Methotrexate and Tubal Pregnancies: Direct or Indirect Abortion?

For a more detailed analysis of expectant management, see Garcia A.J. , Aubert J.M. , “Expectant Management of Presumed Ectopic Pregnancies,” Fertility & Sterility, 48 (1987): 395.

Albert S. , Moraczewski O.P. , “Ectopic Pregnancy Revisited,” Ethics & Medics 23 (March 1998): 3. See also, F. Gary Cunningham, M.D., et al., Williams Obstetrics, 19th edition (Norwalk, CT: Appleton & Lange, 1993), 705–709.

In 1991. a retrospective review of all patients treated for an ectopic pregnancy was done at San Francisco General Hospital. The purpose was to estimate the potential annual cost savings of MTX therapy for ectopic pregnancy. Direct costs were based on review of the hospital's billing statements, whereas indirect costs were based on literature estimations. Of the 50 ectopic pregnancies treated, it was estimated the 15 (30%) were MTX eligible. The average total direct cost of the surgical cases was $10,509 compared with $1,495 for MTX treatment. It was calculated that the potential annual national cost savings would be in excess of $280 million. For a more detailed analysis, see Creinin M.D. , and Washington A.E. , “Cost of Ectopic Management: Surgery Versus Methotrexate,” Fertility & Sterility 60 (1993): 963–969. See also, A.E. Washington and P. Katz, “Ectopic Pregnancy in the United States: Economic Consequences and Payment Source Trends,” Obstetrics and Gynecology 81 (1993): 287–292; and John F. Tuohey, “The Implications of the Ethical and Religious Directives for Catholic Health Care Services on the Clinical Practice of Resolving Ectopic Pregnancies,” Louvain Studies 20 (1995): 43. In 1998 the average cost for a 200 milligram 10 ml vile of methotrexate was $95.00.

Directive 16 states: “In extrauterine pregnancy the affected part of the mother (e.g., cervix, ovary, or fallopian tube) may be removed, even though fetal death is foreseen, provided that: (a) the affected part is presumed already to be so damaged and dangerously affected as to warrant its removal, and that (b) the operation is not just a separation of the embryo or fetus from its site within the part (which would be a direct abortion from a uterine appendage) and that c) the operation cannot be postponed without notably increasing the danger to the mother.” See Ethical and Religious Directives for Catholic Health Care Facilities, no. 16 (Washington D.C.: United States Catholic Conference. 1971).

National Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services, no. 48 (Washington, D.C.: United States Catholic Conference, 1995): 20. It should be noted that there is a footnote to directive 48, concerning the meaning of direct abortion, referring back to directive 45, “Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted.” Ethical and Religious Directives for Catholic Health Care Facilities, 19.

Tuohey , 42.

Michel E. Rivlin M.D. , “Ectopic Pregnancy,” in Manual of Clinical Problems in Obstetrics and Gynecology, 4th edition, eds. Rivlin Michel E. M.D. & Martin Rick W. M.D. (Boston, MA: Little, Brown and Company, 1994), 10.

See Danny Saxon M.D. , “A Study of Ruptured Tubal Ectopic Pregnancy,” Obstetrics & Gynecology 90 (July, 1997): 46. See also Centers for Disease Control and Prevention, “Ectopic Pregnancy - United States, 1990–1992,” Morbidity and Mortality Weekly Report (MMWR) 44 (1995): 46–48.

Rivlin, 10. Rivlin goes on to explain that there is a threefold increased incidence in women older than 35 years of age versus those younger than 35 and a 60% higher risk in black or Hispanic women than n white women. Morbidity and Mortality Weekly Report (MMWR). There is also a geographical effect in the distribution of ectopic gestation: in the West Indies one pregnancy in 28 is ectopic; abdominal pregnancy is much commoner in African countries than in the Western world and cervical pregnancy is more common in Japan See Betty Sweet R.N. , Mayes’ Midwifery: A Textbook for Midwives, 12th ed. (London: Baillière Tindall, 1997), 520.

Rivlin, 10. Hormonal factors that have been implicated with an increased incidence of ectopic pregnancy include the use of the progesterone mini-pill, postcoital estrogens, and the progesterone-containing intrauterine device. Mayes’ Midwifery: A Textbook for Midwives.

