Few precedents exist in case of brain-dead pregnant woman
01/23/2014 6:06 PM
11/12/2014 3:47 PM
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.
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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