When Death Is Not the End: Continuing Somatic Care during Postmortem Pregnancy

Abstract

Brain death during the second trimester of pregnancy creates a unique situation in which the mother is deceased, but life of the developing fetus still depends on somatic functions in the mother’s body. In this article, I show that when a pregnant woman becomes brain dead during the second trimester, it is morally licit, though not morally obligatory, to continue somatic support while the fetus develops. The interventions on the mother’s body are justified for the life of the fetus, especially in light of the unique mother–child dyad and the responsibilities the mother has for her child. However, this therapy is not frequently employed, and its success is unpredictable. In many cases, the expense and uncertain nature of the therapy may make it disproportionate. In such cases, somatic support of the mother’s body may be discontinued.

Summary:

When brain death is diagnosed during pregnancy, it is a challenging decision whether to use artificial ventilation and other heroic measures to support the developing fetus. This paper demonstrates that while these interventions are acceptable, they are not obligatory.

In medicine, pregnancy is a unique situation when each decision must be evaluated based on its impact on two patients simultaneously: the mother and the developing fetus. At times, this can lead to difficult decisions about which treatments to pursue and how to balance the needs of two equally valuable individuals. This balance between caring for both mother and fetus is uniquely apparent when a mother is declared dead under neurological criteria (becomes brain dead) while still carrying a live fetus. At this point, one patient’s life is presumed to have just ended, while the other’s is still barely beginning.

When a pregnant woman becomes brain dead, the clinician has three options: (1) immediately deliver the child, (2) do nothing and thus passively allow the death of the fetus, or (3) begin prolonged somatic support of the mother to allow the fetus more time to mature in hope of a successful delivery at a later date.

In this decision, the stage of the pregnancy greatly influences what is appropriate. If the fetus is in the third trimester and has already reached a stage of viability, saving the fetus’s life is very likely. When survival is likely, attempts should be made to either deliver the fetus immediately or pursue somatic support of the mother to allow the fetus to develop further in utero before being delivered. By contrast, if the fetus is only in the first trimester, there have been no documented cases of survival, even with attempted somatic support (Catlin and Volat 2009). It is difficult to know how many of such attempts have been made. Most clinicians would agree that it likely would be considered futile to pursue further intervention (Spike 1999; Farragher, Marsh, and Laffey 2005).

The most challenging decision occurs when the fetus is in the second trimester of development at the time of maternal brain death. The fetus has not yet reached viability. Extended somatic support will be crucial to survival. Unfortunately, it is unclear how successful that somatic support will be. Worldwide there have been just over forty published reports of brain-dead pregnant women maintained on life support (Erlinger 2017; Esmaeilzadeh et al. 2010; Staff and Nash 2017). Among the most dramatic of these are two case reports of maintaining somatic functions in brain-dead women for over hundred days before the delivery of a healthy infant (Bernstein et al. 1989; Said et al. 2013). All of the reported cases included cessation of maternal ventilatory support shortly after delivery and subsequent cardiopulmonary arrest. These case reports that document live deliveries offer hope that it is possible to save a fetus even months away from viability.

However, others have had great difficulty with such intervention. When detailing their ability to keep a mother stable for only thirty-six hours, one group reflected that the small number of cases in the literature likely represent a publication bias toward successful outcomes (Vives et al. 1996). Given the few successful outcomes reported in the literature, some have concluded that before twenty-four weeks gestation, saving the fetus should not even be attempted (Dillon et al. 1982; J. P. Spike 2014). Certainly prolonged somatic support of a brain-dead mother for the sake of the fetus is far from being routine. When brain death occurs in the second trimester, it is very difficult for a clinician to predict whether prolonged somatic support of the mother will result in delivery of a live child.

In this difficult situation, clinicians and families are left asking, first, whether it is morally permissible to attempt such long, costly, and poorly researched treatments. Further, if it is morally permissible, the question arises whether it is morally obligatory to attempt to save the life of the fetus in this way? In this article, I will show that when a pregnant woman becomes brain dead during the second trimester, it is morally licit, though not morally obligatory, to continue somatic support to allow the fetus to mature until delivery is medically optimal. I will show that it is a morally permissible act to continue somatic support of the mother’s body, whether deceased or not, for a finite period of time to protect the developing fetus, particularly in light of the unique mother–child dyad. I will also examine the reasons—both valid and invalid—that prolonged somatic support may be viewed as extraordinary means, disproportionate to the desired effect, and I will show that choosing to forgo disproportionate treatment in this situation is not equivalent to abortion.

