Patients with ectopic pregnancies

[LeafByNiggle]

I don’t know how to make it clearer for you. I suspect you are focussing on the result for the child, rather than what is done. The moral difference lies in what is done, not the fact that the child will die either way.

The only immediate purpose in delivering an injection to a woman with ectopic pregnancy is to bring about the demise of the child. That act is immoral because it attacks the child - it aims to cause its demise.

Removing the tube targets the tube for it will soon rupture and that must be prevented to save the mother. Harm to the child is incidental and cannot be avoided.

I understand the distinction between the chemical injection and removing the tube. That is not what I was asking about. The only question I asked was the difference between surgically removing just the child (which you say is illicit) and surgically removing the child while contained in a tube (which you say is licit). In both cases the action does not aim to cause the demise of the child (as it clearly is in the case of the chemical injection). Both of the cases I am asking about are surgical, and seem to have the same aim.

 

[Rau]

I understand the distinction between the chemical injection and removing the tube. That is not what I was asking about. The only question I asked was the difference between surgically removing just the child (which you say is illicit) and surgically removing the child while contained in a tube (which you say is licit). In both cases the action does not aim to cause the demise of the child (as it clearly is in the case of the chemical injection). Both of the cases I am asking about are surgical, and seem to have the same aim.

Surgically removing the child attacks the child, by transporting it to an environment where it cannot live. That is the purpose of that procedure. The child is seen as a threat to the tube, so the child is attacked so that the tube is saved.

Removing a section of tube removes that which will otherwise burst. The child is not attacked but is nevertheless caught up in the procedure.

 

[LeafByNiggle]

Let me pose the question a little differently. If the only licit treatment for an ectopic pregnancy is the removal of the tube, let’s go with that. But there is no need to remove both tubes - just the one with the pregnancy. Similarly, there is no need to remove the entire affected tube, since only a small part of it is “diseased”. That is the part where the embryo is attached. What if the doctor removed only the tiniest section of the tube wall where the embryo is attached? Would that preserve the licit nature of the operation? It is still “removing the diseased portion of the tube”. The reason for doing this, of course, is to preserve as much of the fertility for future pregnancies as possible. Removing an entire tube cuts the chances of future pregnancies in half. But removing only a tiny portion of one tube might not hurt those chances at all. In view of this option, is there any reason to continue to say the only licit treatment is one that involves the destruction of the fertility of that tube?

 

[LeafByNiggle]

Surgically removing the child attacks the child, by transporting it to an environment where it cannot live. That is the purpose of that procedure. The child is seen as a threat to the tube, so the child is attacked so that the tube is saved.

Removing a section of tube removes that which will otherwise burst. The child is not attacked but is nevertheless caught up in the procedure.

Why is it not equally true that surgically removing the child contained in a section of tube attacks the child by transporting it to an environment where it cannot live? It cannot go on living in a section of removed tube. But I am actually more interested in an answer to my previous posting - about the ethics of removing the tiniest possible portion of tube where the child is attached.

 

[Rau]

Let me pose the question a little differently. If the only licit treatment for an ectopic pregnancy is the removal of the tube, let’s go with that. But there is no need to remove both tubes - just the one with the pregnancy. Similarly, there is no need to remove the entire affected tube, since only a small part of it is “diseased”. That is the part where the embryo is attached. What if the doctor removed only the tiniest section of the tube wall where the embryo is attached? Would that preserve the licit nature of the operation? It is still “removing the diseased portion of the tube”. The reason for doing this, of course, is to preserve as much of the fertility for future pregnancies as possible. Removing an entire tube cuts the chances of future pregnancies in half. But removing only a tiny portion of one tube might not hurt those chances at all. In view of this option, is there any reason to continue to say the only licit treatment is one that involves the destruction of the fertility of that tube?

The scope of the surgery on the tube is set by the capabilities of surgery. There is no desire to permanently impair the tube. The operation must leave the woman with a body that will no longer threaten her life. If that leaves a still usable tube, well and good.

 

[Rau]

Why is it not equally true that surgically removing the child contained in a section of tube attacks the child by transporting it to an environment where it cannot live? It cannot go on living in a section of removed tube. But I am actually more interested in an answer to my previous posting - about the ethics of removing the tiniest possible portion of tube where the child is attached.

