Comment: Pregnant women and the need to be patient

What would you do? Faced with a heavily pregnant woman suffering from pre-eclampsia which could kill her and the baby, a woman who is refusing all treatment, how would you, the doctor, react? Reports come in that the mother-to-be has been emotionally unstable during the pregnancy, claiming not to care whether she or the baby lives or dies.

In the circumstances, most of us would be tempted to do what the doctors of Ms S did - to carry out the medical treatment she needs to save her life against her will and take the consequences later on. Better to err on the side of saving her life than to abandon her and her foetus to the fate she wished upon them when in no state to make a balanced judgement.

But hang on a minute. This is dangerous ground. If S turns out to have been too seriously mentally ill to give informed consent for medical treatment, then the actions of the courts, doctors and social workers will have been fair enough. But we cannot go around banging women up and operating on them against their will to save the lives of babies they do not care about. Nor can we justify intervening just because their decisions do not seem rational to the rest of us. We have a poor history of judging the mental health of mothers and of pregnant women according to social rather than medical criteria. Can we be sure we are not doing exactly the same thing again now?

In the circumstances, the doctors' response is understandable. Trained to save lives, they will have wanted to give S the treatment they felt she needed to stop her destroying herself and her unborn child. For make no mistake, pre-eclampsia - the condition S was found to be suffering from - is very serious. Mother and foetus could both have died. It may even be that Ms S is alive to sue today only because she was cut open against her will.

The woman brought into casualty late one Saturday night, after an overdose, will be resuscitated by conscientious nurses and doctors, no matter how much she wanted to die. That's their job. But a fully conscious pregnant woman is different. Unlike the pill-popper, she is awake and able to make her own decision. Nor is she actively inflicting harm on herself, she is simply determined to let nature take its course. When patients can give consent but don't, we don't treat them. Aids patients are not forced on to AZT. The victim of multiple heart attacks is not forced into a heart transplant. No one sections the cancer patient who refuses radio- therapy, even if death is certain without it.

Admittedly, there are two lives at stake when a woman is pregnant, but that makes no difference to the treatment that doctors can legitimately give. If a fully conscious, fully informed mother-to-be, in full possession of her senses, refuses the treatment that will save her foetus's life, there is nothing that a doctor can legitimately do to intervene.

It is hard. Much as we might want to rescue that foetus, much as we may hate the woman for her decision, we cannot justify intervention. Once the baby is born, should the mother refuse it life-saving care, then doctors and social workers can take over and edge the mother's judgement out of the picture in the interests of the child. Parents who refuse treatment for a dying son or daughter because of their religious belief should, for example, sometimes be overridden for the sake of their children. But so long as that foetus is inside the womb, then there is still a woman's body that has to be chopped through to give the foetus the treatment it may need. Cutting women open against their will is unacceptable.

The critical phrase, however, is "in full possession of her senses". Here, the world slithers from clear-cut white and black into a murky, muddy grey. Of course we should treat mentally ill people who refuse treatment, but who cannot understand the consequences of that decision. But what counts as mentally ill under these circumstances? Refusing treatment that will save your life seems crazy to most of us. Refusing treatment that could save your baby's life is not the behaviour of a normal mother. But this evidence is not damning enough to section a pregnant woman under the Mental Health Act. And it certainly means every care should be taken to make sure the woman gets proper legal representation, and the chance to put her side of the story if sectioning becomes a possibility.

Who knows yet whether S was mentally ill? The trouble is that, given the record of British doctors and our state representatives in pronouncing on the health of unconventional pregnant women in the past, we cannot help but be suspicious today. This century, unmarried mothers were locked up, sometimes for decades, and so displaying deeply abnormal behaviour for the society at the time. Yes, women sometimes behave strangely in pregnancy. But the fact that we are all still so inclined to treat pregnant women so differently from other patients should make us extremely cautious in judging the case of S.