Ethicists have continued to debate about two means of treating ectopic pregnancy, namely, the removal of the embryo from the tube (salpingostomy) and the use of methotrexate. This article examines the major arguments in favor of considering salpingostomy intentional killing. The article goes on to evaluate the major arguments in favor of the conclusion that methotrexate is intentional killing or intentional mutilation. The tentative conclusion reached is that both salpingostomy and the use of methotrexate should be considered morally permissible.
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References
1.
On February 7, 2007, a version of this paper was presented, with the title, “Ectopic Pregnancy and the Catholic Hospital,” to a group of 170 bishops and ten cardinals from the U.S., Canada, Mexico, Central America, the Caribbean, the Philippines, India, and Europe at a conference titled “Urged on by Christ: Catholic Health Care in Tension with Contemporary Culture,” the twenty-first bishops workshop, Dallas, Texas.
2.
BowringKelly“The Moral Dilemma of Management Procedures for Ectopic Pregnancy,” in Life and Learning, vol. 12, Proceedings of the Twelfth University Faculty for Life Conference at Ave Maria Law School 2002, ed. Joseph W. Koterski, S.J. (Washington, D.C.: University Faculty for Life, 2003), 101.
3.
Pope John Paul II wrote: “by the authority which Christ conferred upon Peter and his successors, in communion with the bishops—who on various occasions have condemned abortion and who in the aforementioned consultation, albeit dispersed throughout the world, have shown unanimous agreement concerning this doctrine—I declare that direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder, since it is the deliberate killing of an innocent human being.” Pope John Paul II, Evangelium vitae (Vatican City: Libreria Editrice Vaticana, 1995), n. 62.
Some authors hold that salpingostomy is not intentional abortion, see, for example, GrisezGermain, Abortion: The Myths, the Realities, the Arguments (Cleveland/New York: Corpus Books, 1970), 340–341; Albert Moraczewski, “Managing Tubal Pregnancies: Part I,” Ethics and Medics 21.6 (June 1996): 1-4. Other authors believe that salpingostomy is intentional abortion, see, for example, Peter A. Clark, “Methotrexate and Tubal Pregnancies: Direct or Indirect Abortion?” Linacre Quartery 67.1 (2000): 7-24; Bowring, “The Moral Dilemma of Management Procedures for Ectopic Pregnancy,” 116.
6.
For a discussion of this once-debated case, see ConneryJohn, Abortion: The Development of the Roman Catholic Perspective (Chicago: Loyola University Press, 1977), 295–300.
7.
ShettlesL.“Tubal Embryo Successfully Transplanted in Utero,”American Journal of Obstetrics and Gynecology163 (1990): 2026.
8.
WallaceC.J.“Transplantation of Ectopic Pregnancy from Fallopian Tube to Cavity of Uterus,”Surgery Gynecology, and Obstetrics24 (1917): 578–579. I have heard both cases explained in terms of heterotopic pregnancy, one tubal pregnancy and the other in utero. This is possible, but the conjecture lacks evidence.
9.
William May writes: “I contend that it is morally imperative today to make every effort possible to discover and transplant into the uterus those unborn babies who have, unfortunately, implanted in the fallopian tube or other ectopic sites and not in the uterus where they belong.” May, “The Management of Ectopic Pregnancies: A Moral Analysis,” in The Fetal Tissue Issue: Medical and Ethical Aspects, eds. Peter J. Cataldo and Albert S. Moraczewski, O.P. (Braintree, MA: The Pope John Center, 1994), 146. In his book, Catholic Bioethics and the Gift of Human Life, 2nd ed. (Huntington, IN: Our Sunday Visitor Publishing, 2008), William May reverses his previous position on the use of methotrexate to treat ectopic pregnancy. He no longer views its use as intentional killing of the embryo. Eugene F. Diamond writes: “The long-term hoped-for solution to the dilemma will be the development of successful techniques for the transplantation of fetuses growing in ectopic location into the uterine cavity.” Diamond, “Moral and Medical Considerations in the Management of Extrauterine Pregnancy,” Linacre Quarterly 66.3 (1999): 11. Bowring writes: “This [transplantation technique] needs to be reconsidered and pursued, especially with the certainty that it is not just plausible, but possible. Convincing the medical field to focus on re-implantation is the true moral imperative in the issue of managing ectopic pregnancy today.” Bowring, “The Moral Dilemma of Management Procedures for Ectopic Pregnancy,” 118.
10.
MayWilliam E.“Methotrexate and Ectopic Pregnancy,”Ethics and Medics23.3 (1998). For his more recent position, one that accepts the use of methotrexate and salpingostomy, see May, Catholic Bioethics and the Gift of Human Life, 201-202.
11.
I would like to thank the chief of maternal fetal medicine at the University of Southern California, T. Murphy Goodwin, M.D., as well as Bryron Calhoun, M.D., the National Medical Advisor for the National Institute of Life Advocates who answered many of my questions about the medical practices discussed in this paper. A reviewer objected to this point noting, “The author has a problem … (of which he may not be aware) in characterizing salpingostomy as not being an attack on the embryo because it can be removed intact. The difficulty is that such a characterization relies on understanding the procedure as one done via laparotomy as opposed to laparoscopy. Laparoscopic salpingostomy does not allow the same sort of unimpeded access to the fallopian tube that laparotomy does. Since most procedures for unruptured ectopic pregnancy are now done laparoscopically, the procedure is often far less discriminating in how intact the embryo remains. [In a laparoscopic salpingostomy] the ectopic pregnancy is removed blindly without any concern for removing it as a discrete and intact entity. Perhaps this point could be addressed given the economic and medical pressures to perform this procedure laparoscopically.” This consideration is important but it does implicitly presuppose what I was trying to show that salpingostomy can be (if performed via laparotomy) in such a way as to preserve the bodily integrity of the embryo. A laproscopic salpingostomy does not do this, but I address this case in the next paragraph of the body of my essay.
