Defensive Medicine is a Symptom of a "Risk Society"
Saturday, January 15, 2011 at 9:29AM
By Amy Tuteur, MD
The conventional wisdom about defensive medicine is that it is caused by doctors and happens to patients. I’d like to propose an alternative view: defensive medicine is “caused” by all of us and doctors are merely responding to our expectations. Defensive medicine appears to be about protecting doctors from liability, but it’s really about protecting patients from any and all risk.
According to Wikipedia:
Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited as the driving force behind defensive medicine…
Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances.
What about defensive medicine in obstetrics?
Consider the explosion in the rate of C-sections and inductions. They satisfy the requirements of assurance behavior.
Reducing adverse outcomes? Check.
Deterring medical malpractice claims? Check.
Pre-empting liability? Check.
Consider the precipitous decline in the rate of VBAC. That’s avoidance behavior: malpractice insurers have forced providers and hospitals to refuse to participate in VBACs.
There’s an important subtext that undergirds defensive medicine that often goes unrecognized and therefore unanalyzed. Defensive medicine is driven by the fact that we live in a “risk society,” a society that is organized around a new understanding of risk.
There have always been risks, of course, but they have traditionally been viewed as outside the control of human beings. The risk society has arisen because of new beliefs that we can and (especially) that we should control every aspect of risk.
In our risk society, we are obsessed with the risk of auto accidents and outfit our cars with ever more airbags and safety features. We are obsessed with risks to our children, and restrict their play outdoors and their independence, and we are obsessed with illness and death, literally passing laws to control personal habits like smoking.
How does the “risk society” impact obstetrics? We have become obsessed with the perfect child, and we construct ever more elaborate requirements to ensure that everything we do contributes to the perfect outcome.
There have always been risks in childbirth. Indeed, it has traditionally been the leading cause of death of babies, and one of the leading causes of death of young women in every time, place and culture. The “risk society” demands that we do everything possible to reduce those risks to zero.
Lay people often conceptualize risk as a dichotomy: an individual is either low risk (it won’t happen) or high risk (it will happen). But that’s not how risk works. Risk exists on a continuum; the risk varies from individual depending on a complex interaction of numerous factors. What’s the risk that a baby will die of group B strep meningitis? That depends on the presence of GBS in the mother’s genital tract, the exposure of the baby when delivered, and the presence or absence of antibiotics. We can determine the risk of GBS meningitis in large populations, but for the individual woman who carries GBS, we cannot predict the risk that her infant will be infected.
What does this have to do with defensive medicine? Consider that in our risk society we are supposed to reduce our risk to zero. How do we do that? We do that by acting to reduce risk regardless of how small the risk might be.
That represents an entirely new approach. Until the advent of the risk society, we determined which tests and procedures to use by establishing a risk threshold. For example, we know that the risk of stillbirth begins to rise in the last weeks of pregnancy (from about 36 weeks onward). The risk of stillbirth begins to increase precipitous at 42 weeks. So we arbitrarilyestablished the risk threshold for postdates induction at 42 weeks.
Lay people, with their dichotomous view of risk, tend to imagine that there is no risk of stillbirth prior to 42 weeks, and there is a risk of stillbirth after 42 weeks. But the reality is that risk exists on a continuum. Defensive medicine can best be conceptualized at lowering the risk threshold. In the case of induction, the risk of stillbirth starts rising long before 42 weeks. Since the risk society mandates that we reduce risk to zero, doctors feel they have no choice, but to offer postdates induction to women by 41 weeks, or even 40 weeks. That’s really the only way to reduce the risk to zero.
This is a critical point. Lay people imagine that defensive medicine offers no benefits to patients and is undertaken solely to protect doctors, but that’s not a complete picture. Defensive medicine is simply lowering the risk threshold. It benefits patients in that the risk of a particular outcome (like postdates stillbirth) is reduced as far as it can be reduced.
So what’s wrong with defensive medicine? Defensive medicine rests on the premise that we must do things to reduce risk. It completely ignores the risks posed by doing things. But that’s not only a feature of defensive medicine, it is a feature of every aspect of a risk society.
Yes, we make cars safer by putting in more safety features, but we increase the price of cars. Yes, we reduce the risk of kidnapping if we don’t let our children play outdoors, but it’s not good for children to grow up cowering inside their houses. Yes, we reduce the risk of illness when we pass laws regulating private habits, but we also reduce freedom. And when we do more inductions for postdates we lower the risk of postdates stillbirth, but raise the risk of C-section.
