Wednesday, February 7, 2007

Ectopic Pregnancy and Abortion [Serge]

A frequent question that is asked of pro-lifers is if we support abortion in the case where a mother's life is in physical danger from her pregnancy. Most often, this occurs due to an ectopic pregnancy, which is a condition in which a human embryo implants somewhere other than the mother's uterus. 98% of the time, this occurs in the Fallopian tube, where the growing child has no chance of survival, and the mother risks death if the Fallopian tube erupts. For that reason, this is a case in which it is better to save one life than to lose both of them. Removing the child, which does kill her, (which is a very different procedure than a suction abortion) is permissible in my view.

I was somewhat surprised to read about the position of the American Life League (ALL) regarding ectopic pregnancy. They also believe that treatment of EP is permissible, but only in a way which causes additional risk for the mother. Here is their statement:

Using the Thomistic Principle of Totality (removal of a pathological part to preserve the life of the person) and the Doctrine of Double Effect, the only moral action in an ectopic pregnancy where a woman's life is directly threatened is the removal of the tube containing the human embryo. The death of the human embryo is unintended although foreseen. Put another way, if there were a way to save both lives, which, of course, are of equal value, one would be obliged morally to do so. At this time, this is not possible.

It is acknowledged that it has become commonplace even in Catholic hospitals to open the tube and "suction out the human embryo" or administer methotrexate either via mouth or laparoscopy. Both of these procedures directly attack an innocent human life and are intrinsically immoral and never can be justified. In fact, they violate the Fifth Commandment, which under all circumstances prohibits a direct attack on innocent human life. There are absolutely no exceptions to the 5th Commandment as described.

While removing the tube containing the human embryo results in the death of a human being as does suctioning out the human embryo or administration of methotrexate, one cannot ethically conclude that all the actions have the same intended end result. The reason for this is that the "means" used to accomplish the "end" are not the same.

Refusal to make this distinction results in a Machiavellian approach employing any "means" to the "end" including the direct assault on the human being intended to result in his death. While it is acknowledged that removal of the tube containing the human embryo may result in sterility, it is not morally justified to directly attack human life by suctioning out the human embryo or administering methotrexate even though fertility is preserved.

Once again, it is important to remember that this child, although undeniably fully human and having intrinsic value, has no chance of living. I agree that if we could save both, we should do so. However, there is no chance that that can occur with today's technology.

Granted that the child cannot survive, it is standard surgical technique to treat a pathological process as conservatively as possible with as little damage to the surrounding tissues. In other words, if there are multiple ways to treat a certain pathology, the surgeon should consider which technique leaves the (God-designed) anatomy functioning as normally as possible.

In the ALL analysis, a surgeon has a moral obligation to perform this procedure in a way which can cause greater anatomical harm to the mother in order to avoid "directly touching" the child. They acknowledge that the end result for the child is the same, and although a salpingectomy has a greater chance of tubal mis function, it should be done.

I do not see how this makes sense.

If the child is doomed, why not perform the procedure that saves the mother in the safest way possible, which leaves her anatomy as untouched as possible? Why does it mitigate the child's death, which is an undeniable but unavoidable tragedy, by causing more harm to the mother?

What if I were attempting to save a very large man from drowning, and he unfortunately panics and pulls me down with him. Assume that there is no way he's going to make it. It seems via this analysis, it would be wrong for me to push him away in an effort to save my life, for this would be a direct action which causes him to go further under the water directly resulting in his death. However, it seems it would be permissible for someone to amputate my arm that the man had grabbed on to, for this would not directly result in his death. Of course, in both cases, he still died, and in the first, I would retain use of both arms. But according to this analysis, the second case would be morally preferable.

I'm interested in comments if I misunderstand this viewpoint, but if I have got it correct, I believe that ALL should seriously reconsider their point of view.

HT: JivinJ

9 comments:

  1. Actually, there is a small chance of the baby surviving, though it's extremely risky. Personally, I'd want the doctor to try something like carefully opening the tube and moving it over atop the uterus, to give the placenta a chance to latch on.

    Risky, yes, but I think women ought to be given the option to try to save these babies.

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  2. I've run across somewhere the assertion that anembryonic pregnancy can be associated with ectopic pregnancy. I gather it isn't known which is cause and which is effect--e.g. whether the ectopic location prevents the development of a visible embryo. And I know that not all ectopic pregnancies are anembryonic.

    Can anembryonic pregnancies (blighted ovum) be regarded as cases where the child, if it existed at fertilization, is at this point already dead? If so, are there any statistics on the number of cases in which ectopic pregnancies are anembryonic?

    Another thought: If the woman begins bleeding as a result of an ectopic pregnancy, is the embryo usually dead by that time even if there was an embryo? E.g. Heartbeat stopped? That might also be helpful for women in need of treatment with conscience worries.

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  3. Excellent post, Serge.

    The ALL position is tied to the Catholic "Doctrine of Double Effect" which they reference in their statement. Essentially, the DDE states that it is never moral to take an action that is intrinsically immoral even if it would have a good outcome. Abortion is intrinsically immoral, therefore it is never a moral choice.

