By Mike Appleton, Weekend Blogger
In 1882 a man named John Kirchbaum submitted a patent application for a device which, when properly attached to a coffin, permitted the presumed deceased person to communicate to those on the surface that the burial had been premature. That someone would consider the erroneous pronouncement of death sufficiently common to support a market for such products strikes one as peculiar today, but the fear of possibly being buried alive was genuine in the 18th and 19th centuries. Until quite recently, after all, a determination of death was made solely by observation. Was the subject breathing? Did he have a heart beat? Under the common law, death was in fact defined as the irreversible cessation of circulatory and respiratory functions.
But in the 20th century two revolutions in medical technology changed attitudes and definitions. The first was the invention of the mechanical ventilator, originally intended to help patients breathe during surgery. The second was the development of anti-rejection drugs and their impact on the science of organ transplantation. The medical community quickly came to realize that continuing to provide oxygen to a deceased person greatly improved the viability of organs needed for transplant purposes. These advances created an obvious ethical and legal dilemma. A living person may agree to donate a kidney to save another’s life because we have two of them. However, other vital organs may only be removed upon the donor’s death. And if respiration is maintained to preserve organs after the donor has “died,” what has happened to our traditional definition of death? How can a person be deemed deceased if his or her breathing is being mechanically maintained?
The answer to the dilemma was the concept of “brain death,” the irreversible cessation of all functions of the entire brain. In 1968 a study committee at the Harvard Medical School created a set of guidelines indicative of what was termed “irreversible coma”: the persistence over a period of 24 hours of a set of conditions including absence of spontaneous breathing or movement, fixed and dilated pupils, unresponsiveness and the absence of reflexes. Twelve years later the National Conference of Commissioners of Uniform State Laws proposed the Uniform Determination of Death Act, which defines death as either “(1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.”
The Uniform Determination of Death Act was approved by the AMA in the fall of 1980 and by the ABA early the following year. Since then it has been adopted by 37 states and the District of Columbia. Of the remaining states that have not formally adopted the UDDA, most have incorporated its definition of brain death into their statutes. It is clearly the prevailing law on the issue in this country.
And that brings us to the case of Marlise Munoz.
In November of last year, Mrs. Munoz was discovered lying unconscious on her kitchen floor. She was rushed to the John Peter Smith Hospital in Fort Worth, where doctors were unable to revive her. She was placed on a ventilator and tests confirmed that she has no brain function. Although a pulmonary embolism is suspected, the precise cause of her condition is not yet known. Under Section 671.001 of the Texas Statutes, a person is dead when “there is irreversible cessation of the person’s spontaneous respiratory and circulatory functions.” When those functions are being mechanically maintained, death is determined by whether “there is irreversible cessation of all spontaneous brain function.”
According to her husband and her parents, Mrs. Munoz had discussed end-of-life issues with her family and it was her wish that she not be connected to life-support equipment if her condition were irreversible. The family has requested the hospital to disconnect the equipment, and the hospital has refused. Why? Because Mrs. Munoz was 14 weeks pregnant at the time of her hospital admission, and the Texas statutes governing advance care directives contains Section 166.049, which provides that “A person may not withdraw or withhold life-sustaining treatment under this sub-chapter from a pregnant patient.” In essence, the hospital is keeping Mrs. Munoz on life-support although she is clinically deceased and over the objections of her family in order to comply with one of Texas’ anti-abortion laws.
The Munoz case raises troubling questions of both logic and constitutionality. Thomas W. Mayo, a bioethicist at the Southern Methodist University School of Law, succinctly addressed the logic issue. “If she is dead,” he said, “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.” Dr. Robert Fine, clinical director of the office of clinical ethics with the Baylor Health Care System, agrees. “This patient is neither terminably nor irreversibly ill. Under Texas law, this patient is legally dead.” That reasoning is apparently unconvincing to hospital officials. “Every day, we have patients and families who must make difficult decisions,” responds Jill Labbe, a hospital spokesperson. “Our position remains the same. We follow the law.”
