Double Effect, Methotrexate, and Ectopic Pregnancy

[VARC]

Again, you are saying that because nothing can be done to save the child you are recommending murder.

There you have it. So according to Joan M, a woman who receives MTX as treatment for ectopic pregnancy is a “murderer”.

Is that truly the catholic religion? Must someone really believe that to remain a catholic in good standing? A simple yes or no will suffice.

 

[VARC]

Thanks for voting everybody. Looks like it’s pretty even but the ayes have it.

 

[fix]

I am well aware that there are Roman Catholic priests that believe what you are proposing. But I seriously doubt that a cleric from any other religion whatsoever would even entertain the idea. And if 9 of 10 catholics disagree with the church’s teaching on contraception, it’s probably a fair bet that 99 out of 100 wouldn’t touch this idea.

Is morality determined by popular opinion?

And it’s not a hyperbole. It’s a reality to thousands of catholic women. I find it very revealing that you can’t type out the unavoidable conclusion of your position: If a woman who has an EP doesn’t put her life in grave danger by refusing MTX treatment, then she is automatically excommunicated.

I do not know that is true in each case.

Because, in your opinion, using MTX to treat an ectopic pregnancy (a condition where the embryo dies no matter what) is the moral eqiuvalent of an elective abortion. If this was the logical conclusion of my position I wouldn’t want to type it out either.

It could be that depending on circumstances.

Many people defend this idea, not because they are concerned for life, nor because they are so moved by its truth, but because they believe that to even question it is to put their faith in God in jeopardy.

I cannot see how you reason that?

I don’t know how we catholics can build our faith on such a foundation. As if our faith would “crumble” if Rome came out tommorow and declared MTX to be acceptable for EP treatment even when Rome herself has not taken a definitive position.

As another poster pointed out in another thread Rome, or a local Bishop, does not come in every single medical case and say stand back while I apply the principle of double effect here.

You asked for views on this topic and we have posted views. Now, your arguments have been refuted, yet you cling to them based on emotion rather than what is true. If Rome were to say it was licit everyone here would accept it. And, if you want to argue you are correct would it not be better to use moral theology reasoning rather than emotion?

I now understand why some catholics vigorously defend what seems to be indefensible to every other christian church or community in the world. Because they attribute this opinion to the church’s infallibilty, their very faith in God is on the line. How very far we have come from the Faith of the Fathers.

I have no idea how you arrive at this?

 

[aboverubies]

I will preface this post by stating that it is purely based on emotion. I am no apologist. I am however a catholic mother who was diagnosed with an ectopic pregnancy two months ago.

I was alone at the hospital (waiting for my husband to arrive ), on morphine for the pain, scared, exhausted and upset.

The obstetrician offered me two choices of treatment. I had never heard of methotrexate before, but I immediately stopped her and said “I am catholic. I cannot do anything that will directly take the life of my baby.”

No access to canon law, the Bishop or the CCC, just pure emotion and gut instinct of what was right and wrong in relation to my unborn child and God’s natural law.

The ob then explained that my ultrasound and bloodwork series results were back and they confirmed that my baby had already died, probably two days earlier.

After some conference with my husband and our priest I chose the methotrexate treatment in order to preserve my fertility and avoid surgery. Morals did not enter into my decision at this stage as our precious baby had already died and only my health and recovery were of concern.

I am at a slightly higher risk now for a repeat ectopic, but I will think and act in the same way should I find myself in that situation again - God forbid. When it came to the crunch I just couldn’t accept an injection that would directly take my child’s life…even to preserve my future fertility. I do however understand the struggle and confusion that must face every catholic mother (and her spouse along with her) who goes through this tradgedy. My heart goes out to them, truly.

 

[jemfinch]

Why do you seem to deny that the drug acts on the baby? Methotrexate causes death to the fetal cells. This kills the baby.

