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Cesarean delivery on maternal request: Can the ethical problem be solved by the principlist approach?

Tore Nilstun1*, Marwan Habiba2, Göran Lingman3, Rodolfo Saracci4, Monica Da Frè5, Marina Cuttini6 and the EUROBS study group

Author Affiliations

1 Department of Medical Ethics, University of Lund, BMC C13, SE-221 84 Lund, Sweden

2 Reproductive Science Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Robert Kilpatrick Building, Leicester Royal Infirmary – PO Box 65, Leicester LE2 7LX, UK

3 Department of Obstetrics and Gynaecology, Lund University, SE-223 85 Lund, Sweden

4 IFC-National Research Council, via Trieste 41, 56100 Pisa, Italy

5 Unit of Epidemiology, Regional Health Agency of Tuscany, Viale Milton 7, IT-50129, Florence, Italy

6 Unit of Epidemiology, Ospedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4, IT-00165 Rome, Italy

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BMC Medical Ethics 2008, 9:11  doi:10.1186/1472-6939-9-11

Published: 17 June 2008


In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.

We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).

Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.

Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.