Sunday, July 18, 2010

Ectopic Pregnancy and Double Effect

Last month Sr. Margaret McBride, an ethical consultant at St. Joseph's Hospital in Phoenix, Arizona, was declared excommunicate by Bishop Thomas Olmsted on the grounds that she had cooperated in the procurement of abortion (apparently by giving the procedure her approval as ethical consultant). McBride defended her decision on the grounds that the life of the mother was at risk (she suffered from pulmonary hypertension, which put her at risk for eclampsia; her condition is sometimes referred to as pre-eclampsia. Eclampsia can be life-threatening, though pre-eclampsia rarely is--unless, of course, it leads to eclampsia). She appealed to the Church's teaching that only direct abortion is gravely sinful; indirect abortion (abortion in which the death of the fetus is not intended, though it may be foreseen) is regarded as, at least in principle, something that can be morally licit under the right conditions.

The basic idea here is to appeal to the principle of double effect, but it is not at all clear that pre-eclampsia constitutes a sufficient condition for invoking that principle. For one thing, pre-eclampsia, in itself, simply isn't as life-threatening as the principle would require. Second, even if the condition were life-threatening, it isn't clear that the principle would apply to this sort of case.

In a statement released in late June, the United States Bishops' Committee on Doctrine drew a distinction between kinds of cases based upon the nature of the threat to the mother's life. They gave the following examples to illustrate the distinction. In one sort of case, we are to imagine a woman whose organs are experiencing problems as a consequence of the added burden of pregnancy; in the other sort of case, we are to imagine a woman with cancer of the uterus. According to the document, the former case is not sufficient to render licit an abortion to save the life of the mother, because to remove the fetus in order to save the mother's life is a direct killing of a human being in order to save the life of another, and this is not permitted by Catholic moral theory: we may not do wrong in order to bring about good. In the latter case, the removal of the cancerous uterus is what is directly intended, and the death of the fetus, though foreseeable, is not intended, so the principle of double effect applies. It is difficult to avoid drawing the inference that, when it is the mother's own organs that threaten her life, they may be removed even if doing so kills another human being who is lurking therein; but when it is another human being who threatens the mother's life, that human being may not be killed, even if it is hiding in one of the mother's organs.

The case of ectopic pregnancy, in light of the directive from the Committee on Doctrine, is particularly interesting. Some Catholics have thought that an ectopic pregnancy is a clear case in which abortion to save the life of the mother would be licit under the principle of double-effect. But clearly not, if the distinction drawn by the Bishops' Committee is correct. In the case of ectopic pregnancy there is nothing organically wrong with the fallopian tube, so it is not analogous to the case of the cancerous utuerus. Instead, the fetus has become lodged in the fallopian tube, and the only way to save the life of the mother is to either (a) remove the fetus from the fallopian tube, which would be a clear case of a direct abortion and hence illicit; or (b) remove the entire fallopian tube, with the fetus in it. It is this latter scenario, (b), that those Catholics who defend this procedure as licit point to as the case covered by the principle of double effect. Their thinking is that the intention is to save the life of the mother, not to kill the fetus, and they save the life of the mother by removing, not the fetus, but the fallopian tube. The death of the fetus is, of course, foreseeable in this scenario, but since it is not intended, these folk reason, it is licit because covered by double effect. But according to the distinction drawn by the Bishops the removal of the fallopian tube cannot be seen as anything other than the removal of the fetus, since the fallopian tube itself is in no need of being removed, and certainly would not need to be removed if there were not a fetus lodged in it. If a stone had become lodged in the fallopian tube there is little doubt that the procedure would be referred to as the removal of the stone and not as the removal of a fallopian tube that just happened to have a stone in it.

Fortunately ectopic pregnancy is extremely rare, occurring in less than 2% of all pregnancies, though it is, apparently, on the rise: it has increased sixfold since 1970. Most patients that present with ectopic pregnancy have no identifiable risk factor, so the temptation to blame the rise of the condition on increasing use of fertility treatments (also frowned upon by Catholic moral theory) must be resisted. However, I won't resist the temptation to report the following (from MedScape):
One study has demonstrated that infertility patients with luteal phase defects have a statistically higher ectopic pregnancy rate than patients whose infertility is caused by anovulation. The risk of ectopic pregnancy and heterotopic pregnancy (ie, pregnancies occurring simultaneously in different body sites) dramatically increases when a patient has used assisted reproductive techniques to conceive, such as in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). In a study of 3000 clinical pregnancies achieved through in vitro fertilization, the ectopic pregnancy rate was 4.5%, which is more than double the background incidence. Furthermore, studies have demonstrated that up to 1% of pregnancies achieved through IVF or GIFT can result in a heterotopic gestation, compared to an incidence of 1 in 30,000 pregnancies for spontaneous conceptions.
So apparently the only method of saving the life of the mother in the case of an ectopic pregnancy is not actually morally licit, according to the most recent statement by the United States Bishops. Not all Catholics commentators have argued that it is licit, but those who have will now have to rethink their arguments.


Michelle said...

