Consent in labour: beyond the legal aspects and epidurals: a reply

We are grateful to Impiumi and Kearsley for their comment [1] on our article [2]. As they rightly remind us, consent is the legal device to give effect to patient autonomy. We agree that the vexed question of whether any or all consent provided by a woman in labour can be said to reflect a genuinely autonomous choice-making consent process merits much more comprehensive attention; we are actively considering expanding this across a range of decisions.

Recognising and responding to capacity concerns is a significant consideration. However, we consider the absence of a consensus on capacity entirely appropriate and in line not only with the statutory provisions of the Mental Capacity Act 2005 (England and Wales), but also with patient-centric care per se. We would be extremely concerned if a consensus view were ever to be proposed. Not surprisingly, the appreciation of capacity issues among healthcare professionals working in areas outside neurology is limited [3] and we do think there may be merit in providing more opportunities for healthcare professionals in the obstetric setting to undergo explicit training in capacity.

The ethical tension created between the desire to relieve pain and respect autonomy in a person whose decision-making capacity may be questionable is undoubtedly challenging, both professionally and personally. We wonder whether it may be worthwhile to reconsider our professional understanding of autonomous decision-making to allow for a less binary approach. For example, David Enoch refers to autonomy in two senses: as sovereignty, signifying the act of making a final decision; and as non-alienation, reflecting a decision-making process which accords with a woman's core values and commitments [4]. If the clinical record contained some explicit indication of a woman's values this might be a way to start thinking about a more authentic consent process. Building on this pragmatically we share the view that there is a need to improve ways of fostering discussion in advance of decisions which a woman might need to make during labour. Designing and tailoring such discussions to make them helpful and meaningful to individual women is a profound challenge which goes beyond mere information provision. Control and a sense of agency are more strongly related to women's positive reports of birth experience than are specific details of the birth experience [5], so optimising the design of such advance discussions is a challenge which should not be ignored.