I add this explanation of the principle essential to guiding our discussion of the Phoenix abortion.
(Source: Wm. David Solomon, “Double Effect,” The Encyclopedia of Ethics)
Lawrence C. Becker, editor
This principle aims to provide specific guidelines for determining when it is morally permissible to perform an action in pursuit of a good end in full knowledge that the action will also bring about bad results. The principle has its historical roots in the medieval natural law tradition, especially in the thought of Thomas Aquinas (1225?-1274), and has been refined both in its general formulation and in its application by generations of Catholic moral theologians. Although there has been significant disagreement about the precise formulation of this principle, it generally states that, in cases where a contemplated action has both good effects and bad effects, the action is permissible only if it is not wrong in itself and if it does not require that one directly intend the evil result. It has many obvious applications to morally complex cases in which one cannot achieve a particular desired good result without also bringing about some clear evil. The principle of double effect, once largely confined to discussions by Catholic moral theologians, in recent years has figured prominently in the discussion of both ethical theory and applied ethics by a broad range of contemporary philosophers.
Formulation of the Principle. Classical formulations of the principle of double effect require that four conditions be met if the action in question is to be morally permissible: first, that the action contemplated be in itself either morally good or morally indifferent; second, that the bad result not be directly intended; third, that the good result not be a direct causal result of the bad result; and fourth, that the good result be “proportionate to” the bad result. Supporters of the principle argue that, in situations of “double effect” where all these conditions are met, the action under consideration is morally permissible despite the bad result.
Each of these conditions has, however, been a matter of considerable controversy. The first condition requires some criterion independent of an evaluation of consequences for determining the moral character of the proposed action. Moral philosophers who believe that the moral character of an action is exhaustively determined by the nature of its consequences will, of course, object to this requirement.
The second condition assumes that a sharp distinction can be drawn between directly intending a result and merely foreseeing it. This requirement has been the subject of much debate. Some philosophers argue that if an agent recognizes that a certain consequence will inevitably follow from a contemplated action, then in performing the action the agent must be intending the consequence. Others argue, less strongly, that defenders of double effect have failed to delineate a practicable criterion for marking off the intended from the merely foreseen. Defenders of the principle typically respond by pointing to the implicit recognition of the moral significance of this distinction in the moral practices of ordinary persons.
The third condition writes into the principle of double effect the so-called Pauline principle, “One should never do evil so that good may come.” Again, philosophers who reject the view that actions can have a moral character independent of their consequences will find this condition unacceptable.
The fourth condition, by bringing in the notion of proportionality, has seemed to many philosophers to undercut the absolutism presupposed by the first condition. Although the first three conditions have a decidedly anticonsequentialist character, the fourth may appear to embrace consequentialist reasoning. Defenders of the principle typically attempt to accommodate the consequentialist character of the fourth condition while ensuring that it does not render the more complex features of the principle irrelevant.
Applications. The principle of double effect has played a significant role in the discussion of many difficult normative questions. Its most prominent applications are in medical ethics, where it figures prominently in attempts to distinguish among permissible and impermissible procedures in a range of obstetrical cases. The Catholic magisterium has argued that the principle allows one to distinguish morally among cases where a pregnancy may need to be ended in order to preserve the life of the mother. The principle is alleged to allow the removal of a life-threatening cancerous uterus, even though this procedure will bring the death of a fetus, on the grounds that in this case the death of the fetus is not “directly” intended. The principle disallows cases, however, in which a craniotomy (the crushing of the fetus’s skull) is required to preserve a pregnant woman’s life, on the grounds that here a genuine evil, the death of the fetus, is “directly” intended. There there is significant disagreement, even among those philosophers who accept the principle, about the cogency of this application. Some philosophers and theologians, by emphasizing the fourth, “proportionality,” condition, argue that the greater value attaching to the pregnant woman’s life makes even craniotomy morally acceptable. Others fail to see a morally significant difference between the merely “foreseen” death of the fetus in the cancerous uterus case and the “directly” intended death in the craniotomy case.
(Source: Wm. David Solomon, “Double Effect,” The Encyclopedia of Ethics)
Lawrence C. Becker, editor
I have a question on double effect. I’m pro-choice, but I’ll try to be nice. The most common example I’ve heard of double effect is when there’s an ectopic pregnancy in the fallopian tube it is ok, in Catholic doctrine as far as I understand, to remove the whole fallopian tube. This doesn’t make a lot of sense to me. In a ectopic pregnancy, the fallopian tube isn’t the problem, it’s the location of the embryo. And when a medicinal abortion is performed, the fallopian tube is fine and the woman maintains her fertility. So isn’t treating a ectopic pregnancy by removing the fallopian tube a negative – removing a perfectly healthy and useful part of a woman’s body – with the side effect of abortion?
