An estimated two percent of all
pregnancies are diagnosed as ectopic pregnancies.[1]
“An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb
(uterus). The baby (embryo) cannot survive, and often does not develop at
all in this type of pregnancy.”[2]
Ectopic pregnancies are life-threatening conditions that require proper
treatment to avoid the death of the mother.[3]
While it would be convenient for
this discussion if life began either at the moment of, or at some moment after
the implantation of the embryo in the uterus, this is simply not the truth.
Life begins at the moment of conception.[4]
It seems, then, that a woman desiring to
act ethically cannot have the embryo medically extracted, because this would be
an abortion.
It does not, however, seem proper to
reason that both the mother and her child should die when it is possible to
save the life of the mother. Following St. Thomas Aquinas’s teaching
on killing and what those in the tradition following him call the principle of
double effect or double effect reasoning (DER), it appears that it would be
ethically permissible to medically extract the embryo provided strict criteria
are met. This paper aims to lay out the criteria under which a woman may,
ethically, have an embryo that was not implanted in the uterus medically
extracted, and attempts to lay out an ethical guideline for which procedure
should be performed by the doctor.
The first basis of DER is found in
St.
Thomas’s Summa Theologica II-II, q. 64, a. 7. In this article of the Summa Theologica, St.
Thomas specifically discusses the question of whether it is lawful to kill a
man in self-defense. “Nothing hinders one act from having two effects,
only one of which is intended while the other is beside the intention.
Now moral acts take their species according to what is intended and not
according to what is beside the intention since this is accidental.”[5]
St.
Thomas correctly notes that an act can have more than the one effect and clearly
places a greater emphasis upon the intent than the effects.[6]
Even United States law recognizes St. Thomas in her distinction between first
degree murder and manslaughter. The government punishes those who kill with “malice aforethought”[7] (first degree murder) more heavily than one who kills “without
malice (manslaughter.)”[8]
St. Thomas concludes that “it is lawful to repel force
by force, provided one does not exceed the limits of a blameless defense.”[9]
St.
Thomas claims that it is possible for one to carry out an act that has an evil
effect provided the effect is not intended.
DER, as it has developed out of this
explanation from St. Thomas by his commentators in the tradition, is
understood to have four criteria that an act must meet to justify the action. The
act must be the least harmful method capable of achieving the end, the act must
be considered good independently of the evil effect, the agent must be more
obliged to pursue the good than to avoid evil, and the agent must intend the
good and not intend the evil as a means to the end.[10]
For the termination of an embryo in an ectopic pregnancy to be ethical it must
not be an intrinsically evil act, the mother must intend to do the good and not
the evil, and the mother must have a proportionally grave reason for acting.[11]
For the procedure to be ethical it
must be the least harmful method capable of achieving the end.
This criterion holds that one can never do an intrinsically wrong act.[12]
The Catechism of the Catholic Church defines intrinsically wrong acts as “acts
which, in and of themselves, independently of circumstances and intentions, are
always gravely illicit by reason of their object ... One may not do evil so that good may result
from it.”[13] While
direct abortion, is intrinsically wrong, the medical extraction of the embryo
in the case of ectopic pregnancy does not necessarily constitute a direct abortion,
“the directly intended termination of pregnancy before viability or the
directly intended distruction of a viable fetus”[14],
but rather an indirect abortion, a medical procedure that causes the
termination pregnancy before viability for the direct purpose of curing a
perportionatly serious condition for the mother which cannot be postponed until
the stage of viability without resulting in the death of the mother and the
unborn child.[15] The
case of an ectopic pregnancy would fit the definition of an indirect abortion
and is morally permissible because “operations, treatments, and medications
that have as their direct purpose the cure of a proportionality serious
pathological condition of a pregnany woman are permitted when they cannot be
safely postponed until the unborn child is viable, even if they will result in
the death of the unborn child.”[16]
The second criterion of DER centers
on the issue of intentionality. Intention “signifies to tend toward something.”[17]
The person that moves to the end is the one that has intentionality.
“Intention belongs first and principally to that which moves to the end.”[18]
In the case of ectopic pregnancy, it is the mother who must have the proper
intention because she is the one which moves to the end.
