Friday, November 16, 2012

Clear principles and muddled thinking (in which I apologize for yesterday, among other things)

I want to start this post by apologizing for the extremely muddled thinking going on in yesterday's post; I blame late night noveling, excess caffeine, allergies, and Benadryl (tm).  In that order. :)

No, seriously, I do know that simply delivering an extremely pre-viable child in a dangerous situation isn't a moral option.  There has to be an underlying pathology of the uterus itself; the classic example is removing a cancerous uterus that unfortunately also removes the pre-viable baby.  Where I erred in yesterday's post was not pondering and describing exactly what others were saying about the condition of the uterus should it be badly infected by infected amniotic fluid, infected placental tissue, etc. and also--if I may be totally honest--in thinking in my muddle-headed way that 17 weeks was closer to viability than it actually is.  I've made this mistake before; the record for survival is held by a baby born at 21 weeks and 5 days gestation, but I always think survival has happened earlier than that until I go check the records.  Could a woman in a potentially fatal crisis situation whose unborn baby was at least 20 weeks gestation attempt delivery with a full neonatal intensive care team on standby in the hopes of making medical history, or would such an attempt be morally invalid?  That is the sort of thing a well-trained Catholic moral theologian would have to answer, but it's clear that 17 weeks is much farther away from the record survival age to make the attempt in any serious way at this time with today's medical technology.  But can a doctor remove badly infected amniotic fluid and placental tissue which is actively killing the mother knowing that his action will have the side-effect of making it necessary to remove from the uterus a baby who cannot survive outside of it?  That is the situation that might--I stress that word--be able to be discussed from a double-effect standpoint.  Whether or not it would be morally possible to make that call is something I'm not prepared to state definitively, but I will say that it would seem to be within the realm of a morally valid, though tragic, option; I would appreciate any knowledgeable person weighing in on that, by the way, as I would like to learn more about this.

But, again, the problem in the case of Savita was not that nobody wanted to discuss difficult moral options; it is that a real possibility of medical negligence exists.  I think we'll find out more eventually about this specific case.

With that, though, I'd like to discuss something I've been pondering in regard not only to this case, but to the underlying principles.

I think that most practicing Catholics, when we discuss what may or may not morally be done in these extreme situations, really do want to form our minds according to Church teaching.  We're not looking for loopholes or "outs" that will let us tiptoe right up to the line of abortion.  That's because the guiding principle here is "Save both the mother and the baby, and take heroic action to do so if necessary and possible," not "How can we get away with abortion without calling it that?"

Unlike the internet discussions of torture among Catholics, then, the principle "Save them both," remains the clear guiding principle.  When the topic is torture, "Treat prisoners humanely" should be the guiding principle, but it often isn't.  I think we can see a difference; with all the speculation on Catholic blogs about what could have or should have been done to save Savita, I have not seen any sincere Catholic saying or even hinting that the Church should just accept abortion in hard cases; but Catholics regularly seem to say or to hint that waterboarding or enhanced interrogation should stay on the table in the hard cases--the ticking time bomb scenarios, and so on.

The danger of stepping away from the clear principle is that we start looking for justifications to do evil instead of the best ways to do good.  If Savita's health care workers at that Catholic hospital had been committed to the principle of saving both the mother and the baby even if heroic measures were necessary, I doubt we'd even be having these conversations right now.  Instead, though, it seems (again, if the news stories are accurate, which as some have pointed out is a pretty big "if") as though poor and even possibly negligent care of both the mother and the baby is what led to the tragic outcome.

