Ethical Choices in Janet’s Pregnancy and Life Support

· Updated on December 11, 2025

Review
 "An Integrated Ethical-Decision-Making Model for Nurses" 
Apply 
the ethical decision-making model in the article to access the
Our Pregnant Daughter Didn't Want This...
case study from the Center for Practical Bioethics.
Review 
the Questions for Discussion following the case. 
Follow 
the steps provided in the model, including the following: 
Step 1: 
Explain the ethical issues, other relevant ethical considerations, and ethical principles relevant to this case study and how they affect the nursing practice.  
Step 2: 
Collect and analyze additional information related to this case study, including researching and explaining any legal considerations.
Step 3:
 Develop alternatives (different options) and compare them.
Step 4: 
Determine your position and justify it: 
What specific actions should be taken to ensure an appropriate outcome? 
Why is your position important, needed, or beneficial for vulnerable populations? 
Are the legal and ethical responsibilities in alignment with each other? If they are not in alignment, how does your position deal with that conflict?
Step 5: 
Find strategies to implement the plan: 
What ethical arguments could you use to persuade someone who disagrees with your position?  
Cite 
at least 3 peer-reviewed sources published within the last 5 years. 
Note
: At least 1 of the sources should provide evidence for your resolution recommendation or plan of action. 
Include
 an APA-formatted reference list.

Paper For Above Instructions

In Our Pregnant Daughter Didn’t Want This… a 29-year-old nurse, Janet, is left in a persistent vegetative state (PVS) after a car crash; her husband dies in the accident. Shortly before, she had completed a detailed advance directive refusing ventilators, feeding tubes, and other life-prolonging measures if she were ever in PVS. Her parents, now her surrogate decision-makers, agree to withdraw life support and provide only palliative care. At the last minute, a resident notes she is about nine weeks pregnant and discovers a Kansas statute stating that a pregnant patient’s advance directive “shall have no effect” during pregnancy. The hospice transfer is put on hold, and her parents cry, “But our daughter didn’t want this!” Center for Practical Bioethics

Park’s integrated ethical decision-making model guides nurses through six steps; your assignment compresses these into five: identify the ethical issues, gather information (including legal), develop options, decide and justify, then plan implementation. SAGE Journals+1 Below I apply those steps to this case.

Step 1: Ethical issues, principles, and impact on nursing practice

Key ethical problems include:

  • Autonomy vs. state fetal-protection law: Janet clearly refused life support in PVS via a valid advance directive, but Kansas law suspends that directive during pregnancy. Center for Practical Bioethics+1

  • Maternal–fetal conflict: Continuing somatic support might benefit the fetus if viability is eventually reached, but it violates Janet’s stated wishes and may prolong a non-cognitive existence many ethicists see as lacking personal benefit. PMC+2American Academy of Neurology+2

  • Surrogate authority and moral distress: Her parents are legally the secondary agents and morally trying to act as faithful surrogates. Being told the state overrides both Janet’s directive and their decision creates intense moral distress for them and for nurses caring for Janet. PubMed+1

Core principles in play:

  • Respect for autonomy: Honoring a competent adult’s advance directive is a central norm in nursing and medical ethics. AMA Journal of Ethics+2PubMed+2

  • Beneficence and nonmaleficence: For Janet, continued life support in PVS arguably offers no benefit and may constitute non-beneficial treatment; for the fetus, continued support could potentially offer life. PMC+1

  • Justice: Pregnant patients in Kansas are treated differently from non-pregnant adults—laws void some of their end-of-life choices solely because they are pregnant, raising fairness and gender-justice concerns. The Washington Post

For nurses, this case highlights professional duties to advocate for patients’ expressed wishes, to support distressed families, and to participate in ethics and legal consultations, while also following institutional policy and state law. PubMed+1

Step 2: Additional clinical and legal information

Clinical context. PVS is defined as wakefulness without awareness; patients can survive for years with artificial nutrition and hydration. American Academy of Neurology Case series of pregnancy in PVS and maternal brain death show that with aggressive support, some fetuses survive, but maternal recovery is extremely unlikely, and families often experience the situation as deeply burdensome. PMC+2PubMed+2

At nine weeks, Janet’s fetus is far from viability, meaning months of intensive life support, possible tracheostomy and feeding tube placement, and risk of complications, all for an uncertain fetal outcome. Jogcr+1

Legal context. The Kansas statute quoted in the case (KSA 65-28,103(4)(b)) states that a pregnant patient’s declaration about withholding or withdrawing life-sustaining procedures “shall have no effect during the course of the qualified patient’s pregnancy.” Center for Practical Bioethics Kansas is one of a number of U.S. states where advance directives are restricted or void for pregnant patients regardless of gestational age, a pattern now being actively challenged in court. The Washington Post

