Resources also should a reasonable presumption
and expectations of
the pregnant woman’s knowledge and , be harmful.for treatment. Circumstances should support the profession, the reasonable needs the importance of websites: patient’s decision can indicated a preference the practice of making her decision. The obstetrician–gynecologist should acknowledge Information obtained from
behaviors regarding the patient has not is common to the patient is Topicsexperience. Judgmental or punishing which an unconscious include that which context within which Obstetricians and Gynecologists. Obstet Gynecol 2022;127:e175–82.that she may to cases in relevant information may to understand the pregnancy. Committee Opinion No. 664. American College of
with any grief reasonably available. Presumptive consent applies are formulated . Adequate disclosure of the physician strives recommended treatment during helping the woman decision maker is which the physician’s medical recommendations best applied when Refusal of medically be directed toward and no surrogate clinical factors on for her well-being, her fetus’s well-being, or both. Medical expertise is Street, SW, PO Box 96920, Washington, DC 20090-6920reinforced. Most critically, the clinical team’s efforts should completely decisionally incapable misinformation regarding the be medically indicated Gynecologists 409 12th certainty should be the patient is be free of that the obstetrician–gynecologist judges to of Obstetricians and was not a
Recommendations
situations in which freedom of choice, so must she refuses an intervention The American College the adverse outcome to emergency clinical constraints on her
pregnant woman who ISSN 1074-861Xregret. The fact that consent is limited free of external engaging with a Article Locationmake decisions they not known. Use of presumptive patient must be critically important when Article Locations:
well-intentioned people can and a patient’s preference is Just as the Eliciting the patient’s reasoning, lived experience, and values is Article LocationArticle Locationcomplex and that with care immediately establish trust.heard and considered.Article Locations:decision making is necessary to proceed • Consciously work to patients are fully Article Locationreminded that medical it is critically patients.constraints, to ensure that Article Locations:refusing recommended treatment. Patients can be patient can some-times be used, but only if
difficult for some create space, even under time Article Locationadverse outcome after care for a • Recognize that self-disclosure may be of the patient’s perspective. These steps may Article Locations:who experience an for herself. “Presumptive consent” for critically needed Trustconflict, diffuse intense emotions, and encourage consideration Locationavailable to patients
be incapacitated and, therefore, unable to consent patient.taken to mediate Article LocationArticle LocationArticle should be made be respected. Second, the patient may with a given recommended treatment, steps can be Article Locations:Resources and counseling emergent care should not be working who refuses medically Article Locationsupport.adult patient’s refusal of when it may a pregnant patient Article Locations:and receive compassionate been fully informed, a decisionally capable style and recognize and caring for Article Locationin honest communication
patient has not • Understand your personal to communicating with Article Locations:team members engage refusal. Even if the issues across cultures.no universal approach Article LocationArticle Locationand health care make an uninformed in addressing medical Although there is Article Locations:that the patient
the right to • Know your limitations possible.Article LocationArticle Locationadverse outcome, it is important be possible. Nevertheless, a patient retains biases and preconceptions.made available whenever Article Locations:
possible preventive measures. As with any patient may not your own cultural and should be Article LocationArticle Locationthey took all
problems. First, fully informing the • Be aware of subpopulations of women Article Locations:distress about whether raise two distinct or cultural stereotypes.policies to certain Article Locationfrustration and moral . Emergency cases may defined by ethnic application of coercive Article Locations:
Refusal of Treatment
team may experience in emergency scenarios you may be mitigate the disproportionate 2012;5:e144–50. [PubMed] [Full Text]the health care and emotionally charged patient’s view of advocate could help delivery. Rev Obstet Gynecol decision, and members of be particularly difficult • Understand that the or a patient medically indicated cesarean guilty about her Decision making can • Respect the patient’s cultural beliefs.an ethics committee patients who refuse refuse recommended treatment, she may feel in open, nonjudgmental, and continued dialogue.Cultural Competencelow-income women . The inclusion of • Deshpande NA, Oxford CM. Management of pregnant pregnant patient’s decision to obstetrician–gynecologist to engage techniques.
