Analysis: Texas life-support case raises ethical questions

Amanda Spadaro

Science Editor

[email protected]

 

33-year-old expecting mother Marlise Muñoz collapsed in her home on November, 26, 2013, the Tuesday before Thanksgiving. After being found by her paramedic husband, Erick Muñoz, she was taken to John Peter Smith (JPS) Hospital in Forth Worth, Texas.

While she remained in the intensive care unit, Muñoz was declared brain-dead on Thanksgiving Day; according to the civil court petition filed in Tarrant County, Muñoz “had lost all activity in her brain stem, and was for all purposes brain dead.” Likely suffering from a pulmonary embolism, a blockage in an artery of her lungs, Muñoz was deprived of oxygen, causing irreparable damage to her brain. Muñoz, mother of one, was 14 weeks pregnant with her second child at the time of her death.

Texas state law also protects the unborn child, an issue that is addressed in a state-specific manner. 38 states have varying degrees of feticide statutes, granting the fetus personhood in criminal prosecutions involving endangerment and attempted feticide. Texas is among 12 states, including Kentucky and South Carolina, that legally order the continued treatment of pregnant women, regardless of the fetus or embryo’s viability or the patient or family’s wishes.

The Texas Advance Directives Act states in Section 166, “a person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient.” Because Muñoz, like her husband, was a paramedic, end-of-life directives had been discussed between Erick and Marlise Muñoz as well as her family. Her wishes were clear: she did not want life-sustaining treatment.

And yet, Muñoz remained connected to life support until 11:30 a.m. on Sunday, Jan. 26, 2014, two months after her initial collapse. Her removal from life support happened only after a judge ruled on Friday, Jan. 24, that her and the family’s wishes were to be met.

In such a complicated and serious medical issue, there are a number of factors that must be considered when individuals find themselves in the similary situations. However, the fact remains that the law must be upheld by those who provide health care, regardless of extraneous considerations.

“Law is law, and hospitals and physicians are bound by their best understanding of the law,”  said Steven Farrelly-Jackson, professor of philosophy at Allegheny College. “If they think that, in a particular situation, the law decrees that something be done, then they have to do it, regardless of the religious beliefs or views of the family or patient.”

In certain situations, the law is in place to protect hospitals from liability, up to the interpretation of the hospital’s lawyers. By removing Muñoz from life support, the hospital would have relinquished legal immunity. In this case, JPS Hospital determined, with the aid of their legal counsel and staff of lawyers, that Muñoz was to remain on life support in accordance with the law.

“JPS Health Network has followed what we believed were the demands of a state statute. From the onset, JPS has said its role was not to make nor contest law but to follow it,” JPS spokesperson Jill Labbe said to The New York Times.

Larry Thompson, a state attorney defending the hospital’s choice to continue life-sustaining treatment, believed that the hospital was protecting the rights of the fetus, as per Texas law.

“There is a life involved, and the life is the unborn child,” Thompson said to the judge hearing the case, as reported by The New York Times.

However, the hospital’s interpretation of the law, in regard to the definition of life-sustaining treatment, has been called under question, providing perhaps the fundamental argument for the family’s legal case.

The Uniform Determination of Death Act was approved for law in 1981, a law that defines two legal deaths: cardiopulmonary death, or the loss of circulatory and respiratory functions, and brain death. Brain death is clarified as the “irreversible cessation of all functions of the entire brain, including the brain stem,” a state that doctors confirmed in Muñoz’s situation.

This definition of death is now acknowledged as legal death in all 50 states. Therefore, the argument becomes whether a dead person is even a patient at all. How can you provide “life-sustaining treatment” for a person who is legally considered dead?

“If she is dead, 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,” said Thomas W. Mayo, health care law expert from Southern Methodist University Law School in Dallas, to The New York Times.

Ultimately, the judge hearing the case, Judge R.H. Wallace Jr., ruled on the side of the family, stating that because the Muñoz was dead, the law no longer applied. Treatment then should not be involved and the family’s wishes should be met.

The difficulty then lies in the interpretation of the law in these unique cases and the ways in which individuals, or family members, can work against the system.

“In this case, the only option when law is involved, is to work within the legal framework,” Farrelly-Jackson said. “You have to get a lawyer, appeal against a legal ruling, and it will go to a court, and the court will hear. Let’s say they overturn the ruling, it can serve as a precedent for future such cases.”

For this situation, the court ruling has provided clarification of the law for future cases of a similar nature. The authors of the law in question have been interviewed by the Associated Press and numerous other reporters.

The authors informed the health care system that they did not intend this law to be enacted when the expecting mother was legally dead. Instead, the intended purpose was for expecting mothers in persistent vegetative states, allowing the fetus to develop until maturity.

The unfortunate nature is the sense of entrapment within the legal framework, which the husband, Erick Muñoz, spoke to.

“If anything good is to come of this, we want to inform people,” he said to CBS News.

The emotional difficulty that stems from this legal framework, then raises the questions of if such laws should even be in place, varying state by state.

“It’s an unenviable place to be in to set up laws like that,” said John Christie-Searles, professor of political science at Allegheny College. “There may be different ways in which different states or different people approach how to handle that. Medicine is such a personalized delivery. I don’t know if you can say that this one policy will make sense for every one in every case at every time.”

The goal of law is to protect, making it almost unavoidable for laws like this to be passed, a fact which Farrelly-Jackson speaks to.

“Sometimes, it’s unfortunate when law comes in at all, when law comes into these awfully personal, private situations and yet it’s inevitable that it’s coming to come in in matters of life and death,” he said.

With such a personal component to this situation, Erick Muñoz has attested to the emotional ramifications of being unable to fulfill his wife’s end-of-life requests.

“I promised her. I told her, I will honor your wishes,” he said in an interview with The Daily Mail.

For the past two months, Erick Muñoz has been taking care of his 14-month-old son, working as a paramedic and visiting his wife, citing to The Daily Mail that the situation has been a “roller coaster of emotions.”

“It’s not a matter of pro-choice and pro-life. It’s about a matter of our daughter’s wishes not being honored by the state of Texas,” Muñoz’s mother, Lynne Machado, said to the New York Times.

Muñoz’s father has similarly struggled with the disrespect for his daughter’s wishes.

“All she is, is a host for a fetus. I get angry with the state. What business did they have delving into these areas?” Ernest Machado said to The New York Times. “They’re prolonging our agony.”

The body of Muñoz, having been hooked up to life support for so long, has begun to stiffen and decay, causing further turmoil for the family.

“When I go by her head, I smell death,” her mother said to The Daily Mail.

Before Muñoz was taken off of life support, the husband named the 23-week-old fetus Nicole, his wife’s middle name.

“The case is sort of humbling because we have all of this technology, this science, but we still have problems understanding what to do and what not to do,” Christie-Searles said. “We’ve made these advancements, but still, even with technology, you need the traditions, morals and understanding of the collective to determine what to do and when to do it.”