In our risk society, though, we apparently don’t care. We consider ourselvesrequired to reduce risk to zero, regardless of the other risks or costs that increase as a result.
Where does that leave us in regard to defensive medicine?
First, we can see that defensive medicine is not the use of tests and procedures on people who don’t need them. It’s lowering the risk threshold for using tests and procedures that we previously reserved for higher risk individuals.
Second, defensive medicine is not really a medical issue, but rather a societal issue. As a society, we need to give up the idea that we can and should reduce all risk to zero. We need to recognize that there are negative consequences to reducing risk, as well as positive ones. Most important, we need to figure out how much risk we are willing to tolerate. Zero risk is not achievable, and the price for attempting to achieve it can be very high.
What does this mean for birth activists?
It means that blaming doctors for defensive medicine not only isn’t working, but it can’t work. It means recognizing that low risk is not no risk and that, therefore, doctors need guidance on what patients believe is acceptable risk. And most of all, it means deciding, as individuals in a risk society, what trade offs we are willing to accept in order to reduce risk.
Amy Tuteur, MD, is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. skepticalob.blogspot.com
Reader Comments (174)
You are blaming the victim. Stop it. If you truly believe that patients can force doctors into doing more caesareans than are necessary, then you must admit that obstetricians can be forced into doing home births by patient preference also. You are completely wrong.
Obstetricians are trained primarily in doing surgery. That is what they do best. That is what they like to do. That is their answer for all of women's problems. So if a woman does not want surgery, then she should stay away from surgeons.
My three critiques with this post:
1) There is no substantiation of the claim that “lay people” have a dichotomous view of risk. The rest of the argument is predicated on this assumption.
2) The post flat out ignores that the “defensive medicine” is defined and self-reported as being practiced to protect the physician (or institution) from liability and this renders the tone of the post farcical.
3) The term “risk society” is attributed to German sociologist Ulrich Beck and the description and motivation of a risk society used here, namely about how a risk society wishes to reduce risk to zero, diverge from Beck’s work. In fact, Beck’s work more aptly reflects the views of a birth activist or critic of modern medicine in that a “risk society” engages in what he calls reflexive modernism—that is, continuously evaluating the latent side effects of this “modern” technology and managing and distributing the risks that result from its use.
Other than that, it’s spot on, in my opinion and an example of solid common ground.
At first glance I thougth this article had a reasonable point of view. Then when I got to the bottom of it I saw who the author was. I changed my mind. Dr. Amy is wildly against home birth, natural birth, unmedicated birth. She only believes birth is a dangerous event to be managed as completely as possible. She posts on midwifery, childbirth and related sites all the time. Always, blaming women who want to have a triumphant birth for being irresponsible.
Though there is some truth in the article above, I now realize that it is just another in her long list of writings that try to expand medical involvement in birth, and make a case for banning women from choosing their own birth methods.
While I continue to despair in your tendency to define people as medical professionals (With Knowledge) or lay people (Without Knowledge), I'm going to actually have to agree with a lot of what you said here. Frankly, I wish you wrote like this more often. I do believe that a lot of defensive medicine originates with professionals promising more than they can truly promise, as Dr. Dorn described. However, I know that my partner and I had to decide what level of risk we were comfortable with in birthing our children. We, personally, feel the risks are higher at the hospital and were willing to accept the smaller risks of home birth. I think first, though, we had to accept that there are risks - everywhere. I don't think that they are generally as high or as many as often tossed about, but they do exist.
I do have a question, though. You state that the risks of stillbirth increase far before 40 weeks, but that induction at 41 or even 40 weeks is "the only way to reduce the risk to zero." May I assume that this is some license, as obviously the risk is not zero, even if all women were induced or sectioned at 40 weeks?
Also, how do you suggest that we begin? Would one way not be to change the way providers speak to patients? And do you not think that OBs-as-primary-maternity-providers encourages the idea we should reduce the risk to zero (by placing all pregnancies under the purview of a specialist)?
Bonnie: I understand that it may be difficult given her tendency towards inflammatory statements, but I think Jill was absolutely correct in bringing this post, because we can't move forward with reading and critiquing all viewpoints.
Bonnie, I was pleased to post this here, not because I agree with all of it but because I think it's worth judging on its own merit.
This post ignores history. Obstetrics was built on the promise of a live and perfect baby, which they can't deliver (no one can, but no one makes promises like obstetricians, either), and are now crying Fred, as a trained-to-believe population now hold obstetricians accountable for their lack of purported divine powers.
