Hypothetical: Brain Dead Pregnant Woman

[Broomstick]

This is somewhat based on a recent news story, but I wanted to make it a more general question. Here's the scenario: A woman is pregnant. Something Terrible happens leaving her brain dead but otherwise pretty much intact. The question is, should life support be continued in an attempt to bring the baby to term, or at least viability, or should life support be discontinued.

Things to consider:

- whether or not the woman has stated her feelings about artificial life support, from "never, not under any circumstances" to "save my baby" to "don't ever unplug me".

- how far along is the pregnancy

- whether next of kin or the state should make this decision

- anything else you want to throw into the mix or used to qualify your answer.

[Flagg]

If she doesn't want life support under any circumstances then it's pretty clear cut, isn't it? I mean if we could do womb transplants or artificial wombs then I'd say you save the fetus, but for now...

[Wicked Pilot]

Normally my decision tree starts with written wishes of the mother. But, what was the likely hood she considered this happening during pregnancy? If there's no mention of pregnancy in her no life support clause, then I may jump that step and put the decision to next of kin, ideally the husband/father. They and the doctors can decide what's possible, and once the pregnancy goes to it's ultimate conclusion, then it's clear cut pull the plug time.

So thinking about a further branch on the tree, let's say the next of kin, husband in this case, and father are different people, how to handle? I'd say next of kin should have total say (en lieu of written guidance) on whether or not to continue pregnancy. Then if eventually a baby if born, then father gets custody if consistent with family laws in that jurisdiction.

Well, that's my thoughts after a whopping two minutes on considering the issue. Totally subject to change.

[Broomstick]

Honestly, I haven't really decided on this myself, but I had the the thought that if the women is brain dead then essentially she's gone. In that case, assuming this was a wanted child, wouldn't the interests of a living fetus then take precedence over a dead woman? Assuming pre-viability of the fetus, pulling the plug in this case is essentially an abortion. If the next of kin want the baby then shouldn't life support be maintained for the sake of the child?

But yes, once the pregnancy is over (however that happens) then it becomes a routine case of brain death.

[Thanas]

I think there is too little additional information here. Did she want children? Does the father want children? At what development stage is the child? Is there a social net in place to take care of the child (assuming there will be)?

[Broomstick]

What is your answer depending on the possible answers to your question? If the next of kin don't want the kid does the state nonetheless have an interest in maintaining the pregnancy if the government is pro-life? (And in that case, wouldn't the government be on the hook for all costs and for the kid afterward?) What if the next of kin does want the kid? What if this is in the US and the family wants the body maintained because they want the kid but can't pay for the life support? How is this different 12 weeks into a pregnancy vs. 30 weeks into a pregnancy when the child could be delivered immediately and maintained outside the womb, even if that's a premature birth? Would it be better even at 30 weeks to try to stretch the pregnancy out just a little longer?

[Thanas]

What is your answer depending on the possible answers to your question? If the next of kin don't want the kid does the state nonetheless have an interest in maintaining the pregnancy if the government is pro-life?

Depends on the laws on the book. Assuming this government is one of those insane "no abortion whatsoever" places then yes.

(And in that case, wouldn't the government be on the hook for all costs and for the kid afterward?)

One would think so but those places do not tend to take that responsibility.

What if the next of kin does want the kid?

With no information about the wishes of the mother then the information of the father should be good enough. Extend in that case.

What if this is in the US and the family wants the body maintained because they want the kid but can't pay for the life support?

Health insurance should cover it, if not then the state should cover it.

How is this different 12 weeks into a pregnancy vs. 30 weeks into a pregnancy when the child could be delivered immediately and maintained outside the womb, even if that's a premature birth?

I think it would result in different stages. If there is no brain activity yet then it obviously is not at the point where it could be considered a person. In which case I don't know if I would personally pull the plug with no additional information whatsoever.

Would it be better even at 30 weeks to try to stretch the pregnancy out just a little longer?

It would be, I would defer to medical opinion then.

[Eternal_Freedom]

OK, here's my decision tree on this:

1. Did the mother clearly state her wishes? If yes, follow them, if not, go to 2.
2. Decision passed to next of kin. If they say "pull the plug, let them go" then we pull theplug and plan the funeral, if he says "let the baby gestate long enough to be sustained outside the womb" then do so, when that point is reached revert to first option. If he says "let the baby come to term and deliver" then do so, then revert to first option.

I really don't see why this would be so complicated. Now, if you had stated that the father was unknown and the woman was unmarried/unattached, that would be more complicated as next of kin woudl be parents/siblings/whoever. In which case, follow the above tree anyway.

If there is no next of kin, that's harder, I would probably defer to medical opinion based on the state of the fetus and whether it was worth continuing.