The Mother as Patient

Throughout most of a pregnancy, the most visible patient the clinician is working with is the mother. When a mother is determined to be “brain-dead,” these words have historically been used to describe certainty of her death. For Christians, death is understood as the moment when the soul departs from the body. Pope John Paul II (2000) confirmed in his address to the International Congress of the Transplantation Society that the neurological criteria used to determine brain death do “not seem to conflict with a sound anthropology” in determining that the disintegration of the whole has taken place and that death has occurred.

There is a growing concern about whether brain death represents with certainty that death has actually occurred (Joffe 2009). One of the reasons there is extensive debate over when death occurs has been to determine when treatments are no longer supporting life (Napier 2009). When death has occurred, discontinuation of “life support” generally becomes a non-issue since life is no longer present (Connery 1980). Beyond when it is appropriate to discontinue somatic support is the question of when it is inappropriate to continue it.

After the mother’s death, the physician’s duty to safeguard her health ends (Mayo 2014). However, the physician and others still have a duty to treat the mother’s body with respect (May 1973; Heywood 2017). Although no longer living, the body was once a human being. As such, the Catechism of the Catholic Church states, “The bodies of the dead must be treated with respect and charity, in faith and hope of the Resurrection. The burial of the dead is a corporal work of mercy; it honors the children of God, who are temples of the Holy Spirit” (US Catholic Church 1994, 2300). We must recognize the body of the deceased as a once living human being and treat it with due respect. Even though the deceased can no longer feel the pain of unnecessary interventions, a person can still be wronged by inappropriate instrumentation or unnecessary mutilation of her body (Glover 1993). For that reason, it is generally considered unethical to continue ventilatory support and other manipulations after a certain diagnosis of death has been made (Farragher, Marsh, and Laffey 2005).

However, it is not uncommon for somatic support of a body to continue for a finite period after brain death has occurred. A common example of this occurs prior to organ donation. A body declared dead by neurologic criteria is often kept on a ventilator for several days before the organs are harvested. After the organs are removed, the life support has achieved its goal and is discontinued. In other circumstances, a body may be kept on a ventilator until family members can arrive to say their farewells.

In the case of the brain-dead pregnant woman, it is acceptable, and in fact sometimes desirable, to continue somatic support of the mother for a finite period to allow fetal development. After delivery of the fetus, the somatic support of the mother reaches its desired outcome. The National Conference of Catholic Bishops acknowledged a similar situation when they wrote that “life-sustaining treatment should not be withdrawn from a pregnant woman if continued treatment may benefit her unborn child” (Committee for Pro-Life Activities 1984, 4). However, in the case of maternal brain death, treatment may not be “life-sustaining” for the pregnant woman’s body. Medical interventions simply provide somatic functions in her body that support the life of the fetus. The Pontifical Academy of Sciences (2006, 10) describes the mother’s organs as “a technical vessel for pregnancy.”

When determining whether medical interventions on the mother’s body are futile and medically ineffective, one must consider the entire situation. Even if the somatic treatments in this case will not restore the life of the mother, there is hope that they will benefit the fetus. If there is no hope of fetal survival, then somatic support could be considered futile. When the fetus is still relying on the mother and there is reasonable hope of fetal survival, however, it can be argued that the treatments, though not directly beneficial to the mother, still have a desired role.

Providing somatic support of a deceased body is not a routine care. Typically after death, somatic support is of no value to the patient or others. However, when the brain-dead patient is pregnant, somatic support is still of value and allows the preservation of the fetal life. Thus, the object of the act, the providing of somatic support to a body that is still nourishing a developing fetus even if the mother is not still alive, is morally permissible.

The Fetus as Patient

It is crucial that clinicians recognize that after the death of the mother they still have a living patient to care for. The developing fetus is a person with moral value equal to that of other human beings. The Catechism of the Catholic Church states that, “Human life must be respected and protected absolutely from the moment of conception. From the first moment of his existence, a human being must be recognized as having the rights of a person—among which is the inviolable right of every innocent being to life” (US Catholic Church 1994, 2270).

The fetus’s “inviolable right” to life must now be central to clinical decisions that are made. The clinicians have clear responsibilities to care for the fetus. As the Congregation for the Doctrine of the Faith (1987, I-1) wrote in Donum vitae, “Since the human embryo must be treated as a person, it must also be defended in its integrity, tended and cared for, to the extent possible, in the same way as any other human being.” This duty to care for the fetus’s life extends beyond the mother’s death.

