Medical Support for
Brain Dead Pregnant Women
On February 8, 2015 Karla Perez, aged 22, complained of a severe headache before falling unconscious at her home in Omaha, Nebraska. At Methodist Women’s Hospital doctors diagnosed her as having suffered an intracranial hemorrhage and, after testing, they determined that she was brain dead.
Karla was pregnant. The fetus was 22 weeks old and too young to survive outside the womb. The members of the Perez family urged the doctors to do everything possible to save the unborn child.
Medical support was provided to Karla’s body to allow the fetus to continue to develop. After 54 days Karla’s body began to shut down, and a C-section was performed to deliver the baby. Baby Angel was placed in the NICU, and was stable with no signs of complications. (1, 2)
Medical support for the body of a brain dead pregnant woman (technically called “somatic support”) may include such measures as use of a ventilator, tube feeding, maintenance of normal body temperature, and drugs for blood pressure, infections, and other medical conditions. (3) Will such somatic support forthe body of a brain dead pregnant woman always succeed in
bringing her child to birth? If a pregnant woman suffers brain death, is there a moral obligation to try to sustain her bodily functions to allow the pregnancy to continue? Can a woman say that she doesn’t want this?
Ethical Considerations
In the Catholic tradition, the embryo/fetus is regarded as a human being with a right to life who is entitled to medical care and treatment. As stated in the Instruction on Respect for Human Life in its Origin and On the Dignity of Procreation from the Vatican Congregation for the Doctrine of the Faith:
Thus the fruit of human generation, from the first moment of its existence, that is to say from the moment the zygote is formed, demands the unconditional respect that is morally due to the human being in his bodily and spiritual totality. The human being is to be respected and treated as a person from the moment of conception; and therefore from that same moment his rights as a person must be recognized, among which in the first place is the inviolable right of every innocent human being to life. This doctrinal reminder provides the fundamental criterion for the solution of the various problems posed by the development of the biomedical sciences in this field: since the embryo must be treated as a person, it must also be defended in its integrity, tended and cared for, to the extent possible, in the same way as any other human being as far as medical assistance is concerned. (4)
Thus in considering somatic support for a brain-dead pregnant woman, there are two patients to consider: the mother and the fetus.
In the Catholic tradition, there is a moral obligation to use medical treatments that offer a reasonable hope of benefitanddo not entail an excessive burden. On the other hand, a person may morally forgo those medical treatments thatdo not offer a reasonable hope of benefit orentail an excessive burden. (5)
The brain-dead pregnant woman, as dead, herself receives no benefit from continued somatic support. If, assessing the medical condition of the fetus, there is a reasonable possibility that, through continued somatic support of the brain-dead mother, the fetus can be brought to birth and in a condition in which s/he can survive, then continued somatic support of the brain-dead mother offers a “reasonable hope of benefit” for the fetus. This was the case with Karla Perez and her baby Angel. On the other hand, if the fetus would not survive to the point of viability or would be “born dying,” then there does not seem to be benefit for the fetus to continue the pregnancy through somatic support for the mother. For example, a case occurred in Ireland in 2014 in which a court rule that somatic support could be removed from a brain dead pregnant woman whose body was becoming a lethal environment due to infections, fungal growths, fever and high blood pressure; doctors judged that the 18 week old fetus could not survive for the additional period of development needed to be delivered safely. (6) Decisions about starting, continuing, or stopping somatic support for a brain-dead pregnant woman in view of the life of the fetus must be made on a case-by-case basis in accord with the medical condition of mother and fetus.
Are there any “excessive burdens” associated with providing somatic support for a brain-dead pregnant woman? Since the woman, as dead, is incapable of having any experiences at all, it is difficult to see how the somatic support could be burdensome for the woman herself. It is true that there is considerable emotional stress for family members of the brain-dead pregnant woman and for her caregivers in awaiting delivery of the child and watching the deterioration of the woman’s body. (7, 8, 9) However, it is not clear that this stress would constitute an “excessive” burden if there is a reasonable possibility that continued somatic support for the mother will have the good outcome of birth of a child.
Some have raised the concern that continued somatic support for a brain-dead pregnant woman violates her human dignity and turns her as a mere “incubator,” disposable after use. (10) On the other hand, providing somatic support for a brain-dead pregnant woman in order to bring the fetus to birth can be seen as a way of bringing good out of a tragic situation (11), and as an act of a mother’s love for her child. For example, the grandmother of baby Angel Perez commented: “Thank God. He’s doing very well. He’s growing and I’m very happy about it. I come to see him every day. I get him dressed, I give him baths, I change him, I hold him. I have no words for the attention and how they took very good care of my daughter.” (12)
Patient autonomy is a value much emphasized today. Suppose that a woman would not want her brain-dead body subjected to continued somatic support with the accompanying deterioration of her body, but would wish immediate burial. In the name of autonomy, can her wishes completely trump the interests of the fetus if she is pregnant when suffering brain death?
Relevant to answering this question is a statement in the Ethical and Religious Directives for Catholic Health Care Services: “The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching” (13; italics added). The point to note is that patient autonomy is limited by the principles of Catholic moral teaching. Thus the woman needs to take into account the status of the embryo/fetus as a human being with a right to life who is entitled to medical care, and the benefits and burdens principle which governs decisions about using/forgoing life-sustaining treatment. A blanket refusal of somatic support in the case of brain death during pregnancy would not be morally justified. The benefits and burdens principle must be applied on a case-by-case basis.
