the ethics of the munoz case nursing

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 continuation of ventilator support in this case,” (Mayo, 2014, p. 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 also illustrates the ways the hospital staff inappropriately resolved the ethical dilemma of the Muñoz case. Maximizing happiness and minimizing suffering are the goals of utilitarian ethics. Keeping a brain-dead patient on life support, against the wishes not only of the patient but the family, benefits no person. In fact, keeping Muñoz on life support causes net harm by wasting valuable resources. The healthcare staff in the Muñoz case violated utilitarian principles by maximizing suffering instead of happiness.
Ethical/Moral Principle
The healthcare staff at the Texas hospital violated several ethical principles including autonomy, self-determination, justice, and fidelity (Berman, Snyder & Frandsen, 2016, p. 86). What the staff might have believed to be nonmaleficence in continuing life support was in fact directly harmful to the family and contrasted with their lack of beneficence or concern for the family’s wellbeing. The principle of beneficence suggests that nurses must act in the patient’s best interest, and are obliged to do good things for patients (Berman, Snyder & Frandsen, 2016, p. 86). Nonmaleficence is the counterpart of beneficence, prohibiting nurses to do direct harm.
The healthcare institution’s hard-lined policy impeded justice. According to Berman, Snyder & Frandsen (2016), nurses need to weigh the facts carefully, which in the Muñoz case never seemed to happen (p. 86). As a result, the institution found itself at the receiving end of a lawsuit that it lost. The courts ultimately enabled justice, but the nurses could have avoided the costly lawsuit had they followed the moral principle of justice to begin with. The concept of fidelity was also violated in this case. Fidelity refers to the nurse’s obligation to honor agreements. Agreements include agreements to follow the patient’s own directives for avoiding unnecessary life support measures.
The ethical principle most egregiously violated in this case is the patient’s right to self-determination. The right to self-determination is linked to the principle of autonomy. Patients always have the right to refuse medical treatment, and must be summarily informed of this right and be given all the information they need to make their decision.
Provisions of the ANA Code of Ethics for Nurses
The ANA Code of Ethics for Nurses includes nine primary provisions, the second of which is about nurse commitment is to the patient, including families (Berman, Snyder & Frandsen, 2016, p. 88). In the Muñoz case, the hospital administration and the nurses that obeyed it did not demonstrate a primary commitment to the patient. Rather, the staff resolved its ethical dilemma by misinterpreting the law. The administration believed that their primary commitment was not to the patient, but to a law that it was actually misinterpreting. The administration also failed to seek legal counsel that could have more readily resolved the issue and avoided further pain, conflict, or expense. In this sense, provision 8 of the ANA Code of Ethics was also violated because the staff did not collaborate with one another. Finally, the nurses and the administration demonstrated a lack of competence in the very laws that govern their own practice. This represents a violation of competency codes as outlined in provision five of the ANA Code of Ethics.
Outcomes
The case was ultimately resolved after the patient’s husband sued the hospital. The judge ruled in favor of Muñoz, and the hospital was essentially forced to remove the patient from the life support system (Powell, 2014, p. 263). The healthcare workers had caused trauma to the Muñoz family, which could have been avoided had the administration more carefully considered what the Texas Advance Directives Act and the pregnancy exclusion really meant, and what their obligations were both under the law and within the ANA Code of Ethics.
Conclusion
In the Marlise Muñoz case, the administration clung to their misinterpretation of the law because they were incompetent and unable to collaborate with professionals who might have lent insight into the situation. Ultimately, the staff violated the sanctity of the patient-healthcare worker relationship, specifically with regards to protecting patient autonomy, ensuring self-determination, and informing the patient (and family) of their rights. The staff also failed to act with the best interests of the patient and family in mind, neglecting one of the main primary provisions of the ANA Code of Ethics: placing the patient’s needs above all else. Even if Texas law had allowed the staff to keep the patient on life support, the nurses should have still honored the wishes of the patient and her family.




References

Berman, A., Snyder, S.J. & Frandsen, G. (2016). Kozier & Erbs Fundamentals of Nursing, Berman & Snyder
Mayo, T.M. (2014). Brain-dead and pregnant in Texas. The American Journal of Bioethics, 14:8, 15-18, DOI: 10.1080/15265161.2014.925365
Powell, T. (2014). Brain death. American Journal of Critical Care 23(3): 263-266.
Truog, R.D. & Miller, F.G. (2014). Changing the conversation about brain death. The American Journal of Bioethics, 14:8, 9-14, DOI: 10.1080/15265161.2014.925154