Methotrexate,Character,and Casuistry: A Lesson from Machiavelli

Peter A. , Clark S.J. , “Methotrexate and Tubal Pregnancies: Direct or Indirect Abortion?” Linacre Quarterly 67: 1 (February 2000): 7–24; John Foran, “Ectopic Pregnancy: Current Treatment Options, deja vu Humanae Vitae,” Linacre Quarterly 66: 1 (January 1999): 21-28; William E. May, “Methotrexate and Ectopic Pregnancy,” Ethics & Medics 23: 3 (March 1998): 1-3; William E. May, “The Management of Ectopic Pregnancies: A Moral Analysis,” The Fetal Tissue Issue: Medical and Ethical Aspects, ed. Peter J. Cataldo and Albert S. Moraczewski, O.P., (Braintree, Mass.: Pope John Center, 1994), 121-47; Albert S. Moraczewski, O.P., “Ectopic Pregnancy Revisited,” Ethics & Medics 23: 3 (March 1998): 3-4; Albert S. Moraczewski, O.P., “Tubal Pregnancies: Part I,” Ethics & Medics 21: 6 (June 1996): 3-4; Albert S. Moraczewski, O.P., “Tubal Pregnancies: Part II,” Ethics & Medics 21: 8 (August 1996): 3-4; Jack Healy, “Ectopic Pregnancy and Methotrexate,” Linacre Quarterly 63: 3 (August 1996): 95-96; 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

For descriptions and variations of these procedures see: Togas Tulandi, “New Protocols for Ectopic Pregnancy,” Contemporary OB/GYN 44: 10 (1999): 42-55; Lau Susie , and Tulandi Togas , “Conservative Medical and Surgical Management of Interstitial Ectopic Pregnancy,” Fertility and Sterility 72: 2 (August 1999): 207–215; a collection of articles under the general title “Modern Diagnosis and Management of Ectopic Pregnancy,” ed. Sandra Ann Carson, Clinical Obstetrics and Gynecology 42: 1 (March 1999): 1-56; LaRynda D. Thoen and Mitchell D. Creinin, “Medical Treatment of Ectopic Pregnancy with Methotrexate,” Fertility and Sterility 68: 4 (October 1997): 727-30; Mylene Yao and Togas Tulandi, “Current Status of Surgical and Nonsurgical Management of Ectopic Pregnancy,” Fertility and Sterility 67 (March 1997): 421-33; Charlotte Floridon, et al., “Ectopic Pregnancy: Histopathology and Assessment of Cell Proliferation with and without Methotrexate Treatment,” Fertility and Sterility 65: 4 (April 1996): 730-738; Sandra A. Carson and John E. Buster, “Ectopic Pregnancy,” The New England Journal of Medicine 329: 16(14 Oct. 1993): 1174-81.

Peter A. , Clark S.J. Ph.D. , “Methotrexate and Tubal Pregnancies: Direct or Indirect Abortion?” Linacre Quarterly 67: 1 (February 2000): 7-24

Peter A. , Clark S.J. Ph.D. , “Methotrexate and Tubal Pregnancies: Direct or Indirect Abortion?” Linacre Quarterly, 10.

Rebeccca Rogers Prevost, Stovall Thomas G. , and Ling Frank W. , “Methotrexate for Treatment of Unruptured Ectopic Pregnancy,” Clinical Pharmacy 11 (June 1992): p. 529.

It almost surely must be directly destructive of the embryo proper when it is injected directly into the gestational sac (a method mentioned occasionally in the medical literature), as distinct from being administered systemically, intramuscularly, or by direct injection into the affected fallopian tube. See Sandra Carson A. , and Buster John E. , “Ectopic Pregnancy,” The New England Journal of Medicine 329: 16 (14 Oct. 1993): 1174-81.

See, for instance, Albert S. , Moraczewski O.P. , “Managing Tubal Pregnancies: Part II,” Ethics & Medics 21: 8 (August 1996): 3-4 and “Ectopic Pregnancy Revisited,” Ethics & Medics 23: 3 (March 1998) 3-4.

Albert S. , Moraczewski O.P. , “Managing Tubal Pregnancies: Part I,” Ethics & Medics 21: 6 (June 1996): 3-4.

See May William E. , “Methotrexate and Ectopic Pregnancy,” Ethics & Medics, 23: 3 (March 1998): 1–3.

National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (Washington, D.C.: United States Catholic Conference, 1971), directive 16.

National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (Washington, D.C.: United States Catholic Conference, 1994), directive 48.

See Tuohey John F. , “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) 42.

It seems that the only new element in Clark's analysis is his interpretation of the proportionate reason clause of the principle of double effect according to Richard McCormick's criteria for determining “whether the value of preserving the health and life of the mother outweighs the premoral evil of the foreseen but unintended death of the nonviable human embryo” (Clark, p. 16).

