This disturbed me

[Pumpkin Seeds]

Well, I don’t actually see much in the way of a living will discussed in the article. At the age of 33, barring consistent medical problems of this nature, I would not expect her to have filled out a form regarding Advanced Directives.  That she was placed on life support means the woman did not have herself listed as a DNR (Do Not Resuscitate) which means she did not have such a form filled out discussing her wishes.  Her “wishes” at this point are probably verbal communications with her husband.  There is no “don’t keep me on life support for long” option in regard to Advance Directives.  So this is an issue of next of kin being able to make the decision of ending the life of a fetus for the mother, not in the mother making this decision for herself in regard to end of life care.

[lilhobbit37]

Just a note to think about.

If the woman is taken off life support and dies naturally, it isn't abortion. It is a natural fetal death due to maternal death.

Abortion is not intended to be used as a maternal carrier dying and fetus being sustained within her body.

The fetus should technically already be dead and may well be brain dead due to lack of oxygen but it is impossible to tell at this point. It has a heartbeat I'm assuming and that is what they are using to determine it is alive but there is no gauge as to what sort of damage occurred from oxygen deficiency.

So perhaps thinking of it in terms of that. This is completely natural and the fetus dying would be as well.

[Pumpkin Seeds]

I honestly doubt the fetus has suffered much, if any damage, due to oxygen deprivation.  Early pregnancy the fetus lives in a hypoxic environment and the damage caused to a fetus due to an interruption in oxygen levels is measured in hours, not minutes.  The blood carries a surplus of oxygen to start and probably enough to supply the hypoxic environment for at least awhile before any permanent damage can be done.

As for the death being natural there are two ways to look on that issue.  The technology is there and the possibility is present for the fetus to be born healthy.  Now letting the fetus die would be natural at this point, but so would allowing many other deaths that medicine actively works to prevent and assist.  Organ transplant is certainly unnatural, but few would argue to stop the advancement on those grounds.

As for abortion versus end-of-life, this is certainly an end-of-life issue.  Abortion is a willing choice by the mother to terminate her pregnancy which is why this goes under a privacy issue.  The problem here is that this is the ability of the “next of kin” to make the decision on whether to remove life support and terminate a pregnancy.  A woman’s mind might change on that matter if she knew that her child’s life was also at stake. 

At the end of the day though this woman will be taken off life support once the pregnancy is over, thus honoring her wishes.  The fetus would be given a chance to live thus possibly preserving her possible wishes to continue the pregnancy.  At 14 weeks the time to make a decision for abortion was fast approaching.  The husband does not make mention that she was considering an abortion and the couple already has one child showing that they were comfortable having children.

So within birthing age, 33; not on birth control, married with a stable relationship, not actively seeking an abortion at the time with a previous child being born recently showing that she is physically capable of giving birth.  Odds are she wanted to keep the baby and may indeed still want to keep the baby.  Were I on an ethics council, how could I make the decision that this woman wouldn't want to endure a few months of life support so that her child would be born?

[IStateYourName]

Well, I don’t actually see much in the way of a living will discussed in the article. At the age of 33, barring consistent medical problems of this nature, I would not expect her to have filled out a form regarding Advanced Directives.

Especially given that we live in a nanny state that seriously limits one's options in this regard.

[Pumpkin Seeds]

Actually no, on any admission to the hospital the admitting nurse is required by law to ask if a person has filled out Advance Directives.  This feature is even built into most computerized systems, such as Epic, where the nurse is immediately prompted to do so.  If the person says no, the nurse must offer information or follow up.  Most patients of her age do nothave one filled out simply because they do not anticipate dying anytime soon.  A DNR form is easy enough to obtain and secure if the person wants to do so.

[chaoslord29]

I think Pumpkin Seeds has made the most pertinent points about Advanced Directive. There's been absolutely no mention of a living will for this woman (I had more or less presumed there was; I mean, I'm twenty-something and I have one) but I'm beginning to think that if there was, this wouldn't even be an issue. In fact, I think the title of the article itself suggests that is in-fact the parents belief that their daughter should not be kept on life-support, which of course would be their right and privilege if only their daughter's life were in play.

