Q: In my family practice I occasionally encounter pregnant patients who are interested in VBAC but have had some difficulty in finding a doctor or center that will accommodate them.  I Googled this issue so I could better advise them and I saw a case where a patient who had had several C-sections and wanted to try VBAC was told by the hospital that not only wouldn’t it let her do so but it would force her to have the C-section if she showed up and would report her to social services (for endangering the baby) if she did and that she could then lose custody of all her children. A judge ruled for the hospital because the patient could not force it to do a medical procedure. I get that but the part about forcing the surgery against her consent seems out of bounds. If a patient is competent then they have autonomy.

A: That is correct, but the practitioner or facility has a duty to remain within the standards of good and accepted medical practice. When those come into conflict with what the patient wants the fiduciary duty of the provider is not delegable to the patient.

This was a 2014 case from Florida in which a woman who had had three prior C-sections wanted to try a trial of labor before committing to a C-section in her current pregnancy. The conflict was between her desire to avoid a fourth surgery and the greater risks with VBAC in a patient who has had multiple prior C-sections.  The hospital took a very aggressive approach, the CEO sending her a letter saying that if she presented at the hospital and still wanted a trial of labor that her prenatal care providers intended to report her to the Department of Children and Family Services which could also remove her current children from her custody, to seek a court order to perform surgery, and to perform the surgery on her without her consent.  A VBAC advocacy group filed for a restraining order against the hospital but the judge ruled that she did not have the right “to compel a physician or medical facility to perform a medical procedure in the manner she wishes against their best medical judgment.” She eventually went to another hospital that agreed to what she wanted but eventually did require a C-section after labor failed to progress.

The hospital’s threats were inappropriately florid and there is also a question as to whether the hospital’s threats that amounted to pre-emptive exclusion of a patient who had been under its care and was now close to delivery constituted constructive abandonment because while it was not barring her it was making the situation so frightening that she would not feel safe to seek care from it.  However, the core medicolegal issue in the judge’s ruling was independently correct.

VBAC after multiple C-sections is a medically contentious issue that is beyond our scope here but as a general principle it is incumbent on a practitioner or facility, as a fiduciary for the patient, to exercise a duty of care that includes making appropriate clinical decisions.

A “hold harmless” letter from the patient would not cure this issue because even if the patient agrees to accept  a negative outcome the practitioner or facility cannot breach its own duty to act to avoid that result.

A patient who objects to offered care would then have to seek care elsewhere.

A practitioner or facility that bows to a patient’s demands in violation of best medical judgment could not then claim that acquiescence as a defense in a subsequent lawsuit for medical negligence because it would actually be admitting to having breached the duty of care.

That all having been said, patients are not hand-puppets – they are supposed to be informed participants in their care and part of that is the right of informed refusal. The advocates for the patient in this case correctly pointed out that the Patient’s Bill of Rights allowed the patient to refuse a C-section. Where their arguments failed, though, is that she could not impose that refusal on an unwilling practitioner or facility.  Her only alternative would be to – as she eventually did – find one that would comply with her wishes.