The case of Adriana Smith, a 30-year-old Georgia nurse who has been brain-dead since early February, became the center of a skirmish between the country’s pro-choice and pro-life factions last month after an Atlanta news station’s interview with Smith’s mother, April Newkirk, was picked up by national media. Smith, Newkirk told a local news station, is being kept alive via life support without her family’s prior consent so that her unborn child can continue to gestate until delivery. (Newkirk did not respond to The Atlantic’s requests for comment.)
To the degree that Georgia’s broad abortion ban influenced Emory University Hospital’s decision not to offer Smith’s family any options with respect to her care, the case is indeed about abortion. But the ethical questions involved in Smith’s story are only tangentially related to abortion itself and have more to do with deciding who ought to make decisions for permanently incapacitated people—an altogether different but equally thorny subject that concerns a related but distinct axis of pro-life and pro-choice conflict. Acknowledging this does not require one to agree that the hospital was correct to proceed with life support without consulting Smith’s family, nor does it imply that simple answers exist as to how medical professionals should handle cases like Smith’s. Instead, it offers clarity on whose choice is really relevant in this debate—Smith’s family’s—and whose life: not only that of Smith’s baby but also her own.
According to her mother, Smith was about nine weeks pregnant in early February when she began to complain of severe headaches. She sought treatment at a local hospital and was discharged with medication, but a day later her boyfriend woke up to find her gasping for air. Smith was taken to Emory, where doctors discovered a number of blood clots in her brain. She was then declared brain-dead—but was immediately placed on life support because of her doctors’ concerns about possibly violating Georgia’s abortion ban by letting her, and by extension her unborn child, die. Smith’s doctors made this decision without consulting Smith’s family, which Newkirk strenuously objects to. Newkirk says she was told that the hospital planned to keep Smith alive until the pregnancy was 32 weeks along, at which point the baby would be delivered by Cesarean section, and also that the baby might die shortly thereafter or be born disabled. “I’m not saying we would have chose to terminate her pregnancy,” Newkirk told the local news station. “What I’m saying is we should have had a choice.” Emory released a statement refusing to comment on Smith’s case but noting that the hospital “uses consensus from clinical experts, medical literature, and legal guidance to support our providers as they make individualized treatment recommendations in compliance with Georgia’s abortion laws and all other applicable laws.”
To advocates for abortion rights, Smith’s story registered as yet another episode in a series of nightmarish outcomes caused by states’ post-Dobbs abortion bans: a 10-year-old rape victim in Ohio driven out of state to terminate her pregnancy; a Texas mom of four forced to carry a fetus with a fatal abnormality to term; another Texas woman who died after doctors refused to treat her miscarriage for some 40 hours. In that sense, Smith’s case falls within the broad realm of unintended consequences linked to these laws. Philosophically, it reflects what abortion advocates take to be the unstated premises of anti-abortion politics: that women’s bodies and lives are expendable resources meant only to produce children. In a New York Times article typical of this line of thinking, the Rutgers Law School professor Kimberly Mutcherson noted that “reproductive justice advocates have long been clear that abortion law is never only about abortion. It is about the exercise of control over all pregnant women, regardless of whether they plan to carry their pregnancies to term.”
Georgia’s anti-abortion statute, State Senator Nabilah Islam Parkes told me last month, has its own specific problems. The state’s Living Infants Fairness and Equality Act bans abortion after a fetal heartbeat can be detected, sometime around six weeks of pregnancy, which Parkes characterized as among the most restrictive—and vaguest—abortion laws in the country. “These institutions”—meaning hospitals—“are very risk averse,” Parkes said, and they fear prosecution for running afoul of unclear anti-abortion laws. Parkes sent a letter to Georgia Attorney General Chris Carr earlier this month asking for formal clarification on whether Smith’s doctors are legally required to keep her alive until the delivery of her baby; Carr has thus far declined to issue a formal legal opinion on the case.
Partially because of fundamental disagreements about the nature of personhood, and perhaps even more the separate informational universes the opposing advocacy camps inhabit, pro-life commentators received Smith’s story in a radically different way. Speaking to the Associated Press last month, Georgia State Senator Edward Setzler praised Emory for keeping Smith alive for the sake of her fetus: “I think it is completely appropriate that the hospital do what they can to save the life of the child. I think this is an unusual circumstance, but I think it highlights the value of innocent human life. I think the hospital is acting appropriately.” Seltzer was far from the only pro-life figure to cheer Emory’s decision.
In response to the outrage over Smith’s case, some pro-life thinkers have questioned whether the abortion ban was salient in the hospital’s decision at all. A spokeswoman for Carr’s office said late last month that “there is nothing in the LIFE Act that requires medical professionals to keep a woman on life support after brain death. Removing life support is not an action with the purpose to terminate a pregnancy.” A representative of Georgia’s state House, meanwhile, told The Washington Post that Georgia’s abortion ban “is completely irrelevant” to Smith’s situation, adding that “any implication otherwise is just another gross mischaracterization of the intent of this legislation by liberal media outlets and left-wing activists.” Some pro-life advocates proposed that the law Smith’s doctors had either cited or meant to cite in their conversation with Newkirk about their legal obligations was not the LIFE Act but rather a more obscure law relating to care for patients with advance health-care directives, as well as a 1986 trial-court ruling mandating that another brain-dead pregnant woman be kept alive in a similar situation, though Smith had no advance directive and the 1986 case was not precedential.
At any rate, from the pro-life vantage point, Smith’s story is not solely about abortion; it’s about preserving Smith’s life, too, as principled pro-life beliefs apply not only to fetuses but to the incapacitated as well. Like 36 other states, Georgia defines death according to a version of the 1981 Uniform Determination of Death Act, which considers anyone with “irreversible cessation of all functions of the entire brain, including the brain stem,” dead—though many pro-life activists take issue with this definition, arguing that brain-dead people are still alive in a meaningful sense. Charles Camosy, a bioethics professor at the Creighton School of Medicine, told me last month that “Adriana requires technology to live—but that’s also true of someone who needs an artificial heart, an ECMO machine, or kidney dialysis. Dependence on machines does not make one dead.”
This question of what constitutes death and the attendant matter of who ought to make decisions for brain-dead people are really at the center of Smith’s story. Developing a theory of what would or would not have justified allowing Smith to die entirely isn’t possible, because the details of Smith’s case, such as her actual diagnosis and condition, are unknown to those outside the situation. Newkirk has not shared much detail about Smith’s medical crisis, nor should she be expected to. This uncertainty haunts the entire debate about Smith’s condition, shrouding much of it in mystery.
What is clear is that mapping abortion rights onto her case is difficult, because Smith herself is likely dead in the eyes of the law, a judgment that seems reasonable enough to me—but that means there can be no legal weighing of maternal interests against those of the fetus, because the mother no longer has any interests. Nor can there be a violation of Smith’s right to choose, because she is no longer making choices. This use of a human body to effectively treat another is certainly grizzly and possibly morally questionable, but it isn’t a case of a woman being forced to carry an unwanted pregnancy to term, as much of the coverage of Smith’s situation has suggested. Nevertheless, Emory did deny Smith’s family the opportunity to decide whether she ought to be kept on life support, despite the fact that they were most equipped to advocate for Smith’s own wishes in her stead. In that respect, there really was a meaningful abrogation of choice.
More than an exemplar of any political principle, Smith’s story is a tragedy, and no rhetorical framing of her relatives’ suffering will help them heal. Newkirk has said that her family is hoping the baby will make it. She plans to name him Chance.
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