Double Effect, Methotrexate, and Ectopic Pregnancy

[VARC]

I am surprised by the position of many bloggers on this site that claim that the use of Methotrexate for eptopic pregnancy is an immoral act. According to the Catholic Health Care Association of the USA, the medical department of the Catholic Church in America whose responsibilities include applying the moral directives of the Church, the use of methotrexate for treatment in eptopic pregnancy is morally permissible because of the principle of double effect.

chausa.org/cgi-bin/MsmGo.exe?grab_id=0&page_id=2028&query=methotrexate&hiword=methotrexate%20

MTX is used as a treatment intended to target the pathogenic cells of the trophoplast which will become the placenta because it has implanted in place which will not allow the fetus to develop and will cause grave harm to the mother. This is permissible because the placenta is not considered a human person. The cells of the fetus itself are not the intended target of the treatment and abortion is the unintended result.

I know that there are some who will disagree with the catholic doctors and moralists who share this position but until there is an ex cathedra decree on the specific use methotrexate as a treatment for EP I think people shouldn’t be so quick to judge women who suffer this tragedy as excommunicated babykillers.

 

[Seatuck]

I am surprised by the position of many bloggers on this site that claim that the use of Methotrexate for eptopic pregnancy is an immoral act. According to the Catholic Health Care Association of the USA, the medical department of the Catholic Church in America whose responsibilities include applying the moral directives of the Church, the use of methotrexate for treatment in eptopic pregnancy is morally permissible because of the principle of double effect.

chausa.org/cgi-bin/MsmGo.exe?grab_id=0&page_id=2028&query=methotrexate&hiword=methotrexate%20

MTX is used as a treatment intended to target the pathogenic cells of the trophoplast which will become the placenta because it has implanted in place which will not allow the fetus to develop and will cause grave harm to the mother. This is permissible because the placenta is not considered a human person. The cells of the fetus itself are not the intended target of the treatment and abortion is the unintended result.

I know that there are some who will disagree with the catholic doctors and moralists who share this position but until there is an ex cathedra decree on the specific use methotrexate as a treatment for EP I think people shouldn’t be so quick to judge women who suffer this tragedy as excommunicated babykillers.

The majority of catholic doctors and moralists are against the use of methotrexate and do indeed see it as providing a direct abortion. The therapuetic effect of the drug is to cause death to the fetus. See the following paper for the various reasons. Page 20 and on I believe.

uffl.org/vol12/bowring12.pdf

The majority of Catholic moralists reject MTX and salpingostomy on the basis that these two amount to no less than a direct abortion. In both cases, the embryo is directly attacked, so the death of the embryo is not the unintended evil effect, but rather the very means used to bring about the intended good effect. Yet, for an act to be morally licit, not only must the intended effect be good, but also the act itself must be good. For this reason, most moralists agree that MTX and salpingostomy do not withstand the application of the principle of double effect.

cuf.org/faithfacts/details_view.asp?ffID=57

 

[VARC]

1. I disagree with your assertion that the majority of catholic doctors see MTX for EP as abortion based on the fact that the CHAUSA, the association of catholic medical professionals in this country, hold a contrary opinion to you.
2. Even if a majority of doctors hold the opinion that MTX treatment for eptopic pregnancy is an abortion it is still merely an opinion even according to the link you provided. Your link states that the immorality MTX is an opinion that is “not yet definitively declared to be so by the Catholic Church’s teaching authority” and that the “Magesterium…has yet to make a definitive staement on this issue”.

My point in this thread was to demonstrate that the issue has yet to be settled by the Magisterium of the Church and your link just proved my case. It is still only an opinion that MTX can’t be used in the case of an eptopic pregnancy. The CHAUSA holds the contrary opinion that the principle of double effect applies to MTX treatment. Either way, the Magesterium hasn’t ruled so catholic may follow thier consciences concerning this issus.

