Is it Ethical to Deny a Pregnant Woman the Right to Refuse Unwanted Treatment?
From my currently inactive "Bioethics Discussion Pages", here is another topic that produced some interesting responses from my visitors. The less recent visitor comments are toward the bottom of this post. The ethical question seems to relate to whether the embryo and fetus which presently cannot develop into a baby without being an integral part of the anatomy and physiology of a woman should be considered part of the woman herself. If my blog visitors have their own personal view of the issue, they are welcome to comment. ..Maurice.
It is now a well established right of every competent adult to refuse unwanted medical treatment for their illness. This right has both legal and ethical consensus. This means that a competent patient can refuse to start a treatment or if a treatment is in progress can order that the treatment be terminated. The request can be made in an advance directive such as a Durable Power of Attorney for Health Care or in a "living will". If a patient is incompetent at the time of the treatment then the patient's legal surrogate or the advance directive written when the patient was competent can "speak" for the patient. Physicians must follow the request of the patient in this regard and if they can't, perhaps because of moral reasons, the physician must attempt to get the patient transferred to another physician who will follow the directive. The request to end treatment is valid even if that treatment is life supportive such as respirator treatment and that termination may lead to the patient's death. The one exception to this right is directed at the pregnant woman. In many states within the United States, state laws prevent a pregnant woman from either writing an advance directive or specifically preventing her from ordering termination of life support. Whether the pregnancy is either early or late is not a consistent criterion amongst these laws. An argument that is given as the reason for this prohibition is that states have an interest in the fetus and that interest is to allow the fetus to be born. This interest may be based on the concept that a fetus is a person and may have certain rights independent of the mother. Some have criticized the concept that a fetus is a person separate from the mother and that such a concept would make the mother only a "container" for the fetus. These critics argue that the mother and fetus are one, the fetus depending on the mother for life and development until birth and, indeed, needs a mother after delivery. Also whether "personhood" begins before birth or after delivery is another point of contention. The state's legal argument also may support religious concerns as expressed, for example, in Catholic religious directives. The question is whether this denial of a right of autonomous medical decision-making for a pregnant woman is ethically just or beneficent. What do you think?
Here is the question:
Is it ethical to deny a pregnant woman the right to refuse unwanted treatment including termination of life support while permitting refusal by all other competent adult men or women?
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Date: Mon, Jun 21, 2004 5:35 PM From: lblydick@cox.net To: DoktorMo@aol.com
Although I can see valid points on both sides of the issue, my question is this: who will make medical decisions for the child once it is born? Chances are high the mother of the child. We are not arguing the mother's right to decline/refuse treatment once the child is born. Certain religions and personal convictions refrain individuals every day from receiving treatment for themselves or a family member. If the woman was planning to give the child up for adoption, signing parental rights away already, then the rights of the fetus/unborn child would be up to the adoptive parents/state. However, if the woman intended on keeping the child, it is her right as a parent to decline treatment for her child - regardless of how the medical community may feel about the issue. Our job in the medical community is to not only promote the well being of our clients, but also be an advocate for them without prejudice.
B.Lydick, Northeastern State University Student
Date: Sun, Jun 6, 2004 4:30 PM From: Jennifer-Barber@ouhsc.edu To: DoktorMo@aol.com
I am a nursing student and also pro choice. My concern is that if we allow this to happen, women will be seen as baby carriers again only. It will put an emphasis on the life of the fetus over that of the mother, similar to the view by many pro life advocates. My fear is that, when this happens, Roe v. Wade takes a giant step backwards.
Date: Wed. Jan 21, 2004 10:38 AM From: khmaio@earthlink.net To: DoktorMo@aol.com
I question the term "refuse".
I would accept the term "decline" and regulary recommend that particular term. "Refuse" signifies a force has been directed and someone is having to respond to that force. I can decline to have sex with someone, it is quite another issue to have to refuse to do so.
The "Right to Refuse" has become a legal term of art, but no one has really examined the term from an ethical point of view.
