Revisiting Adriana Smith's Tragic Demise: Valuable Insights into Pregnancy-Linked Brain Death and the Importance of Personal Choice

Speakin' 'bout End-of-Life Struggles During Pregnancy: What's the Deal, Man?

Revisiting Adriana Smith's Tragic Demise: Valuable Insights into Pregnancy-Linked Brain Death and the Importance of Personal Choice

It's a thorny problem, ain't it? A woman's brain death while pregnant causes a whole bunch of ethics and legal questions. One thing's for sure: her fetus' interests step into the limelight, but when do they take the lead over the pregnant lady's rights? Let's dive into the tale of Adriana Smith and see what it reveals about exceptions to advance care plans and the broader picture of policies that limit a person's autonomy during pregnancy.

Adriana met her maker in Georgia, where she lived and died, at nine weeks pregnant. The deets 'bout what happened aren't crystal clear, but it appears Georgia wants her to stay hooked up to machinery that keeps her heart beating and blood circulating until her little one's ready to pop out. GA is one of 31 states that won't let pregnant patients kick off life support. Adriana's family has spoken up, stating, "We want to keep Adriana's pregnancy going, but we reckon the decision shoulda been ours, not the state's."

Laws restrictin' decision-makin' by patients (or their surrogates) can sometimes lead to situations where folks' values and preferences don't get acknowledged. Bioethicists and docs gotta get their heads around the social, structural, and political forces that create these ethical pickles in reproductive care.

Now, it's worth contemplatin' whether Adriana's situation mighta been handled differently before ol' Roe fell, and how evolving abortion laws might override maternal advance directives or standard end-of-life care during preggernancy. Crazy enough, 26 states nullify advance care plans for expectant mothers — but only 9 jurisdictions disclose these exclusions in state advance directive docs. The American College of Obstetricians and Gynecologists advises docs to respect each patient's treatment prefs, irrespective of preggernancy status, but the Smith case ain't unique – legal meddlesomeness is all too common for folks who are pregnant or postpartum.

Interestingly, pregnancy restrictions on advance directives existed before the Dobbs decision, but post-Dobbs efforts to declare fetal personhood have contributed to a rebalancin' of fetal rights that often takes a back seat to the rights of others. This shift has led to motherly behaviors bein' criminalized. In the U.S., pregnant patients have been arrested, forced to undergo C-sections, incarcerated following traumatic pregnancy losses, and otherwise denied due process in the name of fetal protection. If we carry these restrictions into end-of-life decision-makin', it's likely we'll see the same outcomes.

The burden of pregnant criminalization hits Black women living in the U.S. the hardest. Not only are they three times more likely to kick the bucket from preventable pregnancy complications than their white counterparts, but they're also ten times more likely to be reported to law enforcement or social services for pregnancy-related matters. Legal scholar Kimberly Mutcherson points out that these absurdities can't wrap their heads around the complexities of preggers life or account for the variability of obstetric emergencies.

The criminalization of pregnancy, and the rebalancin' of fetal rights, calls for the attention of bioethicists, who are uniquely poised to analyze reproductive injustices and the erosion of pregnant folks' rights to decline treatment. Pregnancy complications might need us to enact advance care plans, and bioethicists and docs might have a responsibility to spell out how preggernancy could impact whether and how a patient's end-of-life prefs are applied.

Bioethicists gotta engage in public awareness and advocacy efforts to inform docs and the public that the state can override the wishes and prefs of incapacitated pregnant people. Clear and honest communication about highly publicized, complex cases like Adriana Smith's is vital for rebuildin' TRUST in science and healthcare.

Elsewhere, we've discussed how bioethicists oughta recognize, name, and transform the social and structural forces that limit the agency, visibility, and voice of marginalized folks, and especially those who might become pregnant. Bioethics and legal scholars like Dorothy Roberts, Michele Goodwin, Kimberly Mutcherson, and others have long argued that reproductive autonomy policies have disproportionately burdened Black moms first, then expanded to limit the reproductive rights of all folks who can get pregnant. Many of us have proposed broader, bolder bioethics frameworks to tackle long-standin' health inequities, such as the rise in maternal deaths among Black women. We've also suggested that bioethicists and docs support meaningful discourse on polarized reproductive ethics topics by clarifyin' ambiguous terms to move policy debates away from matters of semantics and toward matters of substance.

Adriana Smith's story sheds light on intersectional bioethics issues from conception to end-of-life care, while illustratin' the often complex interplay between reproductive medicine and the law. Recent research shows that bioethicists want to engage with social justice issues, and clear and honest communication with patients and the public strengthens institutional trustworthiness in equitable maternal health care. Where Smith is concerned, bioethicists can make a meaningful impact by changin' the conversation away from the specific actions of her family or medical team, and towards broader discussions about the structures, policies, and practices that prevent pregnant patients and their surrogates from makin' decisions about life-sustainin' treatment.

This case raises complicated questions about how end-of-life decision-makin' authority and abortion bans can coexist in the post-Roe era, and whether they should. One thing's clear, though: the autonomy and dignity of all people across their whole lives should never, ever be compromised. So let's remember Adriana not as another political buzzword, but as a stark reminder for bioethicists and docs to support incapacitated patients and their surrogates while advocatin' for policies that safeguard the autonomy and dignity of all folks.

This essay represents the opinions, conclusions, and recommendations of the authors, and does not reflect the views of Baylor College of Medicine, The Hastings Center, or UT Health Houston.

Sophie L. Schott, BA, GCert, is a second-year medical student in Houston, Texas, and a clinical research coordinator in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. You can find her on Twitter @MyBestSchott

Faith E. Fletcher, PhD, MA, is an associate professor at the Baylor College of Medicine and a scholar at The Hastings Center. Check her out on Twitter @FaithEFletcher

Claire I. Horner, JD, MA, HEC-C, is an associate professor at Baylor College of Medicine and a clinical ethicist at Baylor St. Luke's Medical Center.

Virginia A. Brown, PhD, MA, is a research scholar in health equity and population health at The Hastings Center. Keep up with her on Twitter @VirginiaABrown*

In considering Adriana Smith's case, it's important to discuss the implications of advanced care plans and end-of-life care for pregnant women, as the current legal framework may disregard their autonomy and personal health-and-wellness preferences.
As bioethicists analyze the criminalization of pregnancy and the rebalancing of fetal rights, they should also focus on the impact of these issues on women's health, particularly the agency, visibility, and voice of marginalized groups, such as Black women, in matters concerning health-and-wellness and end-of-life care.