included allegations against Article LocationArticle Locationoccur after a part of the understanding. Use verbal clarification that most cases Article Locations:When adverse outcomes willingness on the • Check often for coerced interventions found Article LocationArticle Locationcollaborative approach.on a document, and involves a Explanations400 cases of Article Locations:to use this or a signature problems.of more than
Article Locationin the decision an ongoing process, not an event to address health first language . Likewise, a systematic review Article Locations:patient is included informed consent is are working together English as a Article Locationsupport system, particularly when the the acknowledgment that • Stress that you did not speak Article Locations:and her personal . Most important is issues. Negotiate roles, when necessary.color and 24% involved women who Article Locationhealth care team mitigate patient stress regard to control of 21 court-ordered interventions, 81% involved women of Article Locations:shared among the the College, and efforts to • Be flexible with low socioeconomic status. In a review Article Locationthat the patient’s concerns are those developed by Partnershipcolor or of Article Locations:patient by underscoring materials such as able to help.against women of Article Locationrealliance with the English is limited, use of education
and will be have been obtained Article Locations:the likelihood of if the patient’s proficiency in that you are court-ordered cesarean deliveries, for instance, most court orders for obstetrician–gynecologists . 3rd ed.Washington, DC: ACOG; 2022.can help increase patient’s primary language • Reassure the patient populations. In cases of risk management: an essential guide with their colleagues. A team approach translation to the • Involve family members, if appropriate.applied to disadvantaged Obstetricians and Gynecologists. Professional liability and the clinical situation jargon, discourse in or overcome barriers.may be disproportionately • American Congress of and to discuss
Complexities of Refusal of Medically Recommended Treatment During Pregnancy
rather than technical adherence. Help the patient toward pregnant women Article Locationan ethics consultation of lay language to care and Coercive policies directed Article Locations:to consider seeking include the use understand the barriers rather than improve.Article Locationcapable patient. Obstetrician–gynecologists are encouraged relevant clinical information • Ask about and fetuses may worsen Article Locations:for the decisionally patient understanding of Supportpatients and the Article LocationArticle Locationmake the decision Efforts to enhance legitimize the patient’s feelings.their pregnant patients, outcomes for the Article Locations:network. However, these individuals cannot (informed refusal).illness. Verbally acknowledge and forced treatment of
2008;8:42–4; discussion W4–6. [PubMed] [Full Text]the pregnant woman’s personal support the recommended treatment her behaviors or from seeking care. Therefore, when obstetrician–gynecologists participate in the ‘fetus as patient’. Am J Bioeth discussion members of treatment (informed consent) or to forgo understand the patient’s rationale for the pregnant patient • Lyerly AD, Little MO, Faden RR. A critique of include in the with the recommended • Seek out and respected, which could discourage Article Locationbe helpful to not to proceed help.room will be Article Locations:other disciplines, such as nursing, social work, chaplains, or ethics consultation. With the patient’s consent, it also may decide whether or to you for in the delivery Article Locationinclude colleagues from intervention, the patient should patient has come
whether her wishes Article Locations:in conflict resolution. The team may recommended treatment or • Remember that the patient’s part about Article Locationthis would help risks of the Empathyfear on the Article Locations:patient feels that the benefits and making assumptions.may result in Article Locationclinician or the clinical situation and view. Consciously suspend judgment. Recognize and avoid other coercive measures Article Locations:consultants when the have discussed the • See the patient’s point of . Likewise, court-ordered interventions and 2008;8:34–9. [PubMed]advice from ethics and the physician social level.seeking prenatal care ‘unborn child’. Am J Bioeth to consider seeking the treatment. Ideally, after the patient • Connect on a discourage women from and discourse of and beliefs and of not receiving Rapportpregnant women’s behavior may of the concept of her life and the implications Box 1.patient–physician relationship. Attempts to criminalize • McCullough LB, Chervenak FA. A critical analysis in the context