We are repeating ourselves. You are again focussing on outcome, not action. We performed necessary surgery on a tube - which is plainly permissible. Harming the child could not be avoided.

 

[Rau]

… This is unlike the surgical removal of just the embryo because the death of the embryo, while probably inevitable, is not essential to the treatment. It is possible to imagine a successful treatment without the death of the embryo, even if such a treatment is currently out of reach of present technology…

When such surgical removal/transplanting of an embryo becomes possible, without certain death, the licitness of that procedure will no doubt be assessed.

 

[Prodigal_Son]

So is the “objective nature of the action” any different between the two actions:

1. Removing the embryo.
2. Removing the embryo with a tube wrapped around him.

They seem the same to me, both in intention and in the objective nature of the action.

I agree that they are the same in intention.

However, think about this: supposing the embryo was not there, and this problem were being caused by something else, it’s clear that removing the tube would not be wrong. Removing the tube is the type of action that saves a woman’s life in this situation, without being (intrinsically) the type of action that kills children. The fact that it kills a child is (in Aquinas’s terms) an accident.

Removing a non-viable embryo does, to me at least, seem like a type of action that kills children – just as leaving a child in sub-zero weather without shelter is the type of action that kills.

I agree, however, that this sort of fine distinction does not matter a huge amount with respect to moral responsibility. I don’t think ANY procedure to end an ectopic pregnancy is seriously immoral in the way that murder is immoral. But some procedures use the death of the fetus as the means of saving life, which is morally objectionable.

Consider the following two scenarios:

(1) You are allowed to rescue your family from drowning, but innocent woman who is already drowning will die if you do.

(2) You have to kill an innocent woman (say, push her off a cliff) in order to get to the place where you can save your family from drowning.

Clearly, it’s permissible to save your family in case 1, but not permissible to save your family in case 2. If the only way to save a pregnant woman’s life is by actively killing a child, such an action does not thereby become permissible. It becomes understandable, yes, but not permissible.

 

[LeafByNiggle]

When such surgical removal/transplanting of an embryo becomes possible, without certain death, the licitness of that procedure will no doubt be assessed.

Why is it that this procedure, to be licit, needs the possibility of the child living, while the other procedure (removal of the child inside a tube) does not require that possibility to be licit?

 

[Prodigal_Son]

Why is it that this procedure, to be licit, needs the possibility of the child living, while the other procedure (removal of the child inside a tube) does not require that possibility to be licit?

For the same reason that it is permissible to let a starving child die while you save a city, even though it is not permissible to starve a child in order to save a city. The first action is a good action that has a negative consequence. The second action is a bad action which has a good result.

 

[LeafByNiggle]

For the same reason that it is permissible to let a starving child die while you save a city, even though it is not permissible to starve a child in order to save a city. The first action is a good action that has a negative consequence. The second action is a bad action which has a good result.

I understand and agree. But as to the specific actions we are talking about, they don’t appear to be so different as the two actions you just cited. The tube is not diseased, except for the unfortunate presence of the child. The tube is being removed, not because it is inherently diseased, but because it has a child in it. Removing the tube is just a convenient way to remove the child. So it is hard to see how removing the tube “accidentally” removes the child. Not that I think it is immoral to remove the tube, or the child without the tube. I just think that in every moral way you can think about it, they are the same operation.

 

[Millie123]

The above refers to “formal cooperation”. All these people seek to enable an abortion. That is wrong.

I assume you do not know whether the patient’s intention is to secure an abortion, or another procedure, you have not encouraged an abortion, nor do you know what the doctor may recommend, nor what response the patient may have to the options to be discussed with the doctor. From your description, it appears you have no knowledge of any intent to seek or perform an abortion. IMHO, as I understand the facts, you do no wrong.

I do have knowledge that a surgery will be taking place…part of my tasks, after I get verification from the doctor that he will be operating on the patient… is to call in surgical staff to prepare for surgery on this patient. As far as my knowledge of whether the doctor will choose the licit way of removing the entire diseased fallopian tube vs the illicit way of just removing the baby, I do not know.

