In medicine, you need to be able to deal with the situation at hand.
By this, I mean the precise moment in time, your patient's real and true condition, not the maybes or the could-bes. Those are important, too, but not nearly as important as now. Now, your patient is in pain. Now, your patient is dying. The future is never set in stone, so you work with what is. You take the history and the circumstances into account in this pivotal moment, for this decision.
Let me use an example from primetime television.
"Private Practice" is a medical drama airing Thursday nights on ABC, directly following "Grey's Anatomy". A recent storyline has involved a young married woman with children of her own offering to give birth to triplets as a surrogate mother. During the pregnancy, her condition deteriorated to the point where she could no longer carry to term safely. One physician argued that all parties -- surrogate, surrogate's husband, and biological parents -- would be best served by a watch-and-wait policy. That physician opposed selective reduction on the grounds that the parents wanted all three children. The other physician, female lead Addison Montgomery, pointed out that the patient might not live long enough to bear all three children. A decision was made to attempt to alleviate the patient's condition using surgery; during that surgery, complications ensued, and the patient was left in a coma with a grim prognosis. Taken off life support, the patient was not expected to survive.
Tonight's episode dealt with the ramifications of a decision made largely in view of the future. Tonight, the worst that could happen was on display: surrogate mother essentially dead, fetuses surviving. The patient's husband felt his wife was denied any dignity in death, that she'd been reduced to an incubator -- and in a way, yes, he was right. His wife remained on life support to give the fetuses extra time to develop in the womb, as opposed to delivery at twenty weeks, which would almost certainly kill them. However, he had not wanted his wife to become a surrogate, and he had advocated for the preservation of her health via selective abortion. His choice at that point accounted for the existing circumstances and prioritized them over a possible happy ending, because the other possibility meant his wife's death.
However, once it became clear that at the very least, the patient's higher brain functions were gone, that her vegetative state was impenetrable, and that she was unlikely to survive if removed from life support, his advocacy for her dignity became a decision rooted in the past, not the present. It took only history into account. At that point, the argument for keeping her on life support until the fetuses' viability gained credibility. Removal of the patient from life support ensured four deaths, even if three of those lives were only conditional on the ability of the patient to sustain them. Keeping her on life support gave very wanted, very nearly viable fetuses a chance to become children.
The husband's attempt to use power of attorney to remove his wife from life support was blocked by a judge's ruling that the patient's removal from life support would invoke fetal homicide laws in the state of California, where feticide in cases of legal abortion is permissible, but anything else is murder. Her decision took only the present into account. The surrogate mother of those three fetuses might have existed solely to provide them room to grow, but under California law, they were entitled to that protection. Regardless of anyone's feelings on the matter, here was a clear application of the fetal homicide law.
Here, too, was a clear application of bioethics in favor of saving as many lives as possible. At that point, while the surrogate mother might technically have been alive, all higher function had ceased; she was effectively dead. If the continuation of her bodily functions allowed for three other lives to continue, those lives had to take precedence. Earlier in the pregnancy, perhaps this clarity would have been harder to find. How long do we keep a woman in the hospital, at great cost to her family, solely to benefit the unborn? At twenty weeks, viability is near enough that the cost, both human and monetary, is not as exorbitant. The grieving process can begin with the knowledge that within two months at most, the family will be able to bury its dead. Negotiations by the surrogate's attorney for six to eight weeks of full coverage stand a better chance than, say, negotiations for coverage between the tenth week and the twenty-eighth, which is where viability usually begins; note please that in some cases, viability has been declared as early as twenty-four weeks, and two infants born at twenty-one weeks gestational age have survived. (Wikipedia - Viability [Fetal]; further sources cited within article)
Television, of course, adds its element of drama. The judge's ruling called for the removal of all but necessary medical personnel from the patient's room; the husband could not legally visit his wife during her pregnancy. One of the doctors, Charlotte King, sympathized with the husband and found a way to get him into the room unsupervised. The husband took that opportunity to remove his wife from life support himself, at which point she began to breathe on her own and the episode ended. The viewer did not find out whether her EEG reflected more than a vegetative state, only that her brain stem was able to sustain her unaided.
Were I that judge, or a material witness, I would testify that the game has changed enough to warrant a reexamination of the case. At the very least, visitors ought to be permitted; the worst is over, after all. The husband has done his potential damage. He cannot interfere further without causing his wife extensive harm, and he does not feel she's just an empty shell. He regards her body as sacred; to further violate its integrity is the ultimate profanity. He will let a doctor be his advocate. Perhaps, in light of the kindness she showed him, he might choose Charlotte King.
I would ask that the condition of the patient be monitored closely for further change. If the trend is toward complete recovery, the option to selectively reduce for the sake of her health must be reintroduced. Our obligation is to the living, the surviving; if she is not simply a dead body on a ventilator with the merest remnants of brain function, then she is alive by default and deserves equal consideration.
Cases like these bring the ethical considerations of surrogacy to the fore. In this particular case, the biological parents' greed very nearly killed a woman with a life of her own. She may never regain functionality as a wife and mother; what quality of life will she have, especially if she becomes able to remember the life she led but unable to go back to it? Even one fetus less might have made a difference, using a procedure that may be distasteful to some but has the potential to save lives. Yes, she was nearer term than many are comfortable with when they consider abortion, but she was also dying, and before viability, whether she had delivered or not, those children would have died outside her womb. Without her, there would have been no children. To forget the surrogate's role in such a pregnancy disregards her rights as a person; she becomes the incubator. She becomes the vessel, existing solely to generate new life. We must remember that we cannot purchase people, only their services. The biological parents in this case could have withheld some payment given one child's death, but to request that the surrogate put her own life on the line when a child -- any child -- was the desired result, and triplets a bonus, was unreasonable.