In our ongoing exploration of the Phoenix abortion and the application of double effect, commenter Marle asks a great clarifying question:
Marle
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.
Gerard M. Nadal
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.
Coming Home 
To play devil’s advocate here — a role I quite frankly relish — it seems to be that the only correct time to remove the tube is immediately at the point of rupture.
Until that moment, the baby is alive and developing, and by some miracle (and miracles do happen), he/she could still detach and implant in the uterus.
To remove the tube with the live, developing baby in it, when there is still a (albeit very tiny) chance of life for the baby seems logically inconsistent to me — particularly since rupture of the tube, while certainly gravely traumatic for the mother, is far from fatal all the time, especially if she is being closely monitored in the hospital.
It seems that the (albeit greater) chance of harm to the mother is being put ahead of the baby’s (albeit tiny) chance at life, when a tube is removed before it shows actual signs of rupture.
This is from a NY Times article:
According to Sara Valdés, the director of the Hospital de Maternidad, women coming to her hospital with ectopic pregnancies cannot be operated on until fetal death or a rupture of the fallopian tube
“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.”
—-> This was exactly the choice that St. Gianna did NOT make — she chose to keep her cancerous uterus in her body (and remove only the fibroma itself, with a much smaller chance of success), because she considered total uterine removal with the healthy baby inside to be tantamount to an abortion.
Therefore, shouldn’t removal of an yet-to-rupture Fallopian tube be considered the same?
Dr Nadal,
Thank you for the links to DDE and I must say it has been interesting reading. To refresh your memory, you sent me these links in reply to a post I made in the discussion under “The Bishop, The Nun, The Mother and Child.”
I must confess find the DDE doctrine interesting, but potentially very dangerous as a basis for making the correct moral decision when (shall we say) the stakes are high.
At one point I found myself reading Summa Theologica on the question of murder. Aquinas writes the following about 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 as explained above (43, 3; I-II, 12, 1). Accordingly the act of self-defense may have two effects, one is the saving of one’s life, the other is the slaying of the aggressor. Therefore this act, since one’s intention is to save one’s own life, is not unlawful, seeing that it is natural to everything to keep itself in “being,” as far as possible. And yet, though proceeding from a good intention, an act may be rendered unlawful, if it be out of proportion to the end. Wherefore if a man, in self-defense, uses more than necessary violence, it will be unlawful: whereas if he repel force with moderation his defense will be lawful, because according to the jurists [Cap. Significasti, De Homicid. volunt. vel casual.], “it is lawful to repel force by force, provided one does not exceed the limits of a blameless defense.” Nor is it necessary for salvation that a man omit the act of moderate self-defense in order to avoid killing the other man, since one is bound to take more care of one’s own life than of another’s. But as it is unlawful to take a man’s life, except for the public authority acting for the common good, as stated above (Article 3), it is not lawful for a man to intend killing a man in self-defense, except for such as have public authority, who while intending to kill a man in self-defense, refer this to the public good, as in the case of a soldier fighting against the foe, and in the minister of the judge struggling with robbers, although even these sin if they be moved by private animosity.”
If to save one’s life, one must take the life of another (here, the child) is this not permitted as an act of self defense?
It seems the Church’s teaching regarding abortion, if employed as a protocol when the mother’s life hangs in the balance, and when no other treatment has proven effective, ultimately reduces to this dogma: no actions are permitted if those actions necessitate the use of direct violence against the child. The Church seems to preclude self-defense as a option for the mother when she is under a violent attack from her unborn child.
I suspect I am still do not completely understand all the ethics involved here. Any counsel you can provide would be welcome.
Hi Gerard, have you seen this article? It was on the Anchoress’ blog. Sorry I don’t have time to write anything about it, but it is about saving pregnant women with pulmonary hypertension, and the doctor in question has a 100% success rate. It may not be applicable to this particular case, but is interesting in that it shows how routinely doctors will make the decision to abort in such cases where it may not be necessary.
http://www.wisn.com/health/17994163/detail.html
Bill: “If to save one’s life, one must take the life of another (here, the child) is this not permitted as an act of self defense?”