Regardless of the hospital’s position, the statute is clearly unconstitutional, at least as applied to this case. Under the decision in Roe v. Wade, 410 U.S. 113 (1973), the state may not impose severe restrictions on a woman’s right to terminate a pregnancy prior to fetal viability. The Texas statute contains no limitations on its applicability. The Texas Alliance for Life, however, as well as other abortion opponents, argue that life-support should be continued for a pregnant woman, even if she is legally dead, effectively turning a corpse into an undead incubator. That rationale, of course, would support a statute mandating life-support for any individual possessing usable organs pending their harvesting.
The Munoz family filed suit last week in the Tarrant County court challenging the hospital’s decision. It is of no consolation to the Munoz family, but perhaps the courts will issue a decision that prevents this shameful episode from being repeated.
I can see why the hospital is leaving her on support until the courts say otherwise: liability. The laws says, with room for interpretation, that treatment cannot be withheld from a pregnant patient. The hospital does not want to be the party doing the interpreting. Thus, the need for a court decision.
It seems like, contrarily to the Schiavo case, a third party – a foetus – is involved, which could justify delaying the cessation of care until the delivery of the foetus, provided this foetus is viable (i.e. without grave deformities) given the circumstances.
RWL:
Mrs. Munoz did not have a written advance care directive. However, both her husband and parents stated that she had always expressed a desire not to be placed on life support under these circumstances (both she and her husband were trained EMTs). Obviously, it is not possible to withdraw life support from the mother without the fetus dying. I do not know the thought processes of the family members, but they were vehemently opposed to the state ordering that a deceased wife and daughter be ordered to serve as a gestation vehicle without their consent. The wishes of family members are routinely honored by hospitals even in the absence of written directives, unless there is a bona fide dispute among family members.
In the case discussed in the article I linked to, the c-section was not performed at 16 weeks. The mother was 16 weeks pregnant when she was pronounced brain dead. Her body was kept on life support for a period of 110 days, or almost 4 months, prior to the c-section. The 110 days is apparently a record. But it means that continuing improvements in medical technology point to the need for continuing study of bioethical standards and practices.
Another law where the legislators are practicing medicine without a license in order to control women.
Attached is a report published in September of 2013 concerning a woman who suffered brain-death in the sixteenth week of her pregnancy. She was kept on life support for a period of 110 days and then delivered by C-section.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883204/
It should be noted that in this reported case, the continuation of the pregnancy was done with the knowledge and consent of the family. And that is really the point. The decision should be left to the woman’s family, particularly if brain-death occurs prior to viability. The statute invoked by the hospital in the Munoz case takes the decision out of the hands of the family, even if brain-death has occurred prior to the stage of the pregnancy at which the interests of the state are entitled to prevail under the ruling in Roe v. Wade.
If the hospital’s position is upheld, I know of no legal or constitutional impediment to enacting legislation mandating that all persons pronounced brain-dead be immediately placed upon life-support systems long enough for the removal of viable organs deemed suitable for transplant purposes. Surely the state’s interest in preserving the life of the unborn can be no greater than its interest in preserving the lives of transplant candidates at risk of death.
Mike A,
According to your original article, there is nothing in writing, stating that this woman wished to have the plug pulled on her. This complicates the entire situation. Why does her husband and family members want the plug pulled on not only his wife, but also on the surviving fetus?
Your second article is very interesting! At 16 weeks, a c-section was performed? Wow!
This is a sad intervention by the state but it’s unfortunately mandatory….. FYI….. The presiding judge recused herself…. No reason why…..
Sincere thanks to annieofwi for her insider’s illumination about what it takes to care for a person who is, seemingly without clinical doubt, brain stem dead.
As I read this thread, I couldn’t help but think of Israel’s former PM Ariel Sharon who, while in a stroke-induced coma, recently died after having been artificially suspended for eight years on life support until some sources were beginning to question the $453 million cost (per year) and almost simultaneously, others were revealing how his organs were deteriorating. Matter of fact, relative to insufficiency of kidney function, this was the primary reason for his (now) official death as I saw reported by one publication.
So, while I wholly agree with those who find such ‘treatment’ ghoulish whether it is done for a high profile adult or with a still womb-protected fetus, isn’t the ethical question really about whether either individual would want to be kept in such state of artificial suspension when there is (really) no known guarantee on how either a previously self-aware man or a still symbiotic or entirely dependent on its host fetus will metabolically evolve through that process to the other side or, to a first awakening moment of healthy consciousness?
