Ethics of keeping brain-dead pregnant woman on life support

Wednesday, January 15, 2014

Good afternoon:

How can it be unethical to keep a brain-dead woman on life support but unlawful to disconnect a brain-dead pregnant woman from life support when both women are medically dead?

Erick Munoz filed a lawsuit yesterday against the John Peter Smith Hospital in Tarrant County, TX (Fort Worth) seeking an order directing the hospital to disconnect his brain-dead wife, Marlise Munoz, from life support. Under ordinary circumstances, he would not have had to file the lawsuit because the hospital would have disconnected her. These are not ordinary circumstances, however, because she was 14 weeks pregnant when she died and the hospital is claiming that it is prohibited by law from disconnecting her.

Section 166.049 of the Texas Health and Safety Code provides in pertinent part:

A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient.

Marjorie Owens, WFFA-TV, Dallas-Fort Worth has the story:

On the morning of Nov. 26, Munoz found his wife unconscious on the floor of the couple’s kitchen. Munoz said later that day he was told by doctors at John Peter Smith Hospital that his wife — who was 14 weeks pregnant with the couple’s second child — was brain dead.

Doctors told her family they suspect she suffered a pulmonary embolism.

Since then, Munoz has been in a battle with the hospital to remove his wife from life support. While tests on his wife’s fetus show a normal heartbeat, Munoz said it was against his wife’s wishes to be kept alive by a machine.

Doctors cannot determine the medical condition of the fetus until it reaches 24 weeks (it’s now at 18 weeks).

He argues that she is not a “pregnant patient” because she is clinically dead and he fears the health of the fetus was compromised by her death.

I agree.

Keeping a clinically dead woman’s lungs functioning on a ventilator so that a fetus can be brought to term in a decomposing body is too ghoulish to consider, except in Texas apparently, which ironically takes pride in executing people sentenced to death, including at least one wrongfully convicted innocent person.

This case reminds me of Jahi McMath, the 13-year-old brain-dead girl who died following surgery to correct sleep apnea by removing her tonsils, adenoids and other sinus tissue obstructing her airway. McMath was not pregnant, of course, and the hospital insisted on disconnecting her from life support over the strenuous objections of her mother, who went to court and obtained a temporary order that stopped the hospital long enough for the mother to find a place that would care for her daughter.

The hospital took the position that absence of brain activity constitutes “death” because there is no conscious awareness and the condition is irreversible. Therefore, the medical staff was ethically required to disconnect her from life support. Although the hospital initially objected to the transfer on ethical grounds, it relented and withdrew its objection conditioned on the coroner issuing a death certificate and serving as a paper middleman accepting possession of the body from the hospital and immediately transferring it to the mother who signed a document accepting full responsibility for whatever happened thereafter.

Meanwhile, Jahi’s brain is liquefying and her body is slowly decomposing on a life support machine at an undisclosed location.

These two tragic cases illustrate the importance of giving some careful thought to our own eventual death while we are “of sound mind and body.” I am referring to preparing a written “living will” that expresses our intent with regard to what we want or do not want done to us while we are alive, but unconscious and unable to communicate. For example, do we want to be resuscitated? A DNR order is an order saying do not resuscitate me.

I am not going to advise anyone about what to put in a living will. That’s for you to figure out. There may be legal requirements that have to be satisfied in your jurisdiction to have a valid living will, so you should consult a lawyer before you make one.

No discussion of end-of-life issues is complete without discussing assisted suicide.

Three states (Vermont, Oregon and Washington) have passed laws permitting physician assisted suicide. One state (Montana) has legalized physician assisted suicide by a court decision. Physician assisted suicide is unlawful in the rest of the states and the District of Columbia.

I believe every person has an inherent right as a conscious organic life form to a humane means of assisted suicide.

The issue that inevitably arises is how should we deal with the eligibility issue?

Should we ignore it?

Must a person be at least a certain age before they are eligible?

How about mental competence? Must they be competent to make the decision? Who decides? According to what standard?

Can someone else, such as a husband or a wife or a family member, make the decision for an incompetent person? For example, someone on life support or someone suffering from dementia or Alzheimer’s?

Should a change-your-mind minimum period for reflection be mandatory?

What about seeing a counselor?

If counseling is required, what qualifications must a person have to become certified as an assisted-suicide counselor?

Should religious counseling be part of the process?

What about the process itself? Big party first? Should hallucinogens be a part of the process? What about choosing among a number options? Cost?

