As a doctor, decision-making is guided—either implicitly or explicitly—by a set of ethical principles. In medical school, we did have some formal training in ethics, but like most doctors, I am not a medical ethicist. Still, I’ve always had an interest in knowing what guides my decisions, and in questioning—within a formal framework—the actions I take on behalf of my patients.

I bring this up because of a disturbing case out of (unsurprisingly) Florida where a woman was forced to undergo a C-section against her will. You may not be an medical ethics geek like I am, but you should know why your doctors make the decisions they do (even if they don’t know themselves). So, once again, grab yourself a nice cup of tea, settle in, and let’s take a deeper look at this.

Not being a medical ethicist puts me at a disadvantage in that I may express ideas that a real ethicist might find simplistic or even just wrong. But I have the advantage of giving you a look at how a practicing physician with an interest in ethics actually thinks. As I said above, we all act based on ethics—we just don’t always know what those are. We have our “implicit ethics”—those feelings and ideas that say, “this action is right” or “that action is wrong”. But acting instinctively isn’t always the best way to do things, especially when you’re making life-and-death decisions. This is why we also have “explicit ethics”.

We see explicit ethics in the policies of medical societies. The American Medical Association and American College of Physicians both have formal, publicly-available ethics manuals, and the The American College of Obstetricians and Gynecologists, while not having a manual as such, does have a committee on ethics that regularly publishes guidelines. Ethics are of course culture-dependent and in our culture we are generally guided by four greater principles (from the ACP Ethics Manual):

Before we apply these principles to the Florida case, we need to remember the history of women’s health in the U.S. We have a centuries-long history of abuse and coercion underlying the practices of obstetrics and gynecology, a history that would be too long to fully address here. Suffice it to say, we have performed involuntary procedures on generations of women, especially African American women. The Supreme Court case Buck v. Bell famously allowed the state to sterilize women against their will. This case has never been formally overturned. The story of Henrietta Lacks give a very good overview of the deep, enduring abuse of women in our medical system (and is told expertly and readably in Rebecca Skloot’s, “The Immortal Life of Henrietta Lacks”.)

This historical setting is crucial to understanding the Florida case. Cherise Doyley was in labor when she was given a tablet and told that a judge would decide if she was allowed to continue her labor or would be forced to have a C-section. In addition to the immense weight of history here—the centuries of abuse of Black women by the medical system—what disappoints and disturbs me is the behavior of the doctors involved.

Our medical system has a history of injustice toward women—even more so, minority women—and it is up to their doctors to advocate for them, to behave ethically on behalf of their patients. The doctors in this case failed miserably. They failed to adhere in even the slightest ways to the explicit medical ethics that guide our practice. According to the article in ProPublica, the doctors were concerned that the patient was making a bad decision, one that could endanger her health and that of her fetus. I don’t have access to the entire two-hour hearing, but the quotes show that the hospital was concerned that Doyley’s uterus might rupture if she continued with a vaginal birth. This may or may not reflect the actual risk (I think it does not) but that is beside the point.

It is not up to us as doctors to decide what risks our patients may take. How would we even define that? What risk is acceptable? Twenty percent? Two percent? That is a decision for the patient, not us. It is our responsibility to communicate the facts to our patients and let them decide. This is how we honor the patient’s autonomy, one of our core medical ethics.

The argument here, apparently, was that the patient wasn’t only deciding for herself but also for her child. That is, ethically, bullshit. The American College of Obstetricians and Gynecologists has explicitly states that, “the College opposes the use of coerced medical interventions for pregnant women, including the use of the courts to mandate medical interventions for unwilling patients.” They also explicitly state that the decisions of the pregnant patient are not to be superseded by concerns about the fetus. But does stating this make it so?

Ethics are subjective. They are an agreed-upon framework of behavior, not engraved on tablets given on a mountain. In this case, this statement is based on sound medical ethics, ethics that require us to advocate for the good of our patients; avoid harming them; preserve their autonomy; and promote justice.

You may personally disagree with this. But as doctors we should be very cautious of letting our implicit ethics—our personal moral or religious beliefs—guide decisions that are not ours to make. I don’t have access to the entire hearing but to the extent that the doctors named in the article—Dr. Erin Burnett and Dr. John Davis—failed to advocate for their patient, they caused moral and physical harm to her, to our profession, and to our society at large.

It is acceptable for doctors to question the decisions made by their patients but that’s about as far as intrusions into patients’ autonomy can go. It is up to us to advocate for our patients, not substitute our own judgement. When doctors behave like gods, we have committed ethical blasphemy.