Marlise Munoz Case Study

Mrs. Munoz’s parents said they wanted to see the law overturned, but they have not sought any legal action against the hospital, though they have not ruled it out either.

The hospital maintains that it is following the law, although several experts in medical ethics said they believed the hospital was misinterpreting it. A crucial issue is whether the law applies to pregnant patients who are brain-dead as opposed to those in a coma or a vegetative state. The law, first passed by the Texas Legislature in 1989 and amended in 1999, states that a person may not withdraw or withhold “life-sustaining treatment” from a pregnant patient.

Mr. and Mrs. Machado said the hospital had made it clear to them that their daughter was brain-dead, but hospital officials have declined to comment on Mrs. Munoz’s care and condition, creating uncertainty over whether the hospital has formally declared her brain-dead.

A spokeswoman for the J.P.S. Health Network, the publicly financed hospital district in Tarrant County that runs the 537-bed John Peter Smith Hospital, defended the hospital’s actions. “In all cases, J.P.S. will follow the law as it applies to health care in the state of Texas,” the spokeswoman, Jill Labbe, said. “Every day, we have patients and families who must make difficult decisions. Our position remains the same. We follow the law.”

Ms. Labbe said that neither she nor the doctors could answer questions about Mrs. Munoz’s condition because her husband had not signed the paperwork allowing them to speak to the news media about his wife’s care.

At least 31 states have adopted laws restricting the ability of doctors to end life support for terminally ill pregnant women, regardless of the wishes of the patient or the family, according to a 2012 report from the Center for Women Policy Studies in Washington. Texas is among 12 of those states with the most restrictive such laws, which require that life-support measures continue no matter how far along the pregnancy is.

Legal and ethical experts, meanwhile, said they were puzzled by the conflicting accounts of her condition. Brain death, an absence of neurological activity, can be readily determined, they said. It is legally death, even if other bodily functions can be maintained.

“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,” said Thomas W. Mayo, an expert on health care law and bioethics at the Southern Methodist University law school in Dallas.

Arthur L. Caplan, director of medical ethics at NYU Langone Medical Center in Manhattan, agreed. “The Texas Legislature can’t require doctors to do the impossible and try to treat someone who’s dead,” Mr. Caplan said. “I don’t think they intended this statute the way the hospital is interpreting it.”

Critics of the hospital’s actions also note that the fetus has not reached the point of viability outside the womb and that Ms. Munoz would have a constitutional right to an abortion.

The restrictive measures were largely adopted in the 1980s, with the spread of laws authorizing patients to make advance directives about end-of-life care like living wills and health care proxies, said Katherine A. Taylor, a lawyer and bioethicist at Drexel University in Philadelphia. The provisions to protect fetuses, she said, helped ease the qualms of the Roman Catholic Church and others about such directives.

“These laws essentially deny women rights that are given others to direct their health care in advance and determine how they want to die,” Ms. Taylor said. “The law can make a woman stay alive to gestate the fetus.”

In Texas, the law and the hospital’s efforts to abide by it have drawn support among opponents of abortion. “The unborn child should be recognized as a separate person,” said Joe Pojman, executive director of Texas Alliance for Life. He added, “I would say that, even if she were brain-dead, I would favor keeping treatments going to allow the child to continue to survive, with the hope the child could be delivered alive.”

Jeffrey P. Spike, professor of clinical ethics at the University of Texas medical school in Houston, said there were some known examples of fetuses having been kept alive while a terminally ill or brain-dead mother was on a respirator. But in every case he knew of, he said, those steps were in line with the family’s wishes.

Mrs. Munoz’s parents and her husband, Erick Munoz, 26, remain in limbo, even as they and other relatives help care for the Munozes’ 15-month-old son, Mateo.Mr. Munoz has returned to his job as a firefighter but continues to sit by his wife’s side at the hospital. She had been due to give birth in mid-May, but the hospital’s plans for the fetus — as well as its health and viability — remain unknown. Mr. Machado said he had been told by the hospital’s medical team that his daughter might have gone an hour or longer without breathing before her husband woke and discovered her, a situation he believes has seriously impaired the fetus. “We know there’s a heartbeat, but that’s all we know,” he said.

Mrs. Machado said the doctors had told her that they would make a decision about what to do with the fetus as it reached 22 to 24 weeks, and that they had discussed whether her daughter could carry the baby to full term to allow for a cesarean-section delivery. “That’s very frustrating for me, especially when we have no input in the decision-making process,” Mr. Machado added. “They’re prolonging our agony.”

On Tuesday afternoon, in the rural community about 30 minutes outside downtown Fort Worth where they live, Mr. Machado and his wife took care of Mateo while the boy’s father was at work in Crowley. As he held Mateo in his arms, Mr. Machado recalled touching his daughter’s skin as she lay in the hospital.

