A state district judge has ruled that Marlise Muñoz, the brain-dead North Texas woman who’s 22 weeks pregnant, must be removed from life support by 5 p.m. Monday.

The decision Friday afternoon comes after John Peter Smith Hospital declared publicly for the first time that Muñoz has indeed been brain dead since late November. The hospital also says the fetus inside Muñoz is "not viable."

For weeks, hospital officials had said she isn’t dead and that her condition is serious.

But in a new court filing, the hospital states that Muñoz met the clinical criteria for brain death on Nov. 28, two days after she was found unconscious at her Haltom City home.

Marlise Muñoz's husband, Erick, sued the hospital last week to have her removed from life support. He has said he and his wife are paramedics who agreed they would not want life support in this situation. This week, attorneys for Erick Muñoz released a statement describing the fetus as "distinctly abnormal," with heart problems, deformed lower extremities and hydrocephalus, or water on the brain.

Hospital officials have said Texas law prohibits them from following Marlise Muñoz's wishes because she is pregnant. John Peter Smith Hospital has refused to disconnect Muñoz from life-support machines, citing the Texas Advance Directives Act concerning end-of-life care. It includes this provision: "A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient."

Inside the hearing

During Friday's hearing in Fort Worth before State District Judge R.H. Wallace, attorneys for Muñoz said that the matter is not a pro-life or pro-choice argument, but it’s turned into that.

Muñoz’s attorneys said the hospital continues to misapply the part of the state law that says a pregnant woman on life support must stay on life support. The attorneys insist that Muñoz is dead and that the law does not apply to a dead person.

JPS attorneys say that the hospital is interpreting the law correctly and that the state has an overriding interest to protect the life of the unborn child.

Muñoz’s lawyers say the situation creates a potential slippery slope. They asked: What will happen to women who die or face death in the future – will they be given blood tests to determine if they are pregnant and then placed on life support?

Muñoz’s family members were at the hearing, including her husband, Erick.

What the hospital says

New court documents filed by JPS late Thursday shed more light on the hospital's perspective. Upon arriving at the Fort Worth hospital, Marlise Muñoz was alive, JPS says in the documents. She was experiencing cardiac arrest and respiratory failure. She was 14 weeks pregnant at the time.

“JPS, therefore, began life sustaining treatment,” the hospital says in the documents. “Ms. Muñoz did not have a written advanced directive and was incapable of communication.”

The response continues: “Despite such treatment, Ms. Muñoz met the clinical criteria for brain death on November 28, 2013.”

In the family's lawsuit, attorneys for Erick Muñoz had stated that his wife had “lost all activity in her brain stem, and was for all purposes brain dead." Erick Muñoz also saw “brain dead” listed in writing in her medical charts.

But regarding Erick Muñoz’s position that since his wife is dead, she should no longer receive life-sustaining treatment, the hospital’s Thursday filing stated:

“His position, however, ignores consideration of the unborn child. [State law] Section 166.049 must convey legislative intent to protect the unborn child, otherwise the legislature would have simply allowed a pregnant patient to decide to let her life, and the life of her unborn child, end. ...

"If the legislature intended for life sustaining treatment to be withdrawn, allowing the unborn child to die, it could have expressed this intent by adding a second sentence to section 166.049 to the effect that, upon the mother's death, the healthcare providers must withdraw life sustaining treatment and let the unborn child die. It did not so provide."

A medical ethicist's opinion

For a recent story on the Muñoz situation, KERA’s Lauren Silverman spoke with SMU  Law professor and medical ethicist Tom Mayo.

“This is the first time I’ve heard of a hospital insisting on treatment over the objection of a family,” he says. “It is more of an ethical issue than a legal issue I think.”

Mayo says it is not illegal for a doctor to withdraw life support on a pregnant patient in Texas.

Mayo tells NPR he believes the exclusion "doesn't apply because I don't think the act applies to someone who is dead. This is all assuming now that the husband has it right, and that we'll see confirmation of her brain death as a result of the hearing."

Mayo says more than 30 other states also have pregnancy exclusion provisions on the books, but this is the first time he's heard of a hospital insisting on treatment over the objection of a family.

A doctor's thoughts

"Knowing of these abnormalities this early in gestation, the likelihood of having a good outcome for the fetus is definitely decreased," says Dr. Sheila Chhutani, an OB-GYN at Texas Health Presbyterian Hospital in Dallas.

She says cases of pregnant brain-dead women are extremely rare. A 2010 study at Heidelberg University in Germany focused on a number of such women around the world. The results for the babies were mixed: five died in utero, and 13 were delivered by cesarean section, one of whom died a month later.

Chhutani says "in dealing with these types of cases, one of the first things is finding out if there are any abnormalities within the fetus, because that can help determine whether or not you take on the burden of keeping this woman alive in order to grow the fetus."

Previous coverage

For previous coverage on the Marlise Muñoz matter, read the stories below:

• Man Sues Fort Worth Hospital To Have Pregnant Wife Taken Off Life Support

• Fetus In North Texas Woman On Life Support Is 'Abnormal,' Family Attorneys Say

• Hearing Set For Friday On Whether To Remove Pregnant Woman From Life Support

• Pregnant Woman On Life Support Draws Attention To Texas Law

• Why Hospitals And Families Still Struggle To Define Death

• A North Texas Woman Who’s Pregnant And Apparently Brain Dead Is Attracting International Attention

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