If a woman believes it is an abortion she can have her tube removed. If another woman believes that it is not abortion but her child will be lost as an unintended effect of the treatmnet, she is free to have that opinion without being labelled a baby killer by over zealous catholic bloggers. She certainly shouldn’t be decalred latae excommunicated by self appointed catholic apologists. Because Rome has not ruled and there are conflicting opinions of doctors and moralists, liberty of conscience is permitted.

 

[Seatuck]

I don’t consider myself to be overzealous at all. I can’t imagine defending the right to life could be overzealous at all. I do respect the reputation of those such as Dr. William May who has given the opinion that this usage is immoral. You seemed to surprised that some here expressed this opinion as well. I merely showed you there is good reason to express this opinion. I don’t see where the suggested opinion on the website of CHAUSA should be given more weight than a well respected moral theologian. That is an independant organization. They hold no moral mandate. I also don’t see where the whole organization uphelds that MTX can be used as such . I only see the opinion of one man. From 1998. Which is almost 10 years ago. There has been much discussion on the topic since then.

You may be correct about most doctors but then again you may not be. We have no evidence of how many doctors belong to CHAUSA and how many agree with the article that has been published in their journal or how many have changed their opinion in the time since that article was written. The moral theologians have more impact on Catholic moral teaching in any event. There seems to be evidence that the majority of them oppose this usage.

Yes you are correct , that Rome has not ruled directly on this. However we do have the principals we have and the use of MTX does not seem to work with the principal of double effect as is laid out for you in the articles I posted.I have read and heard that position upheld many times in many different written places and on Catholic radio. That is why I consider it’s usage immoral and will continue to express that opinion.

BTW this is a message board , not a blog. Just a little nitpick.

 

[VARC]

I’m glad that you agree that it is just an opinion and not a doctrine that is binding on the consciences of catholic women.

I merely cited the website of the CHAUSA because I believe it is the most relevant opinion to the discussion. The CHAUSA is the asociation of every catholic hospital in this country and they are responsible for applying the moral directives of Rome and the bishops of the US. I think the association’s position is more relevant than any single moral theologian including Dr. May.

But Dr. May isn’t the only credible moral theologian to chime in on this issue either. In addition to Fr. O’Rourke cited on the CHAUSA’s website

Peter A. Clark, S.J., Ph.D., is an Associate Professor of Theology and Health Administration and holder of the John McShain Chair in Ethics at Saint Joseph’s University in Philadelphia, Pennsylvania. He is also an Affiliated Scholar-Associate at the Center for Clinical Bioethics at Georgetown University Medical Center and Bioethicist for the Mercy Health System in Philadelphia.

and

Thomas A. Shannon, PhD, is professor emeritus of religion and social ethics in the Department of Humanities and Arts at Worcester Polytechnic Institute in Worcester, Massachusetts. Professor Shannon also holds the Paul McKeever Chair of Moral Theology at St. John’s University in Queens, New York. He is the author, co-author or editor of more than 35 books and 40 articles in bioethics and Roman Catholic social justice.

have also supported the opinion that the use of MTX can be justified using the double effect principle

ama-assn.org/ama1/pub/upload/mm/384/17515-jdsc1.pdf

…but I digress

The point is this…You and Dr. May may have your own opinion on the matter but it needs to be reinterated that it is only an opinion. There are well qualified Moral theologians who hold contary opinions. Because Rome has not ruled, a woman should investigate both positions and make a free choice as to her action based on her conscience without fear. She certainly is not be threatened with latiae excommunication by a catholic apologist.

 

[Ron_Conte]

Use of methotrexate to treat a live ectopic pregnancy is gravely immoral. This drug targets fast growing cells, interfering with dna and rna synthesis. The drug is certainly fatal to prenatals in early pregnancy, when all the cells are dividing and growing rapidly. The drug directly kills an innocent human being, and so it is clearly immoral.

The drug can be used morally in the case of an already deceased ectopic pregnancy, in order to help the body expell the deceased tissue.

