A capacitated pregnant woman has a nearly unqualified right to refuse a cesarean section. Her right to say “no” takes precedence over clinicians’ preferences and even over clinicians’ concerns about fetal health. Leading medical societies, human rights organizations, and appellate courts have all endorsed this principle. Nevertheless, clinicians continue to limit reproductive liberty by forcing and coercing women to have unwanted cesareans. This “Legal Briefing” reviews recent court cases involving this type of obstetric violence. I have organized these court cases into the following six categories:
1. Epidemic of Unwanted Cesareans
2. Court-Ordered Cesareans
3. Physician-Coerced Cesareans
4. Physician-Ordered Cesareans
5. Cesareans for Incapacitated Patients
6. Cesareans for Patients in a Vegetative State or Who Are Brain Dead
Legal Briefing: Unwanted Cesareans and Obstetric Violence
Thaddeus Mason Pope, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 163-73.
Vice President for Aging and Health Policy
Why I Am Tired and InspiredKathy Greenlee is the Vice President for Aging and Health Policy at the Center for Practical Bioethics. She previously served as the U.S. Assistant Secretary for Aging and Administrator of the Administration for Community Living from 2009 to 2016. She will be the keynote speaker at “A Conference on Elder Rights and Protection” in Maui, Hawaii on June 15, 2017, World Elder Abuse Awareness Day.
The United Nations recognizes June 15 as World Elder Abuse Awareness Day. Started in 2006 by Elizabeth Podnieks of the International Network for the Prevention of Elder Abuse, the day has become an international opportunity to highlight the global problem of the abuse of older people.
During my tenure as U.S. Assistant Secretary for Aging, I had the honor of observing “World Day” in venues as exotic as the White House and the United Nations Headquarters in New York City. The problem of abuse of the aged is ubiquitous. It happens in every corner of the world, in every culture. Unfortunately and outrageously, it happens to one out of every 10 older adults in the United States.
The impact of abuse can be immediate, such as a sudden punch or a sexual assault. It can develop over time, as is the case with older adults who are neglected and allowed to languish, decline and die from the horrible circumstances that accompany the failure to receive care. Elder abuse can be caused by family members who strike out because of stress, anger or greed. It can be perpetrated by strangers who befriend older people on the telephone or through the internet or who come through the front door. Criminals prey on the cognitive decline associated with advancing age and the presence of dementia.
Reasons to Be Tired
I became aware of the scourge of elder abuse over 25 years ago when I worked in the Office of the Kansas Attorney General as a young lawyer. In many ways, I have grown up with this issue as a professional. Four aspects of the issue – euphemisms at best and excuses at worst -- continue to motivate and anger me.
1. I am tired of calling elder abuse “scams.” I have not set out to banish the word. But it’s simply not strong enough. These aren’t scams, they are crimes. Older people aren’t tricked, they are exploited. They aren’t stupid, they are scared. By referring to the targeting of older people as scams, we fail to warn sufficiently. We need to do a better job of telling people: When you get old, people will target you and some will try to hurt you. Be aware, be informed and be careful.
2. I am tired of ageism. One of the root causes of abuse is the societal devaluing of old people. Older adults are dismissed, talked down to, ridiculed and, most tragically, ignored. Despite the overwhelming presence of older people in society, on an individual level, older people become invisible. We stop seeing them and we lose them. And in the shadows of their isolation, criminals prey.
3. I am tired of talking about older adults when we should be working with them. I feel strongly that the greatest deficit in the field of aging is the lack of presence of older people themselves. In 1984, I was trained as a volunteer in a domestic violence program. The domestic violence movement in this country was started by formerly battered women. The same can be said about the work against sexual assault. Rape survivors lead the way by bravely speaking out. This is not the case with the work to end elder abuse. The champions in this work are people just like me, professionals who are angered to the point of action and have been for years. We need to provide support and seek opportunities for older people to address the problem of abuse directly and publicly.
4. I am tired of calling them victims, yet we must hold onto this language. It is a crime to hit, slap, rape, abandon, neglect, drug and steal from older adults. Even and especially when the perpetrator is a member of the family. We need adult protective services, law enforcement, prosecutors and judges to recognize these crimes. We need to stop dismissing these crises as family matters.
