Indirect Abortion

INDIRECT ABORTION (Taken from "Medical Ethics" by Edwin F. Healy)

IN DIRECT abortion a living and nonviable fetus is removed from the uterus. The reason for the removal is that the pregnancy, added to some pathological condition from which the mother is suffering, increases her difficulties or even lessens her chances of survival. No condition exists, however, which makes the removal of the uterus itself necessary as a means of saving the mother's life.

The abortion is termed indirect when the pregnant uterus itself is excised because its condition is such that its removal is medically necessary. If the uterus contains a living and nonviable fetus, the fetus will of course inevitably die. There is no direct attack upon the fetus, however, and its death is merely permitted as a secondary effect of an act which needs to be performed and which, as we shall see immediately, it is permissible to perform.

It is licit to excise a diseased uterus which is gravely dangerous, even though the operation will indirectly kill the fetus which is enclosed in the womb. The reason is that we may rightly apply the four conditions of the principle of the twofold effect. The first condition is fulfilled, for the operating surgeon's intention is to save the life of the mother. He, of course, foresees the death of the fetus, but he does not desire this evil effect. The second condition is fulfilled, for the surgeon's act consists in ridding the woman of a diseased part of her body which is jeopardizing her life. Hence that which he sets out to accomplish is licit. If the fetus were not present, the surgical operation of removing a diseased and dangerous part of the woman's body, the cancerous uterus, would obviously be an act which of its nature is not evil. The presence of the living fetus in the diseased womb does not alter the nature of the act which the surgeon performs. The operation is directly remedial regarding the mother's body and is in itself unconnected with the pregnancy. The third condition is fulfilled, for the evil effect (the death of the fetus) does not cause the good effect (saving the life of the mother). Whether the fetus were harmed by the operation or not would make no difference in regard to producing the good effect. The fourth condition is fulfilled, for safeguarding the mother's health is a proportionately grave reason for permitting the death of the fetus.

The physician who performs an operation of this kind should have a nurse procure beforehand a basin of lukewarm water in which the fetus may be baptized immediately after the uterus is removed from the mother. When the diseased womb has been extracted from the woman's body, it should be cut open at once and the fetus should be baptized. If the fetus is very small, baptism by immersion would be preferable. If the fetus is enclosed in the sacs or membranes, the latter must of course be removed, so that in the baptism the water will touch the head of the infant.

In all such operations, where the surgery has important bearing on two lives and not merely one, the surgeon must be sure that the reason for operating is a proportionately grave one. If, for example, the fetus is near viability and an immediate hysterectomy would only probably, and not certainly, diminish the danger of death to the mother, the operation would be illicit. In this case the pregnant uterus may not be excised; for since the surgery would bring certain death to the fetus, the latter's certain right to life must take precedence over the mother's right to a doubtful benefit. Again, if excising the uterus would only probably indirectly cause the death of the fetus, surgery would be licit if needed to remove probable danger to the mother's life. If, moreover, the operation would rarely result in death for the fetus, it would be licitly performed when necessary, not to save the mother's life, but to cure her of a grave disease. A remote hope of saving the mother justifies surgery which is necessary to prevent death of both the mother and the child, for the surgeon is doing all in his power to save both. It is taken for granted that there are no other effective means which would not endanger the fetus.

Tubal Ectopic Pregnancy

In the tubal ectopic pregnancy the fertilized ovum lodges in some part of the Fallopian tube. The reason that it does not continue its descent into the uterus may be the pathological condition of the tube itself or of the ovum. Once the fertilized ovum takes up its nesting place in the tube, it begins to bore into the wall of the tube, seeking as it does life-giving nourishment. This "boring-in" action on the part of the tiny embryo perforates the inner layers of the tube and the tube soon becomes weakened by internal hemorrhaging. There is present a pathological condition of the tube, caused by the erosive action of the trophoblast which is destroying the muscle wall and penetrating blood vessels. The growing fetus causes the tube to swell, and this swelling dangerously stretches the tube's outer wall. Left in this condition, the tube will ordinarily rupture; and unless surgery is performed very soon after the rupturing, the mother may die.

When the Fallopian tube is in this condition, would it be licit to slit it open and remove the fetus? Obviously this action would be gravely evil, for it would constitute a direct, unjust attack on the life of an innocent fetus. It would, in short, be murder. In such a procedure the operating surgeon would set out to destroy the fetus as a means of curing the mother, and thus he would directly intend its death. The same conclusion would follow if the physician used drugs, X ray, or any other method directly to terminate the life of the fetus.

