For weeks, life-support machines have been hooked to the body of a brain-dead woman against the wishes of her family. Thirty-three-year-old Marlise Munoz is pregnant, and the hospital in Fort Worth, Texas, says state law prohibits from cutting life support from a pregnant woman. A medical team monitors the 20-week-old fetus in the I.C.U., in many cases acting as the brain that no longer functions in Munoz's body.
While the case is a lightning rod for medical ethicists -- bringing some of the most complex issues in current medical ethics into play -- it also raises the scientific question of how well technology can replace the functions of a mother's body.
"As far as fetal development, as long as we can control delivery of blood to the fetus and make sure the mother is nutrient-enriched, and as long as the mother's got enough glucose and oxygen, she can serve as a vessel," said R. Phillips Heine, director of maternal fetal medicine at Duke University. "If they can get to a reasonable gestation, there's potential for a very good outcome [for the fetus], so it would be a reasonable option. But I don't want that to sound like I'm not supportive of the family's wishes."
Complicating that decision in this particular case is the way Munoz died: Doctors think a blood clot in her lungs caused her to collapse; she may have gone an hour or more without breathing before her husband found her.
"If the mother was down for an hour, you don't know what happened in utero, how big a hit that kid took," Heine said.
Cases like Munoz's are rare, but not unprecedented: In a 2010 review, researchers found 30 cases of brain-dead pregnant women between 1982 and 2010. Twelve of the fetuses were born and survived the neonatal period.
"Manifold physiological changes occurring during pregnancy and brain death, as well as the prolonged hospital stay after brain death, present enormous challenges, however, both for the treating clinicians and for the family," the authors wrote.
Erick and Marlise Munoz with their son, Mateo.Marlise Munoz/Facebook
Because the brain stem manages functions the body needs to stay alive that seem to happen automatically -- breathing, body temperature -- both technology and a support team must manage those systems in brain-dead patients.
If a decision is made to try for a live birth, the researchers recommend cardiovascular support, respiratory support, nutritional support, endocrine support, and body temperature regulation.
The mother's body is also at risk of infection, gestational diabetes, and deep vein thrombosis. In all of the cases reviewed, the babies were delivered prematurely via C-section when either the mother or the fetus went into distress. While post-natal followup was only reported for half of the babies, they all were developing typically and "apparently had no problems related to their exceptional intrauterine circumstances," the researchers wrote.
For Jeffrey Spike, a professor of clinical ethics at the McGovern Center for Humanities and Ethics at The University of Texas Health Science Center at Houston Medical School who was involved in the case of a brain-dead pregnant woman in the 1990s, so many unknowns mean it's critical to involve the family in the decision-making.
"There's such a long period to have to keep her stable at very high risk that there's no way I would ever say this is ethically obligatory for anybody," Spike said. "It's perfectly likely that after weeks of being very unstable, they can see she's [in distress], and then decide to do a C-section in the middle of the night in the ICU, and then you have to do a C-section of a woman who's been dead for weeks, and it's a nightmare scenario. It's a huge risk."
Even in the case of the baby of a brain-dead mother who was born alive (according to the family's wishes) and discharged healthy after six weeks in the NICU, Spike says that to decide on the basis of viability alone is wrong.
"I think that the woman's preferences should be respected to the degree they can be known," he said. "Even if she wanted to be pregnant, that doesn't mean she wanted to have a child who would never know her, and she could never love and raise as her own. Allowing a fetal death while inside the womb might be the most peaceful, natural, and ethically appropriate outcome in such tragic circumstances."