Marlise Muñoz Case: Bioethics, Autonomy & Texas Law

Introduction

On November 26, 2013, Marlise Muñoz suffered a pulmonary embolism. Within two days, she 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 the right to self-determination, and also shows how legislation can sometimes impede ethical healthcare practice. Furthermore, the Muñoz case illustrates how important competence is in resolving ethical dilemmas.

Ethical Dilemma

The Muñoz case may appear besieged with ethical dilemmas, 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 is that brain death does indeed equal death (Mayo, 2014). Therefore, whether any patient should be kept on life support is not the main ethical dilemma in the Muñoz case.

Crucial and unique to this 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. The most salient ethical dilemma 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 case demonstrated incompetence 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 remove Muñoz from life support, her husband sued and won. The reasons the husband pursued legal action are known only to him, but they likely relate to his rights being infringed upon and his desire not to have the hospital system keep his wife on life support against her wishes. Whereas the husband sought what was best for the patient, the hospital believed the law was immutable. The courts ultimately disagreed, with the judge ruling that no law can require dead people to receive medical care (Powell, 2014, p. 263). The courts thereby helped resolve what the hospital perceived as an ethical dilemma; in fact, there was no genuine dilemma — there was incompetence born of a misinterpretation of the law.

Issues related to competence are therefore important to consider in the Muñoz case. Nevertheless, the main ethical dilemma remains one of conflicting duties and competing ethical codes. Texas law and the pregnancy exclusion effectively override principles in the American Nurses Association (ANA) Code of Ethics, such as preserving the patient's right to self-determination. The central question becomes: which code will nurses be held to — the law or the ethical code governing their profession?

Ethical Theory and Perspective

Ethical theories help shed light on the Muñoz case and its 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 patient's right to self-determination and autonomy. At the same time, the Texas law in this case seemed to categorically deny that right when a brain-dead patient is pregnant. The healthcare staff at the Texas hospital believed they were acting in accordance with a duty to preserve life, when in fact the patient was dead and the fetus was not viable. As Powell (2014) notes, 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 pregnancy was not viable, rendering the hospital's position untenable on several levels.

Utilitarianism also illustrates the ways in which the hospital staff inappropriately resolved the ethical situation. The goals of utilitarian ethics are to maximize happiness and minimize suffering. Keeping a brain-dead patient on life support against the wishes of both the patient and her family benefits no one. In fact, doing so causes net harm by wasting valuable resources. The healthcare staff in the Muñoz case violated utilitarian principles by maximizing suffering rather than happiness.