Bioethics Essay 2

7/29/2019 Bioethics Essay 2

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Alex Woo

11/27/2012

Word Count:1908

Case Study: The Implications of Patients in PVS Carrying out Pregnancies

In some rare cases, a pregnant woman can be determined to be in a persistent vegetative state1

(PVS) despite their body continuing into the latter stages of pregnancy. A woman in PVS with child

questions what obligations each party is responsible for and what role they play in the decision making

process. This includes the use of life support to sustain a patient in PVS and any other procedure

required to insure the highest survival rate of the unborn child. When such a case occurs, I argue that

given an advanced directive2, patient autonomy

3trumps all. If none is given, the decision should rest

within the remaining family (surrogate decision maker), but given the outcome of similar cases there is

no restriction for the physician to care for a pregnant PVS patient until birth occurs.

The case in question deals with a woman who had been in a car accident. The resulting trauma

is determined to have put her into a PVS, and it becomes clear that some amount of gestation4 has

occurred before the initial accident. At this point, the patient is either kept on life support or taken off;

but who has the right to decide that choice? The patients autonomy is challenged given the presence of

a potential personhood5. Does the introduction of an unaccounted for being affect the say of a patient

even if they are in no condition to give an altered decision? If no advanced directive is stated, then the

burden of decision making falls on their surrogate6(Bush 746). Even if these decisions are made, there

are further questions such as the extent that a physician is obliged to support the unborn fetus and PVS

mother while maintaining both the stance of beneficence7

and nonmaleficence8. What is considered as

beneficial to both the mother and fetus must be determined to justify the use of medical intervention to

carry out the pregnancy.


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The first decision to be made in this situation is whether or not to keep the mother on life

support. Based off of the principle of patient autonomy, the mothers wishes should be respected. If the

mother had wanted the use of life support, then that is what should be done for it simply falls in line

with the best form of treatment to bear the child (Sim 670). If stated otherwise, the mother should not

be forced to continue her pregnancy because of the infringement upon the patients autonomy.

Unfortunately, this can only be done if there was some form of last testament which indicated their

opinion given the particular situation. In the event that no opinion is stated a surrogate decision maker,

likely a family member, would be expected to decide on behalf of the would-be mother. In some ways,

this can be seen as more appropriate than abiding solely on a will of the PVS mother because the

surrogate is able to account for the unborn child when making their decision. It is important to

acknowledge that a surrogate has the right to continue the use of life support if that is their decision.

Doing so would be accepting the burden of any medical costs, despite the lack of medical insurance and

should be part of the decision making process when deciding whether or not the pregnancy should be

supported until the latter periods of gestation. The surrogate should also account for the future well-

being of the child and be ready to care for it when deciding. Because of the implications of bearing a

child with no mother, it is morally acceptable for a surrogate to decide to discontinue the use of life

support (Bush 746). It would be unethical and unreasonable for a physician to force the care of the

patient if the surrogate is not willing to take on the burden of the unborn child as well as the costs of

medical care which would question the quality of life of both the unborn fetus as well as the PVS mother

at that moment and in the future. This point leads on to the next problem. What responsibility does the

physician hold as the health care provider towards the mother and child?

The role of the physician is dependent on the decision of the surrogate. The physician has no

moral duty to support mother or child if that is against the wishes of the mother or surrogate (Bush

747). The costs of the process and the allocation of medical resources should be a pertinent point when


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determining the best course of action (Kaufman 214-215). In particular, if the patient does not have

health insurance, it would be unethical to forgo the surrogates decision considering the high costs, the

lack of a mother, and the relatively low chance of success in pregnancies in PVS women. The large

amount of debt and the lack of a biological mother for the child both go against the principle of

beneficence. To bring in an infant into this world with no family or one ruined with debt would arguably

have a low quality of life and would be in the best interest of the parties to not pursue (Kaufman 217).

Finances aside, medically speaking there is little that contradicts the idea that it would be in the best

interest to attempt to carry out pregnancy. In one case, a mother in PVS was able to carry out pregnancy

from only 4 weeks gestation until early labor at 33 weeks (Sim 669). This case suggests that not only can

an infant be born despite a mother in PVS at such an early stage of gestation, but it may be considered

therapeutic for the mother to undergo labor by removing the extra demands of oxygen to support the

infant (Sim 671). Of the 14 published cases dealing with maternal patient in PVS, there is an overall

positive outcome in terms of neonatal survival. Therefore, it would seem to be morally ethical for a

physician to undergo any measure to sustain a mother in PVS until labor occurs if that is the will of

mother or surrogate (Sim 672). Looking at the situation in terms of the principle of beneficence, the

possibility of the infant actually being born is considered a positive for the fetus (Bush 746). Given the

resources, it is in the best interest of the fetus to support the mother in PVS so as to facilitate the

pregnancy. Also, if the physician acts in accordance with the mother or surrogate in supporting the

mother and fetus, the physician maintains the stance of nonmaleficence by doing no harm to either

person. Although there may be some deliberation in deciding what can actually be considered as doing

no harm to the mother.