Would it, however, be likewise illicit to excise a Fallopian tube which contains a living fetus? If the tube itself is healthy, there would of course be no justifying reason for the excision. But in the case of an ectopic pregnancy the Fallopian tube is in a definitely pathological condition. Its inner portion is riddled, greatly weakened, and full of internal hemorrhaging.

Once the tube has ruptured externally, the physician may and should immediately tie off the arteries which supply blood to the tube and then remove the tube by surgery. This operation is obviously justified, for in it are fully verified the four conditions required for the application of the principle of the twofold effect. The excision of this ruptured and gravely dangerous part of the mother's body is similar, in respect to the moral law, to the removal of a pregnant uterus whose cancerous condition is at present gravely threatening the mother's life.

But let us suppose that the tube in the case of an ectopic pregnancy has not yet ruptured. Must the surgeon, before the excision, wait until an external rupture occurs? The answer is that, if the tube is at present in a gravely dangerous condition and if its excision cannot be delayed without a notable increase of danger to the mother, this Fallopian tube may be removed at once. This conclusion is based on two principles: ( 1) Mutilation is licit if it is required to conserve the health of the whole body. (2 ) An act which has two effects, one good, the other bad, may be licitly performed, given certain conditions. The latter principle is correctly applied to the present case. The first condition is fulfilled, for the surgeon's intention is good. He has as his purpose in operating the saving of the mother's life. He foresees, it is true, that the fetus will die when the tube where it is resting is removed from the woman's body, but he does not desire its death. This is a merely permitted evil effect. The second condition is fulfilled, for the surgeon's action is not intrinsically evil. That which he sets out to accomplish is cutting away a pathological or diseased part of the woman's body. The third condition is fulfilled, for the action's evil effect (the death of the fetus) does not cause the good effect (the preserving of the mother's health). Whether the fetus died or not would hardly affect the mother's health. It is the ridding the body of a seriously corrupted part which directly promotes the mother's well-being. It is not the fetus which at present constitutes the threat to the mother's life; it is the diseased organ. The fourth condition is fulfilled, for there is due proportion between the evil effect and the good effect. The death that will result for the fetus is compensated for by the life that will be saved for the mother.

In the analysis of the application of the fourth condition to our present case, it is well to bear in mind the following facts. Tubal pregnancies practically never go to term. In about ninety-nine cases out of a hundred the fetus is aborted (and usually this will occur before the twelfth week), or the tube ruptures externally; and in either case the fetus will perish. Hence when one considers excising a dangerously weakened but externally unruptured tube in ectopic pregnancy, the choice lies between the following two modes of procedure: ( 1) permitting the tube to remain in the woman's body until it ruptures externally. This will bring death to the fetus and will imperil the life of the mother; or (2) excising the tube at once. This latter operation will bring to the mother safety but to the fetus death. In the first procedure the fetus is, practically speaking, just as certain to die as in the second procedure. As far as the fetus is concerned, the difference between the first procedure and the second procedure is that in the first procedure its life probably would be lengthened by a few weeks. Hence in evaluating the fourth condition the physician must have sufficient cause for permitting the life of the fetus to be shortened because of the excision of the tube.

Is it, then, licit in every case of ectopic pregnancy to excise the diseased Fallopian tube? The answer is that the operation is licit if the tube is at present gravely dangerous to the mother, or if putting off the operation would involve grave danger. The physician is the one who must decide when the tube may be considered to be gravely dangerous. He must judge each individual case on its own merits. The general rule which should be followed is this: If delay in excising the diseased Fallopian tube would gravely jeopardize the mother's life, the physician may operate at once. The ultimate decision in a particular case is in the hands of the physician. It may be that in most cases where an ectopic pregnancy is found, the removal of the tube at once is required to avert existing and grave danger from the mother. But this is not true in all cases. In some few cases at least there is no grave danger to the mother when the ectopic is first discovered. In these few cases the immediate removal of the tube is not licit. The diseased tube may not be excised until it is a source of grave danger to the mother. To excise the tube before this time would indirectly shorten the life of the ectopic fetus without a sufficient reason, and this would be illicit. Hence in all cases in which grave danger is not actually present the physician must adopt the expectant treatment.