The Magisterium does not need to rule on each and every drug and each and every medical procedure. Any drug or medical procedure which has the direct effect of killing a developing human being is gravely immoral.

The principle of double effect only applies when the act that has two effects is itself moral or neutral, not when the act is immoral.

 

[VARC]

You said: The principle of double effect only applies when the act that has two effects is itself moral or neutral, not when the act is immoral.

Precisely. According to the 3 catholic moral theologians cited, the use of MTX to treat the rapidly dividing cells of the pathogenic trophoplast(placenta) is a morally neutral act. The fact that MTX will incidentally stop the division of the embryo is an unintended side effect of the treatment.

It’s like giving chemotherapy(which coindentally uses methotraxate) to a pregnant woman. It is justifiable because it is intended to attack cancerous cells even though it will definately kill the baby as well.

Like cancerous cells, a trophoplast that is attached and growing on the tubal wall is pathogenic. It will certainly cause the death of the fetus regardless of the action taken or not taken. Treating the trophoplast with MTX is morally neutral because the undesired outcome for the embryo is unaffected. Because MTX saves the mother’s tube for future procreation, one could even argue that it is a moral good.

 

[VARC]

Also, and more importantly, using MTX to treat a pathogenic trophoplast is morally neutral because a placenta is not human being and if it causing the death of the embryo and the destruction of the mother’s tube it is acceptable to treat it. In short…pro-life doesn’t mean pro-pathogenic placenta. Keep in mind that not doing anything will certainly cause the death of the baby and probably the mother too. How is that pro life?

 

[VARC]

I mispelled ectopic preganacy in the title of the original thread which is here…forums.catholic-questions.org/showthread.php?p=3135281#post3135281

 

[Seatuck]

Also, and more importantly, using MTX to treat a pathogenic trophoplast is morally neutral because a placenta is not human being and if it causing the death of the embryo and the destruction of the mother’s tube it is acceptable to treat it. In short…pro-life doesn’t mean pro-pathogenic placenta. Keep in mind that not doing anything will certainly cause the death of the baby and probably the mother too. How is that pro life?

Methotrexat targets all rapidly growing and multiplying cells. That is why it is effective for treating cancer. Babies are full of rapidly growing and multiplying cells. They are a target of the drug also .

 

[VARC]

MTX itself doesn’t really “target” anything. It is a drug that is used to “target” a pathogenic trophoplast by a doctor. MTX doesn’t differentiate between the cells of a trophoplast, an embryo, or the cells of a cancerous tumor. Nobody has a problem with a pregnant woman taking chemotherapy to treat a tumor even though her baby will die as a secondary result. It is the same scenario. Instead of using MTX to treat a tumor it is used to treat a pathogenic trophoplast that is going to rupture in the tube. The same double effect principle applies.

 

[Listener]

I have trouble seeing the difference, too. I thank God that I won’t ever be in a position to have to deal with this. If you can remove a “diseased tube” (even if an embryo is the cause of the disease), why couldn’t you take a pill that will remove the “growth” that is damaging the tube? I just don’t get it. In both cases, you are simply keeping the tube from rupturing. If you took the pill, you could keep your tube and maybe have another baby somewhere down the road.

Since the baby has a zero chance of survival, it seems that you should do everything you can to save the mother.

Now, here’s a scary thought. Suppose the mother will die very soon if something is not done. Suppose she is lying in the hospital, and they tell her they can give her a pill, but that they don’t do tube removal operations. She really wouldn’t have time to shop for a doctor that would remove her tube. She would die, probably leaving other children as orphans.

One thing that we have to realize is that when the Church studies these things, the Church has no way of predicting what medical procedures will become available in the future. The leaders in the Church just don’t have time to analyze the morality of every single medical procedure that becomes available. It may be that sometimes, we just have to use the primary virtue, which is prudence.

 

[mapleoak]

Because Rome has not ruled, a woman should investigate both positions and make a free choice as to her action based on her conscience without fear.