Despite the technological advances the medical profession has made, the only way to care for and protect the life of an early second trimester fetus is to maintain it in utero. To care for the fetus does not involve any direct intervention on the fetus per se; care of the fetus requires the creation of a hospitable environment in the mother’s womb. During the mother’s life, this involves interventions such as prenatal vitamins and routine prenatal care. After the mother’s death, these interventions become more extensive and require continued support of the mother’s somatic functions.

At all times during pregnancy, treatment decisions are made based on both their effect on the mother and their effect on the fetus. At no point is one person’s life more valuable than another’s. If when the mother becomes brain dead she is truly dead, the clinician no longer has the mother’s life and health to weigh with the same gravity as the fetus’s life. As detailed above, it is still important to respect the mother’s body as that which was once living. However, this due respect cannot equal the moral magnitude of the fetus’s inviolable right to life.

Mother–Child Dyad

The situation of the pregnant woman is very unique. She has willingly entered into a relationship in which for the entirety of the gestation, she will be the only one capable of providing for her child’s needs. Even after the mother’s death, an early second trimester fetus can live only if certain somatic functions are provided through the mother’s body. Since decisions are being made about how to support those somatic functions in the mother, it is important to consider what she would have desired. In a properly ordered marriage, the new life that the mother’s body is nourishing is the pinnacle of self-sacrificing love the parents had for each other. Since before the child’s conception, they together committed to have self-sacrificing love for him or her (Wojtyla 1993).

Having brought the child into the world, the parents have certain responsibilities toward him. As Kant (1996, 64) wrote, “The parents incur an obligation to make the child content with his condition so far as they can. They cannot destroy their child as if he were something they had made (since being endowed with freedom cannot be a product of this kind) or as if he were their property, nor can they even just abandon him to chance, since they have brought not merely a worldly being but a citizen of the world into a condition which cannot now be indifferent to them even just according to concepts of rights.” Parents have entered into a relationship with their child in which they must do their best to provide for his or her needs.

In an article on the duty to protect life, Connery (1980) emphasizes that parents have a special obligation to protect the health of their children. He notes that any person should be willing to supply means to preserve another’s life if he can do so without creating serious burden. He further stresses that the parents’ duty to provide these means to their children is even more important. For an early second trimester fetus, the only way for a mother to provide for her child’s needs is through her womb.

When viewed in this way, it becomes clear that providing somatic support to the mother’s body for the remainder of the gestation supports the outcome she most likely intended, that is to bring to completion the procreation of her child. It is not simply using the mother’s body as a means to an end. Rather, to give somatic support is an action consistent with the decision she and the father made to be open to new life.

Regrettably, the mother will not be able to participate in the education of the child as she likely once intended. The role of her body in supporting the child will end when his gestation is complete. At that time, somatic support of the mother will be brought to its completion and must be appropriately discontinued. Meanwhile, the birth of the child will give new depth and meaning to the words of then Wojtyla (1993, 260), “When their [the parents’] lives in the body cease, their child will continue to live- the child who is ‘flesh of their flesh’, and above all a human person.”

Weighing Proportionality of Intervention

If possible, prolonged maternal somatic support for the sake of promoting fetal survival is generally a morally good decision. However, the Catholic Church has long recognized the need to weigh benefits and burdens of each given treatment. As Pope Pius XII (2009, 329) stated in his address to an International Congress of Anesthesiologists, “Normally one is held to use only ordinary means—according to the circumstances of persons, places, times, and culture—that is to say, means that do not involve any grave burden for oneself or another.” It is only by looking at what prolonged somatic support of the mother requires that an appropriate evaluation of the burdens and benefits of treatment can take place. While the object and end of the act of prolonged somatic survival are good, the circumstances will color each situation to determine whether it is of proportionate means.

When approaching the proxy decision maker, it is important to remember that this decision is unlike anything most individuals will ever confront. The proxy’s decisions simultaneously affect two patients. When deciding on behalf of the mother, she is already deceased. Any decisions the proxy must make on her behalf will not restore her life. The proxy is charged with making decisions in accord with the decisions she would have made (Manninen 2016). The decisions the proxy makes have a greater impact on the outcome of the fetus. However, none of the decisions directly involve treatment of the fetus. They are all interventions directed at the mother’s body to provide the fetus the environment he needs to develop. The proxy is charged with making decisions “in the best interest” of the child who has never been able to make decisions for himself (May 2000). It is in light of this entire situation that the proxy decision maker must weigh whether or not continued somatic support is proportionate.

