An ethical debate

How far should ob-gyns go to save an unborn baby they consider at risk? Some of the very doctors you'd most expect to advocate for pregnant women actually support forced c-sections, a 2003 University of Chicago study found. When the researchers surveyed directors of 42 maternal-fetal medicine programs around the country, 14 percent reported that their hospital had used court orders to compel unwilling women to have O.R. deliveries. What's more, 21 percent of these specialists in the care of pregnant patients consider coerced c-sections "ethically justified" to spare a fetus possible harm  -- even over the woman's physical resistance, as long as her struggles weren't strenuous enough to endanger her or the baby.

ACOG adamantly disagrees. In 2004, its ethics committee ruled that it's never right for health care providers to subject pregnant women to physical force, even with a court order authorizing a c-section or other procedure. The committee also said that seeking such orders against a patient's wishes is "rarely if ever acceptable." The American Medical Association, another prominent doctors' group, has a similar policy.

So what should happen if a doctor is convinced that a vaginal birth would be disastrous? "Personally, I'm willing to counsel women very strongly in that situation  -- and bring in another physician to offer a second opinion about the risks of not having a c-section," says Dr. Lyerly. "I also tell patients that it's a very safe operation  -- and I should know, since I've had three c-sections myself."

However, doctors' opinions can also be tragically wrong. Years ago, a Washington, D.C., hospital got a court order to perform a c-section on Angela Carder, who was gravely ill with cancer. Since the mom was in such poor health, the hospital's doctors believed that delivering the 26-week fetus immediately would give it a better chance of survival than waiting for a natural delivery. The result? Carder and her baby both died soon after the operation. Later, in a landmark 1990 ruling, an appeals court overturned the order, finding that Carder had a right to make medical decisions for herself and her unborn child. Her family also received an undisclosed financial settlement from the hospital.

"I hope that doctors and judges are humbled by this terrible mistake that never should have happened," says Dr. Lyerly. "We can make dire predictions and think patients are too irrational to weigh the risks for themselves, but we're not infallible. And since doctors and moms can both be wrong, and if they can't agree on the best way to give birth, ultimately it has to be the woman's choice."

When surgery is being considered, experts say pregnant women need to feel confident that their wishes will prevail, whether they consent to an elective or emergency c-section or decline one they deem medically unnecessary, as Amber Marlowe did. In 25 years of delivering babies, Dr. Minkoff has learned to respect his patients' decisions about how they want to give birth  -- even if he doesn't always agree. "It's my duty to fully explain why I think a c-section should be seriously considered and the risks of not following my advice," he says. "But in the end, the strongest advocate for the safety and health of an unborn child is the baby's mother. And that's the way it should be, because she has the most at stake."

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