Though I am firmly pro-choice, the point remains that the woman in question is not in a position to make a choice regarding the life of her child, and so I think in this case, and if she is indeed brain-dead or vegetative, and the child is as alive and healthy as one can expect a fetus to be, then there's really only one "life" that should be taken into consideration here.

I mean, assuming she is brain dead, then the parents really only haggling over what's to be done with their daughter's (extremely well preserved) corpse. This really is just giving them more time to get their other affairs in order and prepare for funerary proceedings. All that said, if the hospital is making them foot the bill for keeping their daughter's body 'alive' and subsequently for whatever surgery will be necessary to deliver the baby, that strikes me as pretty . . . well greedy.

[Pumpkin Seeds]

From a purely financial perspective the hospital would make out better pulling the plug.  An ICU bed at a level 1 trauma center has very little, if any time to be empty.  That bed would be filled within hours if not minutes once the body was removed.  The insurance company, no matter how good, would probably only pay for a few days or weeks of ICU treatment.  She will be there for at another month or two, at least.  Pre-natal and labor costs could be absorbed by the insurance company, but there is a lot of risk with this patient and delivery.  Pressure ulcers, nosocomial infections, complications, etc. etc  all conspire against the hospital because any of them could jeopardize being paid for care given.  Far better, financially, for them to pull the plug, bill the insurance company and fill the bed.

[chaoslord29]

From a purely financial perspective the hospital would make out better pulling the plug.  An ICU bed at a level 1 trauma center has very little, if any time to be empty.  That bed would be filled within hours if not minutes once the body was removed.  The insurance company, no matter how good, would probably only pay for a few days or weeks of ICU treatment.  She will be there for at another month or two, at least.  Pre-natal and labor costs could be absorbed by the insurance company, but there is a lot of risk with this patient and delivery.  Pressure ulcers, nosocomial infections, complications, etc. etc  all conspire against the hospital because any of them could jeopardize being paid for care given.  Far better, financially, for them to pull the plug, bill the insurance company and fill the bed.

You really seem to know your stuff where practical medicine is concerned. The question remains though as to who, exactly, is going to be footing the bill for all this treatment. Surely if the insurance company is paying out for it, they're going to be on the side of the parents, unless they're just going to turn around and gouge them. The whole situation is based on a Texas law of course, which could very well be an unfunded, un-subsidized mandate, in which case I'm not certain why the hospital would be in such a rush to follow through on it. Maybe the state has some kind of funding to accommodate for fetuses and infants in this situation?

[IStateYourName]

You really seem to know your stuff where practical medicine is concerned. The question remains though as to who, exactly, is going to be footing the bill for all this treatment. Surely if the insurance company is paying out for it, they're going to be on the side of the parents, unless they're just going to turn around and gouge them. The whole situation is based on a Texas law of course, which could very well be an unfunded, un-subsidized mandate, in which case I'm not certain why the hospital would be in such a rush to follow through on it. Maybe the state has some kind of funding to accommodate for fetuses and infants in this situation?

I'm wondering if the astroturf right-wing groups who rail about every fetus being sacred are going to volunteer to chip in here?  Or, since this case doesn't involve eroding workers' rights or making the rich richer, will we hear only crickets chirping?

[vtboy]

Though I am firmly pro-choice, the point remains that the woman in question is not in a position to make a choice regarding the life of her child, and so I think in this case, and if she is indeed brain-dead or vegetative, and the child is as alive and healthy as one can expect a fetus to be, then there's really only one "life" that should be taken into consideration here.

Would your calculus change if neither the woman's husband nor any other family member was willing to raise the child? If not, would it change if, in the best medical opinion, the child would be born with severe physical and/or mental limitations (making adoption unlikely)?

The question remains though as to who, exactly, is going to be footing the bill for all this treatment.... The whole situation is based on a Texas law of course, which could very well be an unfunded, un-subsidized mandate, in which case I'm not certain why the hospital would be in such a rush to follow through on it. Maybe the state has some kind of funding to accommodate for fetuses and infants in this situation?

Regarding the foregoing questions, does the willingness of the state to take on the burden of nurturing the child (perhaps throughout its life, if it is severely disabled) enter into the matter for you? 