The possibility of that view was rejected over a hundred years ago, as a result of various rulings made by the Holy Office. The best place to discover this is from Bouscaren’s highly influential book (published in 1933, with an Imprimatur) “Ethics of Ectopic Operations”, which was later reissued a bit luridly under the title “When Mother or Baby Must Die”, parts of which can be read online here.
Two years ago I found out I was pregnant. I had some spotting however, and my doctor wanted me to have an ultrasound. We couldn’t get one until the following week so I had to wait.
That weekend, my fallopian tube burst (or had a slow leak because I was in pain for one entire night, then the pain subsided the next day and came back with a vengeance almost immediately after putting my toddler to bed in the evening again).
Because I live in a rural area and the one surgeon who could have done the surgery was on vacation, I was airlifted to the nearest big city. I was operated on almost immediately. I was told later that I had no business being alive at that point.
We were devastated at losing our baby and then discovering that I had only had one functioning fallopian tube as it was and that was the one that had burst. ( I also remember our doctor telling me that the baby was still in the amniotic sac and was floating around my abdomen.)
(On an unrelated note, this near-death experience was what brought me to the Catholic Church just 3 months later.)
I had a hysterosalpingogram six months later to see how blocked my remaining tube was but the doctor said it was diseased and trying to repair it would be difficult and would likely result in ectopic pregnancies at best.
I wanted to try and have that tube repaired but I was already 40 at the time and could not bear the thought of conceiving children only to lose them right away and also of possibly losing my life again.
As a new Catholic I have often wondered about this situation. Should I have gone ahead with a procedure to try and repair a diseased fallopian tube with the hope of a miracle?
This entire subject pains me as it hits so close to home. We feel blessed, knowing now what we do, that we were even able to have our daughter.
No L.
It’s not the same. You can’t bring a baby to term in a fallopian tube. You can’t even bring it to viability.
A regular commenter on my blog is incensed over your comments which I have been following as well. You bring up a point that is interesting. Someone who is pro choice and does not have a problem with choosing abortion anyway is not likely to accept your DE logic. What I like with the DE and other Catholic teaching is that they accept two patients of equal worth and try to save both. That may sound harsh to people who discard life over less serious matters. I also feel that doctors who have accepted abortion in their mind suggest it first as a way to ensure success with the mother in treating her disease when it is not necessary. Of course with any hint of birth defects, that is suggested almost as a way of protecting themselves from any legal actions from disappointed parents.
I cannot tell you the number of first hand stories I have heard from people who told me that the dr. insisted on abortion as the only alternative and they refused and the dr. was wrong. They can be wrong. But in a society that has been calloused as we have, abortion is not the last option but for some suggested option. For drs. who are pro choice as the pediatric cardiologist commenting here states she is, have mentally aborted the child and the act is not hard for them to consider. To those who have decided that abortion is a woman’s choice, this conversation and anguish is like speaking a foreign language.
Gerard, my point is that sometimes — really rarely, but sometimes — ectopic pregnanies can detach from the tube and attach in the uterus, if you pray to St. Gianne for intercession for a miracle and your prayers are answered. Heck, it seems a lot like praying for a miracle if you are pregnant with severe pulmonary hypertension!
Miracles do happen. Look at the saints….and look even the mainstream media:
http://www.news.com.au/miracle-baby-may-be-a-world-first/story-e6frfkp9-1111116487470
Removing the tube and killing a healthy, developing baby before the end of its natural lifespan, just because it’s growing in the wrong place — sure sounds like an abortion to me.
L.
If you don’t grasp the carefully, painfully laid out explanation here of the application of DE, then it means that you implicitly reject DE. Conversation over.
Gerard, I just don’t see how removing a cancerous uterus with a baby inside is different from removing a Fallopian tube with a baby inside. It do not implicitly “reject” DE, but I am indeed failing to grasp its application in specific cases.
Okay, it’s your blog — conversation over!
I wish you peace.
L. There is no difference between removing the tube and the cancerous tumor. They are both DE.
“If to save one’s life, one must take the life of another (here, the child) is this not permitted as an act of self defense?”