What about starting a business that specializes in helping people plan their demise and the ethics of creating legally enforceable contracts with monetary damages for changing your mind?

And so on.

What do you think?

For more information on assisted suicide and euthanasia, go here.

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This is our 853rd post in 26 months. Yesterday, we had 650 visitors, over 1500 page views and only one donation.

Fred

22 Responses to Ethics of keeping brain-dead pregnant woman on life support

  1. breelee says:

    The “baby” went through the same lack of air, shocks and meds mom did. The baby is not well, if alive at all. Let them both go in peace.

    • towerflower says:

      The baby is indeed alive and they have been monitoring a heartbeat since this started. Not all meds are dangerous to a fetus and we don’t really know what the mother has been given.

      But I found this on the American Heart Association and a section on pregnancy and using a defibrillator : “There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus.”

      But no one, not even the husband knows how long she went without oxygen but from everything I have seen, it was only the mother they gave a defibrillator to and nothing was done to the fetus.

  2. towerflower says:

    I disagree, he is a story of a 15 week pregnant woman who was kept alive after brain death in order to deliver her baby.

    http://www.dailystar.co.uk/real-life/350927/Life-after-death-Dead-woman-gives-birth-to-baby-and-saves-four-other-lives

    Afterwards the mother was also able to still donate several organs to save 4 people.

    I feel the baby should be given a chance, the mother is not suffering.

    • Rachael says:

      I believe that is fine if that is what you want. But it is not what she wanted and it is not what her husband wants and it is up to him. Not you not me not the courts.

      • towerflower says:

        I agree that she did not want to be on life support but she also made those feelings known before she was pregnant and nothing was ever said about what to do if this happened while pregnant. I can’t imagine many mothers not wanting to give their baby a chance at a full life.

        My feelings are to the baby and giving the baby a chance at life. After the baby is born then fulfill the mother’s wishes.

        But like you said it isn’t up to you or me.

    • Lyn says:

      Thank you. Agree totally. What is the rush to “pull the plug?” Babies are a blessing, a gift from G-d. I, too, think it should be given a chance, Donating organs, which I hope is possible is also a gift to the sick and needy. What’s with the husband wanting to kill mother and baby?

      • Lyn says:

        Thanks again Towerflower.

      • Rachael says:

        Interesting how you bring G-d into this – when it is convenient for YOU. There is an old Jewish joke about when life begins:

        A rabbi, a priest and a minister are discussing when life begins. The priest says: “In our religion, life begins at conception.” The Minister says: “We disagree. We believe that life begins when the fetus is viable away from the mother’s womb.” The rabbi responds: “You both are wrong. In our religion life begins when the kids graduate college and the dog dies.”

        Anyway, if you believe that G-d has anything to do with this, then you know that G-d “called this woman to be with Him,” as you people would say. You are keeping that baby from being with his/her mom and G-d by playing G-d with man-made machinery that lets a dead person become an incubator until he/she can be out in the world. Who are YOU (I don’t mean you personally, but you collectively that feel it is your place to put a corpse on life support) to act as G-d? Where is your concern for her life? She is disposable after she has served her purpose? If you so believe in G-d, let this baby AND the mom go and be with G-d now.

        I hate to bring religion into this, especially after yelling at you and saying leave G-d out of this, as this is more about modern machinery and nothing to do with G-d, but maybe I am looking at this from my religion in which that “baby” has a potential for life, but is not yet a life. In my religion, G-d is on the side of life. The life of the mother is gone. The baby is potential, but NOT life. The baby cannot live away from the mother. What you are proposing, in my relgion, is against G-d. G-d’s relationship was with the woman, not the unborn child. According to my religion, the baby is not viable until it can breath on it’s own, away from his/her mother. In fact, it is so written in the Bible that life begins with the first breath. After G-d *formed* man in Genesis 2:7, He “breathed into his nostrils the breath of life and it was then that the man became a living being”. Although the man was fully formed by G-d in all respects, he was not a living being until after taking his first breath. There are many other references to breath in the Bible.

        So anyway, as far as I’m concerned, IF you are going to bring G-d into this, you really need to look at what G-d wants, not what YOU want.

      • Allison says:

        Wow, I have been arguing with myself about posting anything concerning your last sentence. ” What’s with the husband wanting to kill mother and baby?” He did not kill the mother, which is also his wife, she died on her own, no one could save her. Do you truly in your heart believe that this man wants to kill his baby? Since you brought God into this, I am pretty sure that is a pretty harsh judgement for you to make when this man has just lost his world and is trying to do what is right. You do not know what his relationship with God is.

