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midwife’s skills and judgment, assuming liability for the care is preferable to not
being involved in the prereferral care.
I. Behavioral Risks in Pregnancy
Many physiologic conditions make pregnancy dangerous to the mother and the baby.
Most of these, such as diabetes, are intrinsic and, except for compliance issues, beyond
the control of the woman. Some, such as alcoholism or cocaine use, are behavioral
problems with substantial voluntary components. An unfortunate nexus of the medical
efforts to improve prenatal health and the political debate on whether the fetus is a
person deserving independent protection is the pregnant woman who engages in
activities that might harm her fetus. Such women have been subjected to forced
medical care, including Cesarean sections, and to incarceration in prison.
Debates over the legality and even the usefulness of coercive policies aimed at
pregnant women have obscured the issues in managing high-risk pregnancies. There is
vast gulf between a physician seeking to have a woman treated against her will and the
much more common problem of helping a patient understand the risks and benefits of
various behaviors and medical care alternatives. In general, physicians providing
personal health services should not attempt to force unwanted medical care on their
pregnant patients. The American Medical Association’s (AMA’s) position is
illustrative.
1. The American Medical Association Policy Statement
[AMA Board of Trustees Report. Legal interventions during pregnancy: court-
ordered medical treatments and legal penalties for potentially harmful behavior by
pregnant women. JAMA. 1990; 264:2663–2670.]
The AMA Board of Trustees recommends adoption of the following statement:
1. Judicial intervention is inappropriate when a woman has made an informed refusal
of a medical treatment designed to benefit her fetus. If an exceptional circumstance
could be found in which a medical treatment poses an insignificant or no health risk
to the woman, entails a minimal invasion of her bodily integrity, and would clearly
prevent substantial and irreversible harm to her fetus, it might be appropriate for a
physician to seek judicial intervention. However, the fundamental principle against
compelled medical procedures should control in all cases that do not present such
exceptional circumstances.
2. The physician’s duty is to provide appropriate information, such that the pregnant
woman may make an informed and thoughtful decision, not to dictate the woman’s
decision.
3. A physician should not be liable for honoring a pregnant woman’s informed refusal
of medical treatment designed to benefit the fetus.
4. Criminal sanctions or civil liability for harmful behavior by the pregnant woman
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