In other words, would either feel eternally grateful for what had been done to them and supposedly for them…no matter how their quality of life and free will, as is similar to yours and mine, may have been somehow diminished or even stolen from them? I mean, how do any of us make these decisions for another being who has neither inclination, opportunity or even a voice to speak for themselves.
In Sharon’s case, his family wanted him kept on life support and in this little fetus’ case the father and parents want the mother’s host body to be let go. And since we can’t, with moral integrity, have it both ways as is determined by even caring surrogates, why aren’t we looking for a space of ‘ethical empathy’ that would promote what these individuals in their current state (not the future) would want for themselves in order to genuinely thrive or, not remain or become even more dependent.
As one among the brightest to bless this planet once so aptly said, “The solution to a problem cannot be solved in the same mindset in which it was created.” –Al Einstein Put another way, perhaps ethical dilemmas such as these need to be regarded and embraced as being more so about what is, rather than what could be.
“there is irreversible cessation of all spontaneous brain function.”
So, when there is evidence of a functioning hypothalamus, is that also evidence of spontaneous brain function?
The Taliban is alive and well in Texas. They prove there is a ‘war on women”, a woman being really, and only, just a womb.
In the Munoz case, there is no proof of an embolism. There is no written record of Mrs. Munoz’s alleged wishes to be disconnected from life support.Therefore, there is no verification that she expressed this wish to her husband or parents who may have ulterior financial motives including payment of life insurance in the event of her death and that of her preborn child. There should be an immediate investigation into the likelihood that her husband assaulted her causing her serious but not yet fatal injury. His potential motive could be financial greed and rage when learning that the preborn infant is not his child, ergo his intense desire to terminate the life of the child.Mrs. Munoz should be thoroughly examined for evidence of assault including chocking, violent head, neck or chest injury, etc. Who first proposed embolism– her husband? Jahi McMath, Mrs. Munoz, and the baby are all still alive, and can recover with administration of pureed USDA organic juices, fruits and vegetables through feeding tubes. Organic foods are the purist nutrition possible, with no Genetically Modified Organisms(GMOs), no pesticides, antibiotics or hormones and few or no other toxins. Dr. Lorraine Day M.D. endorses an vegan organic diet in her DVD and VHS lectures ” Diseases Don’t Just Happen” “Drugs Never Cure Diseases” and Cancer Doesn’t Scare Me Anymore.” Dr. Day cured herself of end stage cancer using an organic vegan diet, sunshine, exercise and a peaceful lifestyle, and she recommends this for everyone. I have e-mailed to Attorney Christopher Dolan and Dr. Paul A. Byrne M.D. a list of the purest brands of organic juices and foods which can help all. There has been no response, but following is the list to help in the case of Mrs. Munoz and her baby. Life is always the right choice:
All must have the round USDA seal certifying organic standards: Uncle Matt’s organic pulp free orange juice, Lakewood pure organic grape, cranberry, grapefruit, pinapple, prune,cherry, and pommegranate juices, Earthbound farms fresh organic carrots, cellery, lettuce, onions, potatoes, cucumbers. Auerpak fresh organic garlic. USDA fresh organic kale, mushrooms, green and red peppers, tomatoes. Woodstock frozen organic spinach, edamame, green beans, broccoli,corn, peas, Debole’s organic pasta, Lundberg organic brown rice, USDA organic black and garbanzo beans, Poland Springs spring water ( not distilled, no flouride ), USDA organic apples, pears, blueberries, raspberries, Dole organic bananas, Real Salt sea salt, Frontierherb organic spices including cayenne, black pepper, parsley, oregano, dill, turmeric, ginger,
paprika, cloves, Full Circle organic maple syrup, Ahlaska organic dry baker’s unsweetened cocoa. Mix some of each savory ingredients together, and some of each sweet ingredients together and admi nister through feeding tubes. Raw fruits and vegetables are best. Boil potatoes, pasta, and rice. All life is worth saving.Also, please donate to the appropriate charities to ease the suffering of the over 2 billion vulnerable people in developing or war torn countries and the over ten billion victim animals in cruel conditions of factory farms for the meat industry to at least allow them free range healthy lives in the sunlight. Since there is not world wide policy to convert to renewable solar, wind and water energy, there will be insufficient oxygen to sustain life on earth in the next 80 years with the continued burning of lethal oil, coal and gas fossil fuels, so out tragic end is scientifically inevitable. In the meantime, we should alleviate the suffering of the most vulnerable on earth, peacefully, humanely and without violence.