I would caution those commenting on this story to avoid one thing, and that is playing into the hands of the pro-abortion stereotype out there which accuses Catholics of being deeply misogynistic and not caring what happens to a pregnant woman--in other words, having a bias toward saving the baby at the expense of the mother, or of promoting the idea that some pregnancies are fatal and we should just accept that as God's will.  Sure, life itself is fatal, and none of us are getting out of it alive; but that doesn't mean that we should stop treating diseases or no longer fight to save lives in emergencies ranging from car crashes to fires to trauma to various forms of sickness.  I can't imagine anybody saying, "Well, sometimes a car crash will be fatal, so maybe we should just accept the possibility of a fatal car crash as the risk of driving instead of working to avoid crashes and rushing crash victims to hospitals, etc." and yet I've heard people take a similarly dismissive attitude about pregnancy and especially those pregnancies made riskier by diseases or infections.  What we should do, if we really want to follow Catholic principles, is work to promote greater understanding of pregnancy and how to recognize early warning signs of risks; encourage better prenatal care across the board; aid pregnant women in the task of effectively communicating their symptoms and health concerns with their doctors; support doctors who are trying to come up with new and better ways to treat women in high-risk pregnancies or crisis situations; and support medical interventions designed to save the lives of both mother and child, including, perhaps, a future possibility of delivering a 17-week fetus and placing him or her immediately in some sort of high-tech incubator that will actually allow him or her to continue to grow and develop in those situations where no other option is possible.

And part of that, for us Catholics especially, would be a more realistic understanding of the benefits of natural family planning and the abandonment of a fatalistic attitude about pregnancy and childbirth which fails to treat women with their proper measure of inherent dignity.  But I think that that is a post for another day.


Rebecca in ID said...

I agree with everything you've said. Thanks for clarifying. I especially appreciate you second to last paragraph--I actually almost added a comment to my last comment to this effect--I should have emphasized that the baby's life is not to be considered of more value than the mother's, and that everything should be done to ensure the safety of both mother and child. You articulated that well; thank you. In stating that we as followers of Christ have to be ready in all areas of life to be ready to die rather than do wrong if necessary, I do not mean to dismiss or devalue anyone's life. I understand that those who may want to resort to torture may have in mind the saving of innocent lives by obtaining this information--and while I do not support the use of torture under any circumstances, I would not want to dismiss or devalue the lives of the people at risk, either. Sometimes when we are clarifying principles we can seem cold or distant in our language, but in order to act humanly while abiding by those principles, we need to act in a spirit of great compassion and care for each person involved.

Red Cardigan said...

Well said, Rebecca! Thanks! :)

In that last paragraph I'm really thinking especially of those Catholic writers who sometimes make it seem as though to be a wife and mother is to take upon oneself the *duty* to die if that's what it takes in the pursuit of the goal of a large family (because for whatever reason they are suspicious about NFP). Luckily that attitude only seems to prevail among a select few, but I sometimes wonder if the people who accuse Catholics of not caring about women's lives are reading those sorts of opinions and taking them as the standard.

JoAnna Wahlund said...

I wasn't in on yesterday's discussion, but I think you were originally correct, RC. The USCCB says:

"47. Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child."

So, if the only way to cure the lethal infection was to deliver the baby (and thus remove the infected amniotic fluid/placenta from the uterus), that would be permitted under moral law, even if the baby wasn't viable.

geeklady said...

I think it is especially important to remember how little we know of her medical condition. She died, not from e miscarriage, as I u derstand it, but from a highly Ab resistant strain of E. coli and blood poisoning. Did she present at the hospital wit the infection, or did she acquire it at the hospital?

When and where she acquired the infection are questions highly pertinent to her death. Her odds, once she had acquired the infection, we're not good.

geeklady said...

Forgive that horrible grammar - Blogger wont let me go back to an error in the comment box and change it when I'm commenting from my iPad.

eulogos said...

Jo Anna Wahlund,

What you say *may* be the case in this specific situation, as there is an organ, the placenta and amnion, which harbored the infection and the removal of which might save the mother, thus incidentally killing the child.

However, if the reason the mother's life was in danger was, say, pulmonary hypertension as in the Kansas City case, then it would clearly not be licit to perform an abortion to save the life of the mother. The death of the fetus can never be the *means* by which the life of the mother is saved, as this would involve a direct attack on the life of the child.

Susan Peterson

eulogos said...