Because there has not been an official pronouncement on any particular action, does not give licensce to “anything goes until such time”. Also when the Church makes an official pronouncement it is not to create some new restriction, but to affirm what has always been true.

She certainly is not be threatened with latiae excommunication by a catholic apologist.

By its nature, it is not impuned by anyone other than oneself.

Precisely. According to the 3 catholic moral theologians cited, the use of MTX to treat the rapidly dividing cells of the pathogenic trophoplast(placenta) is a morally neutral act.

It is not morally neutral because it is an action which is a direct attack on the embryo. To say it is not is the same as saying that shooting a pumpkin with a man holding it is not directly killing the man holding it. One condition of double effect not met.

The fact that MTX will incidentally stop the division of the embryo is an unintended side effect of the treatment.

Because the death of the embryo is not incidental, but directly consequential, that makes two conditions which are not met. To say that the death of the embryo is unintended when it is directly consequential is a contradiction and therefore three conditions are not met.

It’s like giving chemotherapy(which coindentally uses methotraxate) to a pregnant woman. It is justifiable because it is intended to attack cancerous cells even though it will definately kill the baby as well.

It differs from chemotherapy in that administering chemotherapy to treat cancer is a morally neutral act. It is not immoral to treat cancer. Treating the cancer is the intended action. Any effect on the embryo is an indirect effect. Whether it is intended or not is subject to ones will. Therefore treating cancer with chemotherapy can in some cases be immoral if the death of the embryo is intended as well. Intention is separate from whether an action is direct or indirect. There are more conditions to double effect than these as well.

Like cancerous cells, a trophoplast that is attached and growing on the tubal wall is pathogenic.

No, the fact that an ectopic condition exists is not pathology. The ectopic condition may develop into patholgy. To perform any treatment at all that jepordizes the life of the embryo by mere fact that an embryo is ectopic with no pathology present is murder as preventative treatment.

It will certainly cause the death of the fetus regardless of the action taken or not taken.

If it could be said that the death of the embryo was imminent, it does not mean its life can be taken prematurely.

Treating the trophoplast with MTX is morally neutral because the undesired outcome for the embryo is unaffected.

It is not morally neutral because it directly kills the embryo, regardless of whether it would die anyway. To die does not make one morally culpable. To kill certainly does.

Because MTX saves the mother’s tube for future procreation, one could even argue that it is a moral good.

One cannot use immoral means to achieve a moral good.

Also, and more importantly, using MTX to treat a pathogenic trophoplast is morally neutral because a placenta is not human being and if it causing the death of the embryo and the destruction of the mother’s tube it is acceptable to treat it.

The fact that is destroys the placenta in addition to the embryo does not lessen the fact that it directly destroys the embryo and is therefore murder. Man behind the pumpkin.

In short…pro-life doesn’t mean pro-pathogenic placenta. Keep in mind that not doing anything will certainly cause the death of the baby and probably the mother too. How is that pro life?

This represents confusion about murder in the name of preventative treatment. It is also confusing causation with direct intention. The absence of an action to destroy the embryo is not the cause of the embryo’s death. It is a fallacy to say that by not doing anything one is causing death.

 

[Ron_Conte]

If one were to commit abortion by destroying the placenta, and then letting the prenatal die as a result, this would be still a direct abortion.

Methotrexate has the direct effect of killing the growing cells of the prenatal. It also has the direct effect of destroying the placenta, without which the prenatal cannot life. Killing the prenatal by destroying the placenta is still direct abortion.

The term direct in moral theology does not refer to mere physical directness or indirectness. If one were to devise an absurdly indirect means of killing an adult, it would still be the direct and voluntary killing of an innocent human person.

Deliberately destroying the placenta, without which the prenatal cannot live, may seem to be physically indirect, but because the prenatal depends on the placenta for life, it is like cutting off someone’s air supply.

Also, there is no medical reason for destroying the placenta. It is the growth of the prenatal in the wrong location that is the medical ailment. It is intellectually dishonest to solve that problem by claiming that the growth of the placenta is a disease.