There are cases in which the surgeon discovers an ectopic pregnancy during the course of a surgical operation; for example, an appendectomy. May he immediately excise the tube if to wait would necessitate performing another grave operation? In this event, because the expectant treatment would involve so great an added danger to the mother, the surgeon may at once remove the pathological tube. The same solution is to be given when the patient would have to be kept under constant observation in a hospital and she refuses to be hospitalized because she cannot afford the expense.

There are circumstances when the physician will sincerely doubt about the gravity of the danger in a particular ectopic pregnancy. In that event he may and should give the mother the benefit of the doubt. The reason is that an immediate operation will probably have the good effect of saving the mother's life, and will probably have the bad effect of indirectly shortening to some extent the fetus' life. The good effect will thus greatly outweigh the evil effect. Hence the physician preferably will excise the diseased tube at once.

Misconceptions concerning the principles involved can arise because of the fact that the diseased condition of the tube is due to the fetus. Is it not true, one may argue, that the tube's weakened and hemorrhaging condition was brought about by the fetus? Is not the excision of the tube intended to rid the mother of the fetus, the cause of her danger? We reply to this objection by admitting that the fetus did cause the present riddled condition of the tube; but, we add, the tube itself is now seriously diseased and would remain diseased quite independently of the fetus. It is the tube itself, not the fetus, which constitutes the present grave danger to the mother; and so, given certain conditions, it may be excised.

Some who are not acquainted with the facts believe that the Catholic Church has changed her attitude in regard to the licitness of doing surgery on ectopic pregnancies. Up to the present day the Church has made only a few official pronouncements on this question, and these pronouncements refer to the direct attack of the surgeon on the fetus or to the direct removal of a nonviable fetus from the mother's womb. Such procedures even today are condemned by all Catholic moralists. On these questions the Church has not changed her view. Catholic ethicians, however, have changed their view with regard to the licitness of excising the unruptured Fallopian tube in an ectopic pregnancy, but this change of opinion stemmed from new medical findings on this matter. Fifty years ago there was little medical knowledge available with reference to the pathology of an ectopic pregnancy. When medical authorities provided the information that the diseased condition of the Fallopian tube, even before its external rupture, in many cases of ectopic pregnancy constituted a grave and present danger to the mother's life, the moralists declared that the excision of the tube was licit even though the death of the fetus could not be prevented. The moralists made no change in regard to principles or in the application of principles. They merely applied the principles to new facts and arrived at a new conclusion. It is for physicians accurately to present the facts to the moralist. He depends on them for medical information. Given the medical information necessary, he will then apply the ethical principles to the case and pronounce upon the licitness or illicitness of certain procedures.

Ovarian and Abdominal Pregnancies

If an ectopic pregnancy is clinging to an ovary or to the woman's viscera, may the surgeon remove it? The solution to this case is similar to that given in the case of a tubal pregnancy. If the organ to which the fetus is clinging has become so diseased or weakened that it is now a grave source of danger to the woman, the organ may be licitly excised. The organ may have become diseased independently of the fetus or it may have become riddled and weakened because of the "boring-in" action of the fetus. The initial source of the danger does not matter. If at present the condition of the organ is actually pathological and if it is a grave threat to the mother's life, that part of her body may licitly be removed in order to preserve the rest of the body. The same norms about delaying the operation when delay is possible apply in this case as in that of a tubal pregnancy.

It will be noted that, in all the solutions which have been given, the fetus itself is never directly attacked. A pathological organ which is threatening the mother's life is removed, just as it would be removed if it contained no fetus; and the death of the fetus is permitted as a secondary effect of the operation. It is conceivable that there might be a rare case in which the fetus has taken up its lodging next to a vital organ which cannot be removed, such as the liver. If the fetus continues its riddling process, the organ will soon be destroyed and the mother will die. Should such a case ever occur in medical practice, the only thing that could be done to save the mother would be to remove the fetus; and the only argument that could be alleged to justify the removal would be that the fetus, now actually attacking a vital organ of the mother, is an unjust aggressor. The claim that the fetus can ever be, under any circumstances, an unjust aggressor cannot be accepted as correct. The fetus is a living human being. It has been placed by nature where it now resides. It had no voice in the decision. It cannot be called an unjust aggressor, for it is engaged in a purely natural process. Surely we may not call nature unjust. To do so would be to call into question the justice of God, the Author of nature, and this is unthinkable. Hence we must conclude that the fetus may, in no conceivable set of circumstances, be directly killed, for this would be murder. This judgment is confirmed by the words of Pius XI: "What could ever be a sufficient reason for excusing in any way the direct murder of the innocent? . . . Who would call an innocent child an unjust aggressor?"