Geek Lady,

If she had an highly antibiotic resistant strain of ecoli, she may well have gotten it in the hospital, where the most resistant strains hang out. However these strains do get out into the community as patients, doctors, nurses, nurse aides, and visitors leave the hospital. So perhaps she already had it when she came in.

You are right that her prognosis was poor as antibiotics don't transfer well to the placenta and amnion.

As I wrote on the other thread, I think that there is a possibility that this was the result of a self induced abortion, as this was how women who did this used to present. But not necessarily, of course.

AS in most of these notorious situations, the commenting public, including ourselves, never ever has access to all the medical facts of the case, which of course is right, since we don't have a need to know, but which I also find very frustrating.

L. said...

Since I believe a woman should have the right to abort even a perfectly healthy pregnacy (and I truly believe I would do so myself), I can't contribute much to the abortion part of the discussion.

But what I have been saying, in comments on blog posts about this subject, is that perhaps this is also an issue of medical protocol for non-viable pregnancies.

Of course I don't know, but I wonder: Since some antiobiotics can cause birth defects, did the hospital have some firm rule against giving very strong antibiotics/narcotic pain relief to pregnant women, with no exceptions?

I think that even most pro-life people would agree that treating women with non-viable pregnancies, SHOULD be very different from treating women pregnant with babies who have zero chance of survival, such as in this case.

L. said...

Oops, of course I meant treating women with viable vs. non-viable pregnancies.

Maybe the doctors and nurses truly believed that a miracle was possible in this case, that the infection would resolve itself, the pregnancy would continue and the baby would be born, so that was why they withheld antibiotics and pain relief?

Red Cardigan said...

Susan (eulogos) has this right in terms of the principle. Treating a disease of pregnancy in such a way that the pre-viable baby is removed is morally licit IF the disease is located in the uterus and the treatment necessarily removes the baby. Otherwise, as in her example of hypertension, the baby can't be removed.

But even in a case of hypertension, or of cancer elsewhere in the body, etc. it IS morally licit to treat the disease even if the treatment may or even will kill the unborn baby. For example, suppose a high dose of a specific blood pressure medicine would control hypertension, no other drug would work, but the side effects of that drug would include a strong probability of fetal death--the medicine could still be used if it were the best or only option.

I'm very intrigued, Susan, by your suspicion re: attempted self-induced abortion; I wondered about that myself, but I suppose we'll have to wait for further details--if they're ever forthcoming. (For instance, the child was 17 weeks gestation, yet I've seen no mention anywhere regarding gender--has anyone seen that? I'm curious.)

L., the kind of thinking you describe (e.g., don't give antibiotics in case they cause fetal death) would not be medically appropriate even in a Catholic hospital in a Catholic country. I think something else happened, but whether it was malpractice, a failed abortion attempt, or some combination we may never know for sure.

Forgive me if it takes me a while to get back out here--I'm battling a migraine, alas, and am turning in early. :)

L. said...

Red, the thinking behind withholding drugs in case they cause fetal death DOES happen sometimes, whether medically appropriate or not. I'm suggesting this MIGHT have been the thinking behind the decision to withhold them in this case -- just conjecture, nothing more.

Similar to this:

geeklady said...

E. coli ESBL is the strain I've seen referenced - not being familiar with it, I looked it up. It appears to be spreading through the UK and is associated with UTIs. It's unknown how common it is in human gut flora. But with all of this together, I think her acquiring a UTI from this strain which led to both miscarriage and death the most plausible theory, based on the information available.

I thought about this being a self induced miscarriage, especially after the news about the Irish counseling service advising women to lie about attempting pharmaceutical abortions when they presented with a miscarriage. But it both required to many suppositions on my part and was uncharitable enough that I thought it shouldn't be brought up without information explicitly supporting it. It I was in the position of investigating the matter, it would be something to look at, and I would as part of due diligence. But I'm not involved, so I'm just going to leave that bit of speculation aside.

geeklady said...