OB's only started doing VBACs in the late 80's after Ester Zorn, Nancy Wainer, and numerous homebirth midwives, supported women who made the once-a-cesarean, always-a-cesarean, look like a fool's edict. Taken from midwives care and the home into the obstetrical/hospital institution, VBACs were tampered with and drugged, resulting in a few disasters--that is what caused ACOG to limit VBACs (never seeing that medical managing obstetrics was the inducing risk factor), and insurance and hospitals followed the trade Union. And most of the docs wanted to be home by 6 anyway.
Interesting post!
I have thought for a while now that the (perhaps mythical, as we've seen in this series of posts) high rate of obstetrical malpractice suits and the resulting aggressively defensive medicine were a consequence of this story that we tell women: the story that the hospital is the only safe place to deliver your baby, and consequently, if you deliver in the hospital, it will be safe. It seems like part of this must have originated when doctors were initially working hard to discredit midwives and get all women into hospitals. But now we really believe that if anything goes wrong in a hospital, it must be the doctor's fault.
This post points out to me that this mindset doesn't exist in a vacuum. Yes, doctors may have pushed this view that nothing really awful (i.e. death of mom or baby) will happen in the hospital, but they have probably been pushed to that by a society that demands that doctors make birth risk-free!
I think that this post is good because it points out that there is an acceptable level of risk that we all can take on, and indeed do take on in our daily lives. Whether that's letting our children walk a few blocks by themselves, or making our own choices about birth, or even just going along with our doctor. We can accept that "yes, there is a small risk here, and I'm okay with that," and make those "risky" (oooh!) choices, and still be responsible people. And from the perspective of the defensive medicine issue, it would be good if (a) everyone accepted that there are risks inherent in birth and sometimes things just go wrong, awful as it is, and (b) if doctors could accept that a woman is truly conscious of the risks and let her make her own choices without harassment.
"You are blaming the victim."
My whole point is that is the wrong way to look at this and it's wrong on several different levels. First, defensive medicine is not about performing random test and procedures. It's about performing specific tests and procedures that would have been used only for women at a high risk of a bad outcome, but now used for everyone.
Second, everybody's beliefs about risk has been transformed. This is particularly apparent in mothering where mothers are now responsible for monitoring all risks that might impact their children: What's in the food? Will they be kidnapped when they go outside? Will vaccines help them or hurt them?
As a society we have lowered our willingness to tolerate risks and doctors are affected by this change just like everyone else.
"1) There is no substantiation of the claim that “lay people” have a dichotomous view of risk. The rest of the argument is predicated on this assumption."
It's well described in the risk literature but I can provide cites if you'd like.
I, personally at least, would appreciate those citations regarding the dichotomous view of risk.
"This post ignores history. Obstetrics was built on the promise of a live and perfect baby, which they can't deliver (no one can, but no one makes promises like obstetricians, either), and are now crying Fred, as a trained-to-believe population now hold obstetricians accountable for their lack of purported divine powers."
This is one of the things that all doctors despair about. We don't promise perfection; no human being can promise perfection. But people expect perfection any way. Why? Because it is too scary to contemplate that our lives are in the hands of fallible human beings.
What obstetricians can promise is that we can dramatically lower the neonatal and maternal mortality rare dramatically and we have done that.
I have to say Dr. Amy, you can be back in the band, but you're only playing the tambourine for now.
I think I am about to enter the dragon as it pertains to the wave of criticism I may face for my comments here. Well what the hell I'll assume the risk.
here is what I agree with here:
"I’d like to propose an alternative view: defensive medicine is “caused” by all of us and doctors are merely responding to our expectations. Defensive medicine appears to be about protecting doctors from liability, but it’s really about protecting patients from any and all risk."
This is essentially why I think I have left my three births feeling like they absolutely sucked. I wanted my providers to somehow magically make it risk free, delightful, and awesome.
I believe the curent stat. for stillbirths and I am not entirely sure which stat. that is (my ob quoted this) is hovering around 6 per 1,0000. I personally imagine that it is more like 10 per 1,000. per hospital birth and I seriously believe the margin of error is larger than is reported and shown. With the way stats. are developed and reported we still have a while in my opinion before we ever have real time stats.