    However, the DDE allows you to take a morally-neutral action which will have the same effect as the immoral action would. That's why they focus on removing the tube. Removing a Fallopian tube is supposedly a morally-neutral act, even if doing so would cause the same tragic outcome (the death of the unborn child) as an abortion. Therefore, their preferred solution is to remove the tube.

    I have the highest respect for Catholic morality and their commitment to Life, but I think they're totally wrong here. Claiming that removing the tube is acceptable reminds me of an anecdote that an Army Reserve friend of mine once told me. According to his sergeant, it was against regulations to shoot enemy soldiers with a fifty-cal machinegun. Such heavy ordnance was only supposed to be used to destroy enemy equipment, not kill their troops. So the sergeant told them to aim for the enemies' uniforms. Hey, you're just shooting the equipment, not the people! It's not your fault if those bullets over-penetrate and kill someone, right?

    This particular application of the DDE seems to be equally silly to me. Both procedures -- removing the tube and actual abortion -- result in a dead child. However, removing the tube also causes additional risks to the mother. That's not a good thing.

    ...

    However, we should be aware of the slippery slope on which we are standing. The DDE is correct much more often than it's wrong. Claiming that the ends justify the means can lead to some really horrible outcomes. For example, if a euthanasia "patient" will have the same outcome as a hospice patient, then why suffer through the hospice stay? Why not allow euthanasia for the terminally ill? I don't want to eliminate the line between hospice care and euthanasia -- and I don't think that you do, either -- but the logic is disturbingly similar.

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  4. Lydia,

    I believe once a woman begins to bleed from a ruptured Fallopian tube, the embryo must have died. As to your other questions about anembryonic pregnacies - I'll have to do some research and get back to you. You pose some interesting questions. I would believe that in an anembryonic pregnancy, the child in question would have died, but I am not sure.

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  5. Yes, Judy Brown is Catholic. Therefore one must respect how she forms her conscience. We Catholics do not expect everyone to understand our Faith and we respect the right of all persons of other faiths to hold opinions that are opposed to the teachings of the Catholic Church. We however, if we are authentic Catholics, are not likely to abandon our faith-based informed consciences because non-Catholics or even heterodox members of our own Church cannot accept those teachings.

    Below is
    Msgr. Wm. B. Smith's answer to this question
    .

    Question: I read of a “shelling out” procedure for ectopic pregnancy. It said this leaves the fallopian tube in place and intact, arguing that it is the more pro-life and pro-fertility procedure. Is this a direct abortion?

    Answer: I believe it is a morally direct abortion and that it is not a legitimate application of the principle of Double Effect as some have argued (for a summary of opinions, cf. J. E. Foran, M.D., in Linacre Quarterly 66:1 [February 1999] 21-28).

    Factually, according to the Centers for Disease Control there has been a very large increase in ectopic pregnancies in this country: from a 4.5 rate per 1,000 in 1970 to a 19.7 rate in 1992. The CDC attributes major increases to chlamydia and other sexually transmitted diseases that can and do scar fallopian tubes. A number of pelvic inflammatory diseases (PID’s) cause serious infections in fallopian tubes and ovaries—especially affecting the sensitive lining of the tubes known as the endosalpinx. It is almost impossible for ectopic tubal pregnancy to happen without some preexisting disease or irregularity of the endosalpinx.

    Over the past decade, two Catholic moralists have engaged in a nuanced and pointed debate about what is and is not permissible in the moral management of ectopic pregnancies: cf. W. E. May in The Fetal Tissue Issue (Pope John Center, 1994) pp. 121-148; also, Ethics & Medics 23:3 [March 1998] 1-3; and A. S. Moraczewski in E&M 21:6, 21:8 [June and August 1996] and E&M 23:3 [March 1998] 3-4 in response to W. May.

    Some estimate that about half of tubal pregnancies spontaneously resolve, but our present concern is deliberate intervention (surgical or chemical) to resolve the tubal pregnancy. In the past, the vast majority of tubal pregnancies were discovered because of the rupture of the tube, at which point it was too late to do anything except to remove the now damaged and ruptured tube with the death of the unborn a concomitant and unavoidable fact.

    Currently, the diagnosis of unruptured ectopic pregnancy is possible by ultrasound or laparoscopic techniques and this earlier (i.e., pre-rupture) information raises questions of the appropriate management of intact pregnancy.

    All Catholic authors agree that salpingectomy is a licit application of the principle of double effect. That is, full salpingectomy—the entire fallopian tube (together with the ectopic pregnancy) is surgically removed; or, partial salpingectomy—only the damaged segment of the tube enveloping the ectopic pregnancy is removed, and then the severed ends of the tube are brought together and sutured.

    Clearly, the surgery here is on the tube, a portion of which is pathological and poses a significant threat to the health and life of the mother. The death of the unborn is foreseen but not directly intended. The improvement in mother’s health and life is not precisely caused by the death of the unborn but comes through (caused by) the removal of pathological tissue. Thus, an indirect abortion and a legitimate application of double effect.