 

[Rau]

I do have knowledge that a surgery will be taking place…part of my tasks, after I get verification from the doctor that he will be operating on the patient… is to call in surgical staff to prepare for surgery on this patient. As far as my knowledge of whether the doctor will choose the licit way of removing the entire diseased fallopian tube vs the illicit way of just removing the baby, I do not know.

If you had knowledge that the doctor in question would be administering a chemical injection to “resolve” the medical condition (ie. kill the child) you would face a more difficult decision.

As I understand it, a surgery is the only licit medical procedure, though some surgical options are illicit. You are supporting a surgery. It would seem to be the case that some % of cases will be resolved by a licit procedure and some by an illicit procedure, though you never know which it will be in any particular case. The patients require transport (and a surgical team) either way. In the absence of you knowing the procedure intended, I struggle to believe that the “arranging” of transport, or calling in the team, is wrong. Even if you do know what will be done in each case, you have a reason to cooperate “materially” because it is unavoidable in performing the necessary duty of arranging transport and surgeries generally.

IMHO you are not doing wrong as your cooperation is fairly remote. If the matter continues to concern you, try to find another job.

 

[Millie123]

If you had knowledge that the doctor in question would be administering a chemical injection to “resolve” the medical condition (ie. kill the child) you would face a more difficult decision.

As I understand it, a surgery is the only licit medical procedure, though some surgical options are illicit. You are supporting a surgery. It would seem to be the case that some % of cases will be resolved by a licit procedure and some by an illicit procedure, though you never know which it will be in any particular case. The patients require transport (and a surgical team) either way. In the absence of you knowing the procedure intended, I struggle to believe that the “arranging” of transport, or calling in the team, is wrong. Even if you do know what will be done in each case, you have a reason to cooperate “materially” because it is unavoidable in performing the necessary duty of arranging transport and surgeries generally.

IMHO you are not doing wrong as your cooperation is fairly remote. If the matter continues to concern you, try to find another job.

What you say does make sense to me, thank you for taking the time to offer me an explanation, instead of telling me to just do my job. This is what I was looking for when I started this thread, I was wanting someone to help me gain clarification…thanks.

 

[weller2]

So it is hard to see how removing the tube “accidentally” removes the child.

It’s not supposed to make sense, it’s legal fiction.

Catholic ethics is not situational or consequntialist – it’s deontological. Further, it includes an absolute prohibition on feticide, with a very severe sanction (excommunication). Therefore, as far as the pure cannon law is concerned, there is absolutely no way a doctor can treat an ectopic pregnancy. Ectopic pregnancy is treated by the removal of the embryo, which, by definition, constitutes an abortion – an this is excommunicable in any and all circumstances. Further, if you were to take a gun and shot a woman with ectopic pregnancy in the head, then you are in less trouble then if you removed ectopic pregancy – because murder is nor an excommunicable offense, while abortion is.

The only way that a Catholic doctor can treat an ectopic pregnancy is to resort to a legal fiction based on the double effect principle. Justifying a forbidden act (in this case, abortion) under the double effect requires you to fulfill 4 conditions:

(1) The nature-of-the-act condition. The action must be either morally good or indifferent.
(2) The means-end condition. The bad effect must not be the means by which one achieves the good effect.
(3) The right-intention condition. The intention must be the achieving of only the good effect, with the bad effect being only an unintended side effect.
(4) The proportionality condition. The good effect must be at least equivalent in importance to the bad effect.

(4) is obvious.

(3) essentially means that you are allowed to hand-wave all the bad effects as long as you claim that you wanted to achieve only the good effect, and there was just no way you could have avoided the bad effect.

Regarding (1) the problem is that Catholicism ethics assigns moral value to the action itself, irrespectively of the circumstances. Helping the poor is good, even if you are helping them with stolen money. Abortion is evil, even if you are trying to save the woman. This criterion is also the first reason why removing the fetus from the tube is illicit – it is abortion by definition, therefore illicit, end of story. But removal of the tube is morally neutral – it does not kill anyone.

