One mother, 2 lives

December 22, 1993|By Arthur Caplan

LAST WEEK, a three-judge panel in Illinois ruled that a 22-year-old Chicago woman, known only as Mother Doe, has the right to refuse to undergo a Caesarean section.

Mother Doe is 37 weeks pregnant. The doctors at St. Joseph's Hospital in Chicago who had been providing her care during her pregnancy believe that her fetus is not getting enough oxygen in the womb. They think that without the Caesarean, the baby will either die or be born severely brain-damaged. They urgently recommended that she have a C-section.

When she refused, they notified Cook County officials, who went to court to ask for an order to compel the surgery. Mother Doe says that she is opposed to the operation because, as a Pentecostal, she believes God intended her to deliver the child naturally.

The judges apparently had little difficulty deciding that she has the right to risk her fetus' life. Judge Carl McCormick announced the decision 15 minutes after listening to oral arguments from the Cook County public guardian's office that the surgery ought to be done to protect the interest of the fetus.

The decision is being applauded by the American Civil Liberties Union, which represented the woman in court, as well as a long parade of ethicists, lawyers and scholars. As one prominent bioethicist put it, society ought not treat pregnant women as nothing more than fetal containers.

I understand the argument that doctors and courts should not go around strapping pregnant women down on operating tables and forcing surgery upon them.

It is a longstanding, reasonable and honorable principle of modern U.S. medical ethics that competent people have the right to refuse any and all medical care that they do not want. People do have a right to bodily integrity even if it means risking their lives.

But the problem presented by Mother Doe's refusal is that another life hangs in the balance. And the consequences of her decision to refuse care may wind up imposing tremendous costs on the rest of us if her baby is born with severe disabilities.

When the court issued its opinion, the public defender and Cook County took their case to the Illinois Supreme Court. They still hope to have the woman forced to undergo the surgery.

As is all too often true, our legal system seems capable only of seeing black and white where there might be gray. I think there might be a middle ground between obtaining a court order to chain Mother Doe to an operating table and simply walking away from an impending tragedy.

Mother Doe says she is refusing care on religious and personal grounds. I have talked to a number of people involved in Pentecostal churches, and these Christian denominations have absolutely no doctrinal prohibition against accepting medical care.

It is true that many Christians who belong to Pentecostal churches believe that it is God who heals and that prayer can be used to elicit divine intervention to cure the sick and prevent harm during childbirth. But there is no prohibition against seeking medical care or having a Caesarean section in combination with prayer.

Does Mother Doe understand this? Should not the Illinois court have insisted that she receive counseling from both religious leaders and other church members to insure that her refusal of the surgery is truly informed?

There were also hints in the court proceedings that Mother Doe may not be a native English speaker. Does she have some cultural reason not to trust doctors? Does she fear surgery because she is a recent immigrant from a nation where a C-section during birth means a grave risk of death for the mother?

Again, should not the legal system and public policy make sure that a young woman who is invoking personal beliefs about the importance of giving birth naturally really understands the consequences of the choice she is making for her baby and the minimal risks that surgery poses for her?

One of the problems that continues to haunt moral debate about hard choices in health care in this country is that we are so quick to take sides. In the Mother Doe case, the legal system has only served to reinforce this impulse toward polarization.

Surely we can do better. In cases such as that involving Mother Doe, it would be far better to require patients to undergo counseling and conversation with both religious and lay experts. There may be a chance of persuading these patients that there need not be a standoff between their religious faith and medical treatment.

Arthur Caplan is director of the Center for Biomedical Ethics at the University of Minnesota Medical School.

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