Thursday, January 16, 2014

The Texas Medical Association (TMA) may be caught between a rock -- Gov. Rick Perry and his legislative posse -- and a hard place: its members, regarding advanced directives for pregnant women in Texas.

"I'm concerned about the position of the TMA," Robert Luedecke, MD, an anesthesiologist in San Antonio, Texas, told MedPage Today after reading a statement made by Robert Tenery, MD, during an interview with MedPage Today on the Marlise Munoz case.

Tenery had said since Munoz had not updated her Advanced Directive upon learning she was pregnant, it was unusable under the circumstances.

Medicine and Politics

Luedecke said he believes that the Texas law is "unjust." He also believes the majority of TMA members would take offense at it.

"The opinion of most Texas physicians would be that patients, their families, and their doctors are the ones that should be making medical decisions. To have a law that interferes, further complicates things, and I don't see that it is of any benefit at all," Luedecke said.

Luedecke suggested that the TMA is in a tight spot with the Texas legislature, and probably selected a physician who would support the law to avoid conflict.


In a press release about the upcoming 2013 Texas legislative session, the then president of the TMA, Michael E. Speer, MD, said, "It's time to put patients before politics."

That didn't keep Gov. Perry from tangling with the TMA. In September, he refused to expand Medicaid coverage to Texas' residents, roughly 25% of which are uninsured, against the wishes of the majority of the TMA's house of delegates. And he also recalled the legislative body to pass abortion restrictions after the infamous Wendy Davis filibuster.

The TMA did not take an official position on abortion at the time; however, the current president, Stephen L. Brotherton, MD, of Fort Worth, Texas, did write a letter to the House State Affairs Committee stating, "This [abortion] bill includes determinations that should be made by the medical community and science, not by the legislature."

And when pressed for comment on the Munoz case, the TMA -- the largest state medical society in the US -- referred MedPage Today to the Texas Catholic Conference and the Texas Hospital Association (THA) spokesperson, Lance Lunsford.

After TMA offered those suggestions, former TMA president, Tenery, contacted MedPage Today explaining that the organization asked him to provide comment, but Brotherton, now denies Tenery was a TMA spokesperson. Brotherton told Luedecke in an email that MedPage Today was "mistaken."

"I could see why the TMA is dodging," Luedecke said.

Brotherton subsequently told MedPage Today, "The local media noted that 'the doctors' have refused the family's request, implying that they are acting independently of the John Smith Peter Hospital's administrators or legal counsel. I have asked those reporters to note the interlocking responsibility and authority of the physicians with these others. Otherwise, I have no comment, and currently do not anticipate having any."

Updating Advanced Directives

The case, THA's Lunsford told MedPage Today, "underscores the importance of having an advanced directive that is written and on file for members of your family. While this would not completely account for resolution in some cases where state law would supersede an Advanced Directive, it nonetheless provides less gray area at a time where a family has to come to terms with their grief as important decisions have to be made."

Luedecke countered: "People have important life events all the time. What if the Advanced Directive was invalidated when a person gets married, or changes jobs? [If that's the case], there's no reason to have an Advanced Directive."

If Munoz had survived the stroke, she would have had the option to abort. Even under the new, stringent, abortion laws in Texas, an abortion would have technically been an option up to 20 weeks into the pregnancy.

None of the six Texas healthcare professionals interviewed for this story knew that the Texas Advanced Directive form had a pregnancy clause that renders it null and void once the patient has "been diagnosed as pregnant," regardless of the patient's wishes.

And Now the Courts

"This issue needs to go to court," Ellen Yasmeen Sadoun, MD, a practicing family physician outside of Houston, Texas, told MedPage Today. According to the Fort-Worth's Star-Telegram, the family has filed a lawsuit against the hospital to take Munoz off of life support immediately.


"Going against a person's living will and the family's desire to take her off life support isn't ethical at all," Sadoun, who has recently been studying healthcare ethics and healthcare law for her MPH, said.

Certified Nurse-Midwife, Barbara Orcutt, of Flagstaff, Ariz., asserts that Tenery should not have referred to this pregnancy as viable until 24-weeks, "It's not medically correct," Orcutt told MedPage Today. "The premise of Roe was that abortion is not allowed when the fetus is viable, which is earliest at 24-weeks."

And Nancy Forsyth, MSN, RN, NNP-BC, a neonatal nurse practitioner in Lewes, Delaware, told MedPage Today she agrees, "14-weeks is a long way from being considered viable."

Orcutt sees the Advanced Directive laws in Texas as inhumane, "If she [Munoz] had survived the stroke, she would have had lots of options. She could have had an abortion, if she had lived. Many [pregnant] women do survive the stroke. It's not a totally rare thing in pregnancy."