Rebecca Brione

This chapter examines the choice and consent experiences of people who are too often reduced to ‘just a body’ or a ‘single story’. Drawing on two studies carried out for and by the charity Birthrights, into the maternity experiences of disabled women and those facing multiple disadvantage during pregnancy, it identifies three key themes which illustrate some of the ways in which both birthing people and the possibility of consent itself may be invisibilised within care. The first theme, ‘invisible choice’ demonstrates the way in which the ability to consent itself can be invisibilised, either through opportunities to consent not being offered or being subsumed by a focus on apparent clinical risk. The second, ‘failing to be recognised as a person’, describes the way in which women in the studies were conceptualised as walking, talking risky objects, rather than people in their own right, with knowledge and experience which are a vital component of safe and holistic consent discussions. The third, ‘bodily integrity and boundaries’, examines consent failures in the most intimate of spheres: clinical vaginal penetration. In concluding, the chapter reflects on the relationships between consent and choice, and the tensions and complexities in asserting and supporting choice in care.

Consent is the golden principle that determines the legality of most medical treatment. However, whilst choice is the much-vaunted central tenet of maternity care, its importance emphasised in policy documents, the lived experience is often rather different, particularly in the case of individuals constructed as ‘other’. This collection brings together a range of researchers from multiple disciplines to address the issue of choice in the context of reproduction, focussing upon narratives of consent as they pertain to reproductive subjects who all too often are rendered invisible by the law, by the healthcare professionals treating them, or by society. It explores the contours of consent in England and Wales, engaging with reproductive justice by focussing upon the way in which reproductive subjects are othered, treated differently due to their skin colour, their genetic makeup, the fact that they have a serious mental illness or even those who do not want to be mothers. It presents original research, bringing together multiple perspectives in examining the way in which individuals are rendered invisible in the context of reproductive healthcare. The book will be essential reading for academics and professionals in law, nursing, medicine, midwifery, sociology, ethics and anthropology.

van der Pijl et al 1 argue that if ‘stakes are high’ and there is ‘clear conviction by the care provider’ that it is ‘necessary’, episiotomy may be given after ‘opt-out consent’. Here I caution against the applicability of their approach to vaginal examination (VE): another routine intervention in birth to which they suggest their discussion may apply. I highlight three concerns: first, the subjective and unjustified nature of assessments of ‘necessity’; second, the inadequacy of current consent practices in relation to VE; and third, the significant risk of perpetuating under-recognised harms associated with unwanted or unconsented VE. I argue that opt-out consent cannot be ethically justified for VE. Its use would result in further weakening of consent practices, circumvention of individuals’ autonomy, and greater harm for women and birthing people. At the outset, it is important to recognise that the authors do not claim that their approach should be applied to VE, merely that their discussion may have relevance to consent for other interventions beyond episiotomy ‘where consent is also frequently lacking, and which are under-researched’, including VE.1 Nonetheless, it is easy to assume that episiotomy and VE are sufficiently similar that their analysis might be transferred wholesale. I disagree. There are similarities: both interventions are performed on ‘the most intimate and socially sensitive body parts’1; …

This chapter outlines the experiences of non-consented vaginal examinations that women have shared with Birthrights and the Association for Improvements in the Maternity Services (AIMS). It gives a flavour of the issues that arise in cases brought to our attention, the impact on women who have to live with these experiences, and the lack of opportunity for proper redress faced by women. This chapter uses case studies to illustrate the experiences which lead women to seek support from AIMS and Birthrights. These are real case studies: real women. They are almost certainly the tip of the iceberg. As this chapter will show, one issue with vaginal examinations is that women oft en do not know that they can decline consent, and/or do not feel confident in doing so. Th ere are no statistics held on the number of women who experience non-consented vaginal examinations but, with a system that includes vaginal examinations within standard maternity care, Birthrights and AIMS are certain that many more cases exist than those which have come to our attention.

UK maternity policy makes great fanfare about providing person-centered care, built around what the pregnant woman or birthing person needs. Maternity Voices Partnerships involving healthcare professionals and women are supposed to guide policy and practice at the local level. UK consent law prioritizes the pregnant person's own conception of the risks and factors that are material to her care. The COVID-19 pandemic has shown how tenuous a hold these laudable principles actually have when the going gets tough.

Approaches to supporting autonomy in medicine need to be able to support complex and sensitive decision-making, incorporating reflection on the patient's values and goals. This should involve deliberation in partnership between physician and patient, allowing the patient to take responsibility for her decision. Nowhere is this truer than in decisions around pregnancy and Caesarean section where maternal autonomy can seem to directly conflict with foetal interests. Medical and societal expectations and norms such as the expectations of a ‘mother’, constraints of making decisions in an emergency, and the role of technology in viewing the foetus as a separate patient and surgery as a guarantor of results can all act to limit a woman's autonomy. In considering decisions about Caesarean section, maternal interests in bodily integrity can be dismissed as being less important than the foetus's own interests and the mother's duties to it, despite the inherent risks and impacts of such a major surgical procedure...