Blog | Monday, February 10, 2014

What is 'brain dead,' anyway?


You may now be familiar with the very sad case of Marlise Munoz, who lies “brain dead” in a Texas hospital. Or, like many people, you may have chosen to tune out every time the topic gets mentioned because the situation is so awful, and the construct of “brain death” gives you the heebie-jeebies.

At the time she was declared “brain dead,” Munoz was pregnant–14 weeks so. As I write this, her pregnancy is said to be at about 22 weeks. You should know that any baby delivered before 36 weeks is considered “premature.” The earlier in gestation that a baby is delivered, the higher the likelihood is that the child will not survive, or have severe mental and physical impairments. (With current science and medical technology, about 24 weeks of gestation is the earliest boundary of survivability.)

Though the hospital acknowledges that Munoz is indeed clinically ’brain dead,’ and therefore legally dead, administrators there argue that under Texas law they must keep Munoz hooked to a mechanical ventilator and provide her caloric nutrition so as to help the fetus become “viable.”

Welcome to the Twilight Zone, where the law is not clear, and the number of historical cases of brain dead pregnant females is small enough so that either side in this debate can use the evidence to further its case.

Munoz’ husband Erick argues that the hospital administration is a) misinterpreting the Texas statute, since his wife is dead and therefore not obligated to keep her body functioning as a ‘baby production laboratory’ [my phraseology] and b) overstepping its authority in not recognizing either his wife’s prior expressed wish not to be kept alive by mechanical means or his duty as her surrogate to honor her preferences.

On Friday a north Texas judge ruled that the hospital must withdraw the machines by Monday. As of now, no one knows what will happen. Possibilities include a) obeying the order, and stopping the ventilator [update: the hospital will obey] or b) appealing the decision to a higher court.

Erick and Marlise Munoz are (were) trained paramedics, so I assume they are quite knowledgeable about medical issues, and certainly well-qualified to make medical treatment decisions using the best available scientific evidence.

The clash here is about patient autonomy, an individual’s right to decide his/her own treatment (which I will tell you is unusually clear in this case. The vast majority of the time it’s a “best guess”) versus the State’s interest in protecting the vulnerable (fetus in this case). Of course, since this case involves the unborn, people with strong views about abortion have weighed in.

The concept of ‘brain death’ is also confusing. Legally accepted in all 50 states, “brain death” is the irreversible loss of brain function, such that even the brainstem, which controls autonomic functions like breathing have ceased. Therefore the only way to keep such an unfortunate person “alive” is by mechanical means. What the public is uncomfortable with is the idea that a person with a beating heart (the heart muscle can continue pumping autonomously even in the absence of brain function) is “dead.” But by legal and ethical standards, brain death = death. Period.

What adds to our discomfort about the concept is our very humanity; we all still hold out for miracles. Not to rain on anyone’s sunshine, but in brain death there simply are no miracles.

The difference between brain death and a coma (say, like the one former Israeli Prime Minister Ariel Sharon just exited) is that in a coma, the brainstem and other brain parts continue to function, allowing the body to “be alive” in some sense, such that the body can survive in the absence of mechanical means (nutrition must still be provided artificially, however).

My opinion, for what it’s worth (disclaimer: I am only responding to information gleaned from the news, and I am not involved in the case in any way), is that the hospital should respect the wishes of Marlise and Erick Munoz and turn off the ventilator: Allow her to die properly, with the dignity she wanted. Of course, the unborn fetus will then certainly die, too.

Medical ethics is not for the faint of heart.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.