| **Doctors on the defensiveFear of litigation may partly have motivated the rise in caesareans but caution in medicine is no bad thing, says Dr Gerard Panting|
Society Guardian, Friday 1 April 2005 15.58 BST Article historyThe news yesterday that caesarean section rates in England have risen from 22% to 22.7% has predictably been linked to the cost of obstetric negligence claims and the consequent increase in "defensive medicine". The cry is that doctors now have one eye on the law courts instead of both eyes on the patient.
Defensive medicine is bad medicine. It reduces the doctor's exposure to potential censure but at the same time exposes the patient to the risk of unnecessary procedures. So the Royal College of Midwives is right when it says caesarean sections should only be carried out when clinically indicated. And it is true that sections are major procedures, with significant risks of bleeding thrombosis and bladder damage - neither of which is to be sneezed at. But is the college right to say caesarean rates should only be 10% to 15%?
Deciding whether a caesarean should be performed requires balancing consideration of the wellbeing of the mother with that of the health of the unborn child. The consequence of getting it wrong are worst from the infant's point of view: profound lifelong disability, with implications for the entire family. When the stakes are that high, a cautious approach has a lot to recommend it, particularly if the maternity unit has too few midwives or doctors or is otherwise under-resourced. Judging what constitutes best treatment must always include considering all the factors impacting upon a patient's care.
Fear of litigation has been cited as the driving force behind defensive medicine. But would that be so bad? If such cautious medicine has sparked a review, that must be a good thing. If it causes one clinician to seek the views of a second, that, too, is positive, and if in the end the decision is to intervene, rather than take a risk, I, as a patient, am all for that.
The issue of consent must also be thrown into the mix. Competent adult patients cannot be treated against their will, and, in theory at least, the final decision as to whether to go ahead with a caesarean section instead of a vaginal delivery rests with the mother to be, albeit that the pressures upon her may make it impossible for her to choose with complete freedom.
It is true that, if we had enough midwives to provide one-to-one care, caesarean rates would be lower. Closer monitoring allows finer judgements, significant signs will be detected earlier and intervention can be immediate. So it is all very well saying that the caesarean section rate should be 10% lower, but lower rates are dependent on staff we simply do not have. Lacking, as we do, adequate resources and clairvoyance, there is an inevitable increase in the risks to mother and child of a vaginal delivery, thus tipping the balance in favour of a caesarean section.
To give doctors their due, they are generally motivated more by the desire to avoid the harm to the patient that may result in litigation than by fear of litigation itself. Procedures only become too "defensive" when doctors have that eye on the law courts at the expense of the patient. Care of the patient must be the first consideration. Then treatment moves from being defensive and back to defensible and good.
ท Dr Gerard Panting is communication and policy director at the Medical Protection Society
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