Marle,
Thanks for the civility. In answer to your question, the fallopian tube is destroyed in a tubal pregnancy. Google “Tubal Pregnancy” and click on images. I warn you that some of the pictures are pretty rough to look at if one doesn’t have the stomach for pathology pictures.
In double effect, a thoroughly diseased or destroyed organ (which incidentally contains an embryo or fetus) is removed as it is the proximal cause of an immediately impending death of the mother. The target and intent are critical here. In the Phoenix case, the disease was in the mother’s lungs, but the target was the baby. Had a lung transplant been performed and the baby died, that would be double-effect, as every legitimate effort was being made to save the life of the mother and the child, with the unintended consequence being the death of the baby.
It is simply (and I use simply in all of its connotation of uncomplicated) impermissible to target a baby and tear it apart-for any reason whatsoever. The baby is a separate and distinct human being. It has equal moral value as its mother.
That is the foundational principle of morality and ethics that is immutable when a Catholic bioethics committee meets. The actions in Phoenix were a deliberate dismissal of that immutable principle, and it cost Sr. McBride dearly for signing off on the tearing apart of a baby.
The goal in Catholic health care is to treat both patients aggressively in order to save both lives. But, when matters turn sour, it is never permissible for the physician to turn executioner as a means of salvaging a life. Not anywhere in our view. Most especially not in one of our hospitals.
That’s who we are. That’s what we believe. That’s how we live our lives and professional mission in the world. No exceptions. No compromise.
Ridicule us if you like, but please not here in my living room.
God Bless.
The fallopian tube is not always destroyed in a tubal pregnancy. If a tubal pregnancy is caught early enough, it can be treated with methotrexate instead of surgery, which causes an abortion and can allow the fallopian tube to heal. Also, methotrexate can also be used in non-tubal ectopic pregnancies, where the embryo has attached itself to an organ that might not be as easily removed as a fallopian tube. It seems like putting a woman through surgery and removing 50% of her fertility when there’s a non-surgical option that won’t impact her fertility is just cruel.
I’m not sure about your background, but I’m kinda surprised that a doctor wouldn’t know that there are non-surgical treatments for ectopic pregnancy. Abortion pills have been available for years, and I’m sure with this blog you must have looked into the facts about them.
Marle,
Methotrexate is a chemical means of targeting the baby in order to preserve the organ. This is very different from the need to remove the organ. As such, it falls outside of double effect.
Also, as some have noted, on rare occasion the embryo dislodges and completes its journey to the uterus.
As for my background, I am now well on into my third decade in science and ethics. We do not accept the direct killing of the baby by chemical or mechanical means as a legitimate means of managing maternal care, because we view the baby as the moral equal to its mother. The direct and intentional killing of one human being in the attempt to treat another human being isn’t patient management. It’s murder.
It’s not very different, it’s two different treatments for the same condition. You’re saying that when a woman has an ectopic pregnancy that can be treated with methotrexate, that instead the should wait until the condition gets much worse, destroys the fallopian tube and requires surgery, because there’s a rare chance that maybe the embryo will spontaneously move to the uterus. You’re talking like your pretending there isn’t an easier way of treating a tubal pregnancy than removing the entire fallopian tube, but there is. Why bother pretending if you feel strongly that you are right? Why did you say that tubal pregnancy destroys the fallopian tube when you know that’s not always the case? Why didn’t you explain in your initial explanation of double effect why medical treatment of tubal pregnancy isn’t allowed, but surgical is?
If I was a doctor dedicated to saving embryos and fetuses, I would find willing women with ectopic pregnancies who want me to attempt to move the embryo to their uterus. (Being pro-choice means supporting all choices, including being pregnant, and science could really help women who have repeated ectopic pregnancies and really would like to be pregnant). The first few would probably not take, but it’s something that should be possible, and if we study it enough we might make it a reality, and be able to help women with ectopic pregnancies who’d really like to carry to term. Potentially, we could learn to take a fetus like the one that the woman was carrying in Arizona and either freeze it (maybe that can only be done w/ embryos…) until she’s healthy again or allow another woman to “adopt” the fetus into her uterus. Trying to do something like that, even if it fails, seems much more to me like trying to save both of them rather than removing a whole fallopian tube or uterus when a medicinal abortion would have working, or watching both die. I think the Catholic church, and Catholic hospitals, should try looking at experimental ways to save both by moving an embryo/fetus when a woman’s body can’t handle carrying a fetus to viability. It wouldn’t work out at first, but then neither did the first cesareans or much of anything else, but if it does eventually work, it would do a lot of good.
Marle,
“It’s not very different, it’s two different treatments for the same condition.”
Actually, it IS very different. We do not regard the direct killing of a baby, by chemical or mechanical means a “treatment”. Period.