Also, L, I've known lots of doctors, both Catholic and otherwise. "Hoping for a miracle" behavior is... Well, laughably uncharacteristic of a doctor. Doctors, even people of strong faith, are unrelentingly practical. They have to be, because medicine is not like science, where chasing something down it's rabbit hole can turn out to be unexpectedly rewarding.

...I could expound more in the differences between medicine and science, doctors and scientists, but I've got a major meltdown happening. I'll be back. Maybe.

vera said...

Failed abortion attempt? C'mon folks, show some mercy! This was a well educated woman savvy to the dangers of trying to abort at 17 weeks... a dentist, I think they said... no way.

True that for a sleuth, all options are fair game. But at least wait for some real data, before you rush in besmirching the good sense and sanity of this woman.

Red Cardigan said...

Well, look, Vera (and GeekLady too) I don't think it's uncharitable to look at all possible options when reading unclear reports in the news. I've done that many times when reading about unsolved murders, for instance. It's a mental exercise, not an attempt to be uncharitable to real people--even though the people I'm thinking of as "suspect A" or "suspect B" are actual people.

And in the certain populations sex-selection abortions are unfortunately common, but fetal gender is often not discovered until an ultrasound at about 16 weeks. Since septicemia is a known complication of later abortions as well as miscarriages, the possibility of something like this did cross my mind.

But later news articles have made it seem as though this wasn't even a miscarriage in the defined sense, let alone a possible abortion. What it seems like is a simple case of preterm labor, badly mismanaged. Preterm labor can, indeed, be hard to deal with, but I don't understand the long timeline in which antibiotics were not given even though the infection had apparently already arisen.

Again, I don't think speculation is meant to be uncharitable or unmerciful to the deceased woman--or to the hospital staff, for that matter; like I've said, I think this looks like medical malpractice, but I'm not intending a lack of charity to the medical staff in that speculation, and have said all along, and still say, that we need the whole story. This is just one more reminder that we can't take either news articles or the grief-stricken husband's word as to what happened as some sort of manifest truth--we have to wait for the whole story before we'll really understand what happened.

vera said...

More info from some news website:

"The decision to induce labour early would be fully in compliance with the law and the current guidelines set out for doctors by the Irish Medical Council. Those guidelines allow interventions to treat women where necessary, even if that treatment indirectly results in the death to the baby. If they aren't being followed, laws about abortion won't change that. The issue then becomes about medical protocols being followed in hospitals and not about the absence of legal abortion in Ireland.

It is possible that new legislation is necessary to clarify the existing medical consensus. But it does not logically follow that Ireland needs a total rethink of its entire approach to abortion that brings it in line with Europe’s essentially pro-choice culture. Aside from the specific medical case for abortion in Savita’s situation, inducing labour to save her life would not necessarily have conflicted with Catholic moral teaching, either. In 1951, Pope Pius XII explicitly ruled that such a procedure “can be lawful.” If it is true, as the Halappanavar family claims, that the Galway doctors said they would not provide a termination because "this is a Catholic country", then they got their theology unforgivably wrong."

L. said...

Odd, that "failed self-abortion attempt" appears to be a valid conjecture worth considering, while "doctors withholding antibiotics for fear of the rare chance of harming a potentially viable fetus" is laughable?
Pro-life doctors sometimes make ridiculous mistakes, too.

eulogos said...

A quibble unrelated to this situation which might be relevant in another one: the Kansas City case involved PULMONARY hypertension, not plain hypertension i.e. high blood pressure. Pulmonary HTN is high blood pressure in the pulmonary artery which carries blood from the heart to the lungs. It is a very separate medical issue from systemic hypertension. Pregnancy can cause this condition to worsen and this can be fatal. When we discuss such issues, we ought to be careful about the medical issues involved, at least to the degree we are able to know them.

Paul C. said...

Red Cardigan: "But can a doctor remove badly infected amniotic fluid and placental tissue which is actively killing the mother knowing that his action will have the side-effect of making it necessary to remove from the uterus a baby who cannot survive outside of it?"