Harold A. Maio
Date: Mon Jun 2, 2003 8:39 PM From: Kduran14@cs.com To: DoktorMo@aol.com
Dear Dr., I read the article and got into a dilemma of my own. I am pro-choice and believe that the women has the right to determine whether or not to keep a pregnancy. If we give women the right to terminate a pregnancy, why would we deny her the right to refuse unwanted treatment? I believe that she should have the right and the doctor can not deny her that right since its violating the patient's autonomy. On the other hand, I believe that the fetus might have rights too. The mother is ready to give up, but what about the fetus who at this time has no voice? It is our job in the medical community to advocate for those who can not speak for themselves. As you can see, I have thoughts on both sides of the coin. How do we determine which side is the right side?
Date: Mon, Jun 2, 2003 4:37 PM From: TheresaTfrawley@aol.com To: DoktorMo@aol.com
Greetings, I am a student at Salem State College in a medical ethics class with Pricilla Richardson.
In response to the question of a pregnant woman and her choice to refuse medical treatment, the following thoughts come to mind. The woman needs to decide if she wants to terminate the pregnancy or keep the baby. If she decides to keep the child it should be her obligation to seek prenatal care for many reasons. The care of her own health and the fetus that she is going to have are at stake when lack of health care is provided. The patient that refuses medical treatment during pregnancy should be evaluated to determine if they are competent to be their own guardian. Why should the child suffer because the mother refused to take care of her body during this crucial time?
Date: Wed, May 21, 2003 4:24 PM From: marytmcguire@yahoo.com To: DoktorMo@aol.com
Dear Dr.,
The pregnant woman should not be taken off life support until the fetus has reached sufficient development to be viable outside the womb. Then life support for the mother can be terminated.
Thank you, Mary T. McGuire, Student at Salem State College, Massachusetts
Date: Mon, Apr 14, 2003 3:24 PM From: suebdumas@msn.com To: DoktorMo@aol.com
I do believe it is no longer the right of the women but of the baby from the time of conception on. Who is protecting the rights of the unborn child?
Date: Tue, Apr 8, 2003 11:03 AM From: duck@thebest.net To: DoktorMo@aol.com
We allow women the right to have an abortion so what is the difference? Why not allow them to choose what medical treatment they will receive? I disagree with abortion, but for years people have fought for women to have the right of choice. Competent men and women have a right to choose so what makes a pregnant woman any different? We allow her the choice of terminating her pregnancy or continuing it, so why not allow her the choice of what medical treatment she will receive?
Date: Thu, Mar 21, 2002 4:26 PM From: dr__Bob@hotmail.com To: DoktorMo@aol.com
The answer here is strongly shaped by ones views on the beginning of human life. I must point out though that in many situations one persons life or health may hinge on another's but that does not automatically give one control over another's medical decisions. The right of any adult to the control of his or her own body must be considered the most basic of all human rights. If I do not have control of my own body then I control nothing. What if the treatment in question were painful? Would we have the right to insist that a woman suffer pain to allow her child to be born. What then of obstetric anesthesia which may have risks to the fetus. What of the pregnant woman who chooses to use drugs? Should she be imprisoned until she delivers? Yet prison is not a completely safe environment either. What of the pregnant woman who smokes? What of the pregnant woman who is a devout Christian Scientist? Once we start down this road we turn the adult human woman into a biologic incubator
Date: Mon, Feb 18, 2002 7:34 PM From: rull@vision1mm.com To: DoktorMo@aol.com
This is a pro-life topic, looked at from a different angle.
I believe that everyone should be able to refuse unwanted treatment, but for a pregnant female who chose not to abort... I believe that she should do what is best for her fetus. She decided not to abort, to become a mother, and in choosing to be a mother she should put her child/fetus first.
Date: Sat, Feb 9, 2002 4:20 PM From: nightingale857@earthlink.net To: DoktorMo@aol.com
I believe no one whether pregnant or not, should be denied the right to refuse unwanted treatment. It would be ethically wrong to do so. However, the pregnant women presents an ethical dilemma in that her decision could affect the viability of her unborn baby. This then leads to the question of when life begins and inevitably, the pro-life/pro-choice issue. When a parent refuses to seek medical care for their child , for whatever reasons, the court usually gets involved for human rights reasons and in many cases, becomes the advocate of that minor child. Does the parent then loose her autonomy as a result? Who advocates for the unborn child? At what point does an unborn fetus become a child? When the pregnancy is desired?
