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A4585 - Pregnancy as an Exception to Self-Determination: An Appraisal of US Statutes Regulating the Care of Incapacitated Pregnant Women
Author Block: B. P. Sperry1, C. K. Doyle2, J. Chor3, D. B. Kramer4, D. M. Dudzinski5, M. Siegler6, D. P. Sulmasy7, P. S. Mueller1, E. S. DeMartino1; 1Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, United States, 2Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, Chicago, IL, United States, 3Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, United States, 4Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, United States, 5Division of Cardiology, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States, 6MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, United States, 7The Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, D.C., DC, United States.
RATIONALE: Decisional incapacity is rare in pregnant women. Nonetheless, in recent decades, clinical and ethical controversies surrounding such cases and attendant media coverage have resulted in numerous regulatory statutes. To date, state legislation relating to this unique population has not been systematically examined. This study describes the prevalence of laws addressing incapacitating illness during pregnancy, whether fetal viability was proposed by states as a criterion for continuation of life-sustaining therapies (LST), and the powers afforded to alternate decision-makers or advance directives (ADs) in engaging in end-of-life treatment decisions for pregnant patients who lack decisional capacity. METHODS: Using two legal databases (LexisNexis and Fastcase), we reviewed legislation for the 50 US states and the District of Columbia to identify any statutes governing the care of critically ill pregnant women who lack decisional capacity. Three authors independently adjudicated the extracted data. All statutes analyzed were effective in their jurisdictions as of August, 2017. RESULTS: Thirty-three of 51 states’ statutes address the care of incapacitated pregnant patients. With regard to care decisions, there is enormous variability among the states’ statutes. Three states require physicians to test for pregnancy prior to reaching decisions regarding withdrawing or withholding LST in women of childbearing age. Nineteen states prohibit withdrawal of LST if the fetus is considered to be viable with continued application of LST; two states dictate gestational age criteria beyond which LST may not be withdrawn. Fourteen states mandate supporting a pregnant woman’s body with LST until the point of live birth regardless of gestational age. Five states indicate that decisions regarding LST could be influenced by a woman’s AD, whereas twelve direct that a woman’s AD be given no force in the event of pregnancy regardless of any pregnancy-specific direction given by the patient. Three states forbid legal guardians, representatives and surrogates from withdrawing LST from a pregnant patient. Two states forbid withholding cardiopulmonary resuscitation from any pregnant patient. One state will cover all medical expenses incurred by ongoing support of a pregnant woman. CONCLUSION: Legal approaches to caring for pregnant patients lacking decisional capacity vary greatly between US states. Patients, physicians and health care systems should be aware of their states’ statutes governing these challenging clinical circumstances. Whether these statutes reflect communities’ values regarding individuals’ rights to self-determination merits further examination.