Adriana Smith and the ethics of indifference

Fetal personhood laws created a medical and moral tragedy.

By Dara Kass

In the days since the world learned that a baby was delivered Friday via cesarean section to Adriana Smith, a woman declared brain dead in Georgia in February, the public reaction has been a mix of disbelief, heartbreak, and outrage. How did we get here? How could a woman be kept on life support for months, not because she had any chance of survival, but because her pregnancy had become the legal and ethical priority? Though much has been written about the horrifying outcome, to understand how this happened and how to prevent it in the future, we need to examine the laws that created this situation, the institutional indecision that allowed it to continue, and the broader questions of medical ethics and human dignity that it raises.

The groundwork for Smith’s ordeal was laid years ago. In 2019, Georgia passed a six-week abortion ban (HB 481) that included a provision for fetal personhood, defining an embryo or fetus with the same rights as a “dependent minor.” At the time, the law was unenforceable because of the constitutional protections of Roe v. Wade. But in 2022, the U.S. Supreme Court overturned Roe in Dobbs v. Jackson Women’s Health Organization, a case that challenged a Mississippi law banning most abortions after 15 weeks of pregnancy, allowing Georgia’s law to go into effect.

HB 481 not only bans abortion after cardiac activity is detected but also grants embryos and fetuses legal status. Though this provision has rare cause to be tested—it is impossible to prioritize the needs of a fetus over the needs of a mother in a medical emergency—this issue has come up hypothetically when discussing the emergency treatment of patients with some types of miscarriage or pre-viable premature rupture of membranes.

Unfortunately, this situation, in which a pregnant woman was declared brain dead, appears to be the first time since the law was passed that fetal interests, in this case at nine weeks gestation, could be managed independent of those of the mother. No one had tested what it meant under Georgia law for a fetus to have personhood rights when the pregnant person was brain dead just nine weeks into the pregnancy.

Declaring anyone brain dead is devastating. When that person is pregnant, it becomes even more ethically and emotionally fraught. There are only a handful of reports in which a brain-dead pregnant person was kept on life support to continue gestation, and none began as early as nine weeks. It is medically uncertain whether a fetus can survive, much less thrive, under such conditions. Viability, in the context of pregnancy, typically occurs around 23 to 24 weeks, and it is the point at which a fetus can survive outside the womb.

Based on available information, the decision to keep Smith on life support appears not to have been made deliberately or with transparency. It was more likely the result of institutional paralysis: legal fear, ethical uncertainty, and administrative inertia. In many brain-death cases, someone, usually a lead physician or a close family member, must push to initiate a plan to continue or remove life support. But when no one takes that step, the situation defaults into a dangerous limbo: wait and see, wait and see. This is likely what happened in the earliest weeks after Smith was declared brain dead.

By the time Smith reached her second trimester, news broke that she had been on life support for weeks, approaching what some consider the edge of viability. Much of the public attention focused on Georgia’s abortion ban, but it’s more likely the hospital was operating under the assumption that the fetal personhood clause left them no choice. Without court guidance and without the family seeking judicial intervention to remove life support, it seems the hospital defaulted to maintaining the pregnancy. It’s unclear whether family members were fully informed or whether they felt empowered to push back against what the hospital portrayed as a legal requirement.

This is a powerful example of what happens when vague laws meet complex medical realities. Fearing legal liability or reputational harm, hospitals defer to what they interpret as the most conservative or least actionable path. In this case, that path was to continue life support, regardless of the ethical implications or the well-being of the fetus.

This is why hospital systems, particularly in states with abortion bans or fetal personhood laws, must create formal guidance for managing complex pregnancy-related emergencies. When protocols exist, outcomes improve. A recent ProPublica article showed that hospitals with clinical guidelines for pregnancy complications had significantly lower rates of sepsis in early pregnancy loss.

Protocols give physicians clarity and empower them to act ethically and legally in moments of extreme uncertainty. They help avoid the paralysis that occurred in Adriana’s case. Increasingly, hospitals across the country are developing policies to address scenarios like early rupture of membranes, ectopic pregnancies, and fatal fetal anomalies. But very few have discussed yet what to do when a pregnant person becomes brain dead.

It is not enough to call Adriana Smith’s case a tragedy. We must recognize it as a warning. A society that allows women’s bodies to be kept alive against their prior wishes, against their families’ grief, in service of an uncertain pregnancy outcome is a society that has failed to create humane, rational policy.

Even in a post-Dobbs world, most of us could not have imagined a scenario in which someone is brain dead at nine weeks pregnant and kept on life support for months. But now we know. And we cannot unknow it. The next Adriana Smith deserves our proactive energy—our refusal to allow laws to be interpreted in silence and inaction.

Hospitals, particularly in states with restrictive abortion laws, must urgently develop policies for this exact situation: What to do when a pregnant person is declared brain dead. Physicians must be empowered to act based on science, ethics, and the known outcomes of such prolonged support—not on speculative legal interpretations. Families must be informed of their rights and options and not left alone to defer to an overwhelmed and paralyzed institution.

Without proactive action, we will see more cases like this. The Venn diagram of medical ethics, malpractice risk, and criminal liability is sometimes a complete circle. And in that circle, patients, who are real people with histories, relationships, and dreams, are forgotten.

If we care about our patients, families, and shared humanity, we must ensure this never happens again. Adriana Smith is no longer here to speak for herself. The rest of us must do it for her.

Dara Kass, is an emergency physician and the founder of FemInEM, an organization dedicated to the advancement of women in emergency medicine and addressing reproductive healthcare issues in our emergency departments.

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