about the management of her pregnancy and care of her newborn child.29, 50 The physician’s role is to identify and present medically reasonable alternatives for the management of pregnancy, ie, clinical management for which there is an evidence base of net clinical benefit. In a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives. This limitation does not exist in the rights-based reductionist model of women’s rights.

In the professional responsibility model of decision making, the patient has the right to select from among the medically reasonable alternatives. If she rejects them all and also remains a patient, then her refusal is not a simple exercise of a negative right to noninterference. Her refusal is more complex, because it is coupled with a positive right to the services of clinicians and the resources of health care organizations and society.51 In all ethical theories positive rights come with limits. In the clinical setting ethically justified limits originate in professional integrity, because professional integrity prohibits provision of clinical management that is not safe.52

In summary, from the perspective of the professional responsibility model, insistence on implementing the unconstrained rights of pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine. An editorial in Lancet succinctly summarized this point: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.”6

Next section: Professionally-appropriate response