Who is keeping Marlise Munoz on life support against her wishes?

Brain death is death. This is one of the definitions of death. Even in Texas.

Because brain death is death, a do not resuscitate (DNR) order or invalidating a DNR are both meaningless, because you don’t do procedures on dead bodies. This is why taking someone off a ventilator who is brain dead is not homicide, assisted suicide, or even following a DNR, it is simply the cessation of forcing air into a dead body.

So what of this terribly tragic case in Texas of Marlise Munoz found down on the floor by her husband, Erick, in November when she was in the first trimester. The reported cause of her circulatory arrest is pulmonary embolism (more common in pregnancy).  Munoz was a paramedic as is her husband and while she did not have a living will her family (her parents and husband) are well aware that she did not want life support.

The family report that their ability to carry out Marlise’s wishes are being ignored because of a Texas law that invalidates do not resuscitate (DNR) orders in pregnancy.

A spokesperson for John Peter Smith, the hospital in Texas where Ms.Munoz is on a ventilator, is claiming they are only following the law (which, by the way, is not a Texas-only Handmaid’s Tale). Although, it is important to know that law explicitly does not invalidate other laws, meaning brain dead in Texas is still dead, whether you’re pregnant or not.

So there is a huge disconnect here. A law that invalidates a DNR can not apply to a dead person.

The possible scenarios are:

1. Ms. Munoz is not brain dead. She has been tested and did not meet the criteria. She may have severe brain damage and be in a vegetative state, but she does not meet the criteria for brain death. Her family has confused this with brain death, although given her husband is a paramedic I think that confusion would be unlikely. In this situation the Texas law about DNR would sadly apply. It’s a terrible law and essentially reduces women to incubators, allowing the state to defile a woman against her wishes never mind ignoring the obvious concerns about fetal well-being from a catastrophic lack of oxygen. The kind of terrible event that could cause a maternal vegetative state would likely have resulted in even a longer interruption of oxygen supply to the fetus as all organs are sacrificed in catastrophic events in a desperate bid to send oxygen to the brain. A “strong” fetal heart rate doesn’t in any way guarantee fetal health. Anencephalic fetuses have normal heart rates until birth. In this case, the fight is with the state and the hospital is sadly following a terrible, misguided piece of legislation.

2. Ms. Munoz is brain dead so the Texas law about a DNR doesn’t apply. In this case the hospital is a) is following some bizarre pro-life agenda, b) can’t read/understand legislation, c) has an anti-brain death doctor in the ICU (apparently they exist). This scenario has John Peter Smith hospital defiling a dead body as the Texas legislation can not apply here.

3. John Peter Smith hospital has not checked Ms. Munoz for brain death. If you haven’t ascertained if someone is dead, then you can’t be compelled to withdraw life support by the family. The reason? Pro “life”? Anti-brain-death? Fear of alienating patients? Fear of affecting fund-raising? Not understanding the legislation? Who knows?

There are some worrisome facts about the hospital and how they are handling things. Ms. Munoz’s mother reported to the New York Times that, “ … we have no input in the decision making process.”

Then there is the intimation that they are going to do a viability test around 24 weeks (there is no such thing, BTW), but perhaps if the staff/hospital thinks they can get a fetal heart rate at 24 weeks they can somehow circumvent the brain death legislation (although how they could do a C-section or any invasive procedure without family consent is beyond me). But why would the family feel alienated if the hospital is “only following the law.”

Wouldn’t the common enemy be the state? By the way, I did a search on the John Peter Smith website for “abortion’ and not one hit returned. Nothing. Also they offer emergent care for rape victims, yet the website doesn’t mention post coital contraception. Maybe they offer it and are just flying below the radar. Why wouldn’t you say that you offer post coital contraception if your are promoting your rape trauma care program? And finally, the residency at John Peter Smith hospital does not offer abortion training.

What is clear is that Ms. Munoz’s husband and parents feel very alienated by the hospital and powerless. If the hospital were only following state law, I think their anger would be directed only at the state. Also, given Mr. Munoz’s training as a paramedic he would clearly be medically literate enough to handle the in-depth discussions of ICU care and the nuances of brain death versus a coma or vegetative state (the family has reported that Ms. Munoz is brain dead).