        To make such a statement as accusing him of wanting to kill his wife and baby is way out of line and highly offensive.

    • gblock says:

      I wonder if the organ transplants would have taken place if this case had occurred in the US, given the complications (sepsis, etcetera) between the time of brain death and the time that the organs became available. Seems to me like this would have been seen as being likely to cause problems. for the potential transplant patients.

  3. Malisha says:

    Whose legal medical release are they using for treatment? Of which person is that release allowing treatment? If they’re “treating” the deceased mother I would think they need her husband’s release at this point in time; if they’re “treating” the foetus I would think they need the father’s release since the mother is dead. Does State law allow them to treat without a release?

    • aussie says:

      State law seems to say a pregnant patient can’t be taken off life support. Nothing about releases. I imagine it would apply if a pregnant woman was found brain injured unconscious on the street with no ID and they don’t know who she is or her relatives are.

  4. aussie says:

    Imagine a situation where a woman is 7 or 8 months pregnant. The fetus is well and truly viable. If she becomes brain dead, they simply do a C section and save the fetus.

    What at 6 months? what at 5? at 4? when another month in the womb would vastly increase the chance of survival?

    I bet this law came about as the result of someone suing a hospital to NOT turn off support when there was a 4-month or so fetus involved, the family not wanting to compound losing the woman with also losing the much-expected child.

    There are several cases of a healthy baby resulting from the brain-dead or PVS mother being kept ventilated etc long enough for the fetus to become viable.

    • gblock says:

      There are cases in which keeping a woman’s body functioning may make sense in terms of significantly improving the likelihood of a good outcome for the baby. Because of the early stage of this pregnancy and therefore the length of time that the woman’s body would have to keep functioning in order to get a good outcome, this is not one of them.

      • aussie says:

        They’re not aiming for 9 months. Probably planning a C section around the 6 or7 mark if it goes that long.

        I think they just said “pregnant” to avoid arguments about precisely how many weeks in any particular case. I do believe the law was designed to stop doctors pulling the plug in more advanced cases, where the family wanted the child to have a chance. This case I can understand. Something/someone good might come out of it. The Jahi case I can’t — the mother’s actions are mind-boggling. Nothing good for anyone can come out of it.

        • gblock says:

          aussie, in the Texas case, that would still mean at least an additional 3 months gestation. That’s a long time to keep a brain dead body “alive”.

  5. JJ says:

    “A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient.”
    If the woman is legally dead, then you cannot sustain her life. Also, what is the definition of “patient”.
    According to the hospital’s interpretation of the law, a DNR or any other instrument to direct them to take her off life-support would not be honored.
    It is troubling that patients & family are powerless in many medical situations – intimidation by doctors to follow orders; and hospitals make decisions without compromise.

  6. Malisha says:

    If that foetus is a person I’d like to know who has custody. And who will be responsible for the medical bills for that person?

  7. bettykath says:

    The rights of the fetus trump all in some states. I don’t see the hospital having much choice given the law. Legislators seem more and more to betaking on the role of medical practitioners without the training or knowledge.

    I believe the soul of the fetus, if it had already entered its body, left with hers.

  8. William Walton says:

    Prof, my Dad’s decision would be let nature take it’s course. The wonen is brain dead. As a young person I witnessed an autopsy that Dad performed on an idividual who had been buried in a mousleum and when they opened the casket, he found the body was beganing to decomcospe. The undertaker asked if he wanted to take it to the hospital and he said Hell No. Sent an assistant back to the hospital to retrieve the instuments needed and bring back. Dad’s comment was that the brain was the sofest tissue in the body, could not be embalmed, and was the first tissue to break down after death. This tissue along with bacteria will then slough down into the rest of the body and initiate further decomposition. So, this case would render, what bactertial infection/infections have infected the fetus.Therefore, let her and the fetus pass and Rest in Peace.

    • Malisha says:

      Their effort to keep this woman’s body “alive” is a way of the hospital authorities saying she is not a person and she is not a woman because as a person and as a woman she is dead. They are saying that she is a vessel for some other person who has not BECOME a person yet. She is being kept — not “alive” but “corporeally functioning” not as a person but as a vessel.

      It’s terribly revealing. The husband should not be put through this horrible torment. The state has seized the body of a dead woman, labeled it a “patient,” and chosen to convert it into an incubator for a foetus that is, itself, not a “patient” either.

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