Monday, December 30, 2013
A summary of Kaczor on ectopic pregnancy [Megan]
In his article "The Ethics of Ectopic Pregnancy: A Critical Reconsideration of Salpingostomy and Methotrexate," Christopher Kaczor speaks to the debate on the moral permissibility of treatments for tubal pregnancies.
Don't stop reading just because of the medical jargon — Kaczor's arguments are easy to follow and critical to the current conversation. The following is a summary.
An ectopic pregnancy is one in which the embryo implants somewhere other than the uterus, usually in the mother's Fallopian tube. Because of space limitation, the embryo will not fully develop inside the tube and, if the pregnancy continues untreated, will cause the tube to burst. This leads to internal bleeding that could, without immediate medical treatment, kill the mother. The dilemma we face is a situation in which two lives are threatened. Since we don't have a medically consistent way (yet!) to transplant to embryo to the uterus where it can safely develop, the embryo's future is bleak. It cannot develop fully where it is. The greater moral good in this situation is to save one human life — the mother's — rather than lose two.
Traditionally, the conservative view on morally permissible options for treatment of ectopic pregnancy have been:
1) Expectant management, or allowing the pregnancy to spontaneously end naturally, which happens around half the time; and
2) Salpingectomy, or the removal of the entire Fallopian tube with the embryo inside, which foreseeably but unintentionally causes the death of the embryo. The words "foreseeably" and "unintentionally" are key to the conversation (the principle of double-effect).
Either treatment is considered morally permissible — and in many Catholic circles, may be considered the only options — but Kaczor offers valuable insight on a third and (possibly) a fourth option.
Salpingostomy is a procedure that involves the removal of the embryo alone from the Fallopian tube. Objections to this procedure include the certain fatality of the embryo, as well as the idea that "simply removing" the embryo is the same as "simply killing" someone by beheading. Also, many object on grounds that Salpingostomy violates Directives 36 and 45 of the Ethical and Religious Directives for Catholic Health Care Services (see below).
As for the certain fatality of the embryo, the removal of the entire tube fares no better. Speaking like a true ethicist, Kaczor makes the case that the certainty of an effect doesn't necessarily mean that the effect was intended.
Besides, Kaczor writes, there are documented cases (albeit few) such as L. Shuttles in the American Journal of Obstetricians and Gynecology in which an embryo has been successfully transplanted in the uterus. Thus, we see that though no standard procedure has been developed to date, it is possible. It could be argued that removal of the embryo from a location where it will certainly die (in the tube, where it cannot develop fully) to a location where it is at least possible for it to be transplanted is prima facie better for the embryo.
Similarly, acting upon the embryo directly (rather than removing its environment) doesn't necessarily mean that all effects of doing so are intended. Kaczor cites Thomas Aquinas' thoughts on the moral permissibility of acting in self-defense as grounds for showing that it is possible to act on the body of another (even damaging that body) without intending the results.
Lastly, the wording of Directives 36 and 45, if interpreted literally, not only forbid a treatment like Salpingostomy — they also forbid transplantation of the embryo to a safe location — if and when it becomes possible — which would result in the safety and survival of both the embryo and the mother! The directives are better understood as applicable to uterine pregnancies, not tubal pregnancies, Kaczor concludes.
Kaczor also addresses treatment by use of Methotrexate (MXT), a drug that inhibits cellular reproduction in fast-growing tissue. MXT is used to treat certain kinds of cancers and, in the case of ectopic pregnancy, is believed to be effective in halting the growth of the trophoblast (which can continue even after the embryo spontaneously dies) into the wall of the Fallopian tube. If no fetal heartbeat is detected, its use is not problematic and results in less intrusion and shorter recovery time for the mother.
While Kaczor stands his ground by reminding readers "Neither the certainty of the effect nor the acting upon the body of another entails that a lethal effect which follows from the action must be intended," he does note that there are unknowns when it comes to MXT, such as whether or not MXT quickens the embryo's death. Given the lack of information about the way the drug works, he leaves the conversation on MXT open and urges that it remain so until more information is available.
My thoughts are as follows:
Cases involving ectopic pregnancy call for a different kind of conversation than cases of elective abortion. And while all conversations involving human life should be handled carefully and compassionately, it is especially true for these.
Women who are given this diagnosis often face a tremendous emotional trial as well as doubting questions on whether treatment is morally okay. Any treatment (save the extreme rarity of successful transplantation) or lack thereof will involve the death of a human being. We who communicate about these things mustn't forget that.
When individuals ask about cases in which the mother's life is at risk like ectopic pregnancy, I bring up the analogy of a medic on a battlefield with two gravely wounded soldiers before him. He can choose to do nothing and lose two lives, or he can choose to save one. The medic's choice, like the doctor's procedure, does not undermine the humanity and value of the life lost. It is tragic, and the result of living in a broken world.
I think that when treatment is necessary in cases of ectopic pregnancy, Salpingostomy, or removal of the embryo alone, is the better option. It — unlike Salpingectomy, which holds the same outcome for the embryo — preserves the mother's Fallopian tube and fertility. Kaczor's reasoning is sound.
Note: The following are excerpts referred to by Kaczor.
Directive 45: "...every procedure whose sole immediate effect is termination of pregnancy before viability is an abortion."
Directive 36: "It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum."