Knowledge, Practice, and Power: Court-Ordered Cesarean Sections

 

Medical Anthropology Quarterly 1:3:319-334, September 1987

Special Issue on Obstetrics in the United States, Robert Hahn, Guest Editor

 

SUSAN IRWIN

Department of Anthropology, Michigan State University

 

BRIGITTE JORDAN

Department of Anthropology, Michigan State University

 

 

Medical specialists command particular respect in this society, and the application of their specialized knowledge carries considerable weight. In obstetrics expert knowledge is constituted as authoritative through a complex process in which actual social relations are obscured or misrecognized by the actors. When obstetric advice is actively rejected, birthing becomes an arena of struggle and these relations become more visible Refusal by a woman to undergo cesarean section involves a challenge to medical authority a challenge that may be overruled by legal orders supporting the practice of medicine and further legitimating medical knowledge. We review nine cases of court-ordered cesarean section to illustrate how medical power and privilege are maintained in cases of individual resistance.

 

The court ordered cesarean section, a relatively invisible phenomenon of recent origin, epitomizes certain political, intellectual, technological, and legal currents in the contemporary United States. Like other forms of judicially mandated surgery, court ordered cesarean sections stem from a particular definition of authoritative medical knowledge—in this instance, the technical skills attributed to obstetricians that legitimate their control of birthing and discredit the individual and collective expertise of birthing women.

 

“Authoritative knowledge” is legitimate, consequential, official, worthy of discussion and useful for justifying actions by people engaged in accomplishing a certain task or objective (Jordan 1987a, 1987b). For any particular domain, a multitude of ways and kinds of knowing exists, but some are more powerful than others under given circumstances. Some kinds of knowledge carry weight because they explain the state of the world better for the purposes at hand (“efficacy”) and because they are associated with a stronger power base (“structural superiority “). Expert authority is persuasive not only because it seems natural and reasonable, but also because it includes the veiled threat of powerful sanctions. Generally, people accept authoritative knowledge and it is validated and reinforced through this acceptance; those who challenge that knowledge are likely to have sanctions leveled against them.

 

The constitution of authoritative knowledge is an ongoing social process that both builds and reflects power relationships (be they stable or changing) in any given society. Power may be vested in individuals, who use it to achieve desired ends, and in communities or collectivities that support their common interests or positions through its use. Individuals in medicine control particular situations— for example, when a particular doctor manages a specific birth. Collective control is institutional, part of the commonly accepted practice of medicine (Giddens 1979), and is achieved through the social process of “pedagogy” (Bourdieu and Passeron 1977).

 

Pedagogy includes teaching and educating broadly defined; it is the process through which people come to accept the social world as inevitable. This ubiq­uitous practice results in “misrecognition,” the process whereby the authority of any particular knowledge and the power relations supporting it (and benefiting from it) are perceived not as socially constructed, relative, and coercive, but as natural, legitimate, and in the best interest of all parties.[i] Bourdieu and Passeron call this “symbolic violence.” Through pedagogic action, the interests of one class of people are legitimated and accepted, even by those who may suffer as a result. When, for whatever reasons, pedagogy has not worked and someone re­sists, more direct and visible means may be employed, such as court orders or outright force; then symbolic violence is replaced by actual coercion.

 

A consequence of the legitimation of one kind of knowledge as authoritative is the devaluation, often the dismissal, of all other kinds of knowledge. Those who espouse alternative knowledge systems are seen as backward, ignorant, or naïve; whatever they might have to say about the issues up for discussion is judged irrelevant, unfounded, or based on superstition. For example, there is an official school of mathematics that constitutes a widely accepted version of authoritative mathematics. Against this mathematics the practical mathematical reasoning of “just plain folk” engaged in such mundane tasks as grocery shopping or the com­putation of weights and calories is routinely ignored and devalued (Lave 1987). Similarly, there is an official obstetrics in this society, the ethno-obstetrics of bio­medicine, compared to which all other birthing traditions, all other sources of knowledge are found wanting.

 

Most people, medical workers and consumers alike, accept the hegemony of biomedicine in birthing. Most women willingly, gratefully, and deferentially ac­cept medical intervention in this process—certainly in the case of cesarean sec­tion. Regardless of whether the section is, strictly speaking, necessary, most women make sense of the procedure as something that rescues them and their babies from disaster. This is not to say that sections are not, from time to time, life-saving, but rather that women find sense in the procedure in the ways it is said to benefit them, not in the ways it benefits and maintains the system. Occasion­ally however, some women reject the medicalized view and refuse to have a sec­tion. When women reject the authoritative knowledge of physicians, more coer­cive means may be employed to support medical authority. These instances reveal the logic of the power relations inherent in authoritative knowledge as well as the process of creating that logic anew.