Tail can wag about home birth, but as a result of the bullcrap checkerboard legality of home birth in America we have no baseline about what the real stats. are with regard to still birth- so we rely on a study or two here and there that preaches to the choir about the safety of home birth, but we cannot at this time say definitively whether or not American home birth is safe in any percentage because we have no stats. Only disasters are reported, and sensationalized, but I invite anyone to talk to bereaved parents who lose a newborn in the hospital setting, there are plenty of them, they just get marginalized by this society because no one will accept the facts that seemingly uncomplicated pregnancies end tragically. If obstetricians spent their visits explaining to a newly pregnant patient all the risks and percentages of how, where and why pregnancies end tragically, we would not have proliferated. everyone would be terrified to give birth.
Dr. Amy you are correct (this one time and that is conditional, I may always and forever remain one of your academic critics)
When I agreed and allowed a hospital birth and I signed on for the care of my obstetrician. I literally signed on for what I hoped is a zero risk experience. This is impossible. People refuse to believe it, but I tip my hat here to Dr. Henry Dorn and Barbara Hererra for telling people- yes, babies do die at birth. You could be that 1 in 100, in a hospital, it could be no fault of your own or the doctors, or it could be the doctor or hospital midwive's fault and it will be reported the same way. The grieving family will be left to sort out the mess.
We don't know the actual stats. for home birth so you have less guarantee there. Anyone who lulls themselves into thinking that a home birth is somehow safer or carries less risk than a hospital birth is whistling in the dark. Births happen at home, they happen at birth centers, that replicate home that are not on the campus of hospitals and as I like to say home birth opponents cannot explain the mundanity of the normal birth at home, they can only explain the incidence of death. Make no mistake but there is no uniform baseline- is it 1 per 100? 2 per 100? 3 per 100? We don't know, so we cannot say or extrapolate out the true safety or dangerousness.
It is not a feat against nature as the obstetrical community would like us all to believe that someone delivers safely, and vaginally, as a regular, twins, breech or hbac at home. Birth has evolved from being the guaranteed death trap it was before the turn of the century, see Brought to Bed by Judith Leavitt for details, to safe-er. As Susan Jenkins recently noted here: (paraphrasing) No state that has passed regulations regarding home birth has rescinded their laws.
And I agree- doctors try to provide us with a zero risk experience, and they assume the risk of your care. They assume it all- so unfortunately I and anyone else has to begin to understand that if I want to attain a zero risk birth, I may have to hand over my autonomy so that I can get the best odds possible and this Amyquote is rather insightful: "doctors need guidance on what patients believe is acceptable risk." Consumers could not in their wildest imagination say across the board, well a newborn born with a traumatic brain injury,(that I will pay for for a lifetime) or a stillbirth sounds like a reasonable risk to me. where do I sign? Herein lies the conundrum. Again paraphrasing the brilliant Susan Jenkins when she recently noted here: if you are a libertarian with regard to health care then okay, but otherwise, I want to know who is delivering the babies in my state and I want to know what their training is so I can be safe-er. Whether I think a person's choice of birth or decision to risk factor is sound or foolish is not my call to make- but there is no zero risk in birth.
I think I see some good common ground here. I also think this came at a really good place in the series, when it's easier for us to accept that the blame for defensive medicine is something that needs shared, and doesn't rest entirely on doctors' (or the medical establishment's) shoulders.
I think it's important to understand one basic truth though, that I don't think Dr. Amy (feel free to correct me if I'm wrong, but this is my impression from the article, and other articles you've written) believes. In the case of deciding the risk of outdoor play for children, the roles of the individuals are very different. In that case, I am the parent, and my sons are children. It is my job to both teach them to be Independent, and make decisions for them that they are not yet mature enough to make. I know my three-year-old will not run out in the street if he plays in the yard, so I feel comfortable reading a book while he plays. My 18-month-old, on the other hand, runs directly to the street, and so I decided (for him) that he can only play in the front yard if the gates are closed and secured so he can't escape. It's my job as a parent to protect and teach my children.
The relationship between a doctor and a patient does not resemble the relationship between a parent and a child. To suggest as much, as I believe the article does, is both arrogant and insulting. The doctor and the patient are two adults. Regardless of her level of education, the patient is mature enough to make decisions for herself. It is not the doctor's job to decide how much risk, or which risks are appropriate for that mother to take upon herself. It is the doctor's job to inform the mother of the risks and benefits of various options, then to offer a professional recommendation. Then the MOTHER decides what she is willing to do/endure.
That's not what's happening today. Critical information is being withheld, risks of a preferred procedure are being downplayed and risks of another course of action are being exaggerated. That kind of behavior is appropriate for parents to use on very young children (stories of the boogy man, etc.), but not right for doctors to use on their patients. I think the "dichotomous risk" view is actually PERPETUATED--if not created--by doctors in this way. You know I was actually told that having a cesarean would carry NO risk into future pregnancies (except that I would have to have all cesareans from then on). I knew it was a lie when I heard it, because the question I asked was intended to lead into a discussion about possible placental problems in future pregnancies, but that is where the "dichotomous risk" view comes from, not from perceived uneducated, ill-informed "laymen."