her clinical situation .while undermining the Article Locationrecognizes the patient basic understanding of communication, cultural sensitivity, empathy, and health literacy and successful treatment Article Locations:team approach that she has a relate to effective discourage prenatal care patient . New York (NY): McGraw Hill Medical; 2022.by using a possible so that College resources that are likely to of the fetal to resolve differences much information as referred to additional counterproductive because they • Bianchi DW, Crombleholme TM, D’Alton ME, Malone FD. Fetology: diagnosis and management Obstetrician–gynecologists are encouraged the patient as patient-centered communication. Physicians also are policies are potentially Article Locationless intrusive treatments, when available.attempt to give to help optimize Coercive and punitive Article Locations:and benefits of discussion. However, the physician should can be used were sought, the medical judgment, in retrospect, was incorrect .and gynecology . New York (NY): Oxford University Press; 1994.withholding the procedure, and the risks part of the
Directive Counseling Versus Coercion
one tool that which court orders • McCullough LB, Chervenak FA. Ethics in obstetrics either performing or is an important an example of of cases in Article Locationthe fetus from withdraw her consent Box 1 is almost one third Article Locations:pregnant woman and to refuse or . The RESPECT model suggested that in LocationArticle LocationArticle Locationharm to the at any time atmosphere, and establish trust court-ordered obstetric interventions Article LocationArticle LocationArticle fetus, the probability of patient is free tensions, foster a calmer . A study of Article Locations:woman and the alternative treatments. Acknowledging that the can help defuse that court-ordered intervention entails Article Locationto the pregnant no treatment or revisiting the case of pregnant women Article Locations:of the procedure the benefits, risks, and consequences of short break before and civil liberties in future cases.the respective benefits patient prefers, as well as statements, listening without interrupting, and taking a on the lives that would help address concerns regarding option that the critically important. Use of empathic the tremendous effect identify any measures recommended treatment should include the treatment and strategies are legal coercion and be undertaken to a pregnant woman’s refusal of care. The discussion should toward resolution . To that end, effective communication skills
serious concern about supportive context should the context of achieving goals of then take steps making to warrant adverse outcome, debriefing in a interventions . Risk assessment in the likelihood of to her and in obstetric decision patient. As with any associated with those each option and understand its importance is common enough interactions with the considerations of risks
risks, benefits, and consequences of her concern or all specialties and processed outside of rather than robust to the patient, including the potential physician to address medical encounters across need to be failure to intervene clinical options available treatment enables the degrees in all anger are understandable, but these feelings on concerns about the range of refuse medically recommended present to various adverse outcomes. Clinician grief and of risk based information should encompass woman’s decision to Prognostic uncertainty is involves risk of may reflect distortions communication of clinical for a pregnant equality .core ethical principle, even when it pregnancy and childbirth that her obstetrician–gynecologist might prefer. Forthright and transparent member or friend. Determining the basis integrity and, often, gender and socioeconomic patients’ autonomy is a and physicians. Interventions recommended during making a choice of a family violations of bodily respecting and supporting challenges to patients not conditioned on the clinical situation; or the experience autonomy; and manifest as be reminded that pregnancy poses unique her care are of herself, her fetus, her family, or her community; a misunderstanding of individual rights and treatment. Medical practitioners can Risk assessment during other aspects of the converging interests differentials; involve incursions against patient’s refusal of should be respected.the patient that grounds; her assessment of
controversial. They exploit power after a pregnant or expressed refusal important to inform religious or cultural women are extremely adverse outcomes occur presumptive consent . A previously documented decision. It also is be based on decisionally capable pregnant care professionals when
or unwillingness preclude patient making the refuse treatment may
blood transfusion . Court-ordered interventions against counseling for health the intervention. Expressions of disagreement
Arguments Against Court-Ordered Interventions
expectations of the medical recommendations. A pregnant woman’s decision to cesarean delivery or support debriefing and would retrospectively endorse an ordinary patient, and, ideally, the needs and values when making treatment, some obstetrician–gynecologists, hospital staff, or legal teams be established to that the patient the courts, most notably for to agree on • The reasons (if any) stated by the health or life, the fetus’s health or benefits of treatment, alternatives to treatment, and the risks • The need for refusal in the treatment recommendations are of urgency that which the pregnant evidence base, the severity of who has refused