        

In the discussion that follows, we first summarize nine cases in which court orders were sought. In five of these, sections were actually carried out. In all the cases the women differed significantly from the medical staff in what they con­sidered legitimate and consequential grounds for making decisions about birth. After reviewing these cases and the medical evidence used to justify the court orders, we describe how pedagogy is used to support the authority of medicine, how the collectivity of medical experts supports and benefits from this pedagog­ical action, and how medical knowledge is constituted as authoritative.

 

Case Summaries

 

While there is reason to believe that court orders for sections are not all that rare, they are not widely publicized. Most cases are decided quickly in local courts. Thus, there is little publicity, and documentation is difficult to acquire, because rulings are recorded solely in local courthouses. Cases are only indexed and readily retrievable if they are regarded as precedent setting or if appeals are involved. While some of the following accounts appear in published sources, many of them are taken from interviews, medical records, and field notes. Cita­tions are given only when data or quotations come from publicly available sources. We present medical data here in the medical idiom to convey as much as possible the information deemed important by and available to medical and legal personnel.

 

Colorado #1 -1979[ii]

 

The first case of a court ordered section described in the literature, and in­deed the first we are aware of, occurred in Colorado eight years ago. A woman, described as obese, angry, and uncooperative by her physicians, was admitted in labor with ruptured membranes at 7:30 a.m.; at 9:00 a.m. meconium-stained am­niotic fluid[iii] was noted. Later, external and then internal fetal heart monitoring suggested fetal hypoxia[iv] which, coupled with high station and failure to progress, led to a recommendation to section The woman, who had had two gall bladder operations earlier in the pregnancy (before it was known that she was pregnant), refused to consent; the physicians indicated that her reason was fear of surgery. Weighing in excess of 300 pounds and in labor she undoubtedly considered her self at high risk for such a procedure.

 

The hospital legal staff requested a hearing which was convened by a ju­venile court judge in the patient’s hospital room at 5:00 p.m. The woman and the fetus were each represented by court-appointed attorneys. The medical staff tes­tified that the respondent was “a minimum of five to six hours from natural child­birth” (i.e., vaginal delivery); that the fetus “had an 80% chance of death,” should the woman insist on that course, but “a 90% chance of normal birth and development if a Caesarean were promptly performed.” The staff also indicated that a cesarean section is a common medical procedure presenting little chance of severe complication. “The abnormal position of this infant within the womb presented a greater likelihood of complications and risk to the mother than the likely adverse effects of the Caesarean section”. Memorandum in Support of Pe­tition and Order 1979:2).

 

The court found the fetus to be dependent and neglected, and ordered that a section be performed to safeguard the life of the unborn infant. Surgery was performed eleven hours after admission, more than six hours after the internal electronic heart monitor had indicated fetal distress. The baby was reported to be healthy; while the initial Apgar was two, the five-minute Apgar was eight.[v] Phy­sicians admitted surprise at this good outcome; the woman, on the other hand, suffered from delayed healing of the incision wound (Annas 1982; Bowes and Selgestad 1981; Memorandum in Support of Petition and Order 1979).

 

Georgia—1981

 

The second case reported in the literature occurred almost two years later. A woman, pregnant with her fourth child, was diagnosed as having complete pla­centa previa.[vi]  On the basis of two ultrasounds, she was told that she needed to have a cesarean section because of the danger this condition presented to both her and the fetus. With the support of her husband, a Baptist minister, she refused to consent to a section out of a strong conviction that God would heal her body.

 

A few days before the expected date of birth, the hospital requested a court order authorizing a cesarean section, as well as blood transfusions if necessary. The county superior court conducted an emergency hearing at the hospital, for which the parents did not appear. A physician testified that there was a 99% prob­ability of fetal death and a 50% probability of maternal death unless the section were performed. Medical authorities also testified that a 30-minute delay after bleeding commenced could be fatal to the fetus. The next day the parents were present together with their attorney at a joint session of the county superior and juvenile courts; the fetus was represented by a court appointed attorney. At this hearing the courts gave temporary custody to a state agency and indicated that the agency “shall have full authority to make all decisions, including giving consent to the surgical delivery appertaining to the birth of this child.” The mother was ordered to submit to another ultrasound and, if the condition persisted, to a section and all necessary medical procedures. The parents immediately petitioned the Georgia Supreme Court to stay the order, but their motion was denied on the same day.