First point to note is that "placental tissue" is shared between the mother and child, though comprising mainly of cells derived from the child. To remove placental tissue is thus to act directly on the child. So, the double effect reasonings that permit (e.g.) the removal of failing fallopian tubes in an ectopic pregnancy are not applicable.

Secondly, and more importantly, the question you ask has already been answered by official Catholic teaching. The first question and response, found in the link here, certainly seems to address the question raised. How does it not?

Red Cardigan said...

Paul, with all due respect, that link you shared contains an opinion that even an ectopic pregnancy cannot be removed before the sixth month of gestation--but ectopic pregnancies do not proceed that long, because both the mother and the baby will die long before that time frame is reached.

As to the question of the removal of infected uterine contents including amniotic fluid, placenta, etc. or even the whole infected uterus--I would defer to the Church on this as well, but I think that more recent statements might be helpful.

A final note: when I was 14, I met a lovely Catholic lady of 92 who lived in a nursing home. This woman lost her only sister long before because at the time the Church--or, rather the Church's authorities where she lived--completely forbade cesarean sections in Catholic hospitals, and her sister died in childbirth when a c-section would likely have saved her. This lady saw this as a great mystery, especially since a few years later the local authorities of the Church began permitting c-sections in Catholic hospitals; but she did not lose her faith or her trust in God over the situation.

This is why I think there's a twofold danger in "hard case" situations. On the one hand, we must not violate clear principles, such as performing actual abortions. On the other, we should not forbid out of hand what the Church might allow, such as removing diseased uterine tissues or the whole infected uterus in a life-threatening situation that will kill both mother and baby if left untreated. I have a feeling that the Catholic hospitals in my friend's story were lagging behind Church permission for c-sections (which it would seem had already officially been granted), and that if proper communication with the right authorities had been facilitated, my friend's sister and her child might have lived. God's will is a mystery, but that doesn't absolve people from investigating the moral options as fully as possible in these kinds of situations.

Again, my concern here is that we not play into the hands of the pro-abortion zealots who accuse Catholics of abandoning women to die in these situations. We don't, and we need to demonstrate the sort of compassion that shows that we will take heroic means to save both the mother and the baby, and equally heroic measures to save the mother if the baby cannot be saved (such as in the cancerous uterus situation).

vera said...

What a mess. I am getting more and more confused. Has anyone seen a statement from the hospital, or any of the witnessing docs or nurses?

Red, if the story the elderly lady told you is true, then Catholics do sometimes "abandon women to die in these situations." Face it. You can't tapdance it away. Face the harm done without flinching, without hiding behind historical rule-books, without avoiding the remorse that is the key to turning around, for individuals or for an institution.

If you can do that, you will win the support of non-Catholics who understand that all human beings are fallible, and will not hold that against any of you. But heeding church rules and worrying about church reputation before and above the fate of any one human being... that is just plain unsavory regardless of the labels. And there is plenty of that in the church's history. And too little responsibility for it.

Red Cardigan said...

Vera, I think it's more complicated than that. Recall that prior to antibiotics and modern surgical methods, a c-section was most of the time a death sentence for the woman. The thinking was: either the woman and child will both die (because the woman couldn't deliver the baby) or we might be able to save the child, but the mother will likely die. The Church, rightly I think, rejected that kind of thinking as wrong, and, in fact, had a record of opposing some other types of surgery that had nothing to do with childbirth because of the abysmal success rates and risk of complications.

Modern medicine, particularly antibiotics, changed the equation for c-sections (and most other surgeries). The Church actually did respond to that; the link Paul shared above showed the Church in the late 1800s allowing c-sections. But my friend's sister, delivering somewhere around 1910, was denied a c-section by *somebody* claiming that the Church didn't permit them. That person, or those local authorities, didn't have the story right.

