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A new ethical and clinical dilemma in obstetric practice: Cesarean section "on maternal request"

        To the Editors: The recent article by Pinkerton and Finnerty (Pinkerton JV, Finnerty LL. Resolving the clinical and ethical dilemma involved in fetal-maternal conflicts. Am J Obstet Gynecol 1996;175:289-95) outlines the possible ethical conflict between the patient's right to autonomous decision and the physician's right to autonomy in practicing according to acceptable procedures, and many examples are discussed of patients who refuse intervention. Our experience is paradoxically opposite.
        In Italy, the Regione Marche, where our Department of Obstetrics and Gynecology of the University of Ancona is located, has been ratified the law on the rights of pregnant women
        • Legge Regionale n.23 2/6/1992
        Diritti della partoriente e del bambino ospedalizzato.
        that "warrants the active participation of pregnant woman in (decision making during) all the stages of labor and delivery, and in the choice of the route of delivery." The knowledge of the rights that such law grants pregnant women led some of them to demand elective cesarean section, avoiding labor and every risk that they believe—properly or not—may be related to labor and vaginal delivery.
        Last year therefore (the first year of wide application of "law 23") we first observed the phenomenon of elective cesarean section "on maternal request" as a small but not negligible (4%) part of the indications. Such indications, although not necessarily justified by obstetric conditions, cannot be considered an example of "bad medicine" but pose new and wider borders to our practice and allow room for ethical and legal discussion.
        We strongly support patients' right to autonomy, but we foresee that special considerations will have to be given in assessing the standards of care because that will possibly cause a change in health care management by increasing the rate of cesarean section, while there is a general attempt to reduce it to the real obstetric need, or a clinical conflict in special issues, such as that of a multiparous patient who fears to labor again and refuses to be delivered vaginally. Although these are now isolated and extreme cases, it is possible that in some years they will be part of our daily practice.
        Andrea L. Tranquilli, MD, Guiseppe Gioele Garzetti, MD, Department of Obstetrics and Gynecology of the University of Ancona, Ancona, 60123
        6/8/82733
        NO LABEL6/8/82733

        References

          • Legge Regionale n.23 2/6/1992
          Diritti della partoriente e del bambino ospedalizzato.
          Boll Uff Reg. 1992; 32: 2155-2159