I don’t see why anyone would deny that. But it’s not really relevant: we’re talking about the law of double effect. We’re actively discussing issues which we know have both a good effect and a bad effect. If the bad effect is not intended (either as a means or as an end) and the good effect outweighs the bad effect, then it’s permissible to act, intending the good effect, and recognizing that the bad effect will happen as a result.

Even if Methotrexate causes fetal death as a bad effect, if it also causes the placenta to detach from the fallopian tube as a good effect (since this attachment endangers the life of the mother) it would be permissible to use Methotrexate, intending the good effect, because the good effect (which is saving the life of the mother) outweighs the bad effect (the death of the child and the serious risk to the life of the mother).

The placenta is not the only tissue that is attacked.

It is all that is intentionally attacked. This is the same situation as the bombing of a military installation adjacent to civilian buildings (orphanages, perhaps). If the military target is of such strategical importance that it would end the war quickly if it were destroyed, then it would be permissible to bomb it, intending the good effect (the ending of the war) while recognizing that civilians in the adjacent buildings will almost certainly die as a result, as long as the good effect (ending the war) outweighs the bad effect.

It’s the same principle with methotrexate. The placenta is attacked, but unfortunately, so is the baby. As long as the harm to the innocent baby is not intended, either as a means or as an end, and as long as the good effect of the drug outweighs the bad effect of the drug, administering the drug would be moral. If you’re going to argue that it’s not, you need to prove either that the good effect does not outweigh the bad effect. There’s no sense in arguing about whether the drug actually harms the child because that’s a fact even though who believe that it can be morally used recognize.

Jeremy

 

[jemfinch]

A more appropriate analogy is this: A terrorist penetrates the White House and somehow gets to the Oval Office and the President. He has no weapon except a large amount of explosive packed around his body with nails/shrapnel. He calls for everyone to freeze or he will blow up the WH. Next he states that unless the President is shot, he will detonate his bomb. The Secret Service somehow determines that the bomb is very real and the threat 100% credible. (forget how unlikely it is for us to get this far for discussion). NOW we have a similar situation. If you are the Vice President in another building, do you order the President to be shot or accept the loss of the White House and all the staffers present? THAT is the choice you are presenting with your ectopic pregnancy drug.

No, it’s still not an accurate analogy. One could not order the president be shot: we cannot do (directly and intentionally) evil so that good may result. We could not unjustly shoot a hostage (president or not) in order to prevent further evil acts by the perpetrator.

We could, of course, attempt to kill the transgressor: we would be justified in self-defense to do so. If the only way we could kill the transgressor would be in a way that also resulted in the president’s death, we would still licitly perform that action, since we would not intend the death of the president either as a means or as an end, and the good effect (the removal of all those in the whitehouse from serious danger) would outweigh the bad (the death of the president).

Jeremy

 

[fix]

The placenta is a major organ. Attacking that violates the principle of totality. What is the goal of attacking the placenta? How does it help the baby?

Bombing something during war is self defense that may be justified in certain cases. Direct attack on the fetus is very different.

 

[jemfinch]

The placenta is a major organ. Attacking that violates the principle of totality.

I’ve not heard of that principle before, can you provide a reference?

What is the goal of attacking the placenta?

Preserving the life of the mother, who is endangered by it. It would be analogous to an appendectomy or the amputation of a necrotic limb: removal of a part that endangers the whole.

How does it help the baby?

It doesn’t at all. In fact, it harms the baby: this is the bad effect of the act.

Do note that I’m not entirely comfortable with this particular argument based on the principle of double effect; it would seem to justify not only chemical removal of the placenta, but surgical removal, which would constitute (as I understand it) direct abortion. It seems in this case that either the principle of double effect is not sufficiently restricted, or perhaps the definition of “abortion” is insufficiently restricted. Another possibility is that people are making a philosophical error when they distinguish between the removal of the placenta and the direct killing of the innocent child, but if this were the case, it would seem that such an argument would also apply to the removal of the fallopian tube containing a baby, which (as I understand it) the consensus of moral theologians seems to be that such a removal is morally permissible.