    But, different from salpingectomy is salpingostomy—where the tube is sliced longitudinally directly over the ectopic who is extracted with forceps or gentle suction with some appropriate instrument. The unborn is thus detached from the tubal wall and removed (death-dealing).

    Similar to salpingostomy, but non-surgical, is the chemical administration (systemically or injected at the site) of Methotrexate (MTX). Methotrexate is a folic acid antagonist developed over 40 years ago as a chemotherapy for certain types of cancer. MTX inhibits DNA synthesis so that normal implantation enzymatic activity ceases. Its primary effect is on the trophoblast (the precursor of the placenta). Clearly, this is not a cancer case, the point and purpose of MTX here is to shut down (stop) the life support system of the developing child (death-dealing).

    It seems to me that salpingostomy and this administration of MTX are direct abortions, and that the W. E. May analysis is correct while the Moraczewski opinion is mistaken.

    Moraczewski prefers to examine the classical “fontes moralitatis” and ask specifically: what is the moral object of salpingostomy? (E&M 23:3, p. 4). He argues that the specific object and good of that act is “the stopping of the enzymatic activity of the trophoblast.” That enzymatic action would be proper and normal in the uterus but is here causing damage in an abnormal site, the tubal lining.

    Thus, contra W. May, he says his conclusion is not based on the distinction between removing the embryo from the site and destroying it in situ. “It is based on stopping the destructive activity of the trophoblast by removing trophoblastic cells along with the damaged tubal tissue” (Ibid.).

    However, when you do directly remove the embryo from the site, what you do (finis operis) is destroy it in situ. Neither trophoblast nor its activity is in any sense “diseased,” and thus the salpingostomy or MTX is in no sense therapeutic for or to the embryo, it is, rather, a death-dealing procedure meant to improve mother’s health and life. This violates the double effect condition (re causality) that the good effect not be caused by, not come through the evil effect. As mentioned above, tubal pregnancies don’t happen because tiny embryos do what they naturally do; almost always there is a preexisting problem in the endosalpinx from whatever cause.

    Thus, I believe W. E. May is correct (with K. Flannery, S.J.) when he states that salpingectomy is a medical intervention performed on the mother; whereas salpingostomy (or MTX or craniotomy) are interventions performed on the unborn child. Moreover, the procedures are undertaken “not for the benefit of the unborn child, who is killed as a result of their use, but for the benefit of another, the mother” (E&M 23:3, p. 2).

    Since the procedures are not necessary to protect the mother’s life (salpingectomy can preserve that) but allegedly to preserve future fertility, I would judge that the final condition of double effect, proportion, is also not verified here and thus is not a legitimate application of double effect and is a direct abortion.

    Please address questions to Msgr. Wm. B. Smith, St. Joseph’s Seminary, Dunwoodie, Yonkers, N.Y. 10704.

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  6. fredi wrote:
    We however, if we are authentic Catholics, are not likely to abandon our faith-based informed consciences because non-Catholics or even heterodox members of our own Church cannot accept those teachings.

    A fair point. The Catholic dedication to eternal truths is laudable, and it serves to protect the Catholic Church from some of the heresy & insanity that is sweeping through the "mainline" Protestant churches.

    FWIW, I'm a Southern Baptist. We're just a stubborn as Catholics in our own way. :)

    It is almost impossible for ectopic tubal pregnancy to happen without some preexisting disease or irregularity of the endosalpinx.

    That ... is ... interesting. I didn't know that. If it's true, then removing the tube actually makes some sense.

    Thanks. You've given me something to ponder.

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  7. Thanks Freddi. I had already read that article in my research about the Catholic point of view. From what I understand, this "policy" is not an infallable teaching of your magisterium, so it is reasonable to discuss.

    This statement:
    It is almost impossible for ectopic tubal pregnancy to happen without some preexisting disease or irregularity of the endosalpinx.

    There is clear evidence that a salpingotomy (what the church opposes) maintains fertility far more often than a partial salpingectomy. The article admits as such. Therefore, even if "the tube" is the source of the pathology (which there is no consensus about medically), then wouldn't it make more sense to perform a procedure which preserves as much of the tube's function as possible?

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  8. Serge, Msgr. Smith addressed your question as follows:
    Thus, I believe W. E. May is correct (with K. Flannery, S.J.) when he states that salpingectomy is a medical intervention performed on the mother; whereas salpingostomy (or MTX or craniotomy) are interventions performed on the unborn child. Moreover, the procedures are undertaken “not for the benefit of the unborn child, who is killed as a result of their use, but for the benefit of another, the mother” (E&M 23:3, p. 2).

    Since the procedures are not necessary to protect the mother’s life (salpingectomy can preserve that) but allegedly to preserve future fertility, I would judge that the final condition of double effect, proportion, is also not verified here and thus is not a legitimate application of double effect and is a direct abortion.


    I'd rather not engage in a discussion about what are and are not infallible teachings of the Catholic Church and how Catholics should respond to either. If you are interested in reading about my perspective regarding that issue, I refer you to 'Path to Sainthood'.

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