Life support case: Ethical considerations a crucial part of best medical practice

The burial of the brain-dead pregnant woman marks a closure of sorts for her family, following a long saga that began with her admission to hospital about four weeks earlier.

Declared brain dead at a Dublin hospital on December 3rd and subsequently transferred to a local hospital, she became the centre of a legal issue that ended in the High Court. There, three judges cleared the way for the woman's life support to be withdrawn, describing the continuation of somatic support as a "futile exercise".

With constitutional and legal factors to the fore, it seems the practice of ethical medicine was forced into a supporting role. The Eighth Amendment to the Constitution, which enshrines the unborn’s constitutional right to life and the perceived risk of prosecution by doctors should they withdraw life support for the mother, was a major factor.

It appears doctors were also fearful of conviction under the Protection of Life during Pregnancy Act, 2013, which carries a possible 14-year prison sentence for procuring an illegal abortion.

Clinical practice

However, for many observers linking a 16-week pregnancy in a brain-dead woman to abortion is perplexing. In the past, such tragedies have been managed with sound clinical practice guided by medical ethics.

When a person is declared brain dead after a car crash or other cause of catastrophic brain trauma, it means the brain stem – the part that drives basic involuntary acts such as breathing and circulation – is irrevocably damaged.

Once this diagnosis has been carefully made, continuing life support can only be justified for the purpose of harvesting the deceased’s organs for donation or – in the case of a woman in the later stages of pregnancy – to allow for a viable foetus to be delivered by Caesarean section.

Ethical medicine

For many physicians, turning off life support in the case of a young brain-dead woman in the early stages of pregnancy would not pose an especially difficult ethical dilemma. Not that such a decision should be taken lightly by a lone practitioner; in practice doctors consult with health professional colleagues. For especially challenging dilemmas in hospitals, the availability of a clinical ethics service is increasingly considered best practice.

Arguably a necessity rather than an option, such a service can be a powerful motivating force in driving a renewed ethic of care for a broad range of health professionals. It would ensure the kind of dilemmas that are unavoidable in a high-tech environment are dealt with on an inclusive and ongoing basis.

Some important questions arise in the wake of the recent High Court case: do Irish hospitals have access to trained ethicists to help inform best practice? How many hospitals here have a clinical ethics service?

For doctors themselves, the practice of ethical medicine is a cornerstone of professionalism. And while legal issues must be considered, it would not be healthy for the practice of good medicine – or indeed for society in general – for ethical issues to be routinely trumped by legal considerations. Overly defensive medical practice is rarely good for patients and their families.