That's why I brought this up in this particular discussion. If someone did actually claim to Savita and her husband that Church teaching didn't allow *any* options other than letting her die of a raging infection than that person was wrong. It may be--and I think it will end up being--that the medical protocol being followed (as I saw on another website) demanded that Savita be stabilized before *any* surgical procedure was attempted; stabilization did not require removal of her still-living fetus (apart from the moral questions) and in fact that would not have helped if she was too sick for a surgical procedure to be anything but a greater burden and risk to her. Before further options were discussed the child did die, and his or her remains were, in fact, removed. By then it was too late--but that brings us back to the question as to whether the initial treatment of the infection and an attempt to stabilize Savita was sorely lacking in terms of basic care, which to me is the real question in this case.

Paul C. said...

Red Cardigan: "with all due respect, that link you shared contains an opinion that even an ectopic pregnancy cannot be removed before the sixth month of gestation"

No, the ruling does not say that. "Six months" is given as an example in the question. The answer first rules that it is not permitted to extract immature embryos (i.e. non-viable). Then the answer goes on to address the time aspect (where it says "As to the time..."), and indicates how to decide on what might be an appropriate time.

I see nothing problematic with the ruling, and it is just as true today as when it was first made. Perhaps you could further explain your point?

Red Cardigan: "but ectopic pregnancies do not proceed that long, because both the mother and the baby will die long before that time frame is reached"

But what has the genuine seriousness of the situation got to do with your complaint about that ruling? (And I don't understand why you put "with all due respect".)

Red Cardigan: "the Church--or, rather the Church's authorities where she lived--completely forbade cesarean sections in Catholic hospitals"

There is no general Catholic doctrinal problem with cesarean sections. Much the opposite, since as they became safer they were a morally welcome solution to many problems where the doctors of the time all too often resorted to craniotomy. (I wonder if there was some other problem relating to the C-sections. Perhaps people were taking the opportunity of a C-section to also become sterilized, and there were too many unjustified C-sections for that reason).

Red Cardigan: "Modern medicine, particularly antibiotics, changed the equation for c-sections"

No, C-sections started to become much more common somewhere around the 1920s, when the techniques of sterile surgery had become fairly reliable. (Antibiotics weren't around much until a couple of decades later.)

Red Cardigan: "the link Paul shared above showed the Church in the late 1800s allowing c-sections"

To be precise about this: Church teaching had never forbidden C-sections. The allowance here doesn't imply that something was forbidden previously.

L. said...

C-sections were certainly discouraged in Ireland in favor of symphysiotomies. C-sections were seen as "morally hazardous, capping family size and leading to sterilisation and contraception."

Red Cardigan said...

But, Paul, *all* babies removed via the common surgical procedure to remove ectopic pregnancies are non-viable. Because of where and how they are growing, they will kill their mothers *and* die themselves if an attempt is made to allow them to grow to the 22nd or 23rd week past gestation, the earliest survival age. Yet the Church has thus far permitted this under the principle of double effect. The same thing is true in the removal of a cancerous uterus when the baby is still a long way from viability.

But you see, all of these points are a reason why I think that these situations need to be addressed by competent moral theologians in a case-by-case basis. There's too much of a hazard for lay people to say, "Well, Church teaching forbids this completely, so women just have to accept that pregnancy might be fatal," which is not something the Church has said. She is careful to forbid direct abortion outright, but she does allow considerations of double effect to apply in other dire situations.

eulogos said...


First of all, about your lady who said C sections weren't permitted, perhaps she had the story wrong, as people often do have medical stories wrong?
I had never heard of C sections ever being prohibited.
However, there was a time when the uterus was not even sewn back up after a C section, and even when it was, there was no confidence that another pregnancy could be handled, so I can see that this would lead to medical advice not to have any more children, which would pose a moral problem for the couple. Still, I don't see a principle by which the church would have absolutely forbid them. It is obvious that a C section used to be a very dangerous operation, and when they were only undertaken after a long difficult labor (with no IV fluids) the mother would likely be exhausted and dehydraded and a poor surgical candidate. The pubic symphysectomy (I think that would be the term rather than -otomy, because a a -sectomy is a cutting but an -otomy is a removal) is still sometimes used in very primitive conditions; it produces debility for the woman but not death. I had never heard of a time when it was used outside of, say, Africa. L, I am curious, what is the source of your information. It sort of makes sense if C section was often a fatal operation at the time while the cutting of the cartilage of the pelvis was not. But then, why would the lady's sister have died, if there was an alternate operation that would have worked? Perhaps the baby was still not deliverable due to an unfavorable position like transverse lie?

