Letter: Caesareans: doctors owe duty to child

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Letter: Caesareans: doctors owe duty to child

Sir: Barbara Hewson does her case no favours by presenting it in extreme terms ("Freedom tiptoes out the door", 5 March). Autonomy is central to modern medical ethics. But does it automatically overrule any responsibility to the unborn child?

This dilemma is real and complex but cannot be characterised, simply, as courts or doctors exercising an age-old prejudice against women. Doctors and midwives support a patient's right to choose not to have medical treatment even where that decision might jeopardise the patient's own life, but they also feel moral responsibilities for the child.

They deplore the implication that pregnancy itself challenges a woman's mental competence. The BMA, the Mental Health Act Commission and other bodies are currently discussing how to prevent the misuse of the Mental Health Act in connection with Caesarean sections.

Patients are sometimes prepared to take risks, but apart from all the moral considerations about the impact of such risks on the child, doctors have the added burden of also trying to protect themselves from litigation.

A breech delivery is not an automatic death sentence for either mother or child. When I was practising obstetrics, vaginal delivery was the usual option in such cases, but it does carry higher risks of death, injury or permanent disability for the child.

Today, in these circumstances, the treatment of choice is Caesarean section, and doctors may rightly fear that using a less invasive but considerably more risky procedure may result in them being sued if harm results. We may be already at that stage. Last week's British Medical Journal suggested that by the year 2000, the average gynaecologist would spend half his or her time practising medicine and the rest providing reports for litigation.

Surely, we can transcend this confrontational approach and seek instead for courts, health professionals and patients to work together on solutions? Almost invariably, women want the best solution for their baby, but they may disagree with health professionals about how to ensure that. What we desperately need is an agreed way of negotiating that difference.

We are currently awaiting the Appeal Court's reasoning in the most recent case, where the woman was fully legally represented. This in itself is notable progress, and gives us an important opportunity for judges to help resolve the dilemma. If they are able to produce another "judgment of Solomon", as in the Blood case, society will be in their debt.

Let us at least receive proper information about the case and the court's reasoning before we predict a return to the dark ages.


Chairman, Medical Ethics Committee

British Medical Association

London WC1