[Pumpkin Seeds]

The insurance company will foot the bill for the emergency room visit and an extended stay in the ICU.  At some point there will be a dispute over the continual treatment of her in an ICU bed since they would petition for her to be moved to a LTAC facility.  So at some point the insurance company will cease to provide coverage for her care.  Now the hospital may petition for the insurance company to cover pre-natal care and labor and delivery cost for a high risk pregnancy.  From here the insurance company will pick up some of the cost.  The rest may be transferred onto the family, from which the husband will challenge the charges.  The state, since this is a publically funded hospital, will pay for some of this.  Most of this will be handled through a fund set aside by the hospital for such cases and if the cost exceeds this fund, then there will be funds diverted from other areas.  Doubtful the tax payer will ever be charged more since money is already put aside for the hospital and its activities.

Also, IStateYourName, I will go ahead and just deliver a word of caution that delivering one line antagonistic statements in this forum can lead to reprimand by moderators.  Seeing that you are newly registered to the site, I figured this would be a good time to give a friendly bit of advice in that regard.

[Iniquitous]

I think Pumpkin Seeds has made the most pertinent points about Advanced Directive. There's been absolutely no mention of a living will for this woman (I had more or less presumed there was; I mean, I'm twenty-something and I have one) but I'm beginning to think that if there was, this wouldn't even be an issue. In fact, I think the title of the article itself suggests that is in-fact the parents belief that their daughter should not be kept on life-support, which of course would be their right and privilege if only their daughter's life were in play.

Though I am firmly pro-choice, the point remains that the woman in question is not in a position to make a choice regarding the life of her child, and so I think in this case, and if she is indeed brain-dead or vegetative, and the child is as alive and healthy as one can expect a fetus to be, then there's really only one "life" that should be taken into consideration here.

I mean, assuming she is brain dead, then the parents really only haggling over what's to be done with their daughter's (extremely well preserved) corpse. This really is just giving them more time to get their other affairs in order and prepare for funerary proceedings. All that said, if the hospital is making them foot the bill for keeping their daughter's body 'alive' and subsequently for whatever surgery will be necessary to deliver the baby, that strikes me as pretty . . . well greedy.

Bolded the part that I wanted to address.

YES, there would have been an issue. Because Texas is one of several states that has a law requiring them to NOT turn off life support if the woman is pregnant. It would not have mattered if she had a living will/AD written in blood and signed with her soul - the hospital would have denied following her wishes because Texas presumes the right to tell women what they can do with their body.

[IStateYourName]

Also, IStateYourName, I will go ahead and just deliver a word of caution that delivering one line antagonistic statements in this forum can lead to reprimand by moderators.  Seeing that you are newly registered to the site, I figured this would be a good time to give a friendly bit of advice in that regard.

Thanks for the heads-up.  For clarification, I wasn't referring to anyone here who voiced pro-life opinions.  I have nothing against individuals who honestly believe, whether from a religious or ethical perspective, that a fetus ought to be protected...so long as they respect the rights of others who differ.  My issue is with PACs and other such mendacious organizations who can "talk the talk, but not walk the walk" on this issue--who use it much like a matador uses a red flag, to tub-thump and get people worked up whilst pursuing other objectives.

No one who has posted in this thread fits that description.

[Pumpkin Seeds]

Honestly, the law aside, I think most hospital ethic committees would have an issue doing this sort of thing simply from the perspective of the woman will eventually miscarry or give birth.  Then the life support can be discontinued.  If the life support is discontinued early then the baby is gone, there is no reconsideration.  One choice means little difference aside from a baby is born while the other is a permanent ending of potential life. 

Even as a feminist, a liberal, a staunch advocator of pro-choice I could not in full faith make that vote on an ethics committee.  As a healthcare worker, the law gives me some comfort that I do not have to make that decision. 

[chaoslord29]

Bolded the part that I wanted to address.

YES, there would have been an issue. Because Texas is one of several states that has a law requiring them to NOT turn off life support if the woman is pregnant. It would not have mattered if she had a living will/AD written in blood and signed with her soul - the hospital would have denied following her wishes because Texas presumes the right to tell women what they can do with their body.

