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Pregnancy Should Not Override Women's End-of-Life Wishes, Commentary Argues

Pregnancy Should Not Override Women's End-of-Life Wishes, Commentary Argues

February 27, 2014 — Summary of "Death in Pregnancy -- An American Tragedy," Jeffrey Ecker, New England Journal of Medicine, Feb. 5, 2014.

"[A]ctions like those undertaken" in the case of Marlise Muñoz, a brain dead pregnant woman in Texas who was kept on a ventilator and related support to sustain her body's functions against her wishes, "seem a wrongful usurpation of the rights of individuals -- in this case, one particular class of individuals: women," according to a commentary by Jeffrey Ecker, director for Massachusetts General Hospital's Department of Obstetrics and Gynecology and a professor at Harvard Medical School.

Case Background

Muñoz "was 33 years old and the mother of a 15-month-old when she collapsed on November 26, 2013, from what was later determined to be a massive pulmonary embolism," Ecker writes. He adds that Muñoz's husband and family requested that devices sustaining her body's functions be withdrawn after they were told she was brain dead, per her previously expressed end-of-life wishes.

Ecker notes that the situation "would have ended there" in most circumstances, except that in this case, the hospital interpreted a Texas law that bars the withholding of any "'life-sustaining treatment ... from a person known ... to be pregnant'" to mean that it could not end support. Muñoz's husband took the case to court, and two months later, a judge ordered the hospital to withdraw support, ruling that "the law was not meant to apply to anyone who had been declared dead."

Larger Debate Over End-of-Life Care

"Texas is not unique in constraining pregnant women's end-of-life care and decision making," Ecker writes, noting that more than half of states have some type of restrictions.

Regardless of the legislative questions raised by the Muñoz case, Ecker emphasizes that while the "moral status of and respect properly afforded a fetus is a matter of impassioned debate ... the moral standing of women is not in question."

He writes, "As individuals -- just like fathers and men -- mothers and women deserve to have their wishes regarding their liberty, including decisions about health, respected and followed." Women's "right to determine the course of their end-of-life care should be inviolate, unaffected by whether or not they may be pregnant," he argues, adding that any related decisions left to "patients, surrogates, and families outside of pregnancy should remain theirs during pregnancy as well."

Clinicians' Role

If a physician is "asked to violate a pregnant woman's wishes regarding her end-of-life care," he or she "could appropriately choose to support the patient by declaring a conscientious objection," according to Ecker.

He adds that physicians who fear "the consequences of seeming to break the law" could instead object "by making their moral distress clear to their patients and the public and advocating for changes in the law."

Ecker writes that while situations such as the Muñoz case are "rare," the "prevalence of statutes constraining women's autonomy argues that similar conflict and distress will arise again." He concludes, "Using a dead woman's body as an incubator against her wishes ... should be of grave concern to everyone who cares for and about both women and our nation's moral health."