It’s a tragedy any way you look at it, but who is really keeping Ms. Munoz on life support against her wishes? Texas or John Peter Smith hospital?

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • guest

    In Texas women are human incubators and nothing more. Doesn’t matter if they are alive or dead. Their sole purpose is to bear children. They are not deserving of further rights or recognition. Hopefully this case will make other Texans aware of how dysfunctional and misogynistic the government is there (in case it was ever in question).

    Such a tragedy for all involved. A bitter lesson for all those who think modern medicine is in place to help them. We’ve never been further from that than we are now.

    • querywoman

      Yep! That’s how Governor Perry sees us. I didn’t get to have children.

  • CJElizabethM

    Every culture that I’m aware of has norms regarding death and how to treat bodies of the deceased. I have a knee-jerk sense of revulsion when I read about this family’s situation. It’s not as much about pro-life issues (not that I’m a fan of those politics) – they have violated the family’s rights regarding how to handle her death, the right to bury her, and to mourn.

    I think our culture has gotten obsessed with avoiding death. There are times when it makes sense to intervene. There are times when we should consider letting nature take it’s course. Sometimes the decision is hard. For me, the woman is dead. Assuming the fetus is able to live outside of her body, it will not live long. Nature needs to handle this one.

  • SherryH

    From MSN: “According to the medical records we have been provided, the fetus is distinctly abnormal,” the attorneys said. “Even at this early stage, the lower extremities are deformed to the extent that the gender cannot be determined.”

    The attorneys said the fetus also has fluid building up inside the skull and possibly has a heart problem.

    “Quite sadly, this information is not surprising due to the fact that the fetus, after being deprived of oxygen for an indeterminate length of time, is gestating within a dead and deteriorating body.”

    Would you still want to save your baby if you knew it wouldn’t live past birth? Or that it would suffer a short life filled with pain?

    • guest

      So heartbreaking. One can only hope the fetus does not live long out of utero; I have no doubt it will be “birthed.” I cannot imagine the pain the family is going through. The state adds insult to injury.

  • Jewel Markess

    I don’t understand your logic about malpractice caps – it’s clearly not applicable. There was no negligence in Ms Munoz death, the mother had no chance of survival before she got to the hospital. The fetus had zero chance. Now, though I think the family should sue the hospital for their experimentation on the corpse and causing the family pain and anguish and also attempt to extort the money from the family to the tune of $4000 a DAY. Interesting how the Texas law forgets to mention who pays for it. The insurance will not pay for the corpse support. The family knew – unlike some pro-lifers – that the chances of there have been a healthy baby were slim-to-none, and obviously they were right. The mother was without oxygen for over an hour. The fetus was maintained within a deteriorating corpse.

  • querywoman

    So sad! A lawyer or a judge already quit, probably out of disgust.

  • querywoman

    In the cases of both Jahi McMath and Marlise Munoz, they were each surely provided a certain level of care that enabled their bodies to keep functioning.

    There are surely umpteen patients in similar situations who don’t get that crucial care and simply die.
    It’s hard to believe that pregnancy is always caught in unconscious patients.
    So the odds are extremely unfair and skewed.
    I do not want extreme measures to prolong my life, but many people do.

  • querywoman

    I’m not a doctor. so that’s beyond my comprehension. In Jahi’s case, SIX doctors say she’s brain dead. It could be a mistake, but the odds of that six being wrong are miniscule.
    Whatever the crucial care, which I call mad science, that enable each one to keep functioning mechanically, may not function as well on others to “prolong life.”

    So the odds are high that many similar cases don’t extend mechanically functioning, and these two could well be a small percentage as opposed to others who get stop all living processes quickly.
    I quibble the concept of “brain death” in organ harvesting. There have been many questionable cases.

  • querywoman

    Marlise is off life support now. Soon there should be no question that she is dead.

    Erick and his inlaws want this so badly. She left one living child they get to raise now.

  • querywoman

    Erick named his unborn before Marlise was removed from the machines. Apparently, her body has been released to him.
    Rest in peace, Marlise, and live well with your living child.

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