Jeremy

 

[fix]

I’ve not heard of that principle before, can you provide a reference?

Sure:

A simple expression of the principle of totality means, “the parts of the physical entity, as parts, are ordained to the good of the physical whole.” From the medical perspective, the principle of totality would mean that "all the parts of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally subordinated to the good of the whole body."5 The term “totality” points to the duty to preserve intact the physical component of that integrated whole.6

And this is good:

The Moral Dilemma of Management Procedures for Ectopic Pregnancy

Preserving the life of the mother, who is endangered by it. It would be analogous to an appendectomy or the amputation of a necrotic limb: removal of a part that endangers the whole.

We are treating 2 lives here. The baby is not pathology or an unjust agggressor.

It doesn’t at all. In fact, it harms the baby: this is the bad effect of the act.

Right:

under the principle of totality we are not free to
sacrifice our vital organs68 needed to sustain life or those of the unborn baby for
that matter. Dr. May makes a conclusion:
Thus, the ‘therapeutic effect’ [of methotrexate] is achieved only by means
of its lethal effect on the unborn child. Moreover, the ‘therapeutic effect’
does not benefit the unborn child but the mother, and does so only
because its non-therapeutic effect destroys the trophoblast of the unborn
child, thus causing its death.69

Do note that I’m not entirely comfortable with this particular argument based on the principle of double effect; it would seem to justify not only chemical removal of the placenta, but surgical removal, which would constitute (as I understand it) direct abortion. It seems in this case that either the principle of double effect is not sufficiently restricted, or perhaps the definition of “abortion” is insufficiently restricted. Another possibility is that people are making a philosophical error when they distinguish between the removal of the placenta and the direct killing of the innocent child, but if this were the case, it would seem that such an argument would also apply to the removal of the fallopian tube containing a baby, which (as I understand it) the consensus of moral theologians seems to be that such a removal is morally permissible.

Jeremy

The excision of the affected tube is treating the disease, that is why double effect can be applied. Targeting the placenta is not treating the disease:

Clearly, the surgery here is on the tube, a portion of which is pathological and poses a significant threat to the health and life of the mother. The death of the unborn is foreseen but not directly intended. The improvement in mother’s health and life is not precisely caused by the death of the unborn but comes through (caused by) the removal of pathological tissue. Thus, an indirect abortion and a legitimate application of double effect…

… 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)…

… 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…

 

[jemfinch]

The Moral Dilemma of Management Procedures for Ectopic Pregnancy

Very nice, in fact.

The excision of the affected tube is treating the disease, that is why double effect can be applied. Targeting the placenta is not treating the disease:

It seems my misunderstanding was in my belief that the placenta (the trophoblast) was a part of the mother, not a part of the child. If it’s a part of the child, then attacking that part chemically would constitute direct abortion, rather than the medical treatment of a pathological condition of a part of the woman’s body.

Thanks for the link above.

Jeremy

 

[seekerz]

I’ve read this discussion with interest because it illustrates (to me) at least, why the Church has not definitively ruled on Methotrexate.

The scientific principles have to be completely and totally understood (something which apparently has not been achieved by all contributors to this post). Before applying spiritual principles to a scientific/medical quandary, one has to have complete knowledge of the details e.g. how and where exactly does a drug or a disease have it’s effect (just googling it won’t do).

The basic disagreement here, I believe is between those who think the tube is the diseased part and those who believe the disease process is the abnormal location of the pregnancy. I have had my problems with either approach. One thing I can say for certain is that this is a complex issue and those who would reduce it to choosing life versus choosing death are erroneously making it into a simple decision.

No true Catholic would choose to kill their child, even if death seemed inevitable. The idea that some Catholics simply choose MTX because they have no respect for life just does not seem fair to assume.

