In the early hours of June 13, a baby was born to a brain-dead woman in Atlanta. That woman, Adriana Smith, had suffered a catastrophic stroke in February, in the early weeks of her pregnancy. When the baby, Chance, was born via C-section, he weighed less than two pounds. Last week, doctors at Emory University Hospital, where Smith was initially declared brain-dead, turned off the machines that had been sustaining her organs—and finally returned her body to the care of her family.
Usually, when a patient is declared brain-dead, their family is allowed a few hours or days to say their goodbyes before medical staff disconnect the body from a ventilator. This process hasn’t changed since I was a resident in the intensive-care unit nearly a decade ago. Due to patient-privacy rules, Emory hasn’t said what exactly happened in February following Smith’s apparently devastating and irreversible brain damage, but the standard procedure for a brain-dead patient clearly did not play out. Smith’s mother, April Newkirk, told reporters that the hospital instead kept Smith’s body on life support for more than four months without the family’s input or consent.
In a statement last month, Emory said that its treatment decisions are based, in part, on “compliance with Georgia’s abortion laws.” Georgia’s LIFE Act, which has been in effect since the Supreme Court overturned Roe v. Wade, in 2022, grants full constitutional rights to any “unborn child with a detectable human heartbeat” (usually occurring around six weeks of gestation). This concept is known as fetal personhood, and in Smith’s case, it seems to have pushed doctors into an extraordinary—and extraordinarily troubling—situation.
Four fundamental principles underlie health-care ethics: beneficence, non-maleficence, autonomy, and justice. In my experience practicing women’s reproductive health care, including abortion care, applying these principles simultaneously to the mother and the fetus can be—at the very least—fraught. The needs of the pregnant woman and the fetus are often in conflict, and many of the body’s physiological mechanisms to protect the fetus put even the healthiest pregnant woman at risk. Obstetricians often quip that their field is the hardest and most interesting because they must care for two patients at once, but any doctor who tries to truly uphold their ethical duties to two patients simultaneously risks landing in very murky territory.
To be clear, Smith, as a brain-dead patient, was legally and medically deceased, so precepts about doing good and avoiding harm would not have applied to her, at least clinically speaking. But the ethical principle of autonomy applies even after a patient’s death. (Consider the United States’ strict consent laws around organ donation.) In the difficult cases when a patient—including a pregnant patient—is in such dire condition that she cannot speak for herself, a proxy decision maker, typically the next of kin, must be the one to make decisions about withdrawing care based on knowledge of the patient’s wishes or values. Some people might argue that a fetus, unable to speak for itself, should also be regarded as having some degree of autonomy; still, in Smith’s case, the fetus’s next of kin, not doctors, should have acted as a proxy decision maker.
Yet Newkirk told reporters that prior to Chance’s birth, she was given no say in what happened to her daughter’s body, nor to the fetus inside her. Emory doctors simply followed what they believed the law prescribed. Since Smith’s case came to public attention last month, a spokesperson for the Georgia attorney general’s office has insisted that “there is nothing in the LIFE Act that requires medical professionals to keep a woman on life support after brain death.” But in all the months that Smith was kept on organ support (a more accurate term than life support), the attorney general refused to issue a formal legal opinion.
If Smith’s case sets a standard in Georgia and in other states with fetal-personhood laws, the implications could be far-reaching. Doctors might feel compelled to conduct a pregnancy test on any woman of reproductive age who dies in the hospital or is brought in dead. Some women might even sign an advance directive requesting that, should they die at any point in pregnancy, their organs be sustained so their fetus has a chance of survival. In the most extreme interpretation of the law, one can imagine an entire ward filled with dead women on ventilators, their bodies being used as incubators for tiny embryos.
[Read: The anti-abortion movement’s attack on wanted pregnancies]
This image invokes a crucial debate about justice that already permeates the American health-care system. The United States spends extraordinary amounts of money on medical care at the extremes of life: neonatal intensive care on the one end, and ICU care for the elderly on the other. (As of Sunday night, Chance remains in the NICU. Newkirk has said that she hopes he will make it home, as most babies born at 27 weeks do, typically after weeks of intensive care.) In part, routine critical care for the very, very old and very, very prematurely born reflects a strong cultural pressure against assigning relative value to any individual life. But it does not always reflect the values of individual patients and their families. And it can raise uncomfortable questions about both benefits and costs—for example, how to measure the value of keeping one very sick patient alive versus, say, distributing large-scale public-health benefits to underserved populations.
Such questions become especially pointed if you consider how often the health-care system fails people before they reach the brink of death—and how it fails certain people more often, and more egregiously, than others. Research shows that doctors in the U.S. routinely ignore the health concerns of Black women such as Smith, and that Black mothers and their babies die at dramatically high rates compared with their white peers. Justice, then, is not only a question of how doctors assign value to a given human life, but also a question of whose voices they listen to, and whose voices are ignored or silenced. According to Newkirk, back in February, Smith went to Atlanta’s Northside Hospital complaining of severe headaches; doctors sent her home without imaging her brain. (Neither Northside nor Emory Healthcare responded to requests for comment.) A day later, her boyfriend found her struggling to breathe and called 911. She was rushed to a different hospital and at some point fell unconscious. She never woke up.
As a doctor who cares for pregnant women, I know that patients rarely get to choose between a “right” and “wrong” decision. My job is to present all of the imperfect but ethically permissible options, and their implications for the fetus, to the person in front of me. Those options might include seeking treatment elsewhere if my care is limited by the law or other factors. But my years of practice have taught me that the patient, and the patient alone, must be the one to make that difficult, imperfect decision. This approach is a fairly good summary of how most abortion care works in the United States today. But it’s not how all doctors handle such choices. It certainly isn’t what happened at the time of Adriana Smith’s tragic death. Instead, Newkirk’s remarks indicate that no one explained to her exactly how doctors’ decisions may have been constrained by Georgia law, and no one suggested that she might transfer her daughter’s body to another hospital—even another state—where she might have had a say in those decisions.
[Elizabeth Bruenig: Whose choice? Whose life?]
The case of Adriana Smith, though not about abortion, is very much about the ethics of choice. April Newkirk never publicly asked for her daughter’s body to be removed from organ support, but she did insist that the decision should have rested with her family. In an interview last week, Newkirk reiterated that what had happened to her daughter was a breach of autonomy. “I think all women should have a choice about their body,” she said. “And I think I want people to know that.”