I think you might have confused pulmonary hypertension with "regular" hypertension (high blood pressure). The latter is potentially a marker for the development of pre-eclampsia, the former is an entirely different and very serious condition with high mortality rates in pregnancy (50%). The mortality rates outside of pregnancy are pretty high as well (a median survival rate for some types of 3.5 years).

matt said...

To add on to what Michelle said, I don't know the medical specifics of the case (aside from the media), but pulmonary hypertension can range from mild, or fatal (I've treated patients that have die with it). This is separate from PIH (pregnancy induced hypertension) and pre-eclampsia--both of which are typically treatable. In my mind (largely on the grounds of double-effect), there are some conditions that threaten the life of the mother and that would warrant a treatment that threatens the life of the unborn. It's obviously a difficult question and without knowing more of this case--I'd have a hard time saying it was justifiable or not.

Tony said...

Scott, thanks for picking up on this. I have often doubted the validity of the ectopic pregnancy situation as a good double-effect scenario for teaching purposes, even though it is used by Catholic authors quite a bit. It just seems so obvious that if the reason the fallopian tube is presenting problems is not due to the tube itself but due to the baby inside, while the tube would be healthy if the baby were removed, then removing the tube is just an indirect way of talking about removing the baby that is the cause of the problem. And treating the baby as the problem implies that removing the baby is how the problem is solved: the abortion is willed.

In addition, years ago the standard double-effect literature always made it clear (in using ectopic pregnancy) that it is impossible for the baby to survive such a pregnancy, so leaving the fallopian tube alone merely ensures the death of both instead of just the baby. Much was made of this element: the death of the baby is assured no matter what.

Unfortunately for this type of argument, there was a successful delivery of a healthy baby and mother from an ectopic pregnancy last year. Maybe that delivery was a one-in-a-million chance. But it directly undermines the use of the _assured_ death of the baby aspect of the argument.

I much prefer the uterine cancer example, since there it is clear that the mother's own organ is killing her, not some interplay between her organs and the baby. And it is equally clear that the cure consists precisely in removal of the organ itself: removing the baby does not in and of itself make the surgery more successful, more of a cure.

From what little I have read, the woman's doctor thought that her pulmonary hypertension was so severe a threat that just moving her was a serious danger, it wasn't a case where "maybe, eventually, the hypertension might present a direct danger." Nevertheless, it is absolutely clear that the reason the abortion was a "cure" was that the baby was the cause of an added stress to the mother, and removing that added stress was the cure. This means that having the baby no longer involved with the mother's biological system was directly intended (unlike the uterine cancer situation). In the given conditions that there was no actual, and (at the current time) not even a theoretical, back-up for a fetus as support and environment than the mother's uterus, intending to remove the baby from the mother's system cannot be separated from the choice to put the baby where it cannot live. The active choice made was a choice to kill the baby.

Even though the doctor's preference was for a situation where the baby would have remained alive when separating the baby from it's natural life-support system, the doctor WASN'T GIVEN THAT OPTION. Of the options available, the option chosen was to remove the baby from it's NATURAL and ONLY life-giving support. That choice was a choice to kill the baby.

As a follow-up, Sr. McBride has since admitted that she made an error and has repented of her wrong-doing. At least, that's what I read.

davymax3 said...

I like that you pointed this out. I think there are a lot of problems with Catholic moral teaching when it comes to "we can't ever do X." I don't think it makes sense to judge an action all by itself, without also looking at the intent and other things involved. Clearly, a good intent doesn't just magically make every action good. But there's other things going on here. Lying is something that some Catholics I talk to say is wrong no matter what. But what about telling your kid Santa is real or if you're a spy or if you were protecting Anne Frank in your attic. Whenever I bring this up people think I'm just trying to bypass Catholic teachings because I don't like the decision. In fact, it's the exact opposite. I have no problem with the decisions. I have a problem with the methodology. And I think this example points that out well. So, thanks.

Tony said...

davymax, I think that traditional moral teaching says that an action cannot be good if the intent is evil, though an action can be bad if the intent is good but the nature of the act is of itself evil. For example, one old classic case is: a man is told by a mafia strong-arm thug: steal 100,000 from your employer and hand it to me, or I kill your wife. And don't go to the police or I torture and kill your wife. The man reasons: I know that stealing is wrong, but I am not doing it for myself, I am doing it to save a life. So I'll steal.

We know that the guy's long-range intention is good. But the action itself remains stealing. It's own nature remains that of stealing regardless of his long-term intention to save a life, because the nature of the act is real independently of the remote intention. It really is taking money that doesn't belong to him, and that constitutes stealing even if his intention is good.

I think that some people, when they say that you have to take into account the intention, are thinking of the object of the act. The object is needed to define the act itself: THIS money, which is not mine. That's the object of the act. "For my wife" is not the object of the act, it is extrinsic to the act itself.

Now, it is true that the object of the act does indeed depend on the actor's actual knowledge: if he is mistaken about the actual facts, he may be doing an action which from the outside looks like stealing, but the moral quality is that of another act.

Tony said...