It seems that the only new element in Clark's analysis is his interpretation of the proportionate reason clause of the principle of double effect according to Richard McCormick's criteria for determining “whether the value of preserving the health and life of the mother outweighs the premoral evil of the foreseen but unintended death of the nonviable human embryo”, p. 18.

See the letter to the editor by Pochailos Karen D. in Linacre Quarterly 67: 1 (February 2000): 4–6; and three separate letters from Fr. Anthony Zimmerman, Eugene F. Diamond, and John E. Foran in Linacre Quarterly 67: 3 (August 2000): 4-7.

Bernard Häring C.SS.R. , The Law of Christ, vol. 1, tr. Edwin G. Kaiser, C.PP.S., (Westminster, Md.: The Newman Press, 1961), 183. One finds similar restrictions on probabilism in other casuists. See Henry Davis, S.J., Moral and Pastoral Theology, 3rd ed., vol. 1 (New York: Sheed and Ward, 1938), esp. 96100; John A. McHugh, O.P., and Charles J. Callan, O.P., Moral Theology, vol. 1 (New York: Joseph F. Wagner, Inc., 1929), esp. 237-40 and 252. Additionally, see the letter of Fr. Anthony Zimmerman in Linacre Quarterly 67: 3 (August 2000): 4.

Machiavelli , Mandragola trans. Mera J. Flaumenhaft (Prospect Heights, III.: Waveland Press, 1981), Act III, scene 5.

Timoteo Fr . himself announces that he realizes this in Act III, scene 9

Act HI, scene 10.

Act III, scene 11.

This euphemistic formulation is not meant to deny the nearly absolute certainty of the death of the embryo in cases of tubal pregnancy. The point, rather, is to emphasize that death is a certainty for all of us, so that for each of us the outcome is already assured and it is always only a matter of time. It should perhaps be emphasized that in the course of this analysis of the use of methotrexate we assume that the case includes a living human embryo. Without this assumption, the case loses its moral significance. Diagnosing embryonic death removes the moral problem.

One might offer the argument that embryonic death is indirect either because the trophoblast is understood not to be a part of the embryo or because methotrexate is understood to constitute a therapeutic treatment addressed to a pathological site of implantation (assuming, again, something uncertain, viz., that this interpretation is consistent with Catholic faith).

It is appropriate at this stage to point out that this is a matter pertaining not only to the woman, but also or especially to the moral character of the physician and those who cooperate in whatever decision is taken and to the moral character of those who advise one course of action or another (albeit, not subjectively, but objectively).

“Technologic advances now allow routine diagnosis of ectopic pregnancy before clinical symptoms. Although early diagnosis may contribute to a higher incidence, it also has contributed to a concomitant decline in morbidity, deaths, and treatment costs. Further, timely and early diagnosis has made this disorder amenable to medical therapy with success rates similar to traditional surgical management with lower rates of persistence and lower cost. Ectopic pregnancy, when it is managed correctly, clearly has evolved into a medical disease where surgery should be required only for delayed diagnosis or complications.” Buster John E. , and Pisarska Margareta D. , “Medical Management of Ectopic Pregnancy,” Clinical Obstetrics and Gynecology 42: 1 (March 1999): 29.

It is worth calling to mind again that there is no guarantee that Judy will have to sacrifice anything. The embryo within her might well die of natural causes, which would make it appropriate to remove any remaining tissue by whatever means is judged medically appropriate. Salpingectomy is not the only alternative to medical treatment. There is also expectant management. See Cohen Matthew A. , and Sauer Mark V. , “Expectant Management of Ectopic Pregnancy,” Clinical Obstetrics and Gynecology ATA (March 1999): 48–54

It should be noted in passing that there are other medical treatments for ectopic pregnancy and that subtle differences in their various modes of action do not alter the fundamental moral meaning of their use. That is to say, the argument of this paper is not limited to methotrexate. See Sophie Christin-Maitre, Bouchard Philippe , and Spitz Irving M. , “Medical Termination of Pregnancy,” The New England Journal of Medicine 342: 13 (30 March 2000): 946-956.

“In women who wish to preserve their fertility, conservative surgery by linear salpingostomy is considered the gold standard for the management of ectopic pregnancy,” Togas Tulandi and Ahmed Saleh, “Surgical Management of Ectopic Pregnancy,” Clinical Obstetrics and Gynecology 42: 1 (March 1999): 32. In the same issue of that journal see also John Buster E. , and Pisarska Margareta D. , “Medical Management of Ectopic Pregnancy,” 24.

LaRynda D. Thoen and Creinin Mitchell D. , “Medical Treatment of Ectopic Pregnancy with Methotrexate,” Fertility and Sterility 68: 4 (October 1997): 730.