It is important for all members of the treatment team and all decision makers in the case to have frank conversations about what treatment will entail and what the likelihood of success is (Loewy 1987). As the Ethical and Religious Directives for Catholic Health Care Services make clear, such conversations are essential for the informed consent process (US Council of Catholic Bishops 2018). It is very likely that different people, when presented with the same medical situation, will arrive at different conclusions about what represents proportionate treatment.

In the Ethical Religious Directives, the US Council of Catholic Bishops (2018, 57) clarify disproportionate therapies as “those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.” I will consider each of these criteria as they apply to the case of the brain-dead pregnant woman.

Reasonable Hope of Benefit

The decision to continue somatic support of the brain-dead pregnant woman is complicated by physicians’ inexperience in this area and the lack of scientific evidence guiding their efforts. Providers must extrapolate from case reports and the information known from short-term somatic support in organ donation (Lane et al. 2004). Cases like these are relatively rare and will never be routine for providers (Lewis, Varelas, and Greer 2016).

Even among experts, there is debate over when prolonged maternal somatic support is likely to be beneficial. A recent literature review identified only forty-one reported cases of brain death in pregnancy from 1979 to 2015 (Erlinger 2017). The earliest gestational age of these cases was reported by Bernstein and colleagues (1989) who were able to successfully maintain a pregnant body on somatic support beginning at fifteen-weeks gestation. Such reports in the literature spark hope, but they are few and far between. It is unclear how many similar cases have been attempted without success.

Certainly, the potential benefits to the developing fetus are tremendous. Without somatic support of the mother, the child will unquestionably die. With somatic support, he has a chance at life. These benefits are hoped for but unfortunately far from guaranteed. This uncertainty would be a valid reason to choose against prolonged somatic support of the mother’s body.

Excessive Burden

Proxy decision makers must exercise care when determining whether treatment entails an “excessive burden” (US Council of Catholic Bishops 2018). When a woman is brain dead, the treatments can no longer be burdensome to the mother because she is already deceased. The fetus also cannot experience any burden, for the treatment is not acting directly on the fetus. Rather, the treatment is attempting to allow the fetus the environment it needs to develop. A commonly cited reason for a treatment to be disproportionate is a psychological distaste or revulsion to the procedure such that the very thought of the treatment makes it too burdensome (Sullivan 2007).

Many find the idea of maintaining a beating heart and circulation of a dead body for months as understandably grotesque. One author described it as “the stuff of horror movies and distasteful science fiction” (Frader 1993, 348). J. Spike (1999, 62) described in detail the process of one mother’s corpse beginning to waste away as her fetus continued to develop. He wrote, “Everyone found treating a corpse disconcerting, and even macabre.…As Ellen’s abdomen gradually swelled, the rest of her body slowly became emaciated. After a month had passed, visits from family members became less frequent; her father stopped coming to see her because he couldn’t stand to watch what was happening to her.”

When evaluating psychological repugnance as a disproportionate burden, however, one must be careful to consider on whom the burden is being placed. As described above, it is likely that most of the psychological burden will be placed on those caring for the mother’s body and on the family members. It is understandably painful to watch death take its toll on a loved one’s body, just as it is painful to watch a living loved one suffer.

It is unlikely that the mother had enough foresight to explicitly state repugnance to this situation and, especially in light of the mother–child dyad, cannot be assumed to despise it. The child, who will have never known another life, cannot be presumed to be repulsed by such treatment. In the case of a brain-dead pregnant woman, it is likely that the psychological burden will be placed on the caregivers and family members. However, their discomfort alone will rarely, if ever, be enough to justify not pursuing somatic support of the mother.

Excessive Expense

The final burden to consider has been labeled by theologians as that of “exquisite means and extraordinary expense” (Sullivan 2007, 391). Maintaining somatic balance in a body that is deceased and has therefore lost its integrative function requires nothing short of exquisite means. While the medical details of such interventions are not the focus of this article, several examples are offered below as illustrations of some of the complexities (Feldman et al. 2000; Mallampalli and Guy 2005; Wawrzyniak 2015).

