Background Caesarean section on maternal request (CSMR) is a complex ethical issue. Sweden is an intriguing case for studying CSMR due to its restrictive policy that curtail women autonomous choice regarding the mode of birth, despite overall policy developments aiming to strengthen patients' rights, promote person-centred care, and adopt a more individualized approach. This study aims to understand how the tension surrounding CSMR is manifested in Swedish media. An ethical principles approach is used to investigate what image of CSMR is created and conveyed to the public and what main arguments are used for and against CSMR. Methods This study covers news media and specialist press material in Sweden between March 2019 and March 2024. Searches were carried out in Retriever Research and resulted in 188 search hits. The content analysis had both an inductive and a deductive approach based on Beauchamp and Childress's four ethical principles: respect for autonomy, non-maleficence, beneficence, and justice. Results The analysis reveals a struggle in Swedish media over how to approach CSMR, touching on all ethical principles. Regarding autonomy, the debate focuses on whether CSMR is a medical decision about non-indicated surgery or a private choice. In terms of non-maleficence-which is the health professionals' main concern-the media highlights conflicts over interpreting risks associated with caesarean section and vaginal birth. Beneficence involves a tension between portraying vaginal birth as healthy and normal versus caesarean section as a method to protect sexual and bodily function. As regards justice, CSMR is portrayed as a challenge to the fundamental needs-principle in the healthcare system. Conclusions Ultimately, the ethical principles approach to analyzing the media portrayal of CSMR in Sweden highlights the need for decision guidelines and practices that are more open to a woman's own evaluation of different risks while also encouraging critical reflection on the underlying factors shaping treatment preferences for both women and healthcare professionals.