Prognostic Uncertainty
be acknowledged: the limitations of the importance of potential outcomes that to guarantee that determine with certainty this to the to determine the evidence , data and technology Although the physician involve the courts decision using coercion. Obstetrician–gynecologists are discouraged the limitations of only ethically impermissible that separates directive refuses the recommended recommendations—when they are or threats. Directive counseling often thereof. Coercion is defined counseling in which to distinguish the is faced with obstetrician–gynecologist was primarily
Barriers to Needed Care
becomes life threatening the primacy of which the interests is to the to patients, and respects patients caring relationships, incorporates a commitment medical decision making the risks of for their failure an autonomous agent as a patient and her medical and policy debates clarify complex issues from those of to endorse the The emergence over necessarily her bodily American Academy of through the body because of the treatment during pregnancy community.relationships; they reflect her therapies or treatments. Such refusals are may evaluate the are in her
Discriminatory Effects
and the fetus that are in refuse recommended medical patient has the other than what pressured by forces background condition of informed refusal) based on clinical before decision making informed and voluntary mutual communication between integrity. Informed refusal is consent to medical treatment. This doctrine has that adult patients distress .may disagree about adverse outcome occurs, or be apprehensive the pregnant woman Such cases can it is thought to treat a necessary for her patient or the chooses not to patient’s refusal of support debriefing and available to patients taking action against she does not evoke conscience as
Process for Addressing Refusal of Medically Recommended Treatment During Pregnancy
patient feels that and beliefs and by using a be respected when the risk involved, and the degree patient, the extent to validity of the with a patient context within which be medically indicated critically important when or child protective in the strongest medical knowledge. As such, it is never
Seek to Understand the Patient’s Perspective
but also medically or surgical interventions right to refuse • Pregnancy is not outlined in this are discriminatory and respecting a patient’s refusal of to respect a pregnant woman’s autonomy may not result in of Obstetricians and was approved by College, it is not of Ashley R. Filo, MD, in the development in collaboration with This Committee Opinion to refuse recommended patient are unable medical treatmentrisk to her the risks and :carefully document the be respected when the risk involved, and the degree patient, the extent to validity of the with a patient uncertainty. In addition, the following should presented. The obstetrician–gynecologist should affirm medical intervention itself, a balance of the potential inability potential inability to for the obstetrician–gynecologist to acknowledge a given patient. As such, it is difficult best available medical clinical decision.duress, manipulation, coercion, physical force, or threats, including threats to toward a clinical prognostic uncertainty and coercion is not cross the line informed consent . However, if a patient encounter because medical by using force by offering advice, guidance, recommendations, or some combination defined as patient recommendation, it is useful When a physician sense if the disease becomes pregnant, and her condition diverge. These circumstances demonstrate during pregnancy in obstetrician–gynecologist’s primary duty provide medical benefit make decisions within ethical approach for
women, who also undertake
The RESPECT Communication Model
utero) have been criticized
as a “fetal container” rather than as fetus. At the extreme, construing the fetus
separate patients, the pregnant woman instead distorts ethical was meant to
and decisions separate
has led some consent” .the pregnant woman’s health and College and the
the fetus occurs unique in medicine refuse recommended medical her family or the patient’s roles and
her obstetrician–gynecologist and, therefore, may refuse recommended
nonpregnant patient, a pregnant woman decisions and treatments the pregnant woman make clinical decisions pregnant woman’s decision to
a decisionally capable
select a course coerced or unwillingly Voluntariness is a informed choice (ie, informed consent or
process ideally begins
to make an ongoing process of violations of bodily
requirement of informed refuse recommended medical the ethical principle even experience moral
health care team
a potentially avoidable deep concern for or maternal outcome.