As far as I know, the principled stance on lying is this: God made man able to speak so that he could communicate a truth that he held in his mind to others. Truth is one of the great common (and universal) goods, so much so that Christ says "I am the truth". Using speech that opposes the truth in your mind to create in another the opposite of the truth that you hold violates the very nature of speech, and violates our deep obligation to the common and universal good. Therefore, telling a lie is always wrong.

There are times when the other party has no right to a truth, in which case you can either remain silent, or you can speak in such ways that he doesn't notice that you haven't answered the question he asked: Do you have Jews here? " Why, I know you'll kill me if I have Jews, I wouldn't DO it for that reason." No, that is not the reason, the reason lies elsewhere.

Is there a Santa Claus? "Yes, of course there is a Santa Claus: he is also called Saint Nicholas, he was a bishop of Smyrna, and he loved the poor such that he gave away many gifts to them. As a saint in heaven, he continues to intercede with God to shower gifts on those who call on him. Many miracles are attributed to his name."

Wine in the Water said...

I agree that the ectopic pregnancy example is not a good "go-to" example for double-effect. It is too nuanced and Catholic moral theologians are not completely in agreement about it. I too like to go with the much cleaner uterine cancer example.

However, I don't think you have all of the nuances quite down. When double effect is used to justify the removal of the fallopian tube in an ectopic pregnancy, there is usually the inclusion of the detail that the tube must be rupturing. Therefore, the treatment is the removal of a rupturing organ that has a child in it, not a healthy organ that has a child in it. In this case, you can say that you truly would be treating the mother. This also precludes the highly unlikely circumstance (I've never heard of it happening) where an ectopic pregnancy goes to term.

Even here, there is the problem of whether you can truly consider the act of removing the tube with the child in it morally distinct from the act of the killing the child. The reason for this is that it is the child herself who is causing the problem.

But ultimately, this is all actually a moot point. In the case of an ectopic pregnancy, a doctor can remove the child from the ectopic location (whether tube or somewhere else) and attempt to re-implant the child in the uterus. It has very low chances of success, but it has been successful. In this case, there is no need for double effect, both the means and the intent are licit. The action attempts to try to save the lives of both the mother *and* the child, with the understanding that the likelihood of success in the case of the child is low.

Unfortunately, there is so little regard for pre-born human life in our society, most people do not even know that this is an option and most doctors either don't know about it or don't think to offer it.

HBanan said...

I found this article on an ectopic pregnancy where the baby and mother survived. The baby was not in the fallopian tube, it was in the ovary. The mother had an apparently normal experience during pregnancy and had not had an ultrasound, so the doctor only found out when he was doing her caesarian.

There are other cases of babies surviving ectopic pregnancy, but only when they are not stuck in the fallopian tube.

It's a really amazing story, but I don't think it has much bearing on fallopian tube pregnancies. The ovary held up because it was able to stretch, but the tubes would burst early and both mother and baby would die. I don't know at exactly what stage of pregnancy the tube would rupture, but it sounds like the problems start happening in the first trimester, still way too early to save with neonatal care.

I think that the dream for these pregnancies would be a way to somehow do surgery and move the placenta and fetus to the uterus, but I would guess that is impossible since trauma to the uterus could result in miscarriage in any case.

davymax3 said...

Tony, I understand the logic. It just leads to indefensible positions, as in the examples you gave. You're proving my point. If the mafia guy asks me to steal 10 bucks to save my wife's life, you're saying that that's immoral. I maintain that stealing the 10 dollars is the nadir of morality. You are morally obliged to steal that money to save your wife. In the case of me hiding someone in my house from murderers, you should lie as much as possible to try and get them as far away as possible to save the person you are hiding. These examples of equivocation are exactly the problems I have. I think it violates common sense. If I ask someone a question, I'd rather them just straight out lie to me than to speak equivocations that are meant to trick me but could be possibly conceived in some meaning to be true. To say that lying is immoral but the equivocation isn't is absurd. In fact the equivocation seems to me to be a greater "lie."

Also, we are to assume no Catholic can ever be a spy?

davymax3 said...

Also, the Catechism says, "To lie is to speak or act against the truth in order to lead someone into error." But what is the truth? The truth is not a thing, the truth is a Person. If we speak something that is not literally true, this does not mean we are speaking "against the truth." Note, it doesn't not say, speaking or acting falsely. To speak against the truth is of a level above just speaking what is not true. It is similar to the distinction to contrary and contradictory. I think we can morally say things contrary to the truth, but never what is contradictory to the truth. For instance, Peter denied Christ. He spoke in direct contradiction to the truth and against the truth. On the other hand, if we look at the midwives and Pharoah. They didn't speak against the truth. They said what was not true, but in order to save the children that were to be murdered. And, God rewarded them for their actions. Certainly, if this were such a grave sin, God would not have done so. Same with hiding a Jew from the Nazis, you're speaking what is not true, certainly, but in order to prevent someone from sinning (the nazi) and to protect innocent lives. You are not speaking against the truth in this instance and you are not doing so in order to lead someone into error, but to lead someone away from murder. It comes down to speaking a falsehood in order to lead someone away from sin, and speaking a truth that will lead someone into sin and kill innocent lives.