I see what you're getting at, because otherwise this would totally fall under the category of a first term abortion which has been established as a constitutional protection. This law, is there way of circumventing that right under nebulous circumstances. Still, without a living will, there's no way to establish what this woman's intention towards the unborn child would be, and in it's absence, I don't see why the state has any less ability than the parents to make a determination (however much I might disagree with it).

I suppose you could argue that in the case of brain-death or a vegetative state, the woman's body reverts to ownership of the next of kin, whether or not she is technically 'living'.

If we could establish the identity of the father, is there any precedent for having him make a determination in place of a mother who is not otherwise capable of doing so? I figure the less we rely on presumptions about what the mother would have wanted the better, and if he's willing to pay for the associated costs with the incubation and delivery (even if he plans to put the kid up for adoption afterward) he's the only other living person with a claim to the child and so I would say the most directly related party.

Honestly, the law aside, I think most hospital ethic committees would have an issue doing this sort of thing simply from the perspective of the woman will eventually miscarry or give birth.  Then the life support can be discontinued.  If the life support is discontinued early then the baby is gone, there is no reconsideration.  One choice means little difference aside from a baby is born while the other is a permanent ending of potential life. 

Even as a feminist, a liberal, a staunch advocator of pro-choice I could not in full faith make that vote on an ethics committee.  As a healthcare worker, the law gives me some comfort that I do not have to make that decision. 

That's a good point Pumpkin Seeds. The ethics committee is more or less 'hedging there bets' in case the pregnancy otherwise fails in the coming months and it becomes a non-issue. The alternative is to terminate the pregnancy with no clear establishment of the mother's will in regards to such an action and end all potential for good in the child's life.

I'm with Pumpkin Seeds on this one. Politically, I am a staunch defender of abortion rights, even if I can't justify it on a personal ethical level.

[Oniya]

If we could establish the identity of the father, is there any precedent for having him make a determination in place of a mother who is not otherwise capable of doing so? I figure the less we rely on presumptions about what the mother would have wanted the better, and if he's willing to pay for the associated costs with the incubation and delivery (even if he plans to put the kid up for adoption afterward) he's the only other living person with a claim to the child and so I would say the most directly related party.

If I recall correctly, there was a picture of the father (her husband) in the article, holding their 15 month old.

[chaoslord29]

If I recall correctly, there was a picture of the father (her husband) in the article, holding their 15 month old.

I re-read it and you're absolutely right. For some reason I got the impression she was single or divorced.

Going over it again, the husband seems to have more or less refused comment and has made none of the information regarding his wife or the fetuses actual condition available to the public (or the media). The article's author is doing a lot of guesswork based on hearsay from the parent's of the woman in question, and they're the only ones to have affirmed their daughter's desire to be taken of life support.

In other words, I'm beginning to get the feeling they're the only ones making a fuss over their daughter's "continued suffering" while she is on life support. The husband is the one actually handling the affairs and he may very well be prepared to raise and rear the child in the event of a successful delivery of the fetus sometime down the road.

I reaffirm that given the nebulous circumstances, the hospital ethics board made the right decision not to honor the family's wishes for her to be removed from life support upon discovering of the fetus, if only so that the father of said child could be given time to make a determination as to his own position regarding his wife and child. Why should the parent's wishes even factor into anymore? Their daughter was a legal adult when she suffered the blood clot, and she's either tenuously alive in which case they have no claim over her and her husband's life and rights, or else she's dead and her husband as next of kin has full rights as the executor. In either case, there is very little ground for them to overturn the law in question.

[Iniquitous]

When a person dies without an advance directive/living will the corpse becomes the property of the next of kin.  What you are suggesting is the states have the right to step in and claim possession of a corpse to do with as they please no matter what the next of kin wishes. Am I correct in understanding what you are saying? If so, then I say hell no. The state I live does NOT have the right to make claim of my corpse and do what they want with it. Pregnant or not.

And again, it is not an abortion. It is a natural death. After all, when the mother dies while gestating young, it is only natural that the fetus dies as well. Yes, rant and rave about the potential life of that child - but where are the rants and raves for miscarriages? Still births? You don't have the entire country up in arms about those.

From my understanding of the articles I have read, the husband concurs with his inlaws - the wife did not want to be kept alive on life support due to having went through it with a family member not too long before she had the blood clot. The fact he is remaining quiet does NOT mean he is agreeing with the hospital. It means he is trying to cope with this whole mess privately - and who can blame him. He's lost his wife and the state is not allowing him closure by keeping her corpse in the hospital.