Very well written. I appreciate your explanation. You are clear and to the point. Even childbirth has become so foreign that hardly any women even know anything about birth even when they are pushing.
We as a society need to quit diafying our doctors, and understand that they have their own motivations to their behavior and method of practice. The individual should be the main decision maker when it comes to healthcare, and that power should not be handed over to any disinterested third party.
I have heard of dozens of cases where a woman gets care from an OB, and then wonders why they cannot have a natural childbirth. Well, duh, thats what they do (high intervention hospital childbirth). I kinda wish women were told this during the initial consult.
"Congratulations, now here is how I see this going down........"
But I heard far too many times:
"Don't worry about a thing, I have done this many times"
And I am sure you know my backstory, and even after all I went through with this hospital about honesty and patient autonomy, The doctors are telling their patients with past cesarean "Well lets schedule your section....... Well you have to." No information, No referrals to places that can handle a TOLBAC, just "You have to"
And that plain sucks.
But I do know where they are coming from. And I understand they do not wish to lose clients.
"if doctors could accept that a woman is truly conscious of the risks and let her make her own choices without harassment."
My personal view is often caricatured, but, reality it's very close to this. Women have the right to make whatever choice they want about childbirth as long as they understand the risks. The problem is that the philosophy of NCB is not honest about the risks. "Trust birth" rests entirely on the notion that the risks of childbirth are trivial, and they're not. "Some babies die" presumes that these deaths will never be preventable so we shouldn't bother to try.
I have seen my share of bad outcomes among homebirth and NCB advocates, and though the details vary from case to car, but one thing is always the same: the mother invariablely says, "I didn't understand that this could happen.
I think it is commendable that Jill reached out to Amy to participate in this series. The internet allows all of us to be shrill and closed-off to new ideas, so this attempt to find common ground is very encouraging. I have really enjoyed reading this series, even, perhaps especially, those I didn't agree with, because I think it is always a good thing to question your own biases and assumptions and try to understand others' points of view.
I have read many of Amy's comments and posts on other sites, so I'm quite familiar with her perspectives on birth. While I disagree with her on many points -- in particular the demonization of women who choose to pursue natural birth (while there is certainly extremism in every movement, Amy paints with far too broad a brush) and her minimization of the risks of obstetrical interventions such as epidurals -- I pretty much agree with this post. It is Americans' unwillingness to accept any risk of mortality, however small, that has contributed substantially to the way the practice of medicine has evolved in the past thirty years or so. This is true for all areas of medicine, not just obstetrics. There has been a growing resistance to this trend among a minority of doctors, patients, writers, and activists, but it has not yet become mainstream. There is a lot of money in highly interventive, risk-averse medicine, and considerably less money in pulling back from that approach.
Another way to articulate at what Amy is saying is that there is demand on the patient side for the way obstetricians assess risk and recommend interventions even where risks are small. That demand does not come from the women who frequent this site, as most of us look at risk in a more holistic/expansive fashion, but it is out there and it is probably the more prevalent way of looking at risk -- the idea that doing something is better than doing nothing, and especially that if there is any risk of death, no matter how slight, it is always better to intervene than to watch and wait. I expect that many women would say that they would accept risks to themselves and their future pregnancies (of a probably-unnecessary c-section, for example) if doing so would avert a very tiny risk of perinatal death. That is not my view for myself, but I can't say it is wrong for someone else. Each woman has to assess risk in the way that makes her most comfortable. And so, I guess, does every OB and midwife. The best we can do may be to provide mothers with information and choice of care provider, and allow them to assess the risks as they see fit and choose a provider who is on the same page.
I do wonder whether there is any way to avert lawsuits through more honesty upfront about the impossibility of reducing risk in pregnancy and birth to zero. How does the OB community feel about such an approach? Is potential liability preventing it? (E.g., patients will go to a competitor who will promise them a perfect outcome).
