Richard Madsen | August 30, 2021
Responding To: Shared Approaches and Prospects for Peace: Part 2
The Ethics of C-sections in China and the United States
In October 2018, Chinese state media reported the story of a 46 year old man who was detained by Beijing police after assaulting a hospital gynecologist at Peking University First Hospital. This man was accused of repeatedly punching the gynecologist after this last one refused to perform a C-section on his pregnant wife, also in her 40s. The gynecologist felt that the C-section was medically unnecessary, but the pregnant woman and her family insisted on having a C-section, probably because they were worried about the risks of first time vaginal deliveries for women in their 40s. Such extreme conflicts between doctors and family relatives do not happen every day in Chinese public hospitals, but they are common enough to be frequently reported in national media outlets. As an anthropologist, I have been interested in studying these incidents because they help draw attention to an important aspect of Chinese ethical and legal traditions of informed consent in medical procedures, namely the fact that doctors have to discuss health care decisions not only with their patients but also with patients’ family relatives, and the involvement of family relatives can be so significant that conflicts may emerge whenever there is a clash between the views of doctors and those of family relatives.
C-sections are particularly interesting to think about these tensions. Medical technologies are transnational, developed in one place and taken up in others. Some technologies might be perceived as innocuous and unproblematic; others are highly contentious. The cesarean section is a good example of a highly contentious technology. For two decades now, I have visited China as a foreign anthropologist to do ethnographic research on family versus individual rights in medicalized procedures of childbirth care. In the United States, childbirth care is commonly framed as a matter of individual autonomy and choice, underscoring pregnant women’s rights to have access to all the necessary information required to make the right decision and/or give consent to a medical procedure. This idiom of individual reproductive rights is not just an important component of the organizational framework of American hospitals; it is also an important component of the research design of most social science studies of childbirth and cesarean deliveries.
My fieldwork in China has led me to develop an analytical framework that seeks to move beyond this paradigm of individual choice. Instead of assuming that women’s childbirth experiences are a matter of individual choice and leave it at that, this new framework situates women’s childbirth experiences in the context of larger negotiations between multiple actors. Doctors and hospitals play an important role in these negotiations, but so does the family of the pregnant woman. Indeed, the ethics of medical procedures in China treats the family—and not the individual patient—as the key unit of decision-making, and many people in China would find the American emphasis on individual choice as a health care vulnerability. In China, major childbirth medical interventions like C-sections require not only the consent of the individual patient but also the consent of family members. This is not just a bureaucratic requirement and legal imposition; it is also a culturally distributed model of what counts as good, appropriate care in childbirth. For family members, leaving a pregnant woman to make decisions by herself in a situation of vulnerability would be a form of neglect. For the pregnant woman, it would feel very lonely indeed to make important decisions without considering the views of the support network around her. Like other things that matter in life, childbirth is not an issue of individual choice but a process of collective negotiation and the family plays a central role in this process.
This ethical approach treats pregnant women not so much as autonomous, bounded individuals, but as members of specific moral communities and support networks. It is tempting to dismiss this conceptualization as a blatant violation of women’s individual rights, but one might as well ask the question of what can be learned from an ethical approach to maternal healthcare and well-being that is aware of the limits of abstract universalizing notions of individual agency and that insists on the importance of relational ties and support networks as ways of dealing with the uncertainties of childbirth. Much of what is called intersectionality in critical social science studies of childbirth converges with this critique of abstract universalizing notions of individual agency but the main goal of intersectional approaches is to show how women’s childbirth experiences, far from being homogeneous, are shaped by multiple frameworks of inequality including traditional inequalities within the family and the community writ large. This last point is important because it is important not to over-romanticize the beneficial role of women’s relational ties and support networks. In China too, this issue has come to the public attention in September 2017 in the aftermath of a shocking case of a pregnant woman in labor in a public hospital in Yulin who ended up committing suicide after being refused a cesarean, possibly due to the involvement of family relatives. This case initiated a nationwide discussion on whether the current legal model of family-based informed consent should give more decision-making power to pregnant women when their views clash with those of family relatives, thus safeguarding the rights of women in a society where family traditions can play a powerful role.
Gonçalo Santos is an assistant professor of social-cultural anthropology in the department of life sciences and a full member of the Research Center for Anthropology and Health (CIAS) at the University of Coimbra.
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