Medics called for guidelines after two previous cases

Two incidents in which Irish hospitals kept brain dead pregnant women on life support in the past 15 years have prompted calls for guidelines to help medics facing similar cases.

In two known cases since 2001, staff at hospitals in Waterford and Galway kept pregnant women on life support as a result of uncertainty over the hospitals' obligation to the foetus.

In May 2001, a woman who was 14 weeks pregnant and suffered a brain haemorrhage was taken to hospital in Waterford, where she was placed on life support but declared brain dead. Life support was maintained while legal advice was sought, but after two weeks the foetus died and the machine was switched off.

In a second incident, at University Hospital Galway in 2003, a 26-year-old woman presented with a headache and her condition deteriorated over a number of days until, following two series of brainstem tests, she was declared brain dead. As the woman was 13 weeks pregnant, the hospital put her on life support, but eight days later the foetal heartbeat stopped.

Analysing the Waterford case in the Medico-Legal Journal of Ireland in 2001, two specialists suggested there was "a medical and medico-legal imperative" to provide guidelines to assist healthcare professionals should similar cases arise in the future.

Denis Cusack, Professor of Forensic and Legal Medicine at UCD, and Asim Sheikh, a barrister and lecturer at the School of Medicine and Medical Science at UCD, wrote: "The lack of willingness by both the medical profession and legislature in Ireland to take a pro-active stance in the active management of medico-legal and medico-ethical policymaking will only further frustrate those members of the profession on the ground who have been faced – and will continue to be faced – with difficult choices."

Prof Cusack and Mr Sheikh said the health authorities in Waterford had acted on the side of caution, uncertain of their legal obligation to the foetus. “These actions, without clear guidelines, cannot be faulted,” they wrote.

‘An obligation’

They suggested that once maternal death occurred, if there existed reasonable medical evidence that the foetus could be maintained to viability, there would be “an obligation” on medics to maintain medical support of the dead mother and to maintain the foetus to a gestational age of maximum viability.

In a separate analysis following the Galway case, published in the Irish Journal of Medical Science in 2005, three anaesthesia specialists wrote that there was “an imperative to develop guidelines for healthcare providers in Ireland regarding how to resolve the issues raised by maternal brain death”, adding: “It is likely that further similar cases will arise in this country in the future.”

The authors, Dr John Laffey, Dr Rachel Farragher and Dr Brian Marsh, noted that there was no theoretical limit to the amount of time for which maternal somatic function may be sustained, but that successful maternal somatic function was rare.

“The right to life conferred on the foetus from the earliest stages of gestation in this State may only be usefully exercised if there exists some expectation of successful delivery of a live baby,” they wrote.

“If no realistic prospect of success exists, then maternal somatic support would be considered futile, and should not be permitted.”

In the 2001 Waterford case, the then attorney general, Michael McDowell, refused to become a party to High Court proceedings seeking a court order to continue life support for the brain dead woman.

Mr McDowell told the hospital that he was not of the view that a court order would be necessary before the life support could be withdrawn.

Following the case, the chief executive of the South Eastern Health Board called for guidance on how to deal with similar cases in future.

A spokeswoman for the HSE said these types of situations were “very complex” and were “led by the clinical professional judgement of the clinicians involved in the woman’s care”.