Recent legal and ethical scholarship on catastrophic brain injury in pregnancy (e.g., the Muñoz and similar cases) emphasizes the tension between such statutes and constitutional rights to bodily integrity and autonomy, noting a lack of consensus and calling for clearer, ethically defensible standards. ScienceDirect+2Seton Hall eRepository+2

Nurses must therefore understand that legal and ethical guidance may diverge: law in Kansas currently prioritizes fetal interests; professional ethics (and many national bodies, such as ACOG and the AMA) emphasize the pregnant patient’s autonomous choices as primary. OBGYN+2PubMed+2

Step 3: Develop and compare alternatives

Using Park’s model, we generate several plausible options: SAGE Journals+1

  1. Strict legal compliance with full life support

    • Maintain and escalate life support (including tracheostomy and feeding tube) until the fetus is viable or until Janet’s body can no longer sustain pregnancy.

    • Pros: Maximizes potential fetal benefit; clearly complies with Kansas statute; may satisfy some religious or pro-life viewpoints.

    • Cons: Directly violates Janet’s explicit directive and surrogate decision; prolongs a non-cognitive existence; imposes profound emotional, moral, and financial burdens on family and staff; may be seen as instrumentalizing Janet’s body solely as a fetal incubator. UW Departments+3AMA Journal of Ethics+3PMC+3

  2. Status-quo life support only, no new invasive procedures, while seeking ethics/legal review

    • Continue current ventilatory and nutritional support for a short, defined period, but do not add new burdensome interventions (e.g., surgery for trach/PEG) while the ethics committee and legal counsel urgently review the case and statute.

    • Pros: Respects the law’s ambiguity while avoiding further departures from Janet’s wishes; gives time for careful interpretation (e.g., whether the statute truly compels additional procedures in a non-terminal PVS); may allow court clarification.

    • Cons: Still delays honoring her directive; may distress family; fetal prognosis at 9 weeks remains very uncertain.

  3. Honor the advance directive and begin withdrawal of life support now

    • Treat the advance directive as ethically binding and argue that professional duties to respect autonomy and avoid non-beneficial treatment outweigh the statute; proceed with withdrawal while the hospital prepares for possible legal scrutiny.

    • Pros: Fully respects Janet’s expressed preferences and surrogate’s decision; aligns with mainstream bioethics emphasizing patient autonomy and dignity. AMA Journal of Ethics+2PubMed+2

    • Cons: Carries legal risk for clinicians and institution; may violate state law as currently written; could create precedent conflicts within Kansas.

  4. Seek court order to override or narrowly interpret the statute

    • The hospital and family jointly petition a court, arguing that applying the statute here violates constitutional protections and that, at a minimum, invasive new procedures cannot be compelled against a clear advance directive.

    • Pros: Uses legal process to reconcile autonomy with fetal interests; may produce a more nuanced ruling (e.g., allowing withdrawal or at least forbidding additional invasive measures).Seton Hall eRepository+1

    • Cons: Time-consuming, emotionally exhausting; outcome uncertain; interim care decisions still required.

Step 4: Position, justification, and alignment of ethics and law

My position

Using Park’s model and current evidence, I support Option 2 moving promptly toward Option 4, with a clear ethical goal of honoring Janet’s advance directive and not adding new life-prolonging interventions. Concretely, the team should:

  1. Immediately request an ethics consultation and involve legal counsel to clarify the statute and its applicability to PVS and to existing vs. new life-support measures.

  2. Avoid any new invasive procedures (no tracheostomy or new feeding tube) because they directly contradict Janet’s written wishes and go beyond what the statute explicitly requires.

  3. Maintain current support only for a short, defined period while the court or hospital leadership decides whether her directive can be honored or the statute challenged.

  4. Prepare, in collaboration with her parents, for withdrawal of life support and transition to palliative care if legally permitted, consistent with her advance directive.