 

A third ultrasound revealed an unobstructed birth canal. It was concluded that the placenta had moved, an extremely unlikely development, which was con­sidered a miracle by the parents. A few days later, the woman gave birth vaginally to a healthy baby (Annas 1982, Associated Press 1981, Berg 1981, Finamore 1983, Jefferson v. Griffin Spalding County Hospital Authority 1981, Johnston 1981).

 

Illinois—1982

 

In this case a section was recommended because the woman had already had three prior sections, was suffering from anemia, and had been diagnosed as ex­periencing cephalopelvic disproportion[vii]. With the support of her husband, the woman refused a section for religious reasons. A juvenile court judge ruled that the fetus was suffering medical neglect. He awarded temporary protective custody to a hospital lawyer along with the power to consent to a section and to other medical or surgical procedures. We do not know if a section was actually per­formed, but after the birth of a six-pound baby, custody reverted to the parents (American Medical News 1982 Annas 1982).

 

Michigan #1—1982

 

This woman also had a diagnosis of placenta previa some weeks before the expected date of birth and, like the women in Georgia and Illinois, refused on religious grounds. The hospital petitioned the county court which, acting on the information that there was a 90% risk of fetal death, made the fetus a temporary ward of the court and ordered the woman to enter the hospital for necessary treat­ment. The woman went into hiding with her family and the police were unable to deliver the court order in spite of repeated attempts to locate her. She gave birth vaginally to a healthy 9-pound 2-ounce baby three weeks later at a different hos­pital (Associated Press 1982 Cook 1982, Flanigan 1982).

 

Colorado #2—1982

 

A Hmong woman from Laos, close to term with her sixth child, was admitted to the hospital for vaginal bleeding. On ultrasound examination a complete pla­centa previa was diagnosed and a section was recommended. The woman refused, citing fear of surgery. Four days later, after the bleeding had stopped, she checked herself out of the hospital against medical advice.

 

A court order was sought compelling her to return to the hospital and submit to a cesarean section. Medical testimony asserted that there was a 99% probability that both mother and fetus would die unless a section was performed; with sur­gery, there was said to be a 99% probability both would live. It was also asserted that death from bleeding could occur in as short a time as five minutes.

 

The Denver police department was ordered to locate the woman and “to take the child into temporary custody, which necessitates the taking of the Respondent Mother into custody “. If there were time, the mother should be advised of her right to have a hearing and to have an attorney represent her.

 

As the order was handed down the woman’s whereabouts were unknown. She had left her own residence and gone into hiding. She was finally located by an interpreter who called an ambulance. On arrival, medical crews found her in the bathtub, bleeding, she went into shock in the ambulance. At the hospital, though bleeding, she still refused to consent to a section; she was described as ill and withdrawn. The court order was enforced and a section performed; the baby was born with Apgar scores of eight and nine. The mother refused to see the baby for three or four days; finally, she reluctantly agreed to take it (Reporter’s Tran­script 1982 Summons Endorsement 1982).

 

Michigan #2—1983

 

This case involved a West African woman whose first child was born vagi­nally after a section had been recommended and refused. In this particular labor, a section was advised four hours after admission because of “secondary arrest with failure to progress”, based on cervical dilation of 5 cm two and four hours after admission. Fetal heart tones were normal at the time, though late decelerations[viii] had been noted at one point. The woman and her husband refused to consent to surgery. A local circuit judge was contacted who expressed his will­ingness to order a section. While that was in process, the woman gave birth va­ginally to a healthy baby with Apgar scores of eight and nine. The couple were unaware of the legal maneuvers at the time and, as far as we know, were never informed (Jordan 1984; Jordan and Irwin 1987a).

 

California—1983

 

A sixteen-year old Southeast Asian woman, who spoke almost no English, was admitted to a county hospital in early labor at 9:15 p.m.; she had good-qual­ity, irregular contractions, was 4 cm dilated, and 50% effaced.[ix] Fetogram con­firmed a frank breech[x]. Multiple efforts were made to explain the risk to the pa­tient and her family. The patient’s family (particularly her father) repeatedly re­fused a section. When told of the danger to his daughter, her father reportedly said, “She’s only a girl, anyway.”

 

By noon the next day she had dilated to 7 cm with good fetal heart tones; there were facial and labial edema and proteinuria[xi].  By this time hospital admin­istration, the hospital lawyer, interpreters, and a variety of obstetric and pediatric personnel were involved. At 1:55 p.m., a local judge agreed to write an order. As soon as the judge expressed his willingness to issue the order, the family was informed. At 2:10 p.m. the patient signed the consent form, and the surgery pro­ceeded. A 7-pound 2-ounce baby was delivered by section at 2:36 p.m. with Ap­gars of eight and nine. The mother was released four days later.