If a woman has cancer, and is pregnant, and the prenatal is too far from viability to wait and deliver the child, the woman can be treated for cancer, even though the prenatal will die as a result. The treatment for cancer is a moral act; the death of the prenatal is unintended and morally indirect.

In the case of the ectopic pregnancy, the drug methotrexate is given to stop the growth of the prenatal, which is merely another way of saying to kill the prenatal. The death of the prenatal is the moral object of the act. And so use of that drug would be immoral.

 

[VARC]

Since the responses to my last post were so long, I’ll have to only respond to points that I believe are most helpful to the dialouge. Please don’t feel left out mapleoak.

Ron said: Deliberately destroying the placenta, without which the prenatal cannot live, may seem to be physically indirect, but because the prenatal depends on the placenta for life, it is like cutting off someone’s air supply.

This is a moot point. In the case of ectopic pregnancy, the trophoplast(It is technically not a placenta yet) is of absolutely no value to the embryo because it will not allow the embryo to grow properly in the tube. So destroying the trophoplast does’t harm the embryo because the trophoplast doesn’t serve the purpose it was intended to serve. I do agree that deliberately destroying a functioning placenta is the equivalent to murdering a baby.

Ron said: Also, there is no medical reason for destroying the placenta. It is the growth of the prenatal in the wrong location that is the medical ailment.

This is the key point of contention between both sides. I believe (with the above named catholic doctors and theologians) that the improperly implanted trophoplast itself represents a patholgical danger to the mother. And because the trophoplast is of no value to the embryo it is perfectly acceptable to treat it the same way you would treat a cancerous tumor.

Given these opinions, let’s apply the double effect principle

1)The nature of the act is itself good

True. Treating a useless trophoplast with MTX to prevent further damage to the mother is good

2)The intention is for the good effect and not the bad

True assuming that the mother wanted the baby

3)The good effect outweighs the bad effect in a situation sufficiently grave to merit the risk of yielding the bad effect

True. Whether you use MTX, cut out the tube, allow the tube to rupture the net result to the embryo is the same. The only variable is the condition of the mother. Allowing it to rupture and removing the tube mutilate her body and can easily kill her too.

4)The good effect does not go through the bad effect

True. Since the trophoplast is distinct from the embryo the good effect (saving the mother’s life and health) is a result of the morally neutral act (treating the useless trophoplast with MTX)

Conclusion

It really boils down to whether or not you believe that it is immoral to destroy a trophoplast which is no use to the embryo and will cause grave harm to the mother. This is a no brainer to everybody in the world but a few catholics. If the answer is no then the principle of double effect does apply to MTX for eptopic pregnancy.

If you hold that it is immoral, that’s fine with me and you’re free to cut out your tubes. But your opinion is not the definitive position of the Church and catholics are free to hold the contrary view and remain in good standing with the Church until Rome rules otherwise.

 

[VARC]

Thanks for your words encouragement. This issue is of great importance because it is throwing people out of the church. Most people who are faced with this tragic situation use the common sense that you described above. And because they have been led to believe that this is a settled matter equivalent to a procured abortion by unappointed apologists, they falsely believe they are excommuinicated. This causes them to leave the Church.

I believe that these apologists are acting recklessly by asserting that this matter is settled when it is not. I don’t mind anyone expressing they’re opinion but they have to reinterate that it is an opinion and that one can remain in good standing with the Church with a contrary view.

 

[Joan_M]

It really boils down to whether or not you believe that it is immoral to destroy a trophoplast which is no use to the embryo and will cause grave harm to the mother. This is a no brainer to everybody in the world but a few catholics. If the answer is no then the principle of double effect does apply to MTX for eptopic pregnancy.

If you hold that it is immoral, that’s fine with me and you’re free to cut out your tubes. But your opinion is not the definitive position of the Church and catholics are free to hold the contrary view and remain in good standing with the Church until Rome rules otherwise.