HCG stimulates the corpus luteum in the ovary to continue secreting high levels of estrogen and progesterone in order to maintain the integrity of the pregnancy. For a more detailed analysis, see Berkow Robert , M.D., The Merck Manual of Diagnosis and Therapy, 16th ed. (Rahway, NJ: Merck Research Laboratories, 1992), 1850.

Rivlin , 10–11; see also Berkow, 1868; and Cunningham, et al., 698–705.

Orsy S.J. , “New Options for Diagnosis and Treatment of Ectopic Pregnancy,” Journal of the American Medical Association 267 (1992): 534–537.

Rivlin , 12.

Moraczewski Albert , “Managing Tubal Pregnancies: Part II,” Ethics & Medics 21 (August 1996): 3.

Moraczewski Albert Moraczewski states that, “MTX is most effective against rapidly dividing cells as cancer cells, hair follicles, and fetal cells (especially trophoblastic cells). One study found that rapidly dividing cells such as cancer cells were at least one thousand times more sensitive to MTX than normal cells.” Ethics & Medics. It should be noted that MTX treatment applications in obstetrics and gynecology dates back to 1956 when Li, et al., first reported its use on the treatment of gestational trophoblastic disease. For a more detailed account, see Li M.C. , Hertz R. , and Spencer D.B. , “Effect of Methotrexate Therapy Upon Choriocarcinoma and Chorioadenoma,” Procedures in Social Experimental Biological Medicine 93 (1956): 361.

Stovall Thomas G. , “Medical Management of Ectopic Pregnancy,” Current Opinion in Obstetrics & Gynecology 6 (1994): 513. Stovall explains that as a result of increased abdominal-pelvic pain, “it is often difficult to distinguish this normal increase in pain from pain that is associated with ectopic pregnancy rupture…The cause of this pain is unclear. Methotrexate is known to induce abdominal pain and it is also possible that the patient may have some bleeding from the end of the tube which causes peritonitis.” Procedures in Social Experimental Biological Medicine.

Moraczewski , “Ectopic Pregnancy Revisited,” 4. See also Lisa Cannon and Hanna Jesionowska, M.D., “Methotrexate Treatment of Tubal Pregnancy,” Fertility & Sterility 55 (June 1991): 1033–1037.

Stovall , 514.

Moraczewski argues that “the critical point in this analysis is the moral object. To remove any ambiguity here, the term moral object means: ‘the proximate end of a deliberate decision which determines the act of willing on the part of the acting person’ (John Paul II. Veritatis Splendor. 78). The moral object is the precise. proximate objective, seen as a good (real or apparent), which is freely chosen in this particular act by the person. It must be carefully distinguished from the intention (with which it is often confused). The intention is the reason why the person wants to intervene with MTX: the moral object is the immediate goal to be achieved by the use of MTX and chosen by the person as contained in the intention.” Moraczewski, “Managing Tubal Pregnancies: Part II.” 4. Emphasis in the original.

Moraczewski argues that “the critical point in this analysis is the moral object. To remove any ambiguity here, the term moral object means: ‘the proximate end of a deliberate decision which determines the act of willing on the part of the acting person’, 3–4.

Joseph Mangan S.J. , “An Historical Analysis of the Principle of Double Effect,” Theological Studies 10 (March 1949): 41.

For further analysis on the historical development of the principle of double effect, see Christopher Kaczor. “Double-Effect Reasoning from Jean Pierre Gury to Peter Knauer,” Theological Studies 59 (1998): 297–316; Thomas Cavanaugh, “Aquinas’ Account of Double Effect,” Thomist 61 (1997): 107–121; James Keenan, “The Function of the Principle of Double Effect,” Theological Studies 54 (1993): 294–315; and Boyle Joseph “Double Effect and a Certain Kind of Embryotomy,” Irish Theological Quarterly 44 (1977): 303–318.

Gerald Kelly S.J. , Medico-Moral Problems (St. Louis, MO: The Catholic Hospital Association of the United States and Canada, 1958), 13–14.