12.
AquinasThomasSumma theologiae, II-II, q. 64, a. 7.
13.
See, JohnC., FordS.J.“The Morality of Obliteration Bombing,”Theological Studies5 (1944): 261–309.
14.
United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 4th ed. (Washington, D.C.: USCCB, 2001).
15.
Statistic cited by CavagnaroCharles E.M.D. III in “Treating Ectopic Pregnancy: A Moral Analysis (Part II),”NaProEthics Forum4.2 (1999): 4.
16.
MorlockR.J.“Cost-Effectiveness of Single-Dose Methotrexate Compared with Laparoscopic Treatment of Ectopic Pregnancy,”Obstetrics and Gynecology95 (2000): 407–412.
17.
Physicians Vicken Sepilian and Ellen Wood write: “A bhCG level of greater than 15,000 IU/L, fetal cardiac activity, and free fluid in the cul-de-sac on US (presumably representing tubal rupture) are contraindications [for MXT].” Sepilian and Wood, “Ectopic Pregnancy” (2007), http://www.emedicine.com/med/topic3212.htm.
18.
Sepilian, and Wood note: “embryonic cardiac motion can be observed 3.5-4 weeks postconception, about 5.5-6 weeks after the last menstrual period.” Seplian and Wood, “Ectopic Pregnancy.”
19.
A number of ethicists have argued that the use of methotrexate is morally impermissible, for example, Charles E. Cavagnaro, Thomas W. Hilgers, and Bernard Nathanson. Others hold that its use to treat tubal pregnancy is permissible, for example, Albert Moraczewski, O.P., Benedict Ashley, O.P., Patrick Norris, O.P., and Peter Clark, S.J.
20.
Although some experiments have been done directly injecting the embryo, it should also be noted that MXT as normally used is not administered directly upon the body of the embryo, but rather is taken orally by the woman or via injection into her body. Thus, even if “acting upon the body” of the embryo were morally dispositive for determining intentional effects as opposed to side effects, it is not relevant for the normal use of MXT.
21.
ConneryAbortion, 162. As a reviewer helpfully noted, Raynaud himself thought the ectopic fetus was an unjust aggressor and that the distinction between “direct” and “indirect” was not relevant in such cases. Nevertheless, the colorful example does illustrate the general principle that neither the certainty of the effect nor acting upon the body of another entails that a lethal effect which follows from the action must be intended.
22.
MoraczewskiAlbert“Managing Tubal Pregnancies: Part II,”Ethics and Medics21.8 (August 1996): 4.
23.
I argue this point further in my book, The Edge of Life: Human Dignity and Contemporary Bioethics (Dordrecht: Springer, 2005), ch. six. A version of this chapter can also be found in “Moral Absolutism and Ectopic Pregnancy,” Journal of Medicine and Philosophy 26 (2001): 61-74.
24.
The rest of this paragraph is drawn virtually verbatim from one of the reviewer's reports.
25.
FinnisJohn, GrisezGermain, and BoyleJoseph“‘Direct’ and ‘Indirect’: A Reply to Critics of Our Action Theory,”Thomist65 (2001): 20.
26.
MayWilliam E.“Methotrexate and Ectopic Pregnancy,”Ethics & Medics23.3 (March 1998): 1–2. As noted previously, in a later work, Catholic Bioethics and the Gift of Human Life, May came to accept as morally permissible the use of methotrexate.
27.
May, “Methotrexate and Ectopic Pregnancy,” 3.
28.
These matters have been debated in other contexts as well. See, KaczorChristopher, “Intention, Foresight, and Mutilation: A Response to Giebel,”International Philosophical Quarterly47 (2007): 481–486.
29.
Bowring“The Moral Dilemma of Management Procedures for Ectopic Pregnancy,”109.
30.
For example, Cavagnaro speaks of “the shared maternal-fetal organ of pregnancy—the placenta,” in “Treating Ectopic Pregnancy: A Moral Analysis (Part II),” 4.
31.
ConneryAbortion, 300.
32.
ConneryAbortion, 177. A reviewer of this article point out that on Connery's understanding of Lugo's view, methotrexate would not however be licit. I only make reference to the example here to illustrate that acting upon a person is not necessarily to intentionally mutilate that person.
33.
FinnisGrisez, and Boyle“‘Direct’ and ‘Indirect,’”28–29.
34.
Kaczor“Moral Absolutism and Ectopic Pregnancy,”61–74.
35.
I owe this insight to Alexander Pruss, personal conversation.
36.
Alan ShewmonD.“The Dead Donor Rule: Lessons from Linguistics,”Kennedy Institute of Ethics Journal14 (2004): 293–295.
37.
TuoheyJohn F.“The Implications of the Ethical and Religious Directives for Catholic Health Care Services on the Clinical Practice of Resolving Ectopic Pregnancies,”Louvain Studies20 (1995): 46.