Texas learned nothing from the Schiavo case it would seem.
Uh, Texas…There’s no life to sustain,right?
Having been on the staff of more than a half-dozen hospitals, and on the medical ethics committee of one of the largest hospitals in the state, I feel safe in saying that what is being done to this woman in the name of somebody else’s religion is both immoral and unethical.
To second what Annie is saying, this is ugly beyond belief. The hospital staff who must take care of her should be getting some sort of “combat pay.”
I wonder what is next. Is the hospital district going to exercise Eminent Domain of this woman’s body?
What annieofwi wrote:
It truly is ghoulish to see what has happened and her experiences in the nursing profession are certainly helpful in this case. Too bad these hospital administrators haven’t been working the floor in a long time, if at all.
I couldn’t help but think of the Terri Schiavo case. Not making a conclusion as to which way this case should have been decided, the entire matter to me got hijacked by those on a national scale, exploiting in my opinion this woman who suffered a terrible fate. It was reprehensible in my view. It seemed other than her husband or her parents who understandibly have interest and love for Terri, many who never knew her seemed to care more about their own cause and politics than the privacy of these family members or Terri. Politicians need to mind their own business and stay out of these matters. For at least the reason they seem to use it for their own ends.
Keeping this woman’s body to use as an incubator? This is the ultimate trespass on personal freedom. This woman made her wishes known, and they should be followed.
As a personal aside, it’s also creepy and weird.
Decomposition also occurs to the body, despite life support.
Also on a personal note, as a nurse who has cared for brain injured patients in a persistent vegetative state, I can say that is close enough to a living death, but to actually care for a body on life support after brain death, THAT is dead, as dead as dead as one can be. The head and neck area blow up from the oxygen leaking from the respiratorInto the surrounding tissues, the brain starts disintegrating and leaks form orifices, I won’t get any more graphic. To those who think brain death is misdiagnosed, no it isn’t.
To use this woman’s corpse to incubate a 14 week fetus until viability, 20 to 24 weeks, is ghoulish. Her body is dead, her brain is dead. The only reason that fetus is still surviving is because the body is being supported by machinery and a slew of drugs, such as hormones, meds to pump up blood pressure, etc. her digestive tract isn’t functional, kidneys not functional, she’s receiving nutrition via IV. She was without oxygen for up to an hour, is that fetus affected? What of the drugs effects on the fetus. Now the widower who knew best what his wife’s wishes were is being denied his rights as her surrogate decision maker by the hospital because they are misinterpreting the advanced directive clause for pregnant patients. One must be alive to be a patient.
Shame on the state of Texas and this cowardly hospital. I hope the family wins a huge reward or settlement. It’s now almost to the point of viability for the fetus, will it survive, be affected for its entire by being incubated in a dead body? Who will pay for all those weeks of extreme artificial life support for this poor dead woman and her unborn child? At 14 weeks she could’ve made a decision to abort in such circumstances, now that decision has been snatched away from her husband, her surrogate voice, in her death.
How ethical is it for hospital’s administrations and ethics boards to take away the families rights as to the disposition of a dead loved one? Was this hospital pressured by the state of Texas?
If one follows the path of the “may not really be dead” school of thought to its logical conclusion, is anyone short of having their head severed, scattered to a number of pieces, or (really) large hole in torso ever going to be dead? If so, when? No breathing- not enough. No brain activity- not enough. What precisely will be “enough”?
It sounds like only the inability to get a body to breathe by artificial means will work. However, it also seems that a person can “die”, but be kept breathing by artificial means if the equipment is available fast enough.
Cynically, I could go along with the “will Obama-care pay for it” school of thought. I don’t know about you, but I’d rather the Munoz decision be made by the husband and parents (esp when they agree!) than a GS-7, approved by a GS-11.