Legal Perspective
The Code of Iowa Chapter 144A Life-Sustaining Procedures establishes a living will for the state known as a Declaration Relating to Use of Life-Sustaining Procedures. This document gives instructions that life-sustaining procedures not be used if the person signing the document is suffering from an incurable or irreversible condition that will result either in death within a relatively short period of time or a state of permanent unconsciousness. However, the law has a “pregnancy exclusion” clause:
The declaration of a qualified patient known to the attending physician to be pregnant shall not be in effect as long as the fetus could develop to the point of live birth with continued application of life-sustaining procedures. [144A.6]
A “qualified patient” is defined as a person “who has been determined by the attending physician to be in a terminal condition” [144A.2]. A “terminal condition” is defined as “an incurable or irreversible condition that, without the administration of life-sustaining procedures, will, in the opinion of the attending physician, result in death within a relatively short period of time or a state of permanent unconsciousness from which, to a reasonable degree of medical certainty, there can be no recovery” [144A.2]. Thus a “qualified patient” is someone who is still alive. Hencethe stipulation suspending a living will in the case of a pregnant womanmay not legally apply if the woman suffers brain death.
If this is the case, then it is possible that a case could occur in which somatic support for a brain dead pregnant woman ought to be provided from a moral point of view but would not be legally obligatory and not legally guaranteed. For this reason, women of childbearing age are encouraged to add instructions (such as the following) to their advance directives regarding their wishes about somatic support in the case of pregnancy and brain death:
I recognize the embryo/fetus as a human being with a right to life who is entitled to medical care and treatment. If I should suffer brain death while pregnant, I wish my body to be given medical support to allow the pregnancy to continue as long as there is a reasonable possibility that the child could develop to the point of live birth (including delivery by C-section) through such medical support of my body.
If I should suffer brain death while pregnant, continued medical support should NOT be given to my body if, to a reasonable degree of medical certainty, the child would not develop to the point of live birth through such medical support of my body. The child may be allowed to die naturally in my body.
If I should suffer brain death while pregnant and continued medical support of my body has been initiated in order to allow the pregnancy to continue, such medical support of my body should be stopped if it becomes clear, to a reasonable degree of medical certainty, that the child would not develop to the point of live birth through such medical support of my body. The child may be allowed to die naturally in my body.
Notes
1. Darren Boyle, “Brain dead woman gives birth to miracle baby after doctors keep her alive on a ventilator for seven weeks – then allow her to pass away.” Daily Mail 30 April 2015. Accessed July 2016.
2. Elahe Izadi, “Woman delivers baby 54 days after being declared brain dead,” The Washington Post May 1, 2015. baby. Accessed July 2016.
3. Abuhasna Said, Al JundiAmer, Ur Rahman Masood, Abdallah Dirar, and ChedidFaris, “A brain-dead pregnant woman with prolonged somatic support and successful neonatal outcome: A grand rounds case with a detailed review of literature and ethical considerations,” International Journal of Critical Illness & Injury Science 3/3 (July-Sept 2013): 220-24.
4. Congregation for the Doctrine of the Faith, Donum Vitae – Instruction on Respect for Human Life in its Origin and On the Dignity of ProcreationI.1 (1987). Accessed July 2016.
5. United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services, 5th ed., nos. 56-57 (2009). Accessed July 2016.
6. CBC News, “Brain-dead pregnant woman taken off life support after Irish court decision.” December 26, 2014. Accessed July 2016.
7. David J. Powner and Ira M. Bernstein, “Extended somatic support for pregnant women after brain death,” Critical Care Medicine 31/4 (2003):1241-49 at 1247.
8. Jeffrey Spike, “Brain Death, Pregnancy, and Posthumous Motherhood,” The Journal of Clinical Ethics 10/1 (Spring 1999): 57-65 at 60.
9. Anita J. Catlin and Deborah Volat, “When the Fetus is Alive but the Mother is Not: Critical Care Somatic Support as an Accepted Model of Care in the Twenty-First Century?” Critical Care Nursing Clinics of North America 21 (2009): 267-76 at 272.
10. Christoph Anstotz, “Should a Brain-Dead Pregnant Woman Carry Her Child to Full Term? The Case of the ‘Erlanger Baby’,” Bioethics 7/4 (July 1993): 340-50 at 344-46.
11. Joao P. Souza, Antonio Oliveira-Neto, Fernanda GaranhaniSurita, Jose G. Cecatti, Eliana Amaral and Joao L. Pinto e Silva, “The prolongation of somatic support in a pregnant woman with brain-death: a case report,” Reproductive Health 3/3 (27 April 2006): 1-4 at 1, 4.
12. Darren Boyle, “Brain dead woman gives birth to miracle baby after doctors keep her alive on a ventilator for seven weeks – then allow her to pass away.” Daily Mail 30 April 2015. Accessed July 2016.
13. United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services, 5th ed., no. 59 (2009). Accessed July 2016
Medical-Moral Commission of the Archdiocese of Dubuque July 2016.
This document may be reproduced.
1