Except that the child is not “attacking” the body in question.
To compare this with the scenarios you have described is quite ridiculous.
“The Church seems to preclude self-defense as a option for the mother when she is under a violent attack from her unborn child.”
this has to be the most bizarre statement I’ve ever read.
I’m going to assume your ignorance of the pregnant condition on the basis of your sex. Every woman I’ve known who’s been pregnant has never experienced an “attack” by her baby..
Mary Catherine, while I believe it was wholly unintentional on their part, all of my babies did great harm to my body.
So it depends on your definition of “attack” — surely, undeveloped beings can’t fathom intent, but they can indeed do harm to their host bodies.
Gerard, sorry, but…if St. Gianna had chosen to have her cancerous uterus removed, that would have been allowed? I was unable to get a clear answer on that from Google — some sites said she rejected both an abortion (never permitted) and a hysterectomy (which would have been permitted) — but other sites seem to say she regarded the hysterectomy itself as the moral equivalent of an abortion and therefore impermissable. I think that’s why I’m confused.
L, in WHAT way did your babies “attack” your body?
Oh and BTW, the woman is NOT a HOST body.
Please stop espousing the view that the baby is a parasite in a woman’s body.
If this is what you believe, you need more help than Gerard can EVER give you…..
St. Gianna may well have equated the hysterectomy with abortion, though I suspect that as a catholic physician loyal to the magisterium, she understood well the principle of double-effect. In any case, she chose certain death rather than end the life of her child. That was only a part of her life of virtue for which she received the recognition of sainthood.
Saints have been mistaken about points of teaching, but that is not in and of itself necessary and sufficient for impediment to sainthood.
It is the teaching voice of the magisterium that always holds final authority.
“That was only a part of her life of virtue for which she received the recognition of sainthood.”
Sadly, virtue is not one of the admired traits in women any more. Usually virtuous women are punished these days, often by feminists who claim such women are repressed or influenced by patriarchy.
St. Gianna sounds to me like a strong, intelligent woman who made her own choices. She was certainly “influenced by the patriarchy,” but aren’t we all, to some extent? I am a feminist, and I have nothing but admiration for her choice — I only object to the idea that it was the only correct choice someone in her situation should ever be allowed to make.
Mary Catherine, I did not use the word “parasite,” I used to the word “host.” Does a mother not host a child in her womb? But since you brought up the word parasite, I will agree they are different, though there are certainly some similarities.
My embryos/fetuses had no intent to raise my blood pressure, stretch out the skin of my uterus and require surgical intervention for their removal, but I have to say, my particular body was certainly MUCH worse off than if I had never gotten pregnant in the first place.
L,
Nevertheless, your babies did NOT attack you.
A uterus returns to it’s original size quickly, especially if you breastfeed.
And the skin is stretched. Big hairy deal. Your skin will stretch anyway over time with the effects of gravity. I’m very petite and I had 4 children, 2 of whom were large babies. My skin is stretched.
My babies made me anemic. But I lived to tell the tale. I had tear with my first child. And I have nasty varicose veins on my right upper thigh. So what?
Wearing high heels can damage your feet. Did they attack you too?
Grow up and stop your silly whining….
Gentles All,
A parasite is by definition an invasive species. A baby is a member of one’s own species who grows within its mother in the normal course of species reproduction as shaped by evolutionary history. The designation of the baby as parasite is not at all scientifically correct and is employed by those whose agenda is contrary to the natural order.
I agree that human embryos/fetuses are not parasites — a bouncing baby tapeworm will never be a human being. They are only similar in that they take their life from their hosts’ bodies.
Mary Catherine, I am teaching my children to speak nicer to strangers than you are speaking to me, so I should probably just stop talking to you — I will only say that not every woman has a body built for birthing babies.
L, we disagree on such a fundamental thing – a woman’s body is NOT a host body. To state that it is,is to imply that the baby is a parasite.
I am sorry but I view that position as a horrible distortion of femininity AND motherhood.
Because YOUR body did not take well to pregnancy it is not correct to place the blame on the baby. How very sad.