[Broomstick]

It's not that it's hard or complicated, it's that I was interested both in what people thought about the topic and their line of reasoning.

I do find it interesting how many people express this as a decision tree.

[Eternal_Freedom]

I think that has more to do with who you are asking than the question. The majority of people (as far as I can tell) here are scientists of some sort, or have some scientific training, or at the very least follow something akin to the scientific method, and like to think things through first. A decision tree is a handy way to layout your options.

[Thanas]

I think that has more to do with who you are asking than the question. The majority of people (as far as I can tell) here are scientists of some sort, or have some scientific training, or at the very least follow something akin to the scientific method, and like to think things through first. A decision tree is a handy way to layout your options.

That is true.

An additional reason may also be that this is a specific question with a lot of variables instead of a basic premise like "should abortion be legal?".

[Broomstick]

I think it's interesting that instead of a blanket recommendation there is a problem-solving aspect being set up to account for variables.

[Eternal_Freedom]

It's a large and complex issue with many variables, that pretty much dictates that you have to think them through. Otherwise you'll state a position, someone will ask "but what about if xyz happens?" and then you have to stop and rethink. It's much easier and much clearer to have it all thought out at the start.

[Broomstick]

While that may be the case for the folks who tend to hang out here it is not, in my experience, how the average person works.

[Eternal_Freedom]

While that may be the case for the folks who tend to hang out here it is not, in my experience, how the average person works.

For better or for worse, SDN is most assuredly not comprised of "average people." If SDN residents were the average things wold (probably) be better than they are at present.

EDIT: Also, I think the medium has an effect. If you asked people this face-to-face, even most of the people here, you would get a different answer I think. Having it in text form forces you to think about and process the information as you go. It also makes it easier to look back at the situation to check what the variables are, rather than having to recall something you heard said only once.

[aussiemuscle308]

i don't know anybody who has been in that position. There was a movie i saw some years ago, basically the husband had to choose whether they should save the mother or the baby. he chose to save the mother (his wife) and when she regained consciousness, he explained they can 'have another baby'. The woman rejected his reasoning and lambasted him. She would have preferred to give her life to save that of her baby. I think in most circumstances, the mother would prefer their child to live.

[Terralthra]

I may be breaking trend here, but if the mother is provably brain-dead, her late desire to not be on life support is the last thing I consider. She's dead. The person that had those desires is gone. Fulfilling the requests of a dead person is low on my list of concerns, compared to saving a life that isn't actually, you know, over. My concerns would be the viability of the child, the desire for the child on the part of the surviving parent and his family, ability of that family to provide for the life support and for the child when/if it is born, and other practical concerns.

Only if all of those other concerns add up to "toss-up" does the opinion of the late mother come into effect. In all other cases, sorry, but she's dead. Her ghost does not get to take someone else with her to the grave if there's a viable alternative.

[Eternal_Freedom]

That is indeed a good point, and not one I had considered. I suppose following the person's wishes is kind of ingrained in us when thinking of medical questions.

In light of that, I will revise my initial decision tree:

1. Is the mother definitely brain-dead? If yes, go to 3, if not, go to 2.
2. Did the mother clearly state her wishes? If yes, follow them (which may lead to 3 anyway), if not, go to 3.
3. Decision passed to next of kin. If they say "pull the plug, let them go" then we pull theplug and plan the funeral, if he says "let the baby gestate long enough to be sustained outside the womb" then do so, when that point is reached revert to first option. If he says "let the baby come to term and deliver" then do so, then revert to first option.

[Omeganian]

Why is it hypothetical? Such cases are rare, but hardly unique.

[Broomstick]

Because rather highlight a specific case I wanted to present it as a more general ethical problem.

[PainRack]

I think the question needs a little bit of reframing from my point of view.

We know that the chances of carrying a foetus to term is impaired while on life support. The longer the mother is on life support, the worse off the chances of bringing a foetus to term successfully.

The actual considerations I will think of is if the family wants the baby to be bought to term and what is the chances of this being possible? The wishes of the mother regarding termination of life support doesn't factor in the pregnancy(at least, the AMD doesn't) and lastly, the AMD itself is merely a legal expression of the patient wishes. Its reasonable to believe that the pregnancy might have affected her decision to terminate life support if it means terminating the life of the foetus and as such, a consultation with the family should be done before such a decision is made.


What to me will be a real ethical kicker will be if said lady was a Jane Doe............

[Broomstick]

If you're talking about a Jane Doe with no known family... well, she's dead and I'm not sure she gets a say in all this. It then becomes a matter of whether or not society has an interested in preserving the life of the fetus/baby.