Critics to the support of mothers in PVS so as to continue gestation may argue the harm being

done to the mother by the low quality of life. By the definition of what PVS implies, the mother is not

aware of any pain she may have felt if otherwise healthy (Bush 745). With this in mind, the fetuss


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survival becomes more urgent than the recovery of the mother in PVS because of the poor prognosis of

the mother. This allows physicians to take any measure requested by the surrogate to increase the

survival of the fetus. There is also concern towards the viability9 of a fetus when determining the best

course of action. With data from one of the case studies, fetal outcome can be positive with as little as

only 4 weeks gestation pre-PVS while being delivered at 33 weeks (Sim 669). With such little data

regarding the outcomes of such situations, this one case serves as an indicator that there is no reason a

fetus cannot be facilitated in utero until viability. Another concern skeptics may have is the availability of

resources and whether or not a patients insurance status affects the care they receive. The availability

of health insurance should not bar a patient from receiving such treatment, but should be heavily

weighed when a surrogate decides on whether to continue life support or not. The last scenario that can

be argued is if a viable fetus is within a mother who explicitly states she would not want to be put on life

support. Normally, if there is an advanced directive available, then it should be followed regardless as

the last will of the patient, because to do otherwise would imply the fetuss potential personhood is

more important than the autonomy of the mother who did not wish to be kept alive through

extraordinary measures (Bush 746). It is possible to argue the autonomy of a mother by questioning

whether the mother was informed of the current situation when making her decision. If a mother were

to have established not to be held on life support before holding a viable fetus, a surrogate may be able

to act as the informed decision maker arguing the lack of information presented when the decision was

made and thereby acting giving the then informed consent to override the mothers last wish.

From previous cases, it would appear that the longer gestation occurs before brain injury to

mother, the better the rate of survival of fetus. There is also evidence that shows gestation beyond 31

weeks greatly improves the survival of fetuses. However, a 1982 study suggests that attempts to

prolong maternal life in the face of brain death are expensive, frustrating and ultimately futile and

concludes delivery at 28 weeks gestation or as soon as possible is best (Bush 742).The contradicting data


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signifies that there is no clear and cut way to treat all cases and instead should be treated on a case by

case basis. There is also concern for possible publication bias when it comes to maternal PVS patients

(Bush 747)

In each case, it is vital that the autonomy of the mother in PVS be respected, if there is one to

heed to. As recognized in the last paragraph, it may be possible to undermine the autonomy of the

mother by challenging how informed the mother was. This discrepancy further highlights how there is

no definite way to handle these cases, but instead to view them individually, using previous cases as

references. All that can be concluded is that it is morally ethical for a physician to support both a mother

in PVS as well as her unborn fetus through means of medical intervention, as long as either the mother

or her surrogate demonstrate the desire for the life support. In terms of finances, it is wise for the

surrogate to account for the high costs of carrying out pregnancy through life support, but care should

not discriminate based on the lack of health insurance.

1. Persistent Vegetative State A deep state of unconsciousness from which patients do not recover.

(Parks Glossary)

2. Advance DirectiveA document that outlines a persons health care decisions that is used if a person

is unable to speak for him- or herself. (Parks Glossary)

3. Principle of Autonomy Each rational, competent person be given the right to make medical

decisions that affect his or her life. (Parks 19)

4. Gestation- The process of carrying or being carried in the womb between conception and birth.

5. Personhood An individual human being; the presence of particular characteristics that grant

a certain legal, ethical, or moral standing. (Parks Glossary)


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6. Surrogate A person who is acting as decision maker for another person. (Parks Glossary)

7. Principle of BeneficenceTo do good for patients. (Parks 20)

8. Principle of Nonmaleficence If no benefit can be done for a patient, then at least no harmshould come to them. (Parks 20-21)

9. Viability (of fetus) - The potential of the fetus to survive outside the uterus after birth (often defined at

24 weeks gestation).(Bush 740)


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Works Cited

Bush, Melissa C. "Pregnancy in a Persistent Vegetative State:: Case Report, Comparison to Brain Death,

and Review of the Literature." Obstetrical & Gynecological Survey 58.11 (2003): 738-

48. Wolters Kluwer. Web. 27 Nov. 2012. .

Kaufman, Howard H., MD, John Bodensteiner, MD, Mark Gibson, MD, and Robert Hoeldtke, MD.

"Treatment of the Pregnant Patient Who Is Brain Dead or in a Permanent Vegetative

State."Neurosurgical Aspects of Pregnancy. By Christopher M. Loftus. Park Ridge, IL:

American Association of Neurological Surgeons, 1996. 205-20. Print.

Parks, Jennifer A., and Victoria S. Wike. "The "Four Principles" Approach to Biomedical

Ethics."Bioethics in a Changing World. Upper Saddle River, NJ: Prentice Hall, 2010. 18-21.

Print.

Sim, Ki-Bum. "Maternal Persistent Vegetative State with Successful Fetal Outcome."Journal of Korean

Medical Science 16 (2001): 669-72.Biomedsearch. The Korean Academy of Medical Sciences.

Web. 28 Nov. 2012.

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