Date: Fri, Dec 28, 2001 8:35 AM From: adonai@sirinet.net To: DoktorMo@aol.com
United States Law has consistently upheld that a pregnant woman has the right to terminate the life of her baby through abortion. To deny a woman the right to refuse unwanted medical treatment during pregnancy would be inconsistent with previously held decisions regarding her right to terminate, and would open the door for overturning the current abortion laws.
As far as I am concerned, forcing women, whether pregnant or not, to accept medical treatment is in violation of the 14th Amendment, and could not be defended constitutionally.
Thank you, Judie C. Rall, C.C.E., The Center for Unhindered Living, http://www.unhinderedliving.com/
Date: Sun, Sep 30, 2001 7:15 PM From: dr_philo@hotmail.com To: DoktorMo@aol.com
Denying unwanted medical treatment is not a crime, it is a rational personal decision. If a woman is competent, and decides against treatment, she should be able to reserve her personal rights despite being pregnant. More importantly her decision isn't infringing on the rights of any other living person, only on her and her body (including the fetus which is biologically a part of her). Furthermore, to infringe on another person's rights is unethical, and to deny a pregnant woman her rights while allowing others to maintain them is just so.
Date: Sun, Sep 30, 2001 From: francesthomas@waitrose.com To: DoktorMo@aol.com
If pregnancy automatically removes the autonomy of a woman in any respect, the consequence would be the right of others to dictate her actions in almost every respect, since she and her fetus are one. No adult human being can be ethically stripped of rights in any circumstance.
One might wish to force an unwanted Caesarean Section on a pregnant woman, when one anticipates death for the woman and her fetus if an abnormal labour is left to run its course. However, by extending the same logic, one would imprison a pregnant woman whose lifestyle could be said to put her fetus at aviodable risk, for example, a smoker. If you feel little sympathy with smokers, consider force feeding an anaemic vegan, or attaching a ball and chain to an inveterate hang glider.
We all owe our existence to our mothers. If some mothers do not choose to do as we see fit, we continue to owe them respect.
Date: Mon, Sep 3, 2001 7:38 PM From: randr2@juno.com To: DoktorMo@aol.com
It is obvious to me that the issue of treatment refusal by pregnant women raises the same questions as the issue of abortion. It is often a misconception that the abortion issue centers on a woman's right to choose. The issue centers on whether a human being's life is being taken during the act of abortion, not on any right for a choice that could be made before conception. So, the question of whether a pregnant woman has the right to refuse treatment is mostly centered on this same distinction.
My personal opinion is that a woman's right to refuse treatment is overruled by the fetus's right to live. People often make exceptions when it comes to having the right to be free and do as one chooses. These exceptions usually come in when the action of a free person infringes upon another person or persons' lives. Given that I believe in the human status of a fetus, my conscience tells me that the willful destruction of this life is wrong. Although it's difficult to make a black and white distinction between right and wrong in many cases, it seems to me that refusal of treatment would be as murderous as shooting someone in cold blood.
-Rob
posted by Maurice Bernstein, M.D. @ 7:50:00 AM
10 comments
10 Comments:
Ahh, Dr. Bernstien! Another post that I can't just ignore.
I'm of the opinion that we are always responsible for the consequences of our actions, even when society tells us that we can hit the "undo" button ... especially if our actions have an impact on another human life, and most especially if that human life is in any way dependent on us ... and double that if we were responsible for giving that human life its spark - even involutarily.
I believe that from conception on, there are two lives to protect. The child will no more be independent for a while after birth than he was before being born, with the exception of breathing on his own. He would still die if he were left unattended.
Also - I do not believe that independence trumps dependence where the right to live is concerned. Very few of us go through life without needing to be dependent on some extraneous means to remain alive - be it interventional surgery, or simply a treatment and medication regrime.
My answer: whenever a life can be saved - especially a life that hasn't yet got a voice of its own - it should be.
I think it's absolutely vital to respect the rights of every woman (and man) about her decisions regarding termination of treatment or other issues of self-determination.
However, as I understand it, at least one state has a law which allows women to be incarcerated (held without her consent, even within a hospital) if the state determines that she's endangering a fetus (in the case of use of illegal drugs, specifically).
While the state may have an interest in a fetus surviving to birth, the state's interest shouldn't supercede an individual's right of self-determination.