 

Michigan #3—1986

 

A 24-year-old, single black woman, expecting her first baby, had had little prenatal care because she felt she was not getting proper attention at the prenatal clinic. She was admitted to the obstetrics ward in early labor, but her contractions stopped and an induction was performed. After several hours the woman was in great pain. Demerol was given, followed several hours later by epidural anes­thesia,[xii] which apparently did not take. The patient was described as uncoopera­tive and noncompliant, screaming with pain and thrashing about. After a second epidural, there was some relief but “severe decelerations” of the fetal heart tones were noted. The woman was moved to the delivery room for a section, which she refused. At that time she was described as acting crazy, flailing her arms to keep the staff away. She was told that her baby could die, or if it were born alive, it would have cerebral palsy. The father, who was brought into the delivery room, shouted at her: “You are killing my baby!”

 

The staff was ready to anesthetize her, in spite of her objections, when the hospital lawyers gave the okay for the section; they had talked with a local judge, who promised to send a written court order to the hospital. At that point the woman was told that cerebral palsy meant mental retardation and she is reported to have consented to the section with a whispered “Yes.” Surgery resulted in the birth of a 7-pound 15-ounce baby with Apgars of eight and nine.

 

Washington, D.C.—1986

 

A 19-year-old college student was admitted to labor and delivery at 1:45 a.m. experiencing normal contractions; her membranes had ruptured two days earlier at noon. By 11:00 a.m. she was 7 cm dilated but had made no further progress by 10:30 that evening. Because an external electronic fetal monitor was attached, she had to lie in bed, on her left side, for extended periods of time. When she asked to be allowed to walk around to help with her natural delivery, she was advised that hospital regulations and city statutes required her to remain in bed on the monitoring device.

 

The chief of obstetrics examined the patient at noon the following day and reported that there was no evidence of infection or other abnormality. Later that evening the resident in charge wanted to administer pitocin to help speed up the delivery, but he would not do so without her consent to a cesarean delivery should he deem it advisable She refused and requested that she be allowed to continue her natural childbirth in accordance with her Muslim religious principles. Shortly thereafter the physician telephoned a local judge, who convened a hearing at the hospital to determine whether to order the section. The judge appointed attorneys for the parents and the fetus; the hospital’s attorney was also present. The parents were not given an opportunity to confer with their attorney before the hearing, nor were they able to secure the services of a medical expert to counter the testimony of the hospital’s physician.

 

A fourth-year obstetrics and gynecology resident testified that he thought the fetus was in danger of infection because of the length of time since the patient’s membranes had ruptured. On cross-examination, he admitted that there was no objective evidence of any fetal distress. Nevertheless, at 1:05 a.m. the judge ordered surgical intervention. The parents attempted to appeal the ruling but at 2:08 a. m. two appellate justices affirmed the judge’s order. The cesarean delivery was immediately performed; no infection or injury to the fetus was discovered. Legal action against the hospital is still pending (Alternatives 1986, Memorandum Opinion and Order 1986).

 

The Medical Evidence

 

In a society where all actors, be they direct participants or analysts are sub­ject to medical pedagogy, medical practice and expertise “naturally” presents itself as designed for the best interests of mother and baby. Yet this is not neces­sarily the only view. There is considerable evidence that the medicalization of normal birthing is not in women’s best interest (Davis-Floyd 1986, Haire 1972, Odent 1984, Rothman 1982). Obstetrics has a long history of errors, including DES treatment for threatened miscarriage,[xiii] limiting maternal weight gain to un­der 15 pounds, and using diuretics, X-rays, and many other treatments (Rothman 1986). Increasingly, major abdominal surgery (cesarean section) with its attend­ant risks and complications is becoming part of the birth process—now approach­ing one in four U.S. births (Gleicher 1984). Women are isolated from people with shared experience; control of birthing and the concurrent control of women’s bodies reside in physicians, not in women themselves.

 

In the cases we have described, an assortment of medical evidence was used to support the conclusion that sections were necessary in spite of women’s objec­tions. In at least seven of the cases, machine evidence played a major role in the decision to section. But machine data are fallible; in Georgia, for example, the initial ultrasound evidence indicated placenta previa, but on later examination (confirmed by successful vaginal birth) there was no previa. Since it is highly unlikely that the placenta had migrated, we must conclude that the original two ultrasounds were either in error or misinterpreted. Likewise, in Michigan #1 ultrasound data indicated placenta previa, but this woman went into hiding and de­livered vaginally, again casting doubt on the machine data.