This approach respects Janet’s autonomy, minimizes further violation of her expressed values, and supports her parents’ role as surrogates, while recognizing that nurses and physicians cannot unilaterally ignore a statute. SAGE Journals+2PubMed+2

Why this matters for vulnerable populations

Pregnant patients are uniquely vulnerable to laws that effectively treat them differently from all other competent adults by suspending advance directives. The Washington Post+1 A position that foregrounds autonomy and proportionality helps ensure that pregnancy does not erase a woman’s personhood or end-of-life choices, especially for those—like Janet—who thoughtfully completed directives. It also protects families and clinicians from being forced into ethically troubling roles where a loved one’s body is maintained solely for fetal benefit. PMC+2PubMed+2

Alignment (or not) of legal and ethical duties

In Kansas, legal requirements and ethical responsibilities do not fully align. Ethically, most contemporary nursing and medical frameworks would prioritize Janet’s autonomous directive and consider prolonged PVS life support non-beneficial. PubMed+2AMA Journal of Ethics+2 Legally, the statute prioritizes fetal interests by suspending her directive.

Park’s model explicitly anticipates such conflicts and calls nurses to both comply with law and advocate for ethically sound change. SAGE Journals+1 My position navigates this by (a) avoiding legally unnecessary expansions of treatment, (b) engaging the ethics committee and courts, and (c) supporting the family in challenging or narrowing an arguably unjust statute.

Step 5: Strategies to implement the plan and persuade dissenters

To implement this plan, nurses and the interprofessional team can:

  • Frame the argument in principlism language:

    • Autonomy: Janet clearly refused long-term life support in PVS.

    • Beneficence & nonmaleficence: Prolonged somatic support offers her no benefit and may cause suffering to family; fetal prognosis at 9 weeks is uncertain. PMC+2jogi.co.in+2

    • Justice: Treating pregnant people as exceptions to advance-directive rules is discriminatory and undermines trust in advance care planning. The Washington Post+1

  • Use professional standards: Cite nursing and obstetric ethics guidance that strongly supports honoring pregnant patients’ informed decisions, even when fetal interests are at stake. OBGYN+2Lippincott Journals+2

  • Appeal to human dignity and non-instrumentalization: Following Sperling, argue that maintaining a non-conscious woman’s body against her explicit wishes, solely as a means to gestate a fetus, violates her dignity and undermines the trust all patients place in advance directives. AMA Journal of Ethics+2PubMed+2

  • Highlight practical harms: Tabari et al. show that nurses caring for such patients experience significant moral distress; transparent ethical and legal processes protect not only patients and families but also staff. PubMed+2AACN Journals+2

For colleagues who prioritize fetal life absolutely, the ethical response is not to dismiss fetal value but to note that, in very early pregnancy with uncertain viability and massive burdens on a non-consenting woman, respect for her prior autonomous choice reasonably outweighs speculative fetal benefit—a proportionality judgment supported by leading maternal–fetal ethics literature. Lippincott Journals+2PubMed+2

References (APA 7th ed.)

Chervenak, F. A., McCullough, L. B., & Arabin, B. (2021). Ethically justified, practical guidance for the professionally responsible investigation of maternal–fetal intervention for fetal or neonatal benefit. Maternal–Fetal Medicine, 3(3), 147–154. Lippincott Journals+1

Clark, C. (2022). A constitutional standard for the withdrawal of life-sustaining treatment from pregnant women (Student scholarship). Seton Hall University School of Law. Seton Hall eRepository

King, N. M. P. (1991). Maternal–fetal conflicts: Ethical and legal implications for obstetrics. Clinics in Perinatology, 18(1), 167–183. PubMed

Park, E. J. (2012). An integrated ethical decision-making model for nurses. Nursing Ethics, 19(1), 139–159. SAGE Journals+1

Rosell, T. (2021). Case study – Our pregnant daughter didn’t want this… Center for Practical Bioethics. Center for Practical Bioethics

Siwatch, S., Rohilla, M., & Singh, A. (2020). Pregnancy in a persistent vegetative state: A management dilemma—Case report, literature review and ethical concerns. Journal of Obstetrics and Gynaecology of India, 70(4), 310–313. PMC+2PubMed+2

Sperling, D. (2020). Should a patient who is pregnant and brain dead receive life support, despite objection from her appointed surrogate? AMA Journal of Ethics, 22(12), E1004–1009. AMA Journal of Ethics+2PubMed+2

Tabari, K., Uveges, M. K., & Milliken, A. (2020). Ethical issues when caring for a pregnant patient in the intensive care unit. AACN Advanced Critical Care, 31(4), 425–430. PubMed+2AACN Journals+2

The Washington Post. (2025, May 29). Women sue Kansas over law that disregards end-of-life wishes during pregnancy. The Washington Post

University of Washington Department of Bioethics. (n.d.). Maternal/fetal conflict. UW Departments

Burkle, C. M., Schlich, T., & et al. (2015). Medical, legal, and ethical challenges associated with maternal brain death. International Journal of Gynecology & Obstetrics, 128(3), 329–335.

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