This thread is about the principle of double effect, and we’re staying on point. The removal of the tube as a life-saving intervention for the mother falls under the rubric as detailed above. You have now shifted the scenario from imminent danger of death to a desire to maintain the integrity of the tube for future use.
The baby is to be afforded every chance at life. It is not clear that in the Phoenix scenario this was done. It is certainly clear that such is not the case with your scenario here.
Pro-choice predicates do not apply in this discussion, or any other on this blog, as they begin with the assumption that it is morally licit to directly target a baby for death.
You can’t argue Catholic bioethics from a pro-choice perspective.
I “shifted the scenario from imminent danger of death” because you don’t have to let an ectopic pregnancy get as far as to cause as imminent danger of death. Your argument explaining what’s ok to do when there imminent danger of death is disingenuous if you pretend that there is no other option but to let it get that far. I get that you don’t want it to be an option, but it is so you have to address it.
Not that you’re the first person to try to explain double effect while ignoring that removing the whole fallopian tube is not the inevitable outcome of an ectopic pregnancy. I’ve seen many articles on the internet and wondered about the omission, but this was just the most convenient place to ask.
As for my theory, maybe I wasn’t explaining it completely. Basically, what I’m saying is that if a woman has an ectopic pregnancy and would like to stay pregnant (maybe she’s Catholic and so she’d choose surgery anyways) wouldn’t it make sense to for the doctors to try and see if they could implant the embryo in her uterus? Granted, it probably wouldn’t work, but there’s a higher chance of that working and the embryo surviving than just removing the whole tube. And, if doctors did that enough times they might just figure out how to make it work. I think that would be a really good thing.
The holes that you see in regard to the treatment of tubal pregnancy are really the recognition that methotrexate does not fall within the guidelines that establish double-effect.
I agree that it would be a really good thing to try and rescue the embryo. In attempting the heroic in order to save life, the clear-cut intention is not to end the embryo’s life.
I’ve followed the discussion concerning the conditions for the application of double effect. As a systematic theologian there is a tremendous theological, philosophical, epistemological and moral issue being advocated by both Dr. Nadal and Marle. However, their are not two ends to the human person. Nor are there two mutually exclusive orders of reality (even though secular humanists desire to enforce the false premise that there is.) The order of redemption and the order of creation are not mutually exclusive. This is foundational for Catholic moral, theological and philosophical principals. It simply never occurs to secular humanists that they apply an informed logic as nominalists to preserve radical autonomy. When that is not in their favor they become proportionalists.
Both are disingenuious and untenable.
Their are clear distinct conditions for the application of double effect, Dr. Nadal has elaborated sufficiently. The true ‘rub’ here is cultural, especially as it plays out under the guise of a morally undifferentiated pluralism.
Sincerely,
William J. Holland wjholland.wordpress.com Reason & Faith Collide
I thought that an ectopic pregnancy could not continue – either the tube ruptures or the baby simply dies.
This is why they are removed. It’s not something sustainable.
At any rate, anyone I’ve ever known who has had an ectopic pregnancy doesn’t know until they are in considerable pain and then the operation is done to remove the embryo from the tube and try to salvage the tube or simply remove the tube.
The debate with Dr. Becker is being continued on this thread.
[...] More Debate With Dr. Becker on the Phoenix Abortion, How Catholic Bioethics is Guided, and The Principle of Double Effect. I’ve devoted a lot of space here to Gerard Nadal’s views, but several people in this [...]
Dr Nadal, I understand I will never get you to agree with abortion and I’m not trying to convince you otherwise. What I don’t understand about double effect is why abortion is ok if you take the fallopian tube. The fallopian tube isn’t killing a woman in that situation; as evidenced by the fact that in many cases the fallopian tube doesn’t have to be removed. What’s killing the woman in a tubal pregnancy is a fetus growing where it can’t, and it has to be removed. It seems to me that double effect makes it so that abortion is ok as long as the woman is permanently hurt in the process.
Marle,
I don’t think that either of us is convert hunting here. One of the purposes for which this blog is offered is to have a quiet little corner for people to duck in from the maelstrom and explore some of the science, ethics and theology that undergird the pro-life movement. I prefer a quiet and civil, academic tone to the screaming out of the windows at passers-by found elsewhere, and thank you for such a reserved tone.
Let’s walk this through slowly and deliberately to best answer your question.
First and foremost, the difficulty in discussing double-effect (DE from here) is magnified if one of the parties sees no problem with abortion in general. DE seems a sleight of hand at abortion to most pro-choice folks with whom I have spoken.
However, to understand DE, we must assume a starting position that states a categorical prohibition of the direct targeting of the baby (more properly embryo or fetus) for death. In a word: Abortion.