Paramedics Marlise and Erick Munoz of Crowley, Texas, had good reason to talk about their own end-of-life wishes, and Erick says his wife made it clear that she would never want to be kept on life support if there was no chance of recovery, reports the Dallas Morning News.

And there you have it, the husband knew his wife did not want to be on life support. He is in agreement with his inlaws. And furthermore....

Erick says that he's largely been kept in the dark about how the hospital plans to handle the fetus (it says it'll decide what to do once the fetus is at 24 weeks, reports WFAA; it's currently about 20), or what health it's in. Hospital workers reportedly told the family that Marlise — and by extension the fetus — may have gone without breathing for an hour before Erick found her on the kitchen floor; she had gotten up in the middle of the night to check on their crying 15-month-old, notes the Guardian. But critics say the hospital may not be following the letter of the law, which states that "life-sustaining treatment" must be given to a pregnant patient; if she is brain-dead (versus in a coma or vegetative state), she is technically not alive.

And... it's not just the family fighting the law. It is the husband as well.

A man reportedly is fighting a Texas law to get his pregnant wife removed from life support, which he says were her wishes before she was declared brain dead.

But, Erick says he and his wife had discussed and mutually agreed upon “do not resuscitate” (DNR) orders, though one was never signed. She has not shown brain activity since, and doctors are unsure how long the fetus was without oxygen and nutrients, so it's unknown whether the fetus is even viable.

"I don't agree with this law... I don't," he said, adding, he doesn’t expect many people to side with him on this.

Source: http://www.usatoday.com/story/news/nation/2014/01/08/newser-pregnant-life-support/4370971/
            http://www.cbsnews.com/news/pregnant-woman-kept-on-life-support-against-husbands-wishes/

[IStateYourName]

From my understanding of the articles I have read, the husband concurs with his inlaws - the wife did not want to be kept alive on life support due to having went through it with a family member not too long before she had the blood clot. The fact he is remaining quiet does NOT mean he is agreeing with the hospital. It means he is trying to cope with this whole mess privately - and who can blame him. He's lost his wife and the state is not allowing him closure by keeping her corpse in the hospital.

See, this is what vexes me about the pro-life political movement.  Not that there are individuals, like some who posted in this thread, who ethically or religiously feel that a fetus is a human being.

That's fine, and folks like you have every right to hold these beliefs, and to conduct your personal affairs accordingly.  I respect that.  Hence my italicization of political movement, to differentiate.

No, where I have a problem is when people form political movements and decide to force their beliefs onto others by using the State.  When the State becomes co-opted into the anti-abortion movement, that's when I have a problem.  Just like I have a problem with the government of China and its use of forced abortions to enforce the one-child policy, but have no issue with individuals who decide, whether for ecological, political, or practical reasons, to only have one child or to have no children at all...so long as they do not try and form movements to force this on anyone.

[Oniya]

I'd missed the bit that said she was a paramedic.  That would make it less surprising for her to have considered these eventualities. 

[Kythia]

No, where I have a problem is when people form political movements and decide to force their beliefs onto others by using the State. 

See, the problem there is that that's almost certainly not where you have a problem.  Do you have an issue with the civil rights movement forcing their beliefs on others through the state/legislation.  With the anti-murder brigade putting in all this cumbersome murder laws?  I don't know you, granted, but in my experience when people say they object to people forming political groups to force through opinions, what they actually object to is political movements forcing beliefs they don't agree with.

[Iniquitous]

I am of the stance that the doctors are taking this above and beyond the law.

Life sustaining treatment. The woman is DEAD. They have declared her brain dead and thus... dead. Yet they refuse to remove the life support because of this law that says they have to continue life sustaining treatment. Life sustaining treatment to who? The corpse? The fetus. Who determines when the fetus is alive? The law? The doctors? The church? Do you see the problem here?

If she was in a coma or vegative state I could understand keeping her on life support. But she's not. She is as dead as dead gets. She's checked out. Gone. The hospital is keeping her corpse on life support because...?