With regard to the circulatory system alone, management is difficult. A woman’s body after brain death initially experiences a discharge of hormones that result in transiently elevated blood pressure. This is followed by a period of dramatically low blood pressure. Because the uterine vasculature is unable to autoregulate when blood pressure fluctuates, these periods of low blood pressure can greatly reduce blood flow to the placenta and threaten the fetus (Mallampalli and Guy 2005). However, treatment of the low blood pressure is difficult. Intravenous vasopressors, such as dopamine, can be used to raise the blood pressure in the mother’s body but can cause additional placental insufficiency (Souza et al. 2006). Intravenous fluids are often given to raise blood pressure, but because of the low levels of protein in the blood of the brain-dead body, this additional fluid may accumulate in the mother’s lungs and complicate respiration (Mallampalli and Guy 2005).

Management of respiration is also difficult. Because the body will need long-term continuous ventilation, a tracheostomy must be performed. Then, clinicians must balance between ventilating enough to not cause damaging fetal acidemia and yet not too much as to decrease blood flow through the placenta (Mallampalli and Guy 2005).

Other difficulties that may develop in the mother’s body are complex, including panhypopituitarism, diabetes insipidus, severe infection, and difficulty with temperature regulation (Feldman et al. 2000; International Federation of Gynecology and Obstetrics 2011; Gopcevic et al. 2017). Additionally, the developing fetus will require high-level obstetric care including fetal heart rate monitoring, steroids to promote lung maturity, and eventual cesarean section (Feldman et al. 2000). This level of care will require access to an operating room and a high-level neonatal intensive care unit. This level of care may not be available in all locations (Catlin and Volat 2009). All of this will inevitably amount to a tremendous cost, which one author estimated at up to 3 million dollars per successful outcome (J. Spike 1999). Although it is impossible to place a monetary value on a human life, many families and communities will not be able to handle this expense and will need to justifiably judge the therapy as disproportionate.

Discontinuing Somatic Support as Unique from Abortion

As I have discussed above, the life of the developing fetus is invaluable and must be respected. Many may be hesitant to withhold somatic support of the mother believing that to do so would constitute an abortion of the fetus and would therefore be intrinsically evil. Indeed, as Pope John Paul II (1995, 62) stated in his encyclical Evangelium vitae, “I declare that direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder.”

Abortion is defined, however, as “the deliberate and direct killing, by whatever means it is carried out, of a human being in the initial phase of his or her existence, extending from conception to birth” (John Paul II 1995, 58). Abortion is a direct attack on fetal life with the goal of ending the pregnancy. When choosing to discontinue somatic support of a brain-dead mother, the goal is not to destroy the life of the fetus. Instead, it is a judgment call that to pursue such exquisite therapy is disproportionate to the possibility of success. In one such case, Catholic moral theologian Johannes Gründel from the University of Munich emphasized, “To allow nature to take its course in this manner cannot be equivalent to a direct killing of human life in the event of an abortion” (Anstotz 1993, 347).

While it can be difficult to accept the death of the fetus, this does not constitute any attack on the fetus. The intent is not to end the life of the fetus but rather to accept the bleak medical reality of the situation and to choose not to pursue extraordinary therapy. Of importance to this argument is the presumption that the decision maker choosing to forgo treatment does actually value the life of the fetus. The decision that therapy is disproportionate must be based on the burdens that the therapy imposes on those involved. It is not acceptable to forgo therapy because of burdens associated with raising the child as a single parent, with raising a potentially handicapped child, or other attitudes that reduce the inviolable value of the fetus as a human person.

Conclusion

When a pregnant woman becomes brain dead during the second trimester, it is indeed a tragic situation. Many will desire to do anything possible to save the fetus and salvage some good from the situation. Continued somatic support of the mother’s body for a finite period in order to allow fetal maturation can be a morally good act. However, in this extreme situation, the proportionality of the treatment is often tempered by its uncertainty of success and the financial burden. Therefore, while morally permissible, one must not feel morally obligated to choose prolonged somatic support of the mother; to judge somatic support as disproportionate treatment does not constitute an attack on the fetus and is not equivalent to abortion. Such cases are difficult and require strong communication between all decision makers and treatment team members. Together, they must determine when to pursue prolonged somatic support and when the mother’s death will not be the end.

Biographical Note

Jennifer J. Barr, MD, MPH, FACOG, is a maternal–fetal medicine fellow at University of Tennessee Health Science Center. She also holds an MA in theology with an emphasis in bioethics from Holy Apostles College and Seminary in Cromwell, CT. Her research interests include the effects of stress on pregnancy outcomes and interventions to decrease health-related disparities.