The "death of the mother" situations I had heard about was where the alternatives were C sections, from which the mother was likely to die, vs, craniotomy which collapsed the baby's head, as in a partial birth abortion, except that the head was still inside the mother. Old OB books always described how to perform these destructive operations as a last resort and showed pictures of the tools for them. The movie "The Cardinal" turns on an issue with his younger sister, who had been in labor for days and then was taken to the hospital, "too late" for her to be safe to have a section. He refuses to give permission for the destructive operation and his sister dies. He finds this a very heavy moral weight to bear, but eventually is consoled by the beautiful young woman that the baby becomes. There is a chapter in the (anti-Catholic) book "American Freedom and Catholic Power" published in the 1940's about this issue, which ceased to be an issue soon after its publication because of the increasing safety of C section.

There may remain a few extremely rare "mother vs baby" situations in obstetrics. The Catholic principle still stands that we cannot choose between these two lives but must do all we can to save both. We cannot kill one so that the other may live. If both die by natural causes,this is something we must bow to until medicine can save both. To kill one of them would be mortal sin, which is to be feared much more than death. This really becomes a case where the values of those who see only this world are going to be different from those who are not living for this life but for the life to come.

Susan Peterson

Paul C. said...

Red Cardigan: "But, Paul, *all* babies removed via the common surgical procedure to remove ectopic pregnancies are non-viable."

Hmm. In the question addressed to the Holy Office, the questioner aks whether, in particular life-threatening circumstances, it is permitted to perform an abortion. Both the questioner and the Holy Office would well understand that the proposed abortion would be a direct abortion. I.e. one where the goal and purpose of the operation was to carry out an abortion. Neither the questioner, nor the Holy Office, nor any theologian familar with the circumstances, would think that the ruling applied also to indirect actions.

The Church permits the removal of fallopian tubes in the case of ectopic pregnancies, and the removal of the uterus in the case of a mother's cancer, because they can (in applicable circumstances) be justified as indirect. I.e. actions where the immediate goal and purpose is something other than the death of the child.

So that ruling made sense at the time, and still makes sense. Are you still not seeing this?

Red Cardigan said...

No need to get snarky, Paul! We're on the same side on this.

I think that it is *possible* that the removal of badly infected uterine contents and fluids which *also* meant removing the not-yet-viable baby *might* be an indirect action similar to the removal of an ectopic pregnancy or the removal of a cancerous uterus or section of the uterus from a pregnant woman. I think that the question as to whether, to be morally licit, the whole infected uterus would have to be removed (not just the badly infected contents) is one for the moral theologians in a case-by-case basis. If it were possible for the uterus *not* to be removed when the contents were removed then the possibility that the woman could have another child someday would exist; on the other hand, if the uterus had to be so badly infected as to be non-salvageable before it could licitly be removed it would probably be too late to save the mother's life anyway (though as a non-medical person I do not know).

But that's why I keep cautioning people not to take articulated Church teaching about *different* situations and automatically apply them in such a way as to demand a mother's death in another type of situation. Most of us aren't moral theologians and don't know how the principles articulated thus far would be applied to an infected uterus during a pregnancy in which septicemia has set in.

Red Cardigan said...

Well, she was 92 years old, Susan! :) But she did have the impression that the family was told c-sections were immoral and forbidden by the Church, and that a short time later the Church reversed this understanding of c-sections. But, like I said above, I don't think that was *official* Church teaching, just how Church teaching was being applied at the local level.

eulogos said...