“She felt more like a mannequin,” Mr. Machado said. “That makes it very hard for me to go up and visit. I don’t want to remember her as a rubber figure.”

Continue reading the main story
Correction: January 9, 2014

An article on Wednesday about a Texas woman kept on life support because she was pregnant misspelled the given name of a lawyer and bioethicist at Drexel University who discussed the ethics of the hospital’s decision. She is Katherine A. Taylor, not Katharine.

In the 1990s, medical ethicist Jeffrey Spike was part of a hospital team that wrestled with another case of a brain-dead pregnant woman on life support. She was kept alive for 100 days, and a healthy baby boy was eventually delivered by cesarean section.

That case, which did not occur in Texas and is one of the few of its kind recorded in medical journals, was among the most difficult of Spike’s career.

“Some of the national reporting on the Fort Worth case is making it sound like this is just those crazy Texans and abortion,” said Spike, now a professor of clinical ethics at the University of Texas Health Science Center at Houston. “But when I think of that other case, there were the same mixed feelings, people on both sides of the issue, even in a different state and more than 20 years ago.”

He referred to the case of Marlise Muñoz, 14 weeks pregnant when stricken by a fatal embolism Nov. 26 and sustained by artificial means at John Peter Smith Hospital ever since.

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The life support has been undertaken against the wishes of her family. The reason, hospital officials have said, is a 1999 state law requiring a woman in her condition to be sustained until the fetus is viable, usually at 24 to 26 weeks of pregnancy.

The case has generated international headlines and a wrenching series of medical and ethical questions. Adding to the murky nature of the case are its rarity and a lack of medical precedent.

That makes it hard to predict the chances that a healthy baby will be born to a brain-dead mother, Spike said.

Today marks the 59th day that Muñoz has been on life support. That means support would have to be sustained for 70 to 90 days to give the baby the best chance for survival.

While there have been cases in which viable babies were born to brain-dead women on life support that long, they are few.

“There are only one or two [recorded] cases that have lasted as long as what you would hope for your Fort Worth patient,” Spike said Thursday. “One, two or three cases over 20 years. … Instead of saying boldly, ‘We’re going to do this,’ we should be saying, ‘We don’t know if it’s even possible.’

“I would say we won’t have any scientific evidence one way or the other,” Spike said. “In a situation like that, I would call it high risk, and it’s not the kind of decision a doctor should feel comfortable making for the family.”

Before she was stricken, Muñoz and her husband had agreed that they did not want to be kept on life support if something ever happened to them.

On Wednesday, lawyers for the family issued a statement describing the fetus as “distinctly abnormal.”

“The lower extremities are deformed. … It also appears there are further abnormalities,” it said.

Besides Spike’s case, a 2010 study by medical researchers in Heidelberg, Germany, found numerous cases in which viable babies were delivered after periods of life support for women sustained by artificial means.

In a survey of international medical literature from 1982 to 2010, the German researchers found 19 cases of brain-dead women who were put on life support for the purpose of sustaining the fetus. Twelve viable infants were born and survived the neonatal period, the study said.

“According to our findings, prolonged [life] support can lead to the delivery of a viable child,” the study said. “Such children can develop normally without any problems resulting from their intrauterine conditions.”

The authors added, however, that “the number of cases is too small to define the rate at which intensive care support of the brain-dead mother can result in a healthy infant.”

Much also depends on individual circumstances, including periods of oxygen deprivation, gestational age at the time of brain death, and the age of the mother, experts say. In the German study, only three women were sustained as long as would be necessary in Fort Worth. One woman was on life support for 71 days and two others for about 100. Apparently healthy infants were born to all three women.

The German researchers also acknowledged the ethical and moral conundrums presented by these cases.

“Some professionals believe it is not ethically acceptable to maintain the mother’s body after [brain death] to use it as a ‘fetal container,’ ” the study said. “Such a decision should not be simply assumed, but it must be debated. If the mother is to be considered a ‘cadaveric incubator,’ the rights of the fetus should prevail.”

The condition of the woman’s body while on life support only adds to the complexity, Spike said. In the 1990s case, the baby born after 100 days is still doing well today, he said. But the period of gestation was horrific.

“When trying to make a decision about keeping a brain-dead mother on life support for 100 days, it’s good to realize that there is going to be a gradual process of death and decay that will become more and more obvious,” he said. “Even in the first week, when it looks like she’s sleeping, it gets worse and worse and it’s going to get harder and harder for the family to visit.”

The medical staff in the 1990s case was deeply divided.

“In fact, after an informal survey, the opinion of the nursing staff was split close to 50-50,” Spike wrote in 1999. “While everyone found treating a corpse disconcerting, and even macabre, half found it adequately justified by the goal of a healthy baby.”

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