Moraczewski , “Managing Tubal Pregnancies: Part II,” 4.

William E. May “Methotrexate and Ectopic Pregnancy,” Ethics & Medics 23 (March 1998): 1. Emphasis in the original.

William E. May “Methotrexate and Ectopic Pregnancy,” Ethics & Medics 23 (March 1998): 2. Emphasis in the original.

May quotes Hilgers Thomas Drs. , and Bruchalski John to reinforce his position. May states: “Hilgers and Bruchalski inform me that the alleged medical benefits to the mother of using MTX or of a salpingostomy can be seriously questioned, and both judge MTX and salpingostomy to be direct attacks on the life of the unborn. not mere ‘removals.’” Emphasis in the original.

May quotes Hilgers Thomas Drs. , and Bruchalski John to reinforce his position. May states: “Hilgers and Bruchalski inform me that the alleged medical benefits to the mother of using MTX or of a salpingostomy can be seriously questioned, and both judge MTX and salpingostomy to be direct attacks on the life of the unborn. not mere ‘removals.’” Emphasis in the original.

“A ‘slippery slope’ or ‘edge’ argument raises questions about precedents that will be set and the consequences that may follow if a particular practice is accepted.” For a more detailed analysis, see Carol Levine, Cases in Bioethics: Selections from the Hastings Center Report (New York: St. Martin's Press, Inc., 1989), 290.

“A ‘slippery slope’ or ‘edge’ argument raises questions about precedents that will be set and the consequences that may follow if a particular practice is accepted.” For a more detailed analysis, see Carol Levine, Cases in Bioethics: Selections from the Hastings Center Report (New York: St. Martin's Press, Inc., 1989), 3.

“A ‘slippery slope’ or ‘edge’ argument raises questions about precedents that will be set and the consequences that may follow if a particular practice is accepted.” For a more detailed analysis, see Carol Levine, Cases in Bioethics: Selections from the Hastings Center Report (New York: St. Martin's Press, Inc., 1989), 3.

Boyle. 315–316.

Tuohey , 55.

James J. Walter “Proportionate Reason and its Three Levels of Inquiry: Structuring the Ongoing Debate,” Louvain Studies 10 (Spring 1984): 32.

McCormick's criteria for proportionate reason first appeared in Richard McCormick, Ambiguity in Moral Choice (Milwaukee, WI: Marquette University Press, 1973). He later reworked the criteria in response to criticism. His revised criteria can be found in, Doing Evil to Achieve Good, eds. McCormick Richard , & Ramsey Paul (Chicago, IL: Loyola University Press, 1978).

See Janssens Louis , “Norms and Priorities in a Love Ethics,” Louvain Studies (Spring 1977): 213–214. See also Gula, 273.

Thomas J. , O'Donnell S.J. , Morals in Medicine (Westminister, MD: The Newman Press, 1960). 25. For a more detailed analysis of probabilism, see Albert R. Jonsen & Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning (Berkeley, CA: University of California Press, 1988), 164–175, 250–265; and Henry Davis, S.J., Moral and Pastoral Theology, Vol. 1 (New York: Sheed & Ward, 1958), 91–115.

Davis , 95.

Tuohey , 55.

For a more detailed analysis of their ethical positions concerning the moral distinction between the direct killing of an unborn child and the morally justifying reasons for tolerating the evil effect of the foreseen but unintended death of the embryo, see Grisez Germain , Abortion: The Myths, the Realities, and the Arguments (New York: Corpus Books, 1970), 340–341; Boyle, “Double-effect and a Certain Type of Embryotomy,” 303–318 and Patrick Lee, Abortion and Unborn Human Life (Washington. DC: The Catholic University Press of America, 1996). 110–120.

See May William E. , “The Management of Ectopic Pregnancies: A Moral Analysis,” in The Fetal Tissue Issue, eds. Peter J. Cataldo , and Albert S. , Moraczewski O.P. (Braintree. MA: The Pope John XXIII Medical-Moral Center. 1994), 121–148; May, “Methotrexate and Ectopic Pregnancy,” 1–3 and Kevin Flannery, S.J., “What is Included in a Means to an End?”, Gregorianum 74 (1993).