Regarding the ectopic pregnancy situation, Red is right about what the standard argument is, but the situation is not really so simple.

If one uses the "diseased organ" rationale for dealing with pregnancy in the fallopian tube, then the usual method for dealing with fallopian ectopics these days, flushing the tube with methotrexate before it ruptures, removing the embryo and sparing the tube, would be immoral, since this procedure solves the medical problem by a direct attack on the embryo. One would think Catholics would have to refuse such a procedure, and that Catholic hospitals could not perform it. But when I looked at the web sites of some major Catholic hospital groups, such as Ascension Health Care, I found this was not the case. A Catholic doctor on one blog thread also stated this.

That doctor pointed out that although most ectopic pregnancies are in the tube, of which we have one to spare, some implant on the outside of the uterus, a much more difficult situation for the woman. And some implant on other abdominal organs, or on the peritoneum, which we cannot spare. How does one rationalize the removal of an embryo developing on the peritoneum or part of the intestines? One cannot remove all of the peritoneum or intestings. Would one argue that ony the little area around the embryo is defective and require that a little square of peritoneum be removed with the embryo, as opposed to just scraping the embryo off? How big a square? Why wouldn't just the few cells which come with when the embryo is scraped off count as removing a defective organ? According to an OB mentioned above, the doctors use the rationale that bleeding is the abnormal condition they are trying to stop, that stopping the bleeding is their intent, and removing the embryo is the unintended side effect of stopping the bleeding. I would say that this is a dubious argument. But it is the one used. And from there, they manage to rationalize the methotrexate treatment, which is standard of care now, unless a tube is already ruptured. Most of these are caught now before they rupture because of widespread availability of CT scanning.

So what do you think, Erin, about a pregnancy implanted on an abdominal organ? OK to remove a small section of the organ with the embryo and say only that portion of the organ was diseased/defective, and apply the double effect principle?

By the way, very rarely one of these abdominal pregnancies does go to term, in places where women's pregnancies are not carefully followed. This depends very much on where implantation takes place. Live babies have been delivered abdominally from such implantations, but since there is no mechanism for the separation of the placenta and for clamping down on its blood vessels, it is usually a situation of fighting massive hemmorrhage when the placenta is removed.

Red Cardigan said...

Susan, I think that the rationale for removing part of an organ *might* be sound (again, speaking as a non-medical person and someone not formally trained in moral theology) because, in fact, the portion of the organ that is disordered (I prefer that to diseased or damaged) is the part where the baby is growing--intestines, etc. aren't ordered toward the safe growth of a pregnancy. If we look back to the "cancerous uterus" question, what if only the lower right quadrant of the uterus is cancerous--and that happens to be the portion where the embryo has implanted?

In fact, let's look at a complete hypothetical: pregnant woman expecting twins has uterine cancer with a removable tumor in the lower right quadrant of the uterus. Removing that section will also remove and kill the embryo implanted there. However: this woman is expecting fraternal twins, and the other embryo has implanted in the lower *left* quadrant of the uterus. Must we remove the whole uterus for the operation to be morally sound, even though it kills both babies? Or may we remove the lower right area around the tumor and *hope* (since it wouldn't be guaranteed) that our actions didn't disturb the second embryo and that this child might live to be born?

These kinds of speculations make me glad I'm not a moral theologian, frankly.

What I'd really like to see--what most pro-life people would really like to see, I suspect--would be the advancement of medical technology to the point where an ectopic pregnancy could be removed and then re-implantation of the embryo in the uterus attempted. This would provide a morally sound option for nearly all women in this awful situation, and even if the procedure was not 100% successful in all cases, if it were successful at all it could be considered as an alternative to the removal of ectopic pregnancy and death of the embryo.

That wouldn't help women in a cancerous uterus or infected uterus scenario, however. Only artificial womb-level incubator technology might approach that, and while I think that it would be a morally sound option in extreme cases, the danger would be that if the tech were too good, people would want to "grow" babies outside the womb for no good reason at all, which would be morally reprehensible.