If the matter really is so simple, tell me:

1. If removal of the diseased tube is the only moral choice, would surgery be justified if there were no indication of infection or inflammation of the tube?
2. How exactly is a doctor to detect that infection or inflammation and know when it’s moral to proceed with surgery? Non-medical people would need to know this to be able to properly consent to treatment.
3. To what extent would any necessary wait in the above scenario be considered moral, rather than a grave risk to the mother’s life, keeping in mind that fatal rupture is a distinct possibility in tubal pregnancies and that predicting such rupture is not an exact science?
4. If the tube is really the diseased part, why does that disease only become life-threatening when there is a pregnancy in it and why does that threat to life disappear when the pregnancy comes to an end e.g. after use of MTX? Left to it’s own devices, does the tube by itself pose a risk to life? Is it really the pregnancy within the tube that produces the disease and poses the threat of fatal bleeding?
5. If we accept that the risk to life is posed by the abnormally located pregnancy, is there really then any moral difference between treatment methods?

I do not profess to be able to answer all of the above questions to a satisfactory degree, but I think that pondering them will keep us humble and loving in our consideration of this rather complex problem and the choices made by affected couples.

 

[fix]

The scientific principles have to be completely and totally understood (something which apparently has not been achieved by all contributors to this post). Before applying spiritual principles to a scientific/medical quandary, one has to have complete knowledge of the details e.g. how and where exactly does a drug or a disease have it’s effect (just googling it won’t do).

The moralists linked in this thread, on both sides, use medical information from physicians. You cannot get agreement on every issue. Just look at oral contraceptives as one example.

The basic disagreement here, I believe is between those who think the tube is the diseased part and those who believe the disease process is the abnormal location of the pregnancy. I have had my problems with either approach. One thing I can say for certain is that this is a complex issue and those who would reduce it to choosing life versus choosing death are erroneously making it into a simple decision.

Does that mean there is no way to know how best to act?

1. If removal of the diseased tube is the only moral choice, would surgery be justified if there were no indication of infection or inflammation of the tube?

Please see this.

1. How exactly is a doctor to detect that infection or inflammation and know when it’s moral to proceed with surgery? Non-medical people would need to know this to be able to properly consent to treatment.

Please see the above link

1. To what extent would any necessary wait in the above scenario be considered moral, rather than a grave risk to the mother’s life, keeping in mind that fatal rupture is a distinct possibility in tubal pregnancies and that predicting such rupture is not an exact science?

Again see above.

1. If the tube is really the diseased part, why does that disease only become life-threatening when there is a pregnancy in it and why does that threat to life disappear when the pregnancy comes to an end e.g. after use of MTX?

Because the fetus is growing in the wrong place. The fetus is doing what he/she does naturally. Is the baby diseased?

Left to it’s own devices, does the tube by itself pose a risk to life? Is it really the pregnancy within the tube that produces the disease and poses the threat of fatal bleeding?

The health concern is the ruptured tube. The gestation of a baby is normal, not pathological.

1. If we accept that the risk to life is posed by the abnormally located pregnancy, is there really then any moral difference between treatment methods?

Pregnancy is not pathology. Two lives are involved. Why would we ignore one life?

I do not profess to be able to answer all of the above questions to a satisfactory degree, but I think that pondering them will keep us humble and loving in our consideration of this rather complex problem and the choices made by affected couples.

Yes, it is complex. That does not mean one cannot use moral reasoning. You seem to be advocating that because an issue is complex there is no right answer therefore one should conclude all treatments are morally licit. Or, we should consider all the arguments but never draw a firm conclusion.

 

[seekerz]

I read the article with interest, because it does answer some of my questions, notably that removing the tube can also be immoral in certain circumstances.

I still am at a loss to ascertain exactly what medical criteria/technologies are available to a physician to decide in a particular patient whether the tube is diseased or not. Most physicians I know believe that the mere existence of a growing ectopic pregnancy in the tube (unless it is really very early) poses a grave risk to the mother’s life.