 

In cases where the machine output indicated serious danger to the fetus, the results again make us question that interpretation. In Colorado #1 electronic fetal monitor data were interpreted as indicating fetal hypoxia. Yet when a section was performed hours later, the baby was healthy. In Michigan #3 we see a similar situation. Electronic monitors indicated severe decelerations in the fetal heart rate (after an induction, two epidurals and Demerol had been administered). When this woman finally gave in to a section after being threatened with a court order, the baby showed no indication of stress. In one case, Michigan #2, decelerations did not appear until after a section had been recommended to the woman. In Col­orado #1 physicians themselves expressed surprise that the baby was not in worse condition, given the long interval between the diagnosis and the section. They concluded that the adequacy of fetal monitoring was questionable (Bowes and Selgestad 1981:211). Beyond these cases, there is evidence that electronic fetal monitors do not improve outcomes, except possibly in a small number of high-risk cases (Banta and Thacker 1979; Leveno et al. 1986; MacDonald et al. 1985). When we look beyond the data at the general outline of the cases, there are additional reasons to question medical rationale. In none of the cases where there is information about the outcome did the baby evidence stress at birth even though in all cases a significant period of time elapsed between the initial recommendation to section and the actual delivery. While the initial Apgar was low in Colorado #1, the baby recovered quickly and later developed normally. In Colorado #2, where there was clear danger to both mother and fetus, the baby was born with Apgar scores of eight and nine. It appears that the medical evi­dence, combined with the woman’s resistance, prompts an air of urgency that, at least in these cases, is not justified by the outcomes This is not to say that sections are unnecessary, but rather that in situations like these other factors are also at work. In addition to questions about the validity of the medical claims (e.g. whether fetal monitors accurately predict fetal distress), there are also questions about the social discourse of the actors. How is it that medical opinions go un­challenged?

 

The Uses of Pedagogy

 

Most people accept medical authority because medical expertise is respected in the society in which we live. Childbearing women, however, also experience a particular process of indoctrination that involves the entire pregnancy and prep­aration for childbirth. If, as suggested earlier, we conceive of pedagogy as the general social process of teaching and educating, then it becomes clear that child­birth is one of society’s most powerful pedagogic arenas. Throughout the prenatal period, both informally and formally, doctors, birth preparation classes, televi­sion, and other sources teach women to rely on medical judgment and knowledge as the final arbiter in decisions relating to their pregnancies and births.

 

During prenatal consultation women come to internalize the rules of medical discourse. They learn what topics are defined as within and outside their own and the medical staff’s expertise, what constitutes justification for which particular actions, and the like. In the course of this prenatal education women also learn that much of what counts as relevant information is machine-based or in other ways inaccessible to them—for example, in test results, the interpretation of which requires arcane knowledge. Most women are sufficiently socialized in the course of their pregnancies (and indeed before) so that no overt questioning of medical authority occurs.

 

One characteristic that all the women who were subject to court orders have in common is that they were not part of the mainstream of society. In some cases we know explicitly that they had no prenatal care. In others, we must suspect it. Whether for reasons of poverty, ethnicity, illiteracy, or religious preference, it appears that the women with whom we are concerned here lack the “appropriate” ideological indoctrination. They have not been subject to a sufficient degree to the symbolic coercion that obviates physical force. Refusers, then, are those who have not had proper exposure to the “correct” (dominant) way of thinking: poor women who have had little prenatal “care”[xiv], religious women who subscribe to alternative authoritative systems, women with radically different cultural backgrounds, and those who for other reasons (such as fear or prior experience giving birth) reject the logic of obstetric interventions.

 

We are now also in a better position to understand why “prenatal care” is considered so inordinately important within official obstetrics. Within the medical community it is “common knowledge” that women who have regular prenatal medical supervision have better pregnancy outcomes The relationship is thought to be causal, though there are suggestions that a variety of factors other than seeing a physician may be involved. Marilyn Poland (personal communication 1985), for example, found in an inner-city study that a group with inadequate prenatal care also showed much higher use of drugs and alcohol, a poor showing that could have been due not to the absence of medical care but to the routine ingestion of heroin and alcohol. While there is a widespread belief that prenatal care makes a difference, it is unclear in what ways that occurs. Prenatal care may simply constitute a screening mechanism that separates populations with different risks.

 

Even if we assume that prenatal monitoring serves a variety of medical purposes, it is clear that it also prepares women for a medically guided birth. ‘Walk-ins” (women who come to the hospital in labor without having had regular med­ical supervision of their pregnancies) are uniformly considered problems and are often scorned and punished by the staff. What they announce, in admitting that they have had no prenatal care, is not only that they may have a variety of un­treated medical problems but also that they have not been subject to the appro­priate pedagogy. They may not know how to act or talk appropriately; they may refuse what others accept, and thereby cause a rupture that makes stronger coer­cion, sometimes even physical force, necessary.

