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Informed Refusal of Standardized Medical or Midwifery Care

The most important reason for imposing standardized medical/midwifery procedures on pregnancy, labor, birth, the postpartum and neonatal period are to safe guard the life and health of mother and/or baby. In ideal circumstances, proposed procedures/diagnostic tests or prophylactic treatments are individualized to the unique circumstance of each mother, each pregnancy, and each unborn baby. However, our increasingly litigious society has necessitated the near universal implementation of all "standard of care" procedures and protocols for all mothers and in all circumstances to protect the caregiver from possible charges of malpractice. At times this creates a conflict of needs between the client family being served and the caregiver.

The central fact is that each "essential" standard of care procedure -- either through omission by the caregiver or refusal by the client -- can lead to very serious complications of pregnancy or birth or in extreme cases, can result in the death or permanent disability of mother or baby.

It is also true that many of the routine risk-reduction procedures, protocols and prophylactic treatments that currently reflect standardized care, while perhaps benign in and of themselves, can be flawed or give erroneous information. This may result in false assurances in the presence of undetected problems or lead to additional testing (often expensive, invasive, and risky procedures) or unnecessary and inappropriate treatments that interject new risks, pain and in event of a complications from the procedure, can create genuine problems where none existed before. While rarer than complications of pregnancy, it is even possible to suffer death or disability from what turned out to be unnecessary medical treatment. There is nothing about over-treatment that is intrinsically superior to under-treatment. The essential point is that medical care is not a perfected science and no decision or course of action as chosen by either parents or caregiver can guarantee a perfect outcome.

 

After full disclosure of the current standard of care, its purpose, benefits, known risks, contraindications, and risks associated with its refusal, childbearing parents have the legal authority to decline procedures, protocols, and treatments.

 

There is an important distinction to be made between risk-reductions strategies that address the theoretical possibility of developing a complication (possible future harm but no current problem) and those treatments designed to address and ameliorate present-tense complications. Except in an immediate life-threatening emergency ("clear and present danger" to mother or baby), parents have the right to decline those medical/midwifery activities that are "insurance" against potential risks.

 

The question that frequently arises both for parents and the courts is one of declining treatment at the margins, since risks found acceptable for a dramatic gain may not be acceptable to an individual for smaller or uncertain increments of benefit. In general, the courts have interpreted parental rights to decline prophylactic procedures and protocols much more broadly than refusing treatments for complications that have already arisen. However, recent court decisions and AGOC guidelines basically affirm the autonomy of the parents in declining medical advice &/or refusing treatment even in the presence of a complication. Legal theory acknowledges your right to decline non-emergency treatments as well as routine screening procedures (including fetal surveillance during labor, prophylactic hospitalization, etc) even though doing so is perceived by medical standards to increase the level of risk (ie. exposure to potential harm).

In the face of all the pertinent facts and appropriate information about the specific procedure/ protocol/ treatment in question, you have the basic legal right to decline or defer it pending further consideration later.

 

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Procedures Available:

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  • Prenatal panel blood test

  • Follow up CBC

  • HIV testing

  • PAP Screen

  • Gonorrhea and Chlamydia test

  • First trimester screen (10-13+6)

  • NIPT, with known risk factor

  • Nuchal Translucency ultrasound

  • QUAD screen (15- 20 wks)

  • Flu Vaccine, referral for

  • DTAP Vaccine, referral for

  • Cystic Fibrosis

  • Ethnic Origin screening

  • Other genetic screening

  • Anatomical Ultrasound

  • Gestational Diabetes screen

  • FU Antibody screen RH-

  • Prenatal RhoGam (28wks)

  • Postpartum RhoGam

  • Group B Strep Culture

  • ABX for positive GBS 

  • Erythromycin eye treatment

  • Vitamin K injection

  • New Born Screening Test

  • NB Hearing Screen referral

  • Amniotic fluid index

  • Biophysical profile

  • Non- stress test

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