This is, truly, a no brainer to me. All, and I mean all, the arguments being touted to push aborting ectopic pregnancies by use of MTX is pure twaddle.

MTX is not destroying " a trophoplast which is no use to the embryo " it is destroying an embryo, and therefore an abortion.

The use of all this medical twiddle-twaddle in an effort to avoid facing the truth is straight from the devil.

MTX directly attacks the baby. MTX kills the baby. MTX causes abortions. Full stop, finish. Any medical doctor or anyone else who uses scientific terms and obscure terms to try to talk themselves out of this are fooling themselves or trying to fool us.

The time may come - if there are enough faithful doctors left - that it will be possible to open the tube, remove the embryo and move him/her to the uterus where implantation will then take place. It is quite possible that this could happen now, if there was the proper reverence for life instead of this urge to “protect” the mother from surgery.

And, no. I’m not infallible, but I have a finely tuned conscience.

 

[VARC]

This is, truly, a no brainer to me. All, and I mean all, the arguments being touted to push aborting ectopic pregnancies by use of MTX is pure twaddle.

MTX is not destroying " a trophoplast which is no use to the embryo " it is destroying an embryo, and therefore an abortion.

The use of all this medical twiddle-twaddle in an effort to avoid facing the truth is straight from the devil.

MTX directly attacks the baby. MTX kills the baby. MTX causes abortions. Full stop, finish. Any medical doctor or anyone else who uses scientific terms and obscure terms to try to talk themselves out of this are fooling themselves or trying to fool us.

The time may come - if there are enough faithful doctors left - that it will be possible to open the tube, remove the embryo and move him/her to the uterus where implantation will then take place. It is quite possible that this could happen now, if there was the proper reverence for life instead of this urge to “protect” the mother from surgery.

And, no. I’m not infallible, but I have a finely tuned conscience.

Father O’Rourke, Father Clark, Dr. Shannon and I have finely tuned consciences as well. I really don’t see why the other side thinks they have the pro life position. By insisting that a useless trophoplast that has implanted in the tube must be given the moral status of an embryo instead of a tumor, you are actually pro death. Because until the time does come where it is possible to do what you described, you are not protecting life. You are protecting your assumed moral high ground at the expense of innocent lives. I understand your zeal to protect the unborn and I respect your opinion but I take offence that the reasonable explanation of the other side is"twaddle" and that our opinion is “from the devil”.Happy New Year.

 

[VARC]

I usually hate analogies but I want to ask folks about another scenario that has a moral similarity. Would it have been morally acceptable to shoot down the hijacked planes of 9/11? The similarity is that whether you shoot them down or not it isn’t going to change the fate of the people on the planes. However you if you do nothing you condemn 3000 more people to death. So I’m kind of curious, do you believe it is morally permissible to shoot the planes down?

 

[fix]

…MTX inhibits DNA synthesis so that normal implantation enzymatic activity ceases. Its primary effect is on the trophoblast (the precursor of the placenta). Clearly, this is not a cancer case, the point and purpose of MTX here is to shut down (stop) the life support system of the developing child (death-dealing)…

Moraczewski prefers to examine the classical “fontes moralitatis” and ask specifically: what is the moral object of salpingostomy? (E&M 23:3, p. 4). He argues that the specific object and good of that act is “the stopping of the enzymatic activity of the trophoblast.” That enzymatic action would be proper and normal in the uterus but is here causing damage in an abnormal site, the tubal lining…

However, when you do directly remove the embryo from the site, what you do (finis operis) is destroy it in situ. Neither trophoblast nor its activity is in any sense “diseased,” and thus the salpingostomy or MTX is in no sense therapeutic for or to the embryo, it is, rather, a death-dealing procedure meant to improve mother’s health and life. This violates the double effect condition (re causality) that the good effect not be caused by, not come through the evil effect. As mentioned above, tubal pregnancies don’t happen because tiny embryos do what they naturally do; almost always there is a preexisting problem in the endosalpinx from whatever cause…