It is likely a combination of genetics, lifestyle and the healthcare you received.
Every woman’s body is different in the same way that every woman has a different labour with each baby she bears.
Women MUST stop blaming babies.
I see the same thing in discussions about unwanted pregnancies.
It’s always the baby that’s the problem when really it’s the sex.
Mary Catherine, you are the one who keeps using the word “parasite,” which I’m afraid you are putting in my mouth. “Host” is a word that doesn’t always imply parasite, unless the hospitable friend whose dinner party I just attended views me as such. (Hey, for all I know, she might.)
I hosted my babies in my body, despite the physical harm caused to me by the reproductive process. This seems to me to be a very objective statement, and yet you seem to take deep offense at it. I believe you and I likely have vastly different views on femininity and motherhood, and what it means to be a woman, and what nature requires of us.
The fact that my body did not take to childbirth is indeed very likely a result of genetics — I’m not sure how my “lifestyle” would make any difference. I have told my own daughter that if she feels compelled to be a mother, I hope she adopts.
And the fact that you think “the sex” is “the problem” really underscores that one woman’s blessing is another woman’s curse.
…..and in case my last sentence was too obtuse, the intimate relations with the man to whom I am joined in matrimony are not the problem. The problem is a narrow pelvic structure that without the benefit of modern medicine, nature would have culled from the gene pool a generation ago.
Having more babies would be a problem for me — my doctor told me to stop at two, and I didn’t listen, but I think it would be unwise to push my luck too far. So yeah, the baby be “the problem,” and problems are worth avoiding.
Fortunately, my view of femininity and motherhood permits me to say uncle.
Ladies,
This is beginning to shape up into a personal war. Maybe it’s because I’m a guy, or a scientist, or both…but my preference is that conversations stay more objective in nature. As the old Irish cops used to say, “Just the facts Ma’am. Just the facts”.
I do understand that the subjective experience of having carried a child is a powerful reality of women, one I can appreciate and describe, being a father of 3, but not even come close to grasping. I’m smart enough to grasp that much. However, I beg that people show understanding for the individual life experiences that color those subjective realities, producing as many different experiences of pregnancy as there are women who’ve had babies.
That said, may I ask that we declare the parasite issue a dead horse that no amount of whipping will make live again?
agreed Gerard.
Babies are babies and mothers are mothers. 😀
Okay, sorry, I was having a hard day — my high heels were attacking me. 🙂
Dr. Nadal,
I have only heard 1 response to the fact that the “baby” can move into the uterus. L. said “Until that moment, the baby is alive and developing, and by some miracle (and miracles do happen), he/she could still detach and implant in the uterus.
Thank you L. I too believe in miracles. Let me tell you a story.
48 years ago in St. Thomas General Hospital, Ontario, Canada my wifes mother found out very early, within the first month, that she had a tubal pregnancy. The doctor gave her a medication that he said would flush the “baby” out of the tube.
She knew there was no other choice. She took the medication and went home. Being a Christian she and her husband prayed that the “baby” would move into the uterus and reattach there.
Well, that’s exactly what the grace of God allowed to happen and my wife is the proof in the pudding. She went a normal term like nothing unusual happened.
I don’t know what the chemical was supposed to abort the baby or if it was supposed to kill the “baby” but, it did neither. It flushed my wife right into the uterus.
My question to you Dr. Nadal is, what was this medication and why haven’t I heard about it in this discussion?
Respectfully, Steve R.
Hi Steve,
What a miracle! Clearly your wife was meant to live much longer than a few days.
It’s hard to know what medication was used. Hopefully, the medical records still exist somewhere. I would be curious to know what medication your mother-in-law received. It’s quite likely that the drug given was aminopterin, whose use as an abortifacient is noted as early as 1952. Today methotrexate is used in its place.
The reason I haven’t mentioned methotrexate in this discussion is because it is merely a chemical means of aborting the baby, and as such qualifies as the direct targeting of the child. It’s use therefore falls outside of the narrow confines of the principle of double-effect.
Thank God the abortion failed in your wife’s case.