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Ethical Dimensions of Elective Primary Cesarean Delivery

Department of Obstetrics and Gynecology at Maimonides Medical Center, Department of Obstetrics and Gynecology at State University of New York (SUNY) Downstate, and Division of Humanities in Medicine at SUNY Downstate, Brooklyn, New York; Department of Obstetrics and Gynecology at Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York; and Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas

Address reprint requests to: Howard Minkoff, Department of Obstetrics and Gynecology, Maimonides Medical Center, 967 48th Street, Brooklyn, NY 11219; e-mail: hminkoff{at}maimonidesmed.org.

Cesarean deliveries are among the most common surgical procedures performed in the United States. Recent publications demonstrate the reduced risks of these operations and describe their potential benefits to both mothers and children. Recent surveys show that a substantial minority of obstetricians would accede to patients’ requests for elective primary cesarean delivery, and some of these professionals would prefer that mode of delivery for themselves or their partners. However, scant attention has been paid to the ethical underpinnings of surgery by choice in these circumstances or ethically justified criteria for determining the role of patient choice in elective surgery generally. We define and elaborate upon the role of beneficence-, autonomy-, and justice-based considerations in these deliberations. We conclude that beneficence-based clinical judgment still favors vaginal delivery. Additionally, we have no confidence that either offering or performing elective cesarean delivery is consistent with substantive-justice-based considerations and conclude that there is no autonomy-based obligation to offer cesarean delivery in an ethically and legally appropriate informed consent process. Physicians should respond to patient-initiated requests for such procedures with a thorough informed consent process and request that the woman reconsider to ensure that her autonomy is being meaningfully exercised. In such cases, implementing a woman’s request is ethically permissible.

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