The following consent form was developed by a mother* after repeatedly being denied VBAC care by the Obsetricians in her area. This woman's brilliance and tenacity astounds me. Would your OB think differently if he/she were on the receiving end of one of these consent forms? Very likely.
I, the undersigned physician, have, in violation of the Consumer Bill of Rights and Responsibilities, the Emergency Medical Treatment and Active Labor Act, the Patient Self Determination Act, the ethical guidelines of the American Medical Association and the American College of Obstetricians and Gynecologists, Constitutional Law (the right to privacy and self determination protected by the 1st and 14th amendments), international tort law, and case law (of particular interest "In re A.C.", 1987, "In re Fetus Brown, 689 N.E.2d 397, 400 (Ill. App. Ct. 1997)", and "In re Baby Boy Doe, 632 N.E.2d 326 (Ill. App. Ct. 1994)") and the Patient Rights as determined by this institution, deprived my client,________________, of her right to self determination and her right to bodily integrity by ignoring her repeated refusal for delivery by repeat cesarean section. I acknowledge that by refusing to honor my client's denial of consent, I have not only violated the above laws, but I also affirm that I have used unwarranted and unethical pressure including emotional threats to my client's and her unborn child's life and safety, in my attempts to obtain such consent. I further affirm that I have stressed the risks of vaginal birth after cesarean, but neglected to inform my patient of the risks of delivery by repeat cesarean section. I further affirm that I understand, that should I resort to physical force, including but not limited to physical or chemical restraints, to compel my client's cooperation, I will be guilty of criminal battery, which is defined as "any form of non-consensual touching or treatment that occurs in a medical setting".
In compensation for the above violations of my client's rights, I hereby guarantee the following:
- a healthy baby, born in perfect condition, with no physical, mental or developmental defecits whatsoever, whether arising from surgery or any other cause
- no complications for the infant, including but not limited to: persistent pulmonary hypertension, transient tachypnea of the newborn, respiratory distress syndrome, iatrogenic prematurity, lacerations, or hematoma
- a speedy, uncomplicated post-operative recovery for my client. Specifically, I guarantee that my client shall not experience nerve damage, organ damage, hemorrhage (whether sufficient to require transfusion or not), disability or disfigurement, intraoperative or postoperative infection of the wound or surrounding skin and tissues, post partum depression and post partum post traumatic stress disorder (PTSD), and other conditions not listed here.
Signed,
_______________________________________________
*with a blessing from the author, please feel free to use, distribute, or copy this form with the instructions below
For internet posts please link back to the author here: http://gisellestotalwasteofbandwidth.blogspot.com/2009/05/different-kind-of-consent-form.html
For use in the classroom setting or other print-out, please credit "T.G. Perg".
And don't forget to leave plenty of kudos and Thank You's in the comments section below for the author of this brilliant consent form.
Hey Gina- I just followed this link from a HS classmate on Facebook- I saw your blog name and thought, "Wow- I think that's Gina." You must have a big following now!
Katy (from ivillage)
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