St. Thomas in his reply to the fourth objection of ST, I-II, q. 12, a. 1 goes
further to clarify that intention is “an act of the will in regards to the end.”[19]
The mother must will an act ordered to an ethical end, for example the
extraction of her embryo for her own safety, rather than an action ordered to
an unethical end, for example the extraction of the embryo to bring about the
death of her child.
St. Thomas holds that “a thing derives its species from
that which is essential and not from that which is accidental.”[20]
Since what is beside the intention is accidental it is not the primary concern
in determining the morality of the act unless the act is intrinsically evil. While
it may appear that the death of the child is intended because the mother knows
with great assurance that her child is going to die, this is a misapplication
of intentionality. While the evil may be foreseen, provided this
foresight is not willed as an end it remains apart accidental and not essential.
The second condition holds true as well for our situation
because the medical extraction of an ectopic embryo is a good independent of
the evil effect, the death of the child. The intent of the act is
to save the life of the mother, not destroy the child.
The third criterion, that the agent
must have a proportionally grave reason for acting, is grounded in St.
Thomas thought concerning his underlying basis of morality: do good and avoid
evil.
“If we speak of good and evil in general, it belongs to every virtue to do good
and to avoid evil.”[21]
This third criterion holds that “Whether or not the good
effect is a proportionately serious reason is determined according to the
principle that evil is to be avoided or prevented wherever possible, except at
the cost of an equal or a worse evil.”[22]
In the case of an ectopic pregnancy that is not expelled naturally by the body,
a mother will eventually bleed to death. With proper treatment her
life will not only be spared, but she will have a reasonable chance of
successfully conceiving another child. The medical treatment is a hastening of the
sure death of the child to save the life of the mother. Clearly the death
of the embryo is an evil. The evil however is
proportionate to the death of the mother making the treatment a
proportionate response.[23]
Currently there are four treatment options, three surgical
and one medical, for a mother who needs to have the embryo extracted.
The treatment options are the administration of methotrexate (MTX), the
performance of a salpingectomy procedure, the performance of a salpingotomy
procedure, or the performance of the fimbrial expression technique commonly referred
to as the milking technique. While each of these four approaches has their medical advantages only those
treatments which are ethical should be performed.
While doctors have discovered multiple ways to save the life
of a woman with an ectopic pregnancy they are not all ethical. By
applying the principles of DER it becomes clear which of the current medical options
for a woman whose life is in danger due to an ectopic pregnancy are ethical.
Three out of the current four possible procedures are ethical treatment possibilities.
While all three are acceptable, they are not interchangeable. There
is a hierarchy and a clear choice of which is the best option in each individual
case.
MTX is a drug that is injected into
muscles to treat both cancerous conditions and noncancerous conditions like
ectopic pregnancy by stopping the growth of cells. MTX dissolves the embryo
that is located outside of the uterus.[24]
While MTX is a successful way of saving the life of the mother,[25]
it gives no regard to the respect owed to the life of the child.
MTX, by chemically destroying the gestation, physically mutilates the human
person.
It is always
intrinsically wrong to intentionally deform a human body because it fails to
respect the dignity of that human person. While it may be ethical to
kill a soldier in war it is not ethical to dismember the soldier after his
death.
Similarly it may be ethical to terminate the gestation, but it is not ethical
to dismember it.
Of the three ethical possibilities the fimbrial expression
technique if medically possible should be preferred. In the fimbrial expression
technique the embryo is “milked” or “squeezed” out of the tube.
The milking, or squeezing technique, has the advantage of being open to the possibility
of the embryo being implanted in the uterus and carried to term by the mother.
While rare, it is not impossible for the embryo to be successfully implanted in
the uterus and brought to full term. One is led to believe that with further
advances in micro surgery there is a great possibility of greater success in
bringing these embryos to term.[26]
If the milking technique is not medically possible then the
salpingostomy procedure should be performed. In the salpingostomy
procedure, a small opening is made in the fallopian tube and only the embryo is
removed.[27] While
the embryo will die, hthe mother does not intend the death of the embryo and
while she will foresee the death of her child, with proper intention it will be
seen as a side effect of saving her life.