The interest of the state in a given individual's survival would not allow it to force others to "donate" blood or organs, and cannot supercede individual determination in a woman who happens to be pregnant, or who may become pregnant. In fact, the US requires that the state respect corpses enough that it can't "harvest" body parts from corpses without the permission of the donor or survivors. (And we find reports of such "harvests" from other states evidence of depravity.)
(I seem to remember a post on RedStateMoron's blog a good while back where he considered whether he could hospitalize a woman for the remainder of her term because he felt her uncontrolled diabetes endangered the fetus (and her health). If you can find it, you might find the discussion that ensued there of interest.)
The "face the consequences" issue seems especially inapt when applied in a medical context since so much of medicine attempts to alleviate the unwanted consequences of our actions.
I can't imagine telling upper class white folks that they can't get treatment for skin cancer because it's a consequence of their decision to tan when they were young.
Nor can I imagine telling overweight people with heart disease that they can't get heart drugs on Medicare because they brought it on themselves.
And yes, cancer cells are alive and have human DNA. And no, I wouldn't have any problem with someone trying to kill cancer cells by removing them, poisoning them, whatever.
I would like to see someone explain to me a reason why a pregnant woman is not prevented from injuring her fetus by smoking, drinking alcohol, taking drugs both illicit and prescribed, driving while talking on a cell phone, overeating, non-compliance of doctor's orders regarding diabetes or hypertension management but nevertheless in many states prevented from requesting to avoid procedures which will prolonged her terminal illness and make her suffer unnecessarily. I would think that if society wants to prevent injury or death of a fetus for those women who decide not to have an abortion then all actions which lead to fetal injury or death should be forbidden and the women's lives managed by society during the period of their pregnancy. ..Maurice.
"I would think that if society wants to prevent injury or death of a fetus for those women who decide not to have an abortion then all actions which lead to fetal injury or death should be forbidden and the women's lives managed by society during the period of their pregnancy."
Once the child is born, a parent who appears to be abusing or neglecting a child stands to have the child removed from their home. The only time a child is unprotected is, ironically, when the mother is carrying it in her womb.
If that child were seen as a human individual, there would no doubt be laws such as the ones you mention ... but then again, abortion on demand as a method of birth control would also not be legal.
An ignorant and inexperienced sportsman once shot one of our cows when she was pregnant. He mistook her for a deer. The fine he paid, and our remuneration, were double, because in the eyes of the law, he killed two of our cows.
Here in the state of Maine, unborn cows are held in higher respect than unborn humans.
Dr. Bernstein ... that's just wrong.
Wow, do you really mean to compare human women to cows?
Cows are forcibly bred to produce economic good (calves, milk) for their owners?
Seriously, do you want to push that comparison?
If you do, realize some primary differences: 1) You as her owner didn't consent to have her killed. While her consent is irrelevent (since she's a cow and can't legally give consent), yours isn't. If you'd consented to the cow being butchered, you couldn't have gotten paid by the hunter for wrongfully killing its fetus.
Supposedly human women don't have owners, but can consent regarding their own body. (Many states treat the non-consentual killing of a fetus as a murder. It's the consent of the woman that matters.)
2) You were paid because you had an economic loss because you bred the cow to sell (or use economically) the calf. But human babies can't be sold, and there's no liability for economic loss when a fetus is killed. You would have been paid nothing if the animal killed hadn't been an economic loss, I'd guess. (I'm no lawyer, but if the hunter had accidentally run over your pregnant pet cat, no financial damages would have been assessed, right?)
Do you really think of a woman legally as compared to a cow?
"Wow, do you really mean to compare human women to cows?"
No Bardiac, I compare unborn humans to the genetically complete, helpless little humans they really are, whom, I might add, had no choice about being there to begin with - their lives, their presence, are due to other people's actions.
Perhaps I could have used a different analogy ... but I really don't think that the point about ownership was really pertinent to the point I was trying to make - which was about the value of life. To go into legal ownership and material worth is really leading the discussion into territory which is only peripherally related.
Using the same argument, I would be tempted to say that you are comparing an unborn human to an unborn kitten:
"[...] You would have been paid nothing if the animal killed hadn't been an economic loss, I'd guess. (I'm no lawyer, but if the hunter had accidentally run over your pregnant pet cat, no financial damages would have been assessed, right?)"
Now ... is the unborn baby "owned" by the mother ... and if you can really assign "ownership" of a human to another human, then at what point does she stop "owning" it? When it draws its first breath? When it can feed itself? When it leaves home for college?
