Counselling women about choice

Patient choice—informed consent and informed refusal—is an important ethical and legal principle in medicine. In pregnancy this issue is not straightforward: should a pregnant womanʹs autonomous choice be respected when she may cause fetal harm by declining recommended caesarean section? Should a pregnant women be free to choose elective caesarean section as an alternative to labour and vaginal delivery? This chapter reviews cases of court-ordered caesarean, and the ethical and legal paradigms for informed refusal in pregnancy. In general, clinicians should not seek court authority to support medical recommendations. This chapter also reviews arguments for and against offering women elective caesarean without strict medical indication. Although compelling arguments in favour of caesarean on demand can be made, clear evidence showing adequate safety and advantages of elective caesarean over vaginal delivery does not yet exist. Ethics, law, politics and history all inform the issue of choice with respect to caesarean in important ways.