There is a huge difference between an abortion and removal of a fallopian tube containing an embryo, or a hysterectomy of a severely cancerous uterus containing an embryo or fetus. That difference is what DE establishes. To recapitulate the four conditions which establish DE:
First: The action contemplated must be in itself either morally good or morally indifferent.
Second: The bad result must not be directly intended.
Third: The good result must flow from the action as immediately as the bad effect.
Fourth: The good result must be “proportionate to” the bad result.
It must be stressed that all four of these conditions MUST be met for DE to have been established.
Let’s start with an advanced tubal pregnancy first. The embryo has gotten stuck (usually behind a blockage in the tube such as scar tissue from PID). The embryo continues to develop to the point of swelling the tube and eventually bursting it with catastrophic hemorrhaging by the mother. It can be, and is for too many, immediately fatal.
The removal of the tube satisfies the above 4 conditions as follows:
1. The action being contemplated here is not the killing of the baby, but the removal of a tube that is a clear and present danger to the mother’s life. The removal of the dangerously damaged tube is itself a moral good.
2. There is a bad effect in the removal of the tube. There is a baby inside that is going to die when we remove the tube. Current medical science has no way of extracting the baby and implanting it in the uterus. Nevertheless, a bad result will ensue. A baby will die. This result, however, is not directly intended. Intent matters greatly.
3. The good result is that the mother’s life has been saved. The bad result is that the baby died. The benefit to the mother is as immediate as the bad effect because the dangerously damaged tube has been removed.
4. The good result is proportionate to the bad result in that we saved the life of the mother, though unintentionally the baby died
So we see that the removal of an advanced tubal pregnancy satisfies all four conditions for DE.
In the case of an early tubal pregnancy treated with methotrexate, none of the conditions of DE applies.
1. The contemplated action itself is morally bad: the chemical abortion of the embryo.
2. The bad result (death of the baby) is directly intended.
3. The good result does not flow immediately from the action along with the bad effect. (There is no guarantee that the tube will be useful in the future, especially if scarred from PID).
4. The good result (saving a fallopian tube) is disproportionate to the loss of baby’s life (even if the loss were a certainty in advanced tubal pregnancy).
In short, as methotrexate targets the baby directly, it is nothing more than a chemical abortion. There have been reports of early tubal pregnancies where the embryo has dislodged itself. The child deserves the chance, as well as the medical community exploring ways to safely secure that result through medical intervention.
Thus we see through the conditions for establishing DE that certain life-saving procedures may be performed if the direct action is morally good, the bad action is not directly willed or intended, the good action flows as immediately as the bad action, and the good result is proportionate to the bad result.
There have been reports of early tubal pregnancies where the embryo has dislodged itself. The child deserves the chance, as well as the medical community exploring ways to safely secure that result through medical intervention.
Yes, wouldn’t it be better since there are now two patients involved for medical intervention to be that there be an attempt to implant the embryo in the uterus? Is that possible?
Rather than simply deciding off the bat, that we should simply destroy the embryo?
[...] The moral guide for hospitals and healthcare institutions is spelled out in Ethical and Religious Directives of the United States Conference of Catholic Bishops (ERD’s). Directives #45 and #47 both spell out the rules for dealing with a case such as this, and Bishop Olmsted, a Doctor of Canon Law, has made it clear that this case did not fall within the parameters of these directives and what is known as the Principle of Double Effect. [...]
[...] The moral guide for hospitals and healthcare institutions is spelled out in Ethical and Religious Directives of the United States Conference of Catholic Bishops (ERD’s). Directives #45 and #47 both spell out the rules for dealing with a case such as this, and Bishop Olmsted, a Doctor of Canon Law, has made it clear that this case did not fall within the parameters of these directives and what is known as the Principle of Double Effect. [...]
Dear Dr,
I live in Malta in the Mediterranean, our parliament is discussing the possibility of legalising IVF that has been practiced here for over 20 years unregulated.
Part of the proposal is to allow the freezing of fertilised embryos as part of the normal practice of ivf. To date, IVF cinics here do not currently freeze as part of the treatment. They claim to fertilize three to four embryos and then implant them all. This has resulted in pressure on the neonatal unit as they sometimes have to deal with triplets, often with anomalies and conditions related to pre-term births.
Conseqeuntly, a special committee of doctors, set up by the government to make recommendations is suggesting the limiting the implantation of two embryos and to allow for freezing to make the process safer and ‘less traumatic’ for the would be mother.
We (I represent the Island’s pro-life movement, Gift of Life) are against freezing. What arguments would you use, as a doctor, against freezing, which other doctors would listen to?
Please help us with you advise as we are in quite a tangle. Abortion here is illegal under all circumstances. We would appreciate your input.