Here's your answer. They have decided that the fetus is 'alive'. Never mind that it cannot sustain life outside the womb. And this, in my opinion, is heinous. They have set the demarcation point on their own. 14 weeks is the point where THEY consider a fetus alive. Of course, this may change if such a situation occurs again in their hospital. They have the right to say 8 weeks gestation is alive. 4 weeks. 6 weeks. They can move it around as THEY see fit and the wishes of the next of kin and the person who died be damned.

This is wrong. It is sick in my opinion.

[chaoslord29]

That's a pretty hardline stance their Iniquitous Opheliac, and I can definitely see the practical and legal reasoning behind it. I'm in full agreement that if she is brain-dead, then she is dead, and the argument that in all other natural circumstances the fetus would die with the mother is a compelling one. Your followup articles clearing up the husband's position also refutes my question regarding his status as executor. If it is his wish that the wife be taken off life support, it seems the hospital is taking the execution of the law into their own hands by forcing the issue. On the other, I can see why a hospital would want to be careful in this case, as they don't want to suddenly find themselves under state investigation for violating a law they may not be prepared to fight on legal grounds. Similarly, it's easy to see why the family wouldn't have necessarily taken legal action at this point, whatever constitutional protections they might think they have; taking on the state attorney general and legislature is not something you want to do in the heat of the moment or without preparation, and in the mean time the fetus might very well expire on it's own and make the whole issue moot.

As for the status of the fetus as alive, I won't speculate, because as you've pointed out it's difficult to quantify especially on the basis of 'potential' human life. After all, any given egg or sperm is technically, potentially a human life.

All that said, I have to wonder if in this situation there's any particular 'harm'. Who is suffering because this woman is being artificially kept alive? What makes it 'sick' or wrong when there might very well be a healthy baby brought into the world because of it?

The husband? The parents? Why should they care? As long as the cost of the procedures and delivery aren't coming out their pocket and no one is mandating they take custody of the child there's no tangible harm coming to them. You argue that given brain death the woman in question is in fact dead (a position I support) but the parents seem to be insisting that keeping her body alive is somehow prolonging her or there suffering. So what? Get over it. She's dead. Why wait on the funeral? Because you want to have an open casket? That's a religious predilection no more valid than the presumption that life begins at conception. If they're just going to cremate the body or dump it in the ground, I say "wishes of the next of kin" should indeed be damned!

There's something of a contradiction in your argument there because you're saying that the next-of-kin's personal beliefs and preferences over the disposal of corpse take precedence ahead of what could very well be a living thing (given a little time, resources, and the miracle of modern medicine), something that is predicated on slightly different set of personal beliefs held by a different group of people. How can you say one set of beliefs holds more sway over said corpse/fetus than the other? Simply by virtue of her family having closer blood ties?

[Torch]

All that said, I have to wonder if in this situation there's any particular 'harm'. Who is suffering because this woman is being artificially kept alive? What makes it 'sick' or wrong when there might very well be a healthy baby brought into the world because of it?

Because in that action you are reducing a woman's body, her uterus in fact, to the status of being little more than a crock pot.

Being that I am a human being who possesses a uterus (and that uterus has produced two healthy children), crock pot status is not something I wish forced upon me.

[chaoslord29]

Because in that action you are reducing a woman's body, her uterus in fact, to the status of being little more than a crock pot.

Being that I am a human being who possesses a uterus (and that uterus has produced two healthy children), crock pot status is not something I wish forced upon me.

Being that you're alive and healthy, I wouldn't dream of reducing your worth as a human being to the value of one or more of your parts (or objectifying you as a whole for that matter). Seeing however that the woman in this particular case is to all intents and purposes dead, does the same mentality apply?

Is using her body in this fashion not akin to what an organ donor does? Her husband and family don't really have any more use for the physical remains (beyond the ceremonial) and the fetus is immediately dependent on them for life. Is there a significant difference between that situation and if my family refused to donate my flesh and organs to someone who needed them to live because they insisted on having a 'whole' body for an open casket funeral?

I'm not trying to be needlessly provocative here or argue for arguments sake. Like I said, I'm pro-choice and prior to this particular case being brought to my attention I would have said "in all circumstances". My reasons for being so however are somewhat . . . unorthodox.