Reasons to Be Inspired
I am ready to call them survivors. The most hopeful part of the work to end elder abuse is starting to emerge. We need to understand resilience. What does it mean to survive abuse in old age? How does “trauma informed care” relate to these issues? How does a person who needs functional support continue to thrive? How do victims set their own course and live the rest of their lives as survivors?
World Elder Abuse Awareness Day is a day to reflect, focus and applaud. We need this day. We need to shout and talk and listen. We need to tell each of you in the community, “We have a serious problem.” Older people are not safe. For every year we recognize World Day, each of us has taken another lap toward our own old and older age. On this day, we join the world in the sobering acknowledgement of an international epidemic. I am inspired by this work. Inspired by older people. Inspired by survivors. Inspired by our determination to bring this epidemic out into the open and fight together for it to end.
Center for Practical Bioethics
National Latin@ Network
National Center on Elder Abuse
National Committee for the Prevention of Elder Abuse
National Adult Protective Services Association
Elder Justice Coalition
UpToDate is an evidence-based clinical decision support resource which clinicians trust to make the right point-of-care decisions. More than 6,500 world-renowned authors, editors, and peer reviewers use a rigorous editorial process to synthesize the most recent medical information into trusted, evidence-based recommendations that are proven to improve patient care and quality.
Over 1.3 million clinicians in 187 countries and nearly 90% of major academic medical centers in the United States rely on UpToDate to provide the best care. More than 80 research studies confirm widespread usage of UpToDate and the association of its use with improved patient care and hospital performance — including reduced length of stay, fewer adverse complications, and lower mortality.
UpToDate is a product of Wolters Kluwer Health. I co-author a related publication for Wolters Kluwer Law and Business: the 1500-page reference Right to Die: The Law of End-of-Life Decisionmaking.
Some time ago I began to write a blog about support of science, and the role of science in policy and decision making under the Trump administration. While this would seem to be a straightforward task since all of the evidence is amazingly consistent, in fact, it has been difficult. The reason it has been difficult is that each time I compile the sources and information necessary to write this blog something else happens which illustrates starkly the abandonment of the use of science by this administration. At this time, shortly after Trump’s announcement of the United States withdrawal from the Paris Climate Accord, I am trying to start again. I know it may be futile to expect to cover everything but I am writing anyway. There is no shortage of material. For the purpose of this blog I will focus on the message sent by Trump’s science budget proposals and not seek to be all inclusive. After all, it is the budget proposal which best states the administrations intent. I will also try to touch on the anti-science warriors who have been appointed to high level government positions, including cabinet positions.
While it is attractive to think of science as non-political, science exists in the real world and is, in fact, subject in many ways to political considerations. We have been fortunate that the politicians in Washington including both congress and the executive branch have recognized both the economic and humanitarian benefits of scientific research. They have, with a few exceptions maintained and grown the government’s support of scientific research in both basic and applied fields in both biomedical and other areas of research. This seems now to have changed. Congress fortunately has rescued the 2017 fiscal year science and technology budget from major cuts proposed by the Trump administration. However the administration has proposed draconian cuts for the 2018 fiscal year budget which starts in October 2017. It remains to be seen what that budget looks like when it has been through the Congress.
Trump’s proposed budget includes massive cuts to all federal agencies which support research. He proposes a 22% cut to the National Institutes of Health. Both the Environmental Protection Agency and the Food and Drug Administration are slated for 30% budget reductions. Other science supporting agencies are expecting cuts of eleven to thirty two per cent. These are huge budget reductions which will cripple labs and institutions conducting science.
Trump has appointed a series of individuals who are most certainly not advocates of science to important science based government positions. This includes climate change denier Scott Pruitt to head the Environmental Protection Agency. Rick Perry also a climate change skeptic as well as fossil fuel fan is now the head of the Department of Energy. Former CEO of the world’s largest fossil fuel company, Rex Tillerson is now the Secretary of State. Trump consulted with anti-vaccine crusader Robert Kennedy Jr. regarding the establishment of a commission on autism. Eighty five percent of the top science jobs in the federal government lack a Trump nominee.
The role of science as a driver, indeed the driver, of innovation and economic and technological development has been nearly universally acknowledged. We are now moving backward. Our hope lies in the fact that Trump and his cronies cannot kill science. Science is truth and truth will prevail. In the meantime things are pretty much a mess.
The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.