Introduction On November 26, 2013, Marlise Muñoz suffered from a pulmonary embolism. Within two days, the patient was declared brain dead. Muñoz was 33 years old and 14 weeks pregnant. She also happened to reside in Texas. In Texas, a provision of the state’s Advance Directives Act known as the pregnancy exclusion apparently mandates that any pregnant patient must be kept on life support regardless of the fetus’s gestational age, and regardless of the patient’s or her family’s wishes (Mayo, 2014). Based on their interpretation of the pregnancy exclusion, the staff at the Texas hospital refused to abide by the family’s—and the patient’s—wishes, claiming they were constrained by law.

In addition to raising important questions about the efficacy of neurological death, the Muñoz case is instructive for informing future bioethical policies. The case touches upon abortion issues, patient autonomy, and right to self-determination, and also shows how legislation can sometimes impede ethical healthcare practice. Furthermore, the Muñoz case shows how important competence is in resolving ethical dilemmas.

Ethical Dilemma

The Muñoz case seems besieged with ethical dilemmas, and yet further analysis reveals that the issues were relatively straightforward. The healthcare staff and/or the hospital administration violated ethical principles. Although Truog & Miller (2014) claim that brain death is not necessarily a medically accurate or ethical means of determining patient status, the overall consensus in the medical community around the world is that brain death does indeed equal death (Mayo, 2014). Therefore, whether or not any patient should be kept on life support is not the main ethical dilemma in the Muñoz case.

Crucial and unique to the Muñoz case is the patient’s pregnancy because it is the pregnancy exclusion that formed the grounds for the hospital’s decision to disobey the patient’s wishes. It would seem the most salient ethical dilemma in the case is whether healthcare workers have a greater obligation to obey the law or a greater obligation to the ethical provisions of their profession.

Yet as Mayo (2014) points out, the hospital administrators and/or healthcare workers in the Muñoz demonstrated incompetency in their interpretation of the law: “nothing in the Texas Advance Directives Act justified—let alone compelled—the...

15). When the hospital refused to take Muñoz off life support, the husband sued and won. The reasons the husband sued are known only to him, but probably have to do with his rights being infringed upon and his desire to move on with his life and not have an overbearing system keep his wife on life support against her wishes. Whereas the husband wanted what was good for the patient, the hospital believed that the law was immutable. The courts ironically disagreed with the hospital, because the judge resolved that no law can require that dead people receive medical care (Powell, 2014, p. 263). The courts therefore helped the hospital staff resolve what they perceived of as an ethical dilemma; in fact, there was no dilemma, but there was incompetence due to misinterpretation of the law.
Issues related to competence are therefore important to consider in the Muñoz case. Nevertheless, the main ethical dilemma remains related to conflicting duties and competing ethical codes. Texas law and the “pregnancy exclusion” effectively overrides principles in the American Nurses Association (ANA) Code of Ethics such as preserving the patient’s right to self-determination. Which code will nurses be held to: the law or the ethical code governing their profession?

Ethical Theory/Perspective

Ethical theories or perspectives help shed light on the Muñoz case and the ethical dilemma. Deontology informs the duty to act in accordance with presumed universal law. The healthcare professions typically outline several elements of the duty to care, one of which is the right to self-determination and autonomy. At the same time, the Texas law in this case seemed to categorically deny the right to self-determination if a brain dead patient is pregnant. The healthcare staff at the Texas hospital believed that they were acting in accordance with the duty to preserve life, when in fact the patient in question was dead and the fetus was not viable. As much as the hospital staff believed they were doing the right thing by following the law, their position remained untenable on several levels. As Powell (2014) points out, all parties agreed that the fetus “was not and had never been viable,” (p. 263). Had the patient been close to giving birth, the case would have evolved differently. As it was, the patient’s pregnancy was not viable.

Utilitarianism…