Thoughts on Right to Refusal of Treatment.

In the few years that I have been advocating in my community for access to birthing options for women, I have had an idea about a deep connection between the relationship, or lack thereof, between birthing women and their doctors and the complaint from doctors about liability in allowing women access to various birthing options (VBAC, out of hospital birth etc).

I am heartened to see the National Institutes of Health attempting to have open dialogue about reaching a consensus on VBAC in this Country, but quite disappointed about the lack of clear support for a womans right to refusal of treatment. Here is a link to a wonderful legal analysis of this issue.

While the stance taken both in the written report, and in the follow up press hearing on the issue of a woman's right to refusal of treatment involving having a repeat cesarean is disappointing, just the fact that we are discussing it helps to shed light on a very troubling aspect of our medical treatment & management of pregnant women in this Country. A respected national organization has said there is no clear consensus or overall legal support (that is news to us!) for a woman's right to refusal of treatment in all cases . This is truly astounding. In no other area of medicine is this even questioned except with a birthing woman.

The Panels found that a VBAC is a good option for most women, that the issue of a physicians liability in the process of obtaining full informed consent needs to be addressed; these are all findings that move in the right direction. But to fail to declare that a woman does not ALWAYS have the right to refuse major abdominal surgery is very surprising and troubling. Although I do understand the the NIH is not a "legal" or legislative body, I would suggest that they are fully within their duty to name the ethical obligation for physicians and hospitals to maintain policies which support a woman's right to refusal of treatment.

I wonder what the panel proposes when the woman and physician do not agree? Who gets to decide when a pregnant woman should and should not have surgery? Do we really believe that a physician or hospital administrator knows what is best for a birthing woman? better than the fully informed woman would know? I cannot imagine any other patient, besides a pregnant woman, being forced to have major abdominal surgery, Can you?

I also find it interesting that physicians and hospitals continue to use medical liability as a basis for their limiting access to VBAC for birthing women. When the decision is taken away from the patient, as is the case when a VBAC ban is in place, and is the case when physicians are unwilling to allow the woman a trial of labor, does this not automatically increase the liability of the physician? In that case the physician is choosing to limit the involvement of the patient in the decision making process of their own health care. It would seem normal and a natural part of that chosen path that the liability of the physician increase. But when a patient is encouraged and supported in being an active part of the decision making process for their own health care, and when a physician is open and honest about all of the forces which flavor his or her advice for "treatment", and when a physician then allows the patient to determine the course of treatment that is best suited for them, it would seem that liability would dissolve. I do not mean literally dissolve, but in the patients mind.

Studies & reports have shown this to be the case. When patients feel they have a good and open relationship with their physician, when they feel there is a caring relationship there, they are less likely to sue.

"A patient who is upset about the doctor-patient relationship, either because something didn't work out or they perceived a lack of caring, is more likely to sue the doctor. Plaintiff attorneys say that the majority of their calls come from patients who had poor rapport with their physicians"

"Medical mistakes happen because the human body is complex, treatments are complex and there are no guarantees in life. Most patients don't sue their doctors when a bad outcome occurs. The experts in risk warn us that the relationship is the most important prevention for lawsuits, followed by meticulous documentation in the medical record." (emphasis added)
-from article by Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
from the American College of Physicians, ACP Internist Blog, November 9, 2009

In conclusion, I wonder what would happen to the number of malpractice suits filed in this country, if physicians spent more time and effort in building good rapport with their patients than they spent limiting access to full informed consent and right to refusal of treatment. Imagine that.

-Kimberly Rivers
President, Birth Action Coalition
www.birthactioncoalition.org