If the mother is near-term and the baby fully or almost fully developed I'd prefer to simply deliver the child early. Keeping mom on life support a week or two to give the baby a better chance isn't particularly onerous and could make a significant difference to the baby (Aren't there drugs that can be given to speed up certain developments, like the lungs, to greatly improve premature baby outcomes?). Where it gets complicated is earlier in the pregnancy, especially pre-viability. I could see a very heavily pro-life country or institution favoring maintaining the mother on life support. As an example, a Catholic owned and funded hospital might well do that as it would be consistent with their views. More of an issue where the person status of a fetus is more ambiguous.

[Kitsune]

Assume another case
Lets say she dies and she has a harvestable heart
She did not give permission to use her organs
In the next room, there is a four year old child who will die without a heart and they are out of time.
This heart matches and it the only one available.
Do you think the state should have the right to mandate the using of the heart
If not, why is the fetus special compared to the four year old girl?

[Borgholio]

Funny we should be talking about this:

http://www.usatoday.com/story/news/nati ... t/4476153/

FORT WORTH — A Texas man has filed a lawsuit against a Fort Worth hospital in an effort to remove his pregnant brain-dead wife from life support.

In the lawsuit, Erick Munoz's lawyers claim that keeping 33-year-old Marlise Munoz on life support is against her 14th Amendment right since she told loved ones she didn't want to be kept alive by a machine.

STORY: Texas hospital won't unplug brain-dead pregnant woman
STORY: Pregnant, brain-dead Texas woman kept alive

"The Fourteenth Amendment provides that no State shall 'deprive any person of life, liberty or property, without due process of law,; " the suit reads. "The principle that a competent person has a constitutionally protected liberty interest in making decisions regarding their own body began at common law."

The lawsuit further states since Marlise Munoz is brain dead, she "cannot possibly be a 'pregnant patient.' "

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.

“Erick Munoz vehemently opposes any further medical treatment to be undertaken on the deceased body of his wife. ”
— Lawsuit filed against John Peter Smith Hospital

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.

"Erick Munoz vehemently opposes any further medical treatment to be undertaken on the deceased body of his wife," read the lawsuit filed Tuesday in Tarrant County, Texas.

However, officials at John Peter Smith Hospital say it would be against the law to remove Marlise Munoz from life support based on Section 166.049 of the Texas Health and Safety Code.

"A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient," the code reads.

The cases of Marlise Munoz and Jahi McMath, 13, who was declared brain dead after suffering rare complications from a Dec. 9 tonsillectomy, have shone a spotlight on end-of-life issues. Jahi's family wanted to keep her on a ventilator, while the hospital she was in wanted to remove it. She was transported to a new facility where she remains on a ventilator.

STORY: Ethicists criticize treatment of teen, Texas patient

In Munoz's lawsuit, his lawyers cite Section 671.001 of the Texas Health and Safety Code:

"(a) A person is dead when, according to ordinary standards of medical practice, there is irreversible cessation of the person's spontaneous respiratory and circulatory functions…

(b) If artificial means of support preclude a determination that a person's spontaneous respiratory and circulatory functions have ceased, the person is dead when, in the announced opinion of a physician, according to ordinary standards of medical practice, there is irreversible cessation of all spontaneous brain function. Death occurs when the relevant functions cease."

"In the alternative, Section 166.049 is unconstitutional as applied to Marlise as a violation of the Fourteenth Amendment of the United States," the suit reads.

Both paramedics, the couple had extensive talks about life support, Munoz said.

Marlise Munoz's parents have backed up her husband's efforts to remove their daughter from life support.

"There was a lot of twinkle in our eyes and a lot of smiles and laughter, and not anymore," said Lynne Machado, Marlise's mother, in a WFAA-TV report on Jan. 8. "It's just barely getting through the day."FORT WORTH — A Texas man has filed a lawsuit against a Fort Worth hospital in an effort to remove his pregnant brain-dead wife from life support.

In the lawsuit, Erick Munoz's lawyers claim that keeping 33-year-old Marlise Munoz on life support is against her 14th Amendment right since she told loved ones she didn't want to be kept alive by a machine.

STORY: Texas hospital won't unplug brain-dead pregnant woman
STORY: Pregnant, brain-dead Texas woman kept alive

"The Fourteenth Amendment provides that no State shall 'deprive any person of life, liberty or property, without due process of law,; " the suit reads. "The principle that a competent person has a constitutionally protected liberty interest in making decisions regarding their own body began at common law."

The lawsuit further states since Marlise Munoz is brain dead, she "cannot possibly be a 'pregnant patient.' "

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.

“Erick Munoz vehemently opposes any further medical treatment to be undertaken on the deceased body of his wife. ”
— Lawsuit filed against John Peter Smith Hospital

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.