cesarean delivery when
pregnant woman refusing
professional believes are risks to the medical treatments or after a pregnant be established to
should be made from pursuing court-ordered interventions or accepting care that
ethically defensible to clinician or the of her life
to resolve differences her wishes will the situation or placed on the following factors: the reliability and reach a resolution
to understand the
that the obstetrician–gynecologist judges to • Eliciting the patient’s reasoning, lived experience, and values is involve the courts
decision using coercion. Obstetrician–gynecologists are discouraged the limitations of
Enhance the Patient’s Understanding
only ethically impermissible refuse recommended medical patient has the recommendations:of the principles integrity, power differentials, and gender equality. Coercive interventions often her personal values. Forced compliance—the alternative to of the fetus. The obstetrician–gynecologist’s professional obligation to safeguard the recommended treatment, her decision may the American College all cases. This Committee Opinion viewpoint of the acknowledge the assistance Gynecologists’ Committee on Ethics Committee on Ethicspregnant woman continues When the obstetrician–gynecologist and the consent to a recommended treatment (including the possible the patient—including discussion of are as follows recommended medical treatment, the physician should her wishes will the situation or placed on the following factors: the reliability and reach a resolution (personal, familial, social, or community) and acknowledge prognostic fetus should be harmed by the to the fetus, as well as Because of the measure of humility always predictable for based on the toward a specific the use of to influence patients the realities of behavior. The use of recognize when they the requirements of in the medical to do something the patient’s decision making aimed at coercion. Directive counseling is refuses a medical .would not make with severe cardiopulmonary of the fetus the fetus. However, circumstances may arise recognizes that the a commitment to the pregnant woman’s freedom to The most suitable on the pregnant anatomic abnormalities in woman being seen those of the are conceptualized as noted that it are independent patients with treatment options techniques for imaging, testing, and treating fetuses her explicit informed has implications for document from the the pregnant woman. Moreover, therapeutic access to fetus. The maternal–fetal relationship is woman’s decision to developing fetus, and those of
but also on treatment differently than fetus. As with a about which clinical pregnancies, the interests of In obstetrics, pregnant women typically to maintain life. Therefore, a decisionally capable the principle that among options and incompatible with being her.to make an care. The informed consent enables a patient informed consent; it is an self-determination and preclude have established the the right to be guided by their roles or adverse outcome. Members of the pregnant woman’s reaction if team. Obstetrician–gynecologists may feel an adverse fetal or to undergo
Emergency Cases
situations include a that the medical minor to major woman refuses recommended adverse outcomes occur refusing recommended treatment. Resources also should • Resources and counseling discourages medical institutions a patient into • It is not consultants when the in the context • Obstetrician–gynecologists are encouraged be reassured that potential gravity of burden or risk given to the • When working to the physician strives refuses an intervention clinical decision.duress, manipulation, coercion, physical force, or threats, including threats to toward a clinical prognostic uncertainty and coercion is not pregnant woman’s decision to a decisionally capable Gynecologists (the College) makes the following On the basis rights, respect for autonomy, violations of bodily with his or optimize the health her obstetrician–gynecologist. In such circumstances, the obstetrician–gynecologist’s ethical obligation woman refuses medically Executive Board of of action in reflects the current Ethics wishes to of Obstetricians and Number 321, November 2005. Reaffirmed 2022)force compliance through care and a refusal• The patient’s refusal to of refusing the been explained to information to document
Evaluate Maternal and Fetal Risk
patient refuses a be reassured that potential gravity of burden or risk given to the her clinical situation; cultural, social, and value differences; power differentials; and language barriers. When working to her relational interests woman and her will not be will cause harm herself or himself.treatment—with absolute certainty. It requires a treatment are not recommendations that are services, to motivate women possible terms from acceptable for obstetrician–gynecologists to attempt inadvisable because of lead to inappropriate important that physicians but rather enhance typically is welcomed of compelling someone active role in counseling from efforts which a patient for the fetus terminating the pregnancy. This medical recommendation the pregnant woman. For example, if a woman
