Whether a pregnant woman is anything more than a vessel for gestation of a child has long been the subject of heated debate. In many cases, the question arises in the context of a pregnant patient who refuses treatment recommended by her doctor, who then seeks, along with the hospital where the patient is being seen, to compel treatment. These cases squarely raise the question of whether pregnant patients have, or should have, the same right to autonomy and self-determination held by other patients, the right to give — and withhold — informed consent to medical treatment. ¹

The article by Dworetz et al.Reference Dworetz ² raises the question of how and whether a pregnant woman’s treatment preferences should be considered in a much rarer clinical context. The article considers whether a patient who suffers a serious brain or cardiovascular injury while pregnant and is then declared dead in accordance with universally accepted legal and medical criteria can or should have her body maintained by ventilators and other technological support in order to gestate a fetus long enough that it might be delivered via caesarian section and have a chance of survival.

In the mid to late 20th century, judges routinely upheld the rights of hospitals and physicians to override a pregnant woman’s decision to refuse recommended medical treatment such as blood transfusions and caesarian sections, if her physician was able to persuade the judge that the fetus’s health or life was jeopardized by the pregnant patient’s refusal. ³ At a time when beneficent paternalism was the norm, courts and physicians acted on the presumption that “doctor knows best” and that pregnant women’s treatment preferences should be overridden in favor of fetal health.Reference Bassett ⁴ Some courts engaged in “balancing” the pregnant patient’s right to refuse treatment against her future child’s interest in life and health, using legal analysis that explicitly treated a fetus as fully equivalent to a child.Reference Fentiman ⁵

This approach was rejected in the case In re A.C., ⁶ involving Angela Carder, a young woman who survived childhood cancer only to have it recur after she became pregnant. When Carder was twenty-five weeks pregnant, a rapidly growing cancer was discovered, and she was hospitalized. Less than a week later it became clear that Carder was terminally ill and the hospital sought judicial authorization for a caesarian section. After a short hearing, in which evidence was inconclusive as to Carder’s wishes, a judge ordered her to undergo a caesarian to enhance the chance of delivering a living child. Unfortunately, both Ms. Carder and her baby died within two days. On appeal, the court rejected the trial judge’s analytical approach, declaring that “in virtually all cases the question of what is to be done is to be decided by the patient — the pregnant woman — on behalf of herself and the fetus.” The court found that the right of the patient to control what is done to her body was grounded in both common law and the constitutional right to liberty. Further, the court declared that if a patient is unable to provide informed consent as a result of her underlying illness or its treatment, the court must conduct a substituted judgment analysis, deciding what the patient would have wanted if she were competent to express her treatment wishes, rather than using a “best interests” approach. ⁷

In re A.C. was instrumental in shaping the approach of the medical groups involved in providing obstetric and neonatal care, including the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP). ACOG and the AAP were also responding to the surge of technological innovations in prenatal diagnosis and fetal interventions that could pressure pregnant women to consent to treatments that risked their own health. The groups agreed that the pregnant patient should always be the final decisionmaker about treatment for herself and her fetus. ⁸

Yet today the easiest way for a woman to assure that her treatment wishes will be respected if she is, or becomes, pregnant is not available in many states. Since the late 20th century all states have recognized the right of competent individuals to make an advance directive to express those wishes, explaining the type of medical care that they wish to receive if they become incompetent. States encourage all adults to do so, recognizing the valuable guidance that advance directives provide to family members and physicians at a moment of crisis. ⁹

However, over the last three decades, a pregnant woman’s ability to make an advance directive and have it enforced has been sharply curtailed by a majority of states. These states have enacted laws that either completely override an advance directive while the person is pregnant or render it inapplicable if it is likely that providing life-supporting treatment will lead to the birth of a viable infant. ¹⁰

Of course, a brain-dead patient such as the one hypothesized by the authors is not in the same position as a living but arguably incapacitated person like Angela Carder. While they both have autonomy and dignitary interests that the law should respect regarding the treatment of their bodies, ¹¹ their different factual situations compel different legal analyses. The case of Marlise Munoz exemplifies those differences. Ms. Munoz, who was a paramedic, collapsed after suffering a stroke when she was fourteen weeks pregnant. By the time she was discovered she had stopped breathing; although resuscitation was attempted, she never regained consciousness. Doctors determined that she met the criteria for brain death. Nonetheless, the hospital refused to stop treatment, citing the Texas statute prohibiting the withholding or withdrawal of life-sustaining treatment from a pregnant patient pursuant to an advance directive. ¹² Her husband sued to compel the hospital to cease treatment, asserting, along with her parents, that Ms. Munoz would not wish to be maintained on a ventilator and other somatic support if she could not be restored to consciousness. Her family emphasized the loss of dignity and bodily integrity caused by prolonged mechanical support and other interventions, contending that these actions were inappropriate because they did not advance her health in any way.Reference Novack ¹³ Her husband ultimately prevailed, after the trial judge ruled that the statute was simply inapplicable to Ms. Munoz, because she was dead and no longer a patient. ¹⁴

