A 16-year-old single girl arrives in the emergency department with a gunshot wound to the head. The entrance wound is just above one ear, and the exit, with brain protruding, is above the other ear (generally a rapidly lethal injury).
The patient is seven months pregnant. The fetal heart rate is 180 / minute (fast). The mother’s heart stops. Should an emergency cesarean section be performed? What if the girl’s mother is present and declares that no one in the family will take care of the child?
Assume, now, that the situation is a little different. The mother’s heart does not stop, but she becomes apneic and is intubated and placed on a respirator. The fetal heart tones suddenly go to 250 / minute (critical). Should an emergency cesarean section be performed? Would it make any difference if she were nine months pregnant?
Commentary
In the various permutations of the case presented, common features identified are:
- The mother dies during medical surveillance or has a brain lesion certain to result in brain death.
- The fetus has reached a gestational age that predicts viability.
- The mother is a minor.
- The fetus is probably in distress.
Given that the mother has died under medical surveillance, there is substantial probability that the fetus can be successfully removed from the mother’s uterus by rapid, emergency cesarean section.
The risk that the fetus would sustain critical compromise from agonal deterioration of the mother’s supportive physiology is minimal, since she is accessible to cardiorespiratory life support until the section is accomplished and the operation can be accomplished in a minute or two, well within the tolerance of the fetus.
Successful outcome will depend upon prior determination of appropriate protocol in the emergency facility for cardiopulmonary life support for the pregnant patient, emergency postmorten cesarean section, resuscitation of the newborn, and prompt action.
A strong concensus exists that a postmortem cesarean section not only can but also should be performed. Notwithstanding this assertion, a number of ethical and legal concerns need to be addressed.
Potential conflicts for anyone providing health care to a pregnant woman derive from the fact that there are moral obligations to two patients, the mother and her fetus (or the child it will become), and their best interests may not always coincide.
Maternal best interests are protected by both autonomy-based and beneficence-based obligations of the physician, while the fetus (child-to-be) is similarly served by beneficence-based obligations borne by the mother and by the physician:
From medicine’s perspective, the goods to be sought for the child the fetus will become and therefore for the fetus are prevention of premature death, disease, and handicapping conditioning . . . it, therefore, may be appropriate to refer to the fetus as a patient, with the possible exception of abortion of previable fetuses.
In the current case, beneficence-based obligations to the fetus clearly override autonomy-based obligations to the mother, since she cannot make choices or come to reasoned decisions.
The fetus has reached viability when, in the words of Shriner, its “mother’s abdominal and uterine walls” are, “quite literally, all that . . . stand . . . between . . . it .. . and full and immediate human life.”
That the mother has not had the fetus aborted implicitly confers upon her an obligation to protect this fetus; the emergency physician thus has a fiduciary duty to act toward the benefit of the fetus through his or her caregiving relationship to the mother, in addition to a direct duty to the fetus.
A significant conflict would arise if action to be taken on behalf of the fetus were harmful to the mother. In all the permutations given of this case immediate death of the mother is inevitable.
The potential of “mutilating” the mother’s body without her consent — as part of the surgical procedure — is clearly overwhelmed by the benefit of preserving the life of her child.
Finally, there is no basis to presume that her will would be otherwise, were she capable of expressing it.
In conclusion, in all the variations presented, there is a clear ethical duty to proceed in the emergency room to protect the life and well-being of the fetus, including postmortem cesarean section in the instance in which the mother’s heart has stopped, and, in all cases, to treat the mother’s body in the manner most supportive to the physiology of the fetus until it is delivered.
However, these conclusions do not exhaust the problems and obligations that need to be addressed.
The fetal distress evident in the instance in which the mother’s heart does not stop is not necessarily irreversible. The mother’s gunshot wound is a form of trauma having no direct effect on the fetus.
If the mother can be adequately ventilated and her blood pressure maintained, fetal distress should be resolved, unless there has been a placental abruption or the gravid uterus is compromising its own circulation by impinging on the mother’s great vessels. In the latter case, this should resolve when the mother is turned on her side.
If fetal distress is resolved and the mother stablized, the term fetus might be delivered by oxytocic induction of labor, by cesarean section, or by spontaneous onset of labor, depending upon medical indications.
The seven-month fetus would be substantially benefited by continuing gestation through to term, as long as the maternal condition and fetal status permit. Prolonged artificial life support of the mother, even though brain dead, is indicated in order to improve the perinate’s chances of surviving.
Remaining to be resolved are the questions raised by the fact that the mother is a minor and that her mother declares that no one in the family will take care of the child. What are the rights of the family, and what are their obligations?
The question of rights and obligations of the dying girl’s parents is not easily answered. As a pregnant 16-year-old, she might be viewed as an emancipated minor or, otherwise, as the minor child for whom they are responsible.
If she is not married, her parents would certainly be considered next of kin and entitled to be and obligated to a status of surrogate decision makers.
Courtesy and compassion would demand that they be given the opportunity to consent to appropriate treatment for their daughter and her fetus and be appropriately informed toward such consent.
Should they refuse consent to treatments required for the preservation of life and health of the fetus (child-to-be), the state can be expected to exercise its duty to protect the fetus from neglect and harm.
The state should also be prepared to support the child after its birth, or arrange for adoptive parents to care for the newborn, if the next of kin formally relinquish this responsibility.
The unwillingness of the kin to support the fetus-newborn should not condition the care in any way. In the tragic circumstances of the prolonged dying of the mother, should she be life-supported after brain death in order to prolong gestation, counseling should be made available to the family as needed to cope with their extended grief.
Adequate management of cases of this nature will depend upon appropriate prior planning. A responsible emergency center should plan for the contingencies posed by this case.
This would include prior consideration of the ethical and legal obligations, the medical management protocols for prompt, effective treatment, including appropriate working relations with an intensive level perinatal center for the management of the seven-month fetus and newborn, and administrative arrangements with appropriate judicial jurisdictions for effective legal protection and support of the interests and rights of the patients and their caretakers.