If she gives birth to that baby in a toilet, and lets it die there, she is considered a murderer ... but if she has an abortionist puncture its head and suction out its brain before it draws its first breath (the possible difference of a matter of minutes, and the fact that another person is actively killing the infant,) then neither the mother nor the abortionist are considered guilty.
Also, once the child is born, and she is considered a murderer if she terminates it, it's still fully dependent on her. The most apparent difference is that it breathes on its own, needs to be fed and changes, and she can set it down somewhere else at will.
What will we have next - mothers who will move from not wanting to be inconvenieced by their own previous actions and end up as baby incubators -- to mothers who don't want to be inconvience by screaming infants, and end up as "nannies?"
Here is a comment on this topic which I received yesterday by e-mail from a visitor to my now inactive "Bioethics Discussion Pages". ..Maurice.
This is a fairly uncomplicated question in the world of bioemedical ethics. The woman has, through the principle of autonomy, the right to refuse medical treatment. Furthermore, the decision in roe v. wade establishes the lack of rights for the unborn fetus. Depending upon what term the woman is, she may rightfully decide to refuse treatment and ergo, end if not seriously affect the pregnancy. If the woman is in her third trimester then there is no reason why her discontinuing treatment could not occur within the same context as performing a c-section to remove the baby that is in all likelihood, viable. Some respondents have brought up the issue of life support - this is entirely different. Were the woman to be on life support then she would not be the one refusing medical treatment. In such cases, it is often the family that is left to decide the fate of the unborn child - for obvious reasons said family often choses to keep the woman alive so that she can birth a health baby.
Although I might disagree with this in principle, the scope of bioethics as it stands, which is in effect, a reflection of the values of the society in which one lives, I believe it to be ethically sound. All the many issues surrounding the life of that child and its best interests are a moot point.
Sarah Gebauer
Coordinator, Ethics Network
(604) 587-4486
Here is another comment on this topic by e-mail today from a visitor to my now inactive "Bioethics Discussion Pages". ..Maurice.
Here is the problem: everyone here ASSUMES that there is no other help/useful option for the woman and/or fetus other than the medical pronouncement which you all are arguing about whether the woman has the right to refuse/decline. Since when are physicians/medicine infallible? If medicine is so infallible, why do "consent" forms go on and on about how medicine is an "art" and can't guarantee any good result??? What about all the cases of "forced c-sections" where the mom went into hiding and, some time later, re-appeared with a healthy baby? And if a pregnant woman doesn't have the right to make decisions that affect her own body, why should she have the right to vote, or do anything else which competent adults have the right to do?
Here is another comment for this topic sent to me by e-mail. ..Maurice.
It is not ethical or acceptable to deny, decline, negate, refuse, or whatever
else one wishes to verbalize it as, a person's right to refuse medical
treatment. after reading many of the responses and mulling over this question,
this is my answer. the reasons behind this are that while the fetus is a part of
the mother in a holistic view the mother is still the legal guardian of the
fetus and is knowledgeably denying medical treatment to the fetus as well. if
the mother is not doing this knowledgeably or it isn't explained to the mother
that this is so, then someone didn't do their job by explaining the consequences
of her decision to her in a way she comprehends, and the requirements concerning
the right to refuse medical treatment were not met. the patient/guardian
refusing treatment must be knowledgeable or made knowledgeable of consequences
of their decision. this overrides the stipulation of "the fetus has a right
too." and if the rights to the fetus are immediately signed over to an entity
other than the birth mother, this leads to the assumption that the adoptive
entity can terminate the pregnancy. if this is so, then all of a sudden any
adoptive "parent" can essentially force a woman to get an abortion if it is
early enough in the pregnancy for the termination to take place. this would be
absolutely absurd if it were true, so obviously the adoptive entity has no legal
right to the fetus/child until birth, and therefore said entity can't invoke the
right as a legal guardian to force the mother to continue medical treatment
until birth or a point where the fetus is capable of survival outside of the
uterus. the pregnant woman refusing treatment is using her rights as competent
guardian and vessel for the fetus to terminate treatment for both fetus and
herself. it's the same as the mother of a child on life support deciding to
discontinue the life support for her child. whether the public deems her
decision good or bad, it is still just what it is: her decision.
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