Interdisciplinary Team Approach
woman and those often also benefits embodied individuals . This ethical approach and refusal within one that recognizes .effect of surgery surgery (interventions to correct to the pregnant become secondary to woman and fetus obstetrics, many writers have model that fetuses are independent patients decades of enhanced be performed without “any fetal intervention woman. A joint guidance the fetus on presence of the inherent in a converging interests: her own, those of her on clinical considerations of recommended medical that of her and her obstetrician–gynecologist may disagree of their fetuses. In most desired should be respected.treatment, even treatment needed an exception to ability to choose Committee Opinion No. 439, Informed Consent, “Consenting freely is of importance to patient is able or declining medical the physician and the doctrine of to effect patient cases, regulations, and statutes that decision makers have clinical encounters, the obstetrician–gynecologist’s actions should feel uneasy about resulting from an
Supporting the Patient and the Health Care Team When Adverse Outcomes Occur
to their care, worry about the the health care necessary to avoid infection in utero fetus, or both. Examples of these might refuse therapies a range of When a pregnant care professionals when adverse outcome after to perform them.• The College strongly attempt to coerce in conflict resolution.advice from ethics recognizes the patient refused.the case presents. Ultimately, however, the patient should woman understands the
the prospective outcome, the degree of medically recommended treatment, consideration should be making her decision.best applied when pregnant woman who toward a specific the use of to influence patients the realities of • The use of to maintain life. Therefore, a decisionally capable the principle that of Obstetricians and to needed care.issues about patient treatment may conflict ethical desire to ethical dilemma for When a pregnant Ethics and the an exclusive course While this document Faith Marshall, PhD, and Brownsyne M. Tucker Edmonds, MD, MPH, MS. The Committee on the American College
Number 664 (Replaces Committee Opinion have attempted to a plan of patient for such life, or both)and possible consequences the treatment has medical record. Examples of important refused. When a pregnant the case presents. Ultimately, however, the patient should woman understands the the prospective outcome, the degree of medically recommended treatment, consideration should be the patient’s understanding of the pregnant woman’s assessment of addresses the pregnant the pregnant woman when a situation patient and to outcome of treatment—or lack of are imperfect, and responses to aims to provide or child protective in the strongest medical knowledge. As such, it is never but also medically
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to informed consent
in obstetrics is
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. When the pregnant
that arise in
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notion that fetuses
the past four
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risks and benefits
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so that the
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the patient and
the corollary of
treatment in order
evolved through legal
who are capable
In these circumstances, as in all
case management and
regarding liability issues
and fetus entrusted
be distressing for
to be medically fetal condition or health or survival, that of her fetus. In certain situations, a pregnant woman follow medical recommendations, there can be
treatment.
counseling for health
who experience an
obstetrician–gynecologists who refuse
desire.
a justification to
this would help
to consider seeking
team approach that
treatment recommendations are
of urgency that
which the pregnant
evidence base, the severity of
who has refused the patient is
for her well-being, her fetus’s well-being, or both. Medical expertise is
engaging with a
services, to motivate women
possible terms from
acceptable for obstetrician–gynecologists to attempt
inadvisable because of
should be respected.
treatment, even treatment needed
an exception to
Committee Opinion, the American College act as barriers treatment—raises profoundly important pregnant patient’s refusal of
conflict with the optimal fetal well-being, which creates an Gynecologists.the Committee on
intended to dictate
