Lives at stake. How to respond to a woman's refusal of cesarean surgery when she risks losing her child or her life.

What can healthcare providers do if a pregnant woman refuses cesarean delivery when the life of the fetus and perhaps her own life are in jeopardy? Only in exceptional circumstances would it be morally permissible, or morally required, to compel her to submit to invasive medical procedures against her will. Ethical analysis of all maternal-fetal issues depends on how the maternal-fetal dyad is conceptualized. The pregnant woman and her fetus may be viewed as an organic whole (the one-patient model) or as two distinct individuals (the two-patient model). The one-patient model balances prospective benefits to the fetus with possible harm to the mother. In exceptional situations, such as near certainty of serious harm to the fetus and the mother if a cesarean is not performed, a physician or institution wishing to override the woman's refusal within the one-patient model invokes paternalism. Recourse to the courts to force the woman to undergo the cesarean would probably not be feasible when applying the one-patient model. The two-patient model focuses more on fetal well-being because it views the fetus as a distinct individual and patient. Catholic institutions usually subscribe to the two-patient model. When near-certain harm to the fetus is coupled with probable benefit to the woman, the institution may ethically override her right of refusal of a cesarean. However, the institution must be prepared to face legal scrutiny should they override the woman's wishes. Other means of achieving the goals of medicine (such as persuasion based on a good doctor-patient relationship) are preferable from both an ethical and a human standpoint.