 

Court-ordered cesarean sections fall along a continuum that begins with those who undergo sections because they are socialized to accept medicalized birthing and ends with those who are forcibly anesthetized[xv]. This continuum of coercion extends from symbolic to actual and works to establish, maintain, dis­play, and enforce existing power relationships.

 

It is interesting to look at cases where women were successful in resisting the threat of court orders. While most women in U.S. society, regardless of class, religion, or ethnicity, accept medical logic, not all do. Middle class women who resist are much more likely to have the resources (i.e., the linguistic and cultural capital, as well as the financial base) to do so successfully. Most of these resisters remove themselves from the biomedical arena entirely, opting for home birth. A few are able to negotiate with their physicians, at least for some period of time.

 

In one case we know of, an experienced, professional woman and her husband (who, not insignificantly, was a lawyer) held out against the doctor’s insistence and machine evidence with great anxiety about their choice. Eventually, the woman gave birth vaginally to a healthy baby. This, however, happened over the course of one day; both they and we doubt that they could have continued to resist a section over a longer period of time.

 

Constituencies of Knowers

 

Cesarean sections are so much a part of the standard, legitimized form of birthing that refusing to submit to one marks a woman as rejecting legitimate medical advice. She is likely to be seen as idiosyncratically deficient, individually culpable, maybe even a tragic case. She will not be seen as the victim of the structural distribution of power and authority, as someone resisting the symbolic vio­lence of the transaction.

 

One significant feature of the imposition of a discourse based on legitimated expert knowledge is that women’s voices are not heard. We mean this literally. In the official documents there is no recognition that these women themselves might have something significant to say about matters at hand—that is, about their own labor and delivery. For them, isolated in their individual labors, there is no community of practitioners that would pay heed.

 

Pregnant women are not collectively organized. When they are together, it is with a few friends, perhaps a sister, or a childbirth class (where the legitimacy of medical discourse, not collective action, is taught). Because of the isolation of most women, refusing a section is a personal act, known only to the women involved and perhaps a few family members and friends Of the women we discuss here, those who successfully refused sections had the support and help of family members (and perhaps a religious community). While they were not isolated or reduced to individual action quite like the women who were served with court orders while in labor, their situations and actions nevertheless remain personal. The knowledge that some women resist medical advice is not publicly available to large numbers of people.

 

Hospital staff members on the other hand, are part of a collectivity in the hospital, in local professional associations, in the readership of specialized jour­nals. They share a particular view of the world that is upheld in their daily inter­actions with patients as well as with their peers. It is this community that defines legitimate topics, current issues, the nature of evidence, and the construction of a reasonable argument. It is this community, and not birthing women, that deter­mines the structure of childbirth and the acceptable alternative practices. Within this community, once one physician has done a court-ordered cesarean section, it becomes a thinkable option for others. The cases described here were written about in the literature, discussed at ethics committee meetings, reviewed at grand rounds, talked about over lunch, and retold at cocktail parties. While they are not widely publicized, they become part of the repertoire of the medical and legal communities in which they were carried out.

 

Medical Knowledge as Authoritative Knowledge

 

Medical work is organized around particular, exclusive bodies of expert knowledge, recognized and certified by the state. Most patients’ knowledge is rather different from the officially sanctioned version; it is often based in experi­ence rather than academic preparation. The perspective of a woman giving birth is embedded in experience, while the practice of medicine demands that doctors rely on abstract, decontextualized knowledge. When contextualized knowledge is invoked, it is easily dismissed as personal, subjective, idiosyncratic, lacking breadth, magnifying personal history—in a word, unscientific.

 

Since full records of all transactions between the medical staff and the court system are unavailable, we are limited to court records for evidence of the medical testimony. Whatever the physicians may have said, what the judges listened for, heard, and recorded as evidence were numbers: “99% probability of fetal death”; “bleeding can be fatal in five minutes”, “fetal heart rate decreased to 80 beats per minute.” [xvi]   Women’s formulations, however phrased, are seen as inadequate. In Michigan #2, for example, the woman’s previous experience of successful vaginal birth after a recommendation to section was ignored, while much was made of marginal medical evidence. In the Washington D.C. case, a resident’s assessment of the probability of infection drove the effort to get a court order, even though there was no evidence of actual infection. Both women were over­ruled by officially acceptable, though not well-founded medical interpretations.