"Erick Munoz vehemently opposes any further medical treatment to be undertaken on the deceased body of his wife," read the lawsuit filed Tuesday in Tarrant County, Texas.

However, officials at John Peter Smith Hospital say it would be against the law to remove Marlise Munoz from life support based on Section 166.049 of the Texas Health and Safety Code.

"A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient," the code reads.

The cases of Marlise Munoz and Jahi McMath, 13, who was declared brain dead after suffering rare complications from a Dec. 9 tonsillectomy, have shone a spotlight on end-of-life issues. Jahi's family wanted to keep her on a ventilator, while the hospital she was in wanted to remove it. She was transported to a new facility where she remains on a ventilator.

STORY: Ethicists criticize treatment of teen, Texas patient

In Munoz's lawsuit, his lawyers cite Section 671.001 of the Texas Health and Safety Code:

"(a) A person is dead when, according to ordinary standards of medical practice, there is irreversible cessation of the person's spontaneous respiratory and circulatory functions…

(b) If artificial means of support preclude a determination that a person's spontaneous respiratory and circulatory functions have ceased, the person is dead when, in the announced opinion of a physician, according to ordinary standards of medical practice, there is irreversible cessation of all spontaneous brain function. Death occurs when the relevant functions cease."

"In the alternative, Section 166.049 is unconstitutional as applied to Marlise as a violation of the Fourteenth Amendment of the United States," the suit reads.

Both paramedics, the couple had extensive talks about life support, Munoz said.

Marlise Munoz's parents have backed up her husband's efforts to remove their daughter from life support.

"There was a lot of twinkle in our eyes and a lot of smiles and laughter, and not anymore," said Lynne Machado, Marlise's mother, in a WFAA-TV report on Jan. 8. "It's just barely getting through the day."FORT WORTH — A Texas man has filed a lawsuit against a Fort Worth hospital in an effort to remove his pregnant brain-dead wife from life support.

In the lawsuit, Erick Munoz's lawyers claim that keeping 33-year-old Marlise Munoz on life support is against her 14th Amendment right since she told loved ones she didn't want to be kept alive by a machine.

STORY: Texas hospital won't unplug brain-dead pregnant woman
STORY: Pregnant, brain-dead Texas woman kept alive

"The Fourteenth Amendment provides that no State shall 'deprive any person of life, liberty or property, without due process of law,; " the suit reads. "The principle that a competent person has a constitutionally protected liberty interest in making decisions regarding their own body began at common law."

The lawsuit further states since Marlise Munoz is brain dead, she "cannot possibly be a 'pregnant patient.' "

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.

“Erick Munoz vehemently opposes any further medical treatment to be undertaken on the deceased body of his wife. ”
— Lawsuit filed against John Peter Smith Hospital

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.

"Erick Munoz vehemently opposes any further medical treatment to be undertaken on the deceased body of his wife," read the lawsuit filed Tuesday in Tarrant County, Texas.

However, officials at John Peter Smith Hospital say it would be against the law to remove Marlise Munoz from life support based on Section 166.049 of the Texas Health and Safety Code.

"A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient," the code reads.

The cases of Marlise Munoz and Jahi McMath, 13, who was declared brain dead after suffering rare complications from a Dec. 9 tonsillectomy, have shone a spotlight on end-of-life issues. Jahi's family wanted to keep her on a ventilator, while the hospital she was in wanted to remove it. She was transported to a new facility where she remains on a ventilator.

STORY: Ethicists criticize treatment of teen, Texas patient

In Munoz's lawsuit, his lawyers cite Section 671.001 of the Texas Health and Safety Code:

"(a) A person is dead when, according to ordinary standards of medical practice, there is irreversible cessation of the person's spontaneous respiratory and circulatory functions…

(b) If artificial means of support preclude a determination that a person's spontaneous respiratory and circulatory functions have ceased, the person is dead when, in the announced opinion of a physician, according to ordinary standards of medical practice, there is irreversible cessation of all spontaneous brain function. Death occurs when the relevant functions cease."

"In the alternative, Section 166.049 is unconstitutional as applied to Marlise as a violation of the Fourteenth Amendment of the United States," the suit reads.

Both paramedics, the couple had extensive talks about life support, Munoz said.

Marlise Munoz's parents have backed up her husband's efforts to remove their daughter from life support.

"There was a lot of twinkle in our eyes and a lot of smiles and laughter, and not anymore," said Lynne Machado, Marlise's mother, in a WFAA-TV report on Jan. 8. "It's just barely getting through the day."

[Broomstick]

To be honest, that case was one of the inspirations for this thread.