Informed consent and refusal in obstetrics: A practical ethical guide

The ethical principle of autonomy gives women a fundamental right to security of person. The principles of beneficence and nonmaleficence are caregivers’ duties to “do what is best,” and “do no harm.” Usually, women and caregivers agree on the best course of action and informed consent is straightforward. Occasionally however, a woman declines recommended treatment or requests treatment that a clinician believes is unsafe. When this occurs, the historical adage: “the doctor knows best” is no longer valid. Ethical tension between autonomy, beneficence, and nonmaleficence may cause conflict between a woman and her caregivers that can impede communication, compromise care, and contribute to poor outcomes. In these situations, negotiating informed consent or refusal can be challenging. By accepting a woman’s refusal, caregivers commonly believe they incur ethical and legal liability. Accordingly, they may withdraw care or coerce women to accept intervention. However, coercion negates consent and abandonment is unprofessional. This commentary explores how practical knowledge of the ethical and legal basis of informed consent and refusal can build trust, preserve the therapeutic alliance, and minimize risk when women refuse medical advice.