But, aren’t we removing the tube because there is a child inside? Well… no. We’re removing the tube, because it will rupture and we’re keeping quiet on the reason why it will rupture. This is how we satisty condition (2) of the double effect. If we remove the tube, then it will not rupture, simply because it is no longer there! Now, the removal of the tube will kill the embryo – this is true. But (2) does not demand that the bad effect does not happen – it demands, that the bad effect does not happen because of the good effect. The embryo dies because the tube was removed, not because the tube will not rapture. What (2) demands is that you must demonstrate that there is no causal relationship between the effects.

A simple way to visualize it is by flipping dominos. Say you have one white domino (good effect), and one black domino (bad effect). If you flip the white domino, so that it falls on the black one, then the flipping of the black one proceeds from flipping of the white one – this does not satisfy the double effect. On the other hand, if you take some green dominos and place them so they will independenly flip both the white and black after you initiate the process – then this falls under the double effect.

Now, if you go all the way back and read the Gospel, then you will realize that this kind of ethical hair-splitting is exactly what Jesus was criticising Pharisees for.

 

[Rau]

…But, aren’t we removing the tube because there is a child inside? Well… no. We’re removing the tube, because it will rupture and we’re keeping quiet on the reason why it will rupture…

No, we’re not “keeping quiet” on the reason the tube will rupture - we know all too well (sadly). The reality is - the reason does not matter. Leave the tube to rupture, and the woman will likely die. The only treatment that can be applied to the woman’s body is the removal of the tube (or part thereof) and the woman is entitled to treatment directed at her body. The attendant side-effect is well understood (sadly).

There are many other circumstances where the same principle is applied to discern the moral course. It is not specific to ectopic pregnancies or medical matters.

 

[weller2]

No, we’re not “keeping quiet” on the reason the tube will rupture - we know all too well (sadly).

Oh, but yes you are. If you were to simply acknowledge that ectopic pregnancy is always treated by removal of the embryo (with or without the tube), then you’d have to agree that any procedure aiming to treat this must fall under CCC 2271, as removal of the embryo is means to preventing rapture of the tube.

The tube is not diseased, except for the unfortunate presence of the child. The tube is being removed, not because it is inherently diseased, but because it has a child in it.

The truth here is that a diseased tube is a moral/legal fiction created to avoid having the procedure classified as abortion. The tube will not rupture because it is inherently faulty – it will rupture because the growing fetus will subject it to stresses larger than it is intended to handle. (Blaming the tube is akin to trying to to pump a 2bar car tyre to 10bar, getting maimed in the resulting explosion and then suing the tyre manufacturer for a faulty product.) However the diseased tube smoke screen allows you to treat the resulting fetal death to a secondary, unintended consequence instead of means to saving the woman – it makes the abortion indirect, and so CCC 2271 no longer applies.

The reason a Catholic doctor must resort to this moral fiction is because the Catholic Church, contrary to Jewish law, denies the woman right to self-defense in this scenario and throws in an excommunication sanction to boot. This results in a paradoxical situation where removing an ectopic pregnancy without resorting to the above excuse carries a much more severe canonical sanction than murder. Yup, saving a woman’s life will get you excommunicated while intentionally killing her will not.

If CCC 2271 and related sanction were simply dropped, then, per CCC 2270, abortion would have been simply equated with homicide. This would end the absurd distinction between direct and indirect feticide, and therapeutic abortion would be a licit form of self-defense provided all other treatment options were exhausted (this follows naturally from applying CCC 2264 in this situation).

 

[Rau]

Oh, but yes you are. If you were to simply acknowledge that ectopic pregnancy is always treated by removal of the embryo (with or without the tube), then you’d have to agree that any procedure aiming to treat this must fall under CCC 2271, as removal of the embryo is means to preventing rapture of the tube.

The truth here is that a diseased tube is a moral/legal fiction created to avoid having the procedure classified as abortion. The tube will not rupture because it is inherently faulty – it will rupture because the growing fetus will subject it to stresses larger than it is intended to handle. (Blaming the tube is akin to trying to to pump a 2bar car tyre to 10bar, getting maimed in the resulting explosion and then suing the tyre manufacturer for a faulty product.) However the diseased tube smoke screen allows you to treat the resulting fetal death to a secondary, unintended consequence instead of means to saving the woman – it makes the abortion indirect, and so CCC 2271 no longer applies.