I think this post is spot-on, and in a vacuum would agree pretty much 100%. As it is NOT in a vacuum, I take issue with the fact that the Dr. makes many of her points playing up the very thing she describes here. I completely agree with the issue being our society's failure to understand risk assessment (as a pro-vaccination, car-seat-paranoid, libertarian, pro-science, pro-free-range-kids, anti-helicoptering, natural birthing attachment parent, I realize I am not easily typecast and sometimes can understand both sides for that reason). I just wish that we could look at risk in a more sane way in our culture, and I don't think comment fights about homebirth being a death trap add to that discussion. I'd add more but the kids are antsy. I have loved this discussion though, thank you everyone for a week of amazing posts.
"What obstetricians can promise is that we can dramatically lower the neonatal and maternal mortality rare dramatically and we have done that."
Really? So why then do we rank lower than over 3 dozen countries in results... many of them being countries that don't utilize doctors for birth except when it is truly needed?
I also have to agree that it sounds like you are blaming the victim. It's what the patient demands so it's what has to be offered... that is the feel I get of what you are saying. So if that's how it works then why don't doctors support women when they choose other methods, when they don't want the interventions, when they want to do things differently then the norm. I think if everything you are saying in this article is accurate & if this is truly the cause (therefore, we, as women, are just as much to blame as the doctors) then why isn't the natural childbirth & homebirth movement having better results. Why are we insulted, coerced & belitted so often for 'not caring about the life of our child', when in reality we do... we have weighed our options, weighed the pros & cons & decided which set of risks we are willing to accept. We don't claim that natural childbirth & homebirth is risk free... we say that compared to the fighting & interventions & insane rate of c/s (and all the RISKS that go along with those interventions & c/s), the risks of something going wrong at home are easier to take and our odds are better that nothing major will go wrong.
"Really? So why then do we rank lower than over 3 dozen countries in results... many of them being countries that don't utilize doctors for birth except when it is truly needed?"
We don't.
The US has one of the lowest perinatal mortality rates in the world, lower than Demark, the UK and the Netherlands.
I think most others have expressed my thoughts eloquently. Most importantly, as Jill articulated it, this is not exactly about "defensive medicine" in its agreed-upon definition, it's about risk-averseness in general. This doesn't fall only to the [painting with broad strokes here] patients, who expect perfect babies. It falls also to the doctors who expect to be held blameless in the event of maloccurrence. There has to be some give on both sides, and the post ends with a start at that.
In a sense, yes, I agree that we have gotten ourselves into this mess. On the whole, we are more risk-averse than I prefer, and our ability to assess risks, just from a cognitive perspective, is notoriously limited. My concern, as a feminist sensitized to privilege and power disparities, is the uneven way in which this plays out in the doctor/patient relationship. We may have unrealistic expectations or poor assessments of risk, but that doesn't mean that we want to be "saved from ourselves" either. I can't speak for all women, but I know that what I want is the ability to pick my battles, and manage my OWN risks. My prenatal care provider is not the one responsible for that, they are a resource who can help me make those calculations. I know that I have been branded with the "NCB advocate" label in the past, but the truth is that what I believe is very far from that. I'm not a "trust birther" -- I've definitely been jumped on by the Mothering crowd for my beliefs. Some babies die, and some of those deaths may be preventable with maximal intervention, but the ultimate decision is in the hands of the patient who needs to come to the decision both with eyes open, and with all the information. Because of the power dynamic, patients are both vulnerable to the oversell ("we will make it all okay") and to coercion when things are going the way that the doctor isn't comfortable with.
Unfortunately, I think that the socialization process of medical school may leave practitioners with a skewed sense of their "rightness" and their entitlement to power over the patient. So much of it, from the way we do medical school to the fact that hierarchical structure is reinforced at virtually every turn in a medical setting (I've been asked to put on a gown when I came in with a suspected concussion. I said no.) is set up to make it clear that some people are the Deciders, and others aren't. Lest we think that doctors aren't making overblown claims about their capabilities, recall that episode of The Doctors where Lisa Masterson basically said "just do what I say, we'll take care of you." But whether a doctor is scientifically correct about a particular risk or condition is really irrelevant when it comes to what happens to another person's body and their experience of it.
On the whole, there is a lot of criticism of women perceived to be sacrificing babies for their birth experience -- I am certain that somewhere you understand that "experience" is not just about scented candles or medals for unmedicated delivery, but about being treated with dignity, about being with a provider one trusts to have her best interest in mind, and about being able to manage the situation in whatever way she needs to. It is about being able to determine one's own values and act on them, and to live with the consequences of those decisions. It's about trusting women to make their own decisions, even if they are bad decisions. While it may put doctors in a stressful position to see their clients doing things that may hurt them (as a lawyer, I deeply empathize) I suspect that women who feel as though they were the primary decision makers are unlikely to sue.