 

The point is not only that in at least some cases technological data were over-interpreted (e.g., Michigan #2, where fetal monitor output was overzealously interpreted, or Georgia, where ultrasound readings were represented as unambig­uously true), but also that if produced by the medical staff any number, reasonable or not, had legitimacy. It is not just that authority is vested in medical workers. Authoritative knowledge is embodied in the technological devices of biomedi­cine. Thus, machine data take on an authority beyond their warrant. They are invested with an objective reality that belies the fact that machine output must be interpreted.

 

In the past many physical functions were invisible. There was little in the way of physical examination; patients themselves often declared what was wrong with them. As contemporary biomedicine developed, physical functions became visible in a new way (Foucault 1975, Reiser 1978). Machine data are visible to physicians, while often remaining invisible to patients, since their interpretation requires specialized knowledge. This situation is paradoxical. The empirical at­titude which aims at least rhetorically to reveal, actually alienates women from the birth event by obscuring data from everyday understanding.

 

In the transaction between the medical and legal systems, medical opinion (any one medical opinion) is treated as authoritative. Thus generally only one or two physicians from the same institution testified in our sample of cases, and even when the woman was represented by an attorney, there were no attempts to solicit conflicting medical opinions. In short, there were no efforts to validate the wom­an’s position. Unlike malpractice cases, where considerable time is spent prepar­ing and analyzing both sides of the argument, time here is at a premium. The people who initiate the legal action and command the resources (e.g., have a law­yer on staff) are at an advantage.

 

Legal complicity in the construction of monolithic medical authority is evi­dent in the lack of credibility given to women in these cases. Consider the explicit likening of a pregnant woman to an individual who is mentally incompetent. The ruling in the Georgia case, and several others thereafter, cited Strunk v. Strunk (1969) in support of the decision to compel surgery. In Strunk the mother of a mentally incompetent ward of the state sought permission to transplant one of the ward’s kidneys to his brother, who suffered from renal failure. In determining the course of action desired by the incompetent boy, the court accepted medical testimony that removing a kidney would be less injurious than the emotional impact of the brother’s death (Finamore 1983:91).

 

The Georgia case resembles Strunk only in that each case involves the im­position of surgery on one individual for the benefit of another. The two cases differ in the competence of the person on whom the surgery is imposed. Accord­ing to common law, no competent person has the legal duty to submit to medical treatment for the good of another living person (Finamore 1983:92). Certainly, no parent has ever been required to undergo surgery for the benefit of a child (Annas 1982). Though these women were not overtly characterized as mentally incompetent, they were effectively treated as such. In upholding the expert authority of physicians, the courts implicitly certify the deficient nature of the wom­en’s reasoning.

 

The two cases also differ in the status of the patient. In Strunk, the boys were separable agents; one was clearly ill, while the other risked major surgery and the loss of a vital organ. In the Georgia case, and the others as well, the fetus con­tained within the woman’s body seems to be viewed as a full-fledged patient (it is the focus of monitoring and the object of concern). Not only is the fetus seen as a patient but responsibility for it rests with medical experts, not with the woman. More and more, the authority of a growing cadre of experts in childbirth and child care has been legitimated by the courts (Atkins and Hoggett 1984).

 

The power of authoritative knowledge is not that it is correct but that it counts. In spite of the fact that medical opinions change over time and that doctors often disagree with one another, assertions made by medical professionals are consistently respected by the members of this society, including the legal establishment. The hegemony of medical authority is clear when we begin to search for the views of the women. We simply do not find them. Women’s stories and accounts of their experience are left out of all the records. Neither their grounds for refusing sections, nor the deliberations and reasonings they engaged in, nor the knowledge they drew on to construct a different reality is given a legitimate place in the records. So we can only conjecture. In Michigan #2, for example, there was no official recognition that this woman’s previous labor had taken a similar course and that she might justifiably draw on that experience to decide on a course of action. Instead, it was concluded that she was willing to “sacrifice” this fetus to avoid having a section.

 

Conclusion

 

The medical staff, on one hand, are involved in a difficult situation. They know they should care for these women; they know that their’ machines are falli­ble; they sometimes disagree with each other; and they feel threatened by mal­practice suits.[xvii] On the other hand, if we look not at the bind of individual prac­titioners but at what they do and the circumstances in which they do it—the col­lective rather than the individual situation—we see a different context with dif­ferent constraints. Staff members are part of an extended network of people doing the same work. Birthing women are not; most never even attend another woman giving birth. Medical workers have standard patterns of activity and sets of rela­tionships. They control the setting, they determine the right way to give birth.

