Brain dead and pregnant, what is
the prudent course?
Thirty-three-year old Marlise Munoz collapsed on her kitchen floor on Nov. 26 from what appeared to be a blood clot in her lungs. She suffered cardiac arrest. She was 14 weeks pregnant. She was not breathing for an unknown length of time, possibly as long as an hour. As a consequence, the fetus was severely harmed due to deprivation of oxygen. Medical records showed the fetus to be "distinctly abnormal."
Shortly after being admitted to John Peter Smith Hospital in Fort Worth, Texas, she was declared brain dead. Dr. Robert Fine, director of the Office of Clinical Ethics and Palliative Care at the Baylor Health Care System said, "Marlise is neither terminally or irreversibly ill. Under Texas law, she is legally dead."
There is nothing in Catholic teaching that contradicts the determination of death using the rigorous application of neurological criteria. These criteria include a complete lack of blood flow to the brain, the absence of any electrical activity in the upper and lower brain, the absence of cranial nerve response and the inability of the patient to breathe on his or her own.
The Texas Advance Directives Act, first passed by the Texas Legislature in 1989 and amended in 1999, prohibits withdrawal of life-sustaining treatment from a pregnant woman so as not to jeopardize the life of her unborn child. Twenty-four other states have similar laws.
The crucial issue is whether this law applies to pregnant patients who are brain dead, as opposed to those in a coma or a vegetative state. Peter Smith Hospital defended its actions of keeping Marlise on life-sustaining treatment by interpreting the law as applying to brain dead pregnant women. Dr. Jeffrey P. Spike, a professor at the McGovern Center for Humanities and Ethics at the University of Texas Health Science Center at Houston said that there were about 30 known cases of babies being born to women whose bodies were sustained after they became neurologically dead, what he called "posthumous motherhood."
In a study of a few dozen cases of continued pregnancies inside brain dead women, only one of the five fetuses that were between 13 and 15 weeks at the time of the mother's brain death was successfully delivered by cesarean section.
Marlise's husband, Erick, and her parents insisted that she did not wish to be kept on life support for any extended period of time. Erick indicated that medical records showed the fetus may have suffered from abnormalities and hydrocephalus, an accumulation of fluids in the cavities of the brain, as well as a possible heart problem.
They were stunned when they were told that the hospital was not going to comply with their instructions. Erick went to court in January and secured a judge's order ending the hospital's treatment for Marlise. Erick named the baby girl Nicole, his wife's middle name. Marlise was removed from all life support equipment on Jan 26.
A number of ethicists have weighed in on this case. Many have said that Marlise was a dead person serving as a dysfunctional incubator. She was an artificially maintained ecosystem, a mere vessel. Marlise's father, Ernest Machado, said that his daughter was merely a "host for the fetus."
Thomas W. Mayo, an expert on health care law and bioethics at Southern Methodist University Law School in Dallas, commented that the fetus was gestating within a dead and deteriorating body. "If she is dead, I don't see how she can be a patient, and I don't see how we can be talking about treatment options for her."
Arthur L. Caplan, director of medical ethics at NYU Langone Medical Center in Manhattan, similarly said, "The Texas Legislature can't require doctors to do the impossible and try to treat someone who's dead."
A number of people and organizations maintained that the true reason that Marlise was removed from life-sustaining treatment was due to the fetus' disabilities. This amounted to a "premeditated killing and execution of the child."
We must always act in a child's best interest in determining whether continuing medical treatment would be disproportionately burdensome on the patient. In this case, the mother was dead and the fetus was the patient. Nicole was removed from life support when the fetus was 22 weeks. A fetus cannot survive without receiving from his or her mother's oxygenated blood until the fetus reaches 23 or 24 weeks of gestation.
In light of this fact, I believe it would have been more prudent to continue treatment for Marlise until Nicole reached viability (at 24 weeks) and deliver her by cesarean section. Something we will never know is what Marlise would have wanted, and how Nicole's "abnormalities" might have affected Erick's decision to end treatment.
(Rev. Gerald D. Coleman, SS, is vice president for corporate ethics for the Daughters of Charity Health System.)
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