Should DNRs be ignored in order to protect an unborn fetus? | The Tylt
Should DNRs be ignored in order to protect an unborn fetus?
According to a recent New York Times piece, 31 states have laws that prevent pregnant women from making end-of-life decisions. The New York Times editorial board writes:
In at least 12 of these states...pregnancy-exclusion laws prohibit doctors from following a woman’s wishes to remove life support from her own body even in the earliest stages of pregnancy. In 19 others, such laws deprive women of the ability to dictate their own end-of-life decisions once a fetus is viable, even overriding living wills. Five states mention the well-being of the pregnant woman, while others focus on the survival of the fetus, even if a woman is suffering tremendous pain.
Meaning, in states where these laws apply, pregnant women who have signed a DNR–a do-not-resuscitate order instructing doctors to not perform CPR if a patient's heart stops beating or if a patient stops breathing–will be put on life support regardless. In these states, pregnancy trumps the patient's right to a natural death.
As the Times's editorial board points out, choosing an unborn fetus's rights over a living human being's is a clear violation of that person's autonomy over their body and their life. The laws mentioned above are relatively recent, too–most were established in the 1990s. The Times reports:
They are a product of the anti-abortion movement’s determination to establish the legal 'personhood' of fetuses—and to make sure that their rights supersede those of the women who are carrying them.
In one such case, Marlise Muñoz, 14 weeks pregnant, was declared brain-dead at the hospital after her husband found her unconscious in their home. Both Muñoz and her husband were paramedics, and her family was familiar with her wishes; under no circumstances did she want to be on life support.
Already a tragic situation, the hospital overrode Muñoz's DNR, claiming it had a legal obligation to do so for the sake of the fetus. The hospital's legal team relayed that in Texas, it would be considered criminal homicide to cause the death of the fetus. The Times explains the impact this kind of state-wide decision making can have on women's rights:
The Muñoz case illustrates what’s at stake when the distilled ideology of the anti-abortion movement makes its way into the laws of the land. Statutes that give fetuses more rights than the women who carry them are bound to lead to heartbreaking outcomes when applied in the real world, however infrequently.
After months of legal battles, according to the Times, "Doctors eventually found that the fetus was likely nonviable, with severe deformities of the lower extremities and hydrocephalus, or fluid in the skull."
The laws mentioned above were created in order to protect the best interests of an unborn child. There a number of reasons why someone might sign a DNR, and it is not the job of medical professionals or the law to question why they do, but in the case of pregnancy, it is only reasonable to take into account the other life that will end as a direct result of said DNR.
Furthermore, there have been instances where keeping mothers on life support, also known as somatic support, has resulted in a healthy birth. Obviously cases of overriding a pregnant woman's DNR is a rare occurrence, but there is evidence to support the motivations behind doing so: To deliver a healthy baby.
Prolonging somatic support in a pregnant woman with brain death to allow fetal survival resulted in a successful outcome in terms of saving the life of the fetus. The results are consistent with previous published case reports in the literature on the appropriateness and safety of such a strategy that involved an intensive multidisciplinary approach. Despite being a tragedy, maternal death can represent an opportunity to save the life of the fetus and for organ donation.
Although the NCBI makes note that "the decision for prolonging pregnancy should be taken in collaboration with a surrogate decision maker from the family," it makes a clear conclusion in favor of the unborn fetus:
It is noteworthy to say that with extended somatic support, the pregnant mother will serve as an incubator. Therefore, this will violate her right to autonomy and bodily integrity, which are mostly cited issues in this context. However, these issues are not relevant as the patient is already dead.
Overriding a DNR order is a blatant disregard of one's rights. As The Hospitalist points out:
In 1983, the President’s Commission for the Study of Ethical Problems in Medicine supported DNR protocols (“no code”) based on three value considerations: self-determination, well-being, and equity.
A competent patient’s decision to forgo CPR is an example of self-determination or autonomy, which means that patients with mental capacity have the legal right to decide on medical interventions that are consistent with their values, even if their choices disagree with the wishes of family members or their physicians.
The Journal's Kate Butler explains a case in Ireland similar to Muñoz's. A mother of two who was 15-weeks pregnant was tragically declared brain-dead, but kept alive in the interest of her unborn child. Despite the woman's family's attempts to have her taken off of life support, the hospital continued to do so under Ireland's 2013 Protection of Life During Pregnancy Act (which was partially repealed in 2018).
The ambiguities and ensuing problems arising from the 2013 act are not accidental or due to some governmental oversight. They are intentional. This new legislation makes that clear.
Instead of providing guidelines or allowing for discretion, the government shut down any potential for female autonomy in pregnancy.
There are also instances where a DNR is not involved at all, making the question of keeping pregnant women on life support a strictly ethical one, rather than legal. CNN's Ed Payne reported on one such case in 2014:
Here, both [Robyn Benson's] husband, Dylan, and the doctors are trying to keep [Benson] on a ventilator until they can deliver the baby via a C-section. And the life inside her is growing normally.
Five weeks have passed since Dylan Benson found his wife unconscious. The odds are getting better for the boy he's named Iver.
'The doctors have said that he now has higher than an 80% of survival and that increases with every day that passes,' Benson said.
In this case, a child's life was saved because a mother was left on life support. Although tragic, these instances must be treated with care, empathy and a case-by-case outlook.