Cases like those of Ms. Munoz and the hypothetical patient posited by the authors are both tragic and rare. As the authors note, since 1982 fewer than fifty cases have been reported worldwide.Reference Lewis ¹⁵ The authors are rightly concerned about the complex and emotionally fraught discussions to have with the patient’s family, the clinical difficulties of predicting the likely outcome if the patient’s body is maintained on somatic support in order to make the delivery of a viable infant possible, and the inevitable uncertainty about the long-term physical and cognitive prospects of an infant born under such circumstances. They acknowledge the potentially enormous financial costs of attempting to maintain a dead body and of providing ongoing medical and other care to a child born extremely prematurely. They are also appropriately concerned with the emotional toll that caring for such a patient and fetus will entail for health care professionals and the stress suffered by family and clinicians alike due to uncertainty about the law governing the patient in a particular jurisdiction, especially when clarity about the law may not come for weeks or months. They argue that hospitals should prepare for these cases in advance, by establishing protocols that will help clinicians and families in these difficult situations and also permit them to comply with applicable state law.

Yet while these cases raise important and complex clinical, ethical, financial and legal issues, it is important to place them in a broader clinical and ethical context. Hundreds of pregnant patients die each year in the United States, often because of inadequate or sub-standard care before, during, and after their pregnancy. ¹⁶ An important bioethical issue inherent in the Munoz case and others like it is the ethical duty to do justice in allocating scarce resources. Rather than viewing a person who suffers a stroke and brain death while pregnant as an individual or family tragedy, out of which some good may be realized if only her bodily functions can be maintained long enough for a child to be born,Reference Warren ¹⁷ the principles of beneficence and justice should lead us to advocate for preventative health care designed to minimize the risk of strokes and other cardiovascular injuries in the first place, as well as providing appropriate treatment when they occur.

Maternal and infant mortality and morbidity rates in the United States are extremely high compared with those of other wealthy countries ¹⁸ and demonstrate enormous racial and ethnic disparities. For example, in 2024, American Indians and Alaska Natives were four times as likely to die as a result of pregnancy as non-Hispanic whites; the maternal mortality rate for non-Hispanic Blacks was three times that of non-Hispanic whites. Maternal mortality rates for Asian and Hispanic mothers are comparable to that of non-Hispanic white mothers. ¹⁹ Infant mortality data show similar differences, with Black, American Indian, and Native Alaskan infants dying at more than twice the rate of non-Hispanic white infants. ²⁰

A major cause of racial disparities in maternal and infant mortality is the lack of access to care. Regular access to quality healthcare for girls and women is crucial in preparing them for a healthy pregnancy. One-third of maternal deaths in the United States are due to heart conditions and stroke, and the vast majority of these are preventable.Reference Gregory ²¹ Although Medicaid provides coverage for about 40% of American births, ²² many low-income women do not qualify until they are pregnant. Thus, many of the underlying health conditions that put pregnant patients at risk, such as diabetes, cardiovascular disease, and obesity, are not treated. This is a particular problem in the ten states that declined to participate in the Medicaid expansion program authorized by the Affordable Care Act, which made it possible for people with incomes above the federal poverty level to enroll in Medicaid. Maternal and infant mortality rates are higher in these non-expansion states than those that participated in the Medicaid expansion.Reference Constantin and Wehby ²³ About one-third of Medicaid-eligible women do not receive prenatal care during the first trimester, a critical time for identifying and addressing potential health problems.Reference Ranji ²⁴ In addition, 35% of US counties are “maternity care deserts,” counties in which there is no birthing facility or obstetric clinician. ²⁵ The deep cuts to Medicaid authorized by the “Big Beautiful Bill” in 2025 will exacerbate all these obstacles to obtaining care, as many fewer people will be eligible for coverage and stringent work requirements will make it harder for eligible individuals to qualify.Reference Alker and Schneider ²⁶

Finally, there continue to be striking racial differences in the quality of healthcare received, both within and between hospitals and health care systems, including a failure to diagnose and promptly treat serious disease. For example, a study of maternal mortality found that although Black and white women had similar incidences of five underlying conditions that are major causes of maternal death, Black women’s fatality rates were two to three times higher than those of white women with the same condition.Reference Tucker ²⁷ In yet another example of the Trump administration’s war on science, the administration has gutted research into health disparities based on race and gender, including research on maternal and infant mortality, ²⁸ and eliminated programs to collect data about adverse pregnancy outcomes that could inform government health policy. ²⁹

Complex bioethics cases offer an important opportunity for learning. They can enhance readers’ understanding of clinical issues and educate them about the realities of communicating with patients and their families at a difficult moment. They can also help clinicians better understand the complexities of American law. But bioethics also demands that we recognize the impact of systemic problems in healthcare delivery and financing and the continuing ethical obligation to do justice, not only to individual patients but also to the many Americans who are unserved and underserved by our healthcare system.