 

Court-ordered cesarean sections maintain medical authority by contributing to the reproduction of relations in which physicians control birthing. They support current social relations by legitimating certain knowledge and disallowing other forms, and they do this by resorting to an agency of the state when normal, sym­bolic means of domination do not work. This is a situation in which collective ends are supported through individual action. It is through this active process that power and privilege are maintained or challenged. The power of doctors (and judges) is contingent on the real situations where that power is both played out and reinforced. If the refusal of a section can be interpreted as resistance to the dominant ideology, a court-ordered cesarean section is an overt repression of al­ternative actions and alternative ways of knowing A court-ordered cesarean sec­tion not only determines the authority of a particular doctor over a particular woman, it confirms medical authority in birthing.

 

NOTES

 

Acknowledgments. We are especially grateful to all those individuals who have been willing to talk with us about their involvement in court-ordered sessions. We thank Mary Alfano, Mary Lynn Buss, Robbie Davis-Floyd, Tracy Dobson, Al Haverkamp, Hugh Hol­trop, Bruce Miller, Charles Senger, Ronald C. Simons, Barrie Thorne, Mary Ann Zettelmaier, and two anonymous reviewers for discussion of and comments on the cases and ideas used here. We particularly thank Robert Hahn and Alan Harwood for their assistance patience and perseverance.

 

Correspondence may be addressed to the authors at the Department of Anthropology Michigan State University, East Lansing, MI 48824.

 

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Alternatives

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American Medical News

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Annas, George J.

1982 Forced Cesareans: The Most Unkindest Cut of All. The Hastings Center Report l2(3):l6-17, 45.

 

Associated Press

1981 Agency Is Given Custody of Unborn Child. Atlanta Journal Constitution 25 Jan­uary B4.

 

1982 Pregnant Woman is Still in Hiding. Detroit Free Press 13 June A3.

 

Atkins Susan and Brenda Hoggett

1984 Women and the Law. New York: Basil Blackwell.

 

Banta, David, and Stephen Thacker

1979 The Premature Delivery of Medical Technology: A Case Report. Washington, D.C.: National Center for Health Services Research, Department of Health, Educa­tion and Welfare.

 

Berg, Robert N.                                                                                             -

1981 Georgia Supreme Court Orders C-Section—Mother Nature Reverses on Appeal. Journal of the Medical Association of Georgia 70:451-453.

 

Bourdieu, Pierre, and Jean-Claude Passeron

1977 Reproduction in Education, Society and Culture. Richard Nice, transl. London: Sage Publications.

 

Bowes, Watson A. Jr., and Brad Selgestad

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Cook, Henry

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Davis-Floyd, Robbie

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Endnotes

 


 


[i] This is of course very similar to notions of ideology and false consciousness.

 

[ii]  We earlier erroneously reported this case as having occurred in 1980 (Irwin and Jordan 1985).

 

[iii] Meconium staining of the amniotic fluid occurs when fetal fecal matter is expelled before birth sometimes this is indicative of fetal distress.

 

[iv] Insufficient oxygen is reaching the fetus.

 

[v] An Apgar is an assessment of the physical state of a newborn. A perfect Apgar score is ten with anything below seven considered indicative of distress.

 

[vi] Placenta previa is a condition in which the placenta blocks the opening of the uterus.

 

[vii] Cephalopelvic disproportion is a condition in which the fetal head is too large to fit through the pelvis.

 

[viii] Late decelerations are a type of fetal heart rate pattern commonly believed to be indicative of fetal distress.

 

[ix]  Effacement is the progressive thinning of the cervix that occurs before dilation en­larges the external opening of the uterus sufficiently to permit passage of the fetal head.

 

[x]  In a frank breech presentation, the baby’s buttocks are in position to be born first rather than the head; the legs are extended along the trunk.

 

[xi] Facial and labial edema refers to swelling due to fluid retention in intercellular spaces of the face and labia. Proteinuria is the presence of protein in the urine. Edema and proteinuria are possible indicators of pre-eclampsia, a condition dangerous to both woman and baby.

 

[xii] Epidural anesthesia is produced by injecting an anesthetic agent into the epidural space of the spine.

 

[xiii] Diethylstilbestrol was given to pregnant women in the 1940s and l950s to prevent miscarriage and has been found to cause cancer in their daughters decades later.

 

[xiv] The word itself masks domination as well as self-deception among medical workers.

 

[xv] We know of several instances where women refusing sections were anesthetized and subjected to surgery against their expressed wishes. One such case is reported in the lit­erature (Jurow and Paul 1984).

 

[xvi] As one of our reviewers pointed out, these statements demonstrate the symbolic rather than the statistical value of numbers. Numeric estimates have been used for the pur­pose of “legal persuasion and social control; tolerance for possibility has given way to exaggerated symbolic statements which differ in intent and derivation from statistical prob­ability statements.”

 

[xvii] See Jordan and Irwin (1987b) for more on the medical staff predicament.