Salpingectomy removes one or both fallopian tubes and with
them the embryo.[28]
This procedure is ethically acceptable for the same reasons the salpingostomy
procedure is.
The fimbrial expression technique should be preferred if
medically possible over the salpingostomy and salpingectomy procedures because,
while both are not intrinsically evil and proportionate, the current evidence
suggests that the fimbrial expression technique is the better medical option,
allowing for the mother’s continued thriving and possibility of conceiving
again.
In cases where the fimbrial expression technique is not medically
preferable, the salpingectomy procedure should be preferred. “On
balance, current evidence supports salpingectomy as the surgical treatment of choice
unless there is uncontrollable bleeding or the tube is grossly damaged.”[29]
In the cases of uncontrollable bleeding, a tube that is grossly damaged or when
other conditions are present which make salpingostomy a better medical option
it can be performed as an ethical procedure.
What is important in making this classification of a
hierarchy is that the procedure done be medically the best for the mother. While
the destruction of the child is a grave evil, the death of the mother and her
child would also be a grave evil. Applying the principle of double effect, a
solid philosophical principle, one is left with ethical treatments for the
mother.
[1]
Mayo Clinic. Ectopic Pregnancy. December 19th,
2009. http://www.mayoclinic.com/health/ectopic-pregnancy/DS00622/DSECTION=risk-factors
(accessed March 8, 2011).
[2]
Pub Med Health. Ectopic Pregnancy. February 21,
2010. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/ (accessed March 8, 2011).
[3]
Cleveland Clinic. Diseases &
Conditions Ectopic Pregnancy. July 16, 2007. https://my.clevelandclinic.org/disorders/Ectopic_Pregnancy/hic_Ectopic_Pregnancy.aspx (accessed
March 2011, 8).
[4]
For an
explanation on the beginning of life at conception, see Gallagher John. Is the Human Embryo a Person?
(Toronto: Human Life Research Institute Reports, 1985).
[5]
Thomas Aquinas, Summa Theologiae,
II-II, q.
64, a.
7, in Summa Theologica: Complete EnglishEdition in Five Volumes, vol. 4, trans. Fathers of the English Dominican
Province (Notre Dame, IN: Christian Classics, 1981), 1471-1472.
[6]
Cavanaugh
T.A.,
Double-Effect Reasoning Doing Good and
Avoiding Evil (Oxford: Oxford University Press, 2006), 4.
[7]
18
USC CHAPTER 51 – HOMICIDE http://uscode.house.gov/uscode-cgi/fastweb.exe?getdoc+uscview+t17t20+638+49++%28murder%29%20%20%20%20%20%20%20%20%20%20
[8] 18 USC CHAPTER 51 - HOMICIDE
Conference,
2000), 435.
[23]
Long,
Steven A, The Teleological Grammar Of The Moral Act (Naples: Sapientia Press,
2007), 132
[24]
Long,
Steven A, The Teleological Grammar Of The Moral Act (Naples: Sapientia Press,
2007), 132
[25]
Rulin, Marvin M.D. "Clinical
Commentary Is Salpingostomoy the surgical treatment of choice for unruptured
tubal pregnancy?" Journal of Obstetrics & Gynecology, December
1995: 1010.
[26]
Kaczor, Christopher. "Moral Absolutism
and Ectopic Pregnancy." Journal of Medicine and Philosophy, 2001: 61-74.
[27]
Al-Dadawi, Ismail MB, ChB. Al-Aker M.D.. Tulandi, Togas, Murad M.D. MHCM.
"Robot - assisted
Salpingostomoy for Ectopic Pregnacy." J Obstet
Gynaecol Can, 2010: 627.
[28]
Mosby Inc. Mosby's Dictionary of Medicine, Nursing & Health
Professions. St. Louis: Elsevier Inc., 2009,
1653.
[29]
Cheong, Ying M.D.
"Controversies in the managment of ectopic pregnancy." Reproductive
BioMedicine Online, August 2007: 396 - 402.
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