The reason a Catholic doctor must resort to this moral fiction is because the Catholic Church, contrary to Jewish law, denies the woman right to self-defense in this scenario and throws in an excommunication sanction to boot. This results in a paradoxical situation where removing an ectopic pregnancy without resorting to the above excuse carries a much more severe canonical sanction than murder. Yup, saving a woman’s life will get you excommunicated while intentionally killing her will not.

If CCC 2271 and related sanction were simply dropped, then, per CCC 2270, abortion would have been simply equated with homicide. This would end the absurd distinction between direct and indirect feticide, and therapeutic abortion would be a licit form of self-defense provided all other treatment options were exhausted (this follows naturally from applying CCC 2264 in this situation).

The tube is not being “blamed”. The facts are fully understood and acknowledged. There is no conspiracy! The tube is the thing that, by rupturing, will bleed and cause depth.

If the child were safe within the womb, but due to some weird effect, were causing a tube to rupture, we would still be required to remove the tube, not attack the child, though both may save the woman.

 

[bbentrup]

LeafbyNiggle, my understanding is that you are correct.

Intentional killing of innocent human life, in Catholic understanding, can never be directly intended either as a means or an end. If there are viable alternatives to an indirect action that is substantially likely to result in death, those alternatives must be used first.

Current science says there are no viable alternatives in the case of ectopic pregnancies.

In the removal of the fetus, but not the fallopian tube, the intent must be examined. As far as I understand, the Catholic definition of intent is synonymous with desire, whereas in other systems of analysis, presumptions are made with respect to consequences if they are substantially certain to result. Again, I think Catholic theology is willing to make distinctions where appropriate. An action that will lead with substantial certainty with death is not necessarily the same as intending that death.

If the intent is to destroy life, the direct removal of the human embryo is clearly immoral. This would parallel the case of killing the embryo in the fallopian tube. If the principal intent is to save the life of the mother by intending to kill the child, that is a bad means to a good end, and also immoral.

However, if the intent is to save the the mother’s life [end] by direct removal of the human embryo with the sincere hope that both can be spared [means], there is no illicit intent. Removal is not intrinsically harmful (for example, Caesarean births), only circumstantially so (before 22 weeks). It doesn’t matter in Catholic theology that there is a substantial certainty that the human embryo will die (though if abortion were illegal, it might rise to some legal problems). The moral obligation is to give the removed embryo ordinary care under the circumstances, which might mean preparing incubation for some amount of time.

In such a removal process, the outside observer may not be able to discern whether the intent of the mother or doctor is morally unlawful or not; only God who knows the decisions of the heart can truly judge.

Since this procedure is likely morally permissible, whether the tube is removed or not would be technically morally irrelevant as long as it doesn’t affect the survival percentage either way.

**

 

[Rau]

However, if the intent is to save the the mother’s life [end] by direct removal of the human embryo with the sincere hope that both can be spared [means], there is no illicit intent. Removal is not intrinsically harmful (for example, Caesarean births), only circumstantially so (before 22 weeks). It doesn’t matter in Catholic theology that there is a substantial certainty that the human embryo will die (though if abortion were illegal, it might rise to some legal problems). The moral obligation is to give the removed embryo ordinary care under the circumstances, which might mean preparing incubation for some amount of time.

In such a removal process, the outside observer may not be able to discern whether the intent of the mother or doctor is morally unlawful or not; only God who knows the decisions of the heart can truly judge.

Since this procedure is likely morally permissible, whether the tube is removed or not would be technically morally irrelevant as long as it doesn’t affect the survival percentage either way.

**

There is no prospect of saving the child with current technology. The death of the child as an indirect, undesired, unintended but unavoidable consequence of removing the tube before it ruptures is fully understood.

Removing just the child (alive) would be a better alternative were such a procedure viable (ie. in the best interests of both patients). Of some interest would be the question of what survival rate such a future procedure must have (for the child) for it to be considered the preferred course of action It currently would have a zero% survival rate (essentially instant death) and this together with the fact the procedure is directed at the child causes it to be viewed as attacking the child.