I guess the point I’m trying to make is that it may be practically impossible to make a temporal distinction between healthy tube and diseased tube in the typical ectopic pregnancy without running the risk of encountering ruptured tube, a grave risk to life. I’d like to hear a Catholic doctor’s opinion on this one.

Personally (I mean no offence to any experts) I think this is one case in which an unviable (unable to develop to term) pregnancy is causing risk to the mother’s life - the very process of the pregnancy developing is what poses that risk - and we interfere with that development (in one of a variety of ways) to save the only life we can. Whatever treatment is given is going to bring an end to the pregancy, so to me the only difference is the intent: namely saving mother’s life.

The line between direct and indirect attack here just never really made sense to me: remove the trophoblast while at the same time killing the baby’s cells or remove the tube while simultaneously cutting off the baby’s blood and nutrient supply, thus killing it instantly…I really wish I could see the difference.

 

[TAS2000]

You misquote me by ommitting the subject, to twist it to support your personnal feelings.

The Church does NOT demand that ANYONE “risk death”. What it does say is that you can not knowingly commit murder, which will damn you to hell for all eternity, for the sake of your convieneince. To say any less or change positions on the matter is to crumble the fabric of our belief in the Chrch as God’s infallable representative on earth. So the church is not cruel, unfeeling, driving people away etc., unless those people refuse to accept obvious TRUTH.
…The MEANS matters to the church just as much.

MY point was for the church to change stands on so obvious a position as murder being wrong would prove that religion itself is just a bunch of personnal beliefs and feelings, not OBJECTIVE TRUTH. Anyone but someone so intent on twisting the truth to make it seem uncaring and unfeeling to support their own ends could never have read this as supposed “proof” that we are afraid to question. In fact, to me, this proves the opposite. We MUST question whether or not new medical procedures fit in with the truth before we simply accept them as expedient means to an end. So again the question is does MTX treat any grave medical condition, or does it simply end a pregnancy?

 

[seekerz]

So again the question is does MTX treat any grave medical condition, or does it simply end a pregnancy?

Methotrexate treats the grave medical condition of an abnormally located pregnancy, the same condition that removing the tube treats. I know it’s difficult to accept, but without a pregnancy inside it, the tube would pose no risk to the woman’s life.

The risk is posed by the pregnancy growing in that limited space with the risk of fatal bleeding if the trophoblast causes sufficient damage to the tube. The poor baby itself poses no risk, but the trophoblast (early stage placenta) digs into the wall of the tube, weakening it and eventually causing bleeding/rupture.

If you want to consider the tube the grave disease, it means waiting until some damage is done by the trophoblast, but there is no camera in there to look at the tube and know exactly when it’s close to rupture. Practically that means, not only is the morality of tube removal versus methotrexate at issue here, but also the morality of waiting for tube damage while allowing risk to the mother’s life.

Try digesting and balancing all of that while a mother’s life hangs in the balance and any objective person will agree on this: it is no easy decision for the people involved.

 

[Doc_Keele]

I fail to see the analogy? In the case of ectopic pregnancy are you saying the baby is an unjust aggressor?

It is.

 

[Bookcat]

one can not use methotrexate…on a living child…

ncbcenter.org/NetCommunity/Page.aspx?pid=940

 

[Doc_Keele]

Why not - adults take methotrexate. What do you think the treatment for choriocarcinoma involves?

 

[fix]

It is.

The baby is innocent. In fact, one cannot imagine a more innocent person. They cannot be an unjust aggressor.

 

[Doc_Keele]

The baby is innocent. In fact, one cannot imagine a more innocent person. They cannot be an unjust aggressor.

Well you’re asserting that innocence precludes one being an unjust aggressor. This is not the case. If someone had a psychotic reaction through no fault of their own, and attacked you, they would be an unjust aggressor. They would not be morally or criminally responsible, but you would still be entitled to defend yourself.