Thursday, November 15, 2012

Woman dies of medical malpractice; Catholic Church blamed

A reader asked me yesterday to comment on the tragic death of Savita Halappanavar, the Indian woman living in Ireland who died of septicemia following a miscarriage.  I wrote back and said that I intended to hold off on commenting until I'd seen a realistic discussion of the medical issues; the brief news articles I had read simply didn't make much sense.

But the blogger at The Thirsty Gargoyle has the scoop:
Obviously this is horrible, sickening, and tragic. 

I hope those investigations get to the bottom of what happened. I'd hope too, that appropriate action be taken if anyone claimed that the hospital couldn't help Savita as it would be against the law for it to do so, especially on the spurious grounds that, as was supposedly said, 'this is a Catholic country'. And if the hospital's negligence veered into the realms of the criminal, then I really hope there are suitable consequences.

The thing is, assuming that the reporting is accurate, and given the Irish Times' recent record on life issues, it may not be, this doesn't make sense. As far as I can see, Galway University Hospital would have been fully within its legal rights to have induced a preterm delivery -- or foetal evacuation -- in an attempt to save both mother and child. Indeed, not merely would it have been within its rights to do so, doing so would have been normal medical practice. 
This is exactly the sort of thing that Dr Berry Kiely talked about back on what was an uncommonly good Vincent Browne show back in the Spring -- you induce a preterm delivery, thus saving the mother, and you do everything you can to try to save the child. You almost certainly fail, but you try. [...]
Update: It's been pointed out to me that according to the reports, Savita was admitted to hospital with a miscarriage underway, her cervix being open from Sunday, but that antibiotics were only brought into play on Tuesday night, a full two days later; it's as though she spent two days there with an open wound. Again, I'm no doctor and would appreciate if someone could clarify this, but given that this was a case of death from infection,  it seems to me to have been utterly egregious medical negligence from the start, and nothing whatsoever to do with the law, medical guidelines, or religious principles.
I encourage you to read the whole thing, but here are the important points:

1. It is not against either Irish law or Catholic teaching to deliver an extremely pre-term baby provided that the usual principle of double effect is in play; that is, the death of the baby is accepted as a result of the early delivery [please see bracketed comment below for clarification] but not desired for its own sake, and the intent is to save the mother, though any efforts that can be made to save the child once he or she is delivered should be taken.  But a delivery of this sort is, quite simply, not an abortion.  There is no benefit to be gained by directly and intentionally killing the child first and then delivering his or her corpse; the mother's life can be saved by delivering a live child, even if no baby has ever survived being born at seventeen weeks and the best care will probably not change that fact. (See Update 1 and 3 below.)  [I'm adding a note here: after thinking and reading more about this, what I mean is this: the early delivery itself can't be the only action being taken, but the action being taken to save the life of the mother has the unintended side effect of early delivery: that is, removal of infected placenta and amniotic fluid etc., removal of a cancerous or infected uterus, or something similar which also results in the removal of the baby.  An early delivery of a living baby from a healthy uterus is only a moral option if the baby has reached viability.  Right now, the earliest a child has survived outside the womb is just over 22 weeks.  But in this particular case the important fact is that it was the infection, not the baby, that was a danger to the mother.]

2. In fact, a surgical abortion at seventeen weeks gestation could quite possibly have exacerbated the already-existing infection, since the source of the infection was presumably due to the fully-dilated cervix and the leaking amniotic fluid.  The most common surgical method of abortion at 17 weeks is the dilation and evacuation method; the cervix is dilated, and the fetus is dismembered via forceps with the arms and legs cut off and removed first, followed by the head and torso which are separated from each other.  Since Savita was already fully dilated the method would still have required the insertion of forceps into her presumably infected cervix and the dismemberment and removal of her fetus; the risk of further infection from inadvertent remains left in the uterus would, I think, require great caution in the reassembly of the pieces of the dead fetus to ensure that nothing had been left behind.  Again, compared to simply inducing labor and having Savita deliver a whole and intact child who would almost certainly die soon afterward, the D&E procedure seems like an unnecessary risk.

3.  Someone pointed out to me that in the United States it is standard procedure not to allow a pregnant woman who is leaking amniotic fluid to go more than a certain number of hours before inducing labor precisely because of the risk of infection; that Savita presented at the hospital with the symptoms, not of a standard miscarriage, but of preterm labor seems to be the case from the reports.  Even if the hospital attempted to stop the preterm labor (which may or may not have been a possible response--the medical details are unclear), it seems extremely odd that it was not standard procedure for them to administer antibiotics immediately since she was fully dilated and had been leaking amniotic fluid for an undetermined amount of time.  But the real issue here, as the Thirsty Gargoyle highlights above, is this: she was admitted to the hospital Sunday night and was not given antibiotics until Tuesday. If the doctor in charge or the hospital is now attempting to blame the Catholic Church and Irish law for this woman's presumably (on the information that has been made public) preventable death, then the doctor and the hospital would appear to be in full "CYA" mode, and instead of dragging the red herring of Ireland's pro-life laws and the Catholic Church's teachings across the trail, they should be exposed and held accountable for this apparently grotesque failure to practice medicine according to accepted standards of care.

The bottom line here is this: barring some startling new information or revelations regarding this case, it would seem from the available information that what killed Savita Halappanavar was not at all respect for unborn human life, but gross disrespect for both her life and the life of her child, manifested in substandard medical care.  Again, I'm going only by the available information, but if that information is at all accurate, then abortion would not have done a thing for Savita, especially if she was still denied proper recourse to basic antibiotics until far too late in the game.  Perhaps we will learn more, but no matter what we learn, I am certain that a typical D&E abortion would have been extremely painful under the circumstances (presuming an infected cervix), would have added to the risk of infection, and would, given the inexplicable lack of antibiotic treatment, not in any way have changed the outcome of this tragic case.

UPDATE 1: A commenter links to this interesting post, which claims that the Church has always taught that the delivery of pre-viable children is indeed an abortion and is forbidden.  I am a little unclear about this; for instance, removal of the section of a fallopian tube containing an ectopic pregnancy is permitted, and the use of certain medical treatments such as cancer treatments which are known to cause fetal death are also permitted, and neither of these things is considered abortion even if it is known that the death of the unborn child will be the result of the medical action.  Yet when I was sharing the points the Thirsty Gargoyle made I do remember being mildly surprised by the use of the principle of double effect here--still, I summed up the points made in Thirsty Gargyole's post to which I had linked, which was my intention.  This is one of those circumstances where I think the opinion of a Catholic moral theologian might be much more valuable than that of a mere lay blogger (me, that is).  I can see both sides of this argument, and if the Church has ruled definitively on the question and someone can share that, I'll be glad to link to it.

UPDATE 2:  You know, the more I think about this case, the stranger it seems to me.  Savita came to the hospital that Sunday night with a fully dilated cervix and was leaking amniotic fluid.  Was this a miscarriage where the baby was indeed actively dying, or was this preterm labor/PPROM that the hospital failed to address adequately?

UPDATE 3: The evacuation of an infected placenta which will result in the death of a child is briefly mentioned here (link via Thirsty Gargoyle's article).  I apologize for the inexact language I used before which made it sound like delivery of a baby known to be pre-viable was the option being discussed; it is the necessity of removing the infected placenta and any remaining infected amniotic fluid to save the mother's life which is the option being discussed, with the simultaneous but unavoidable removal of the pre-viable baby as the secondary and undesired effect.  I had thought that there might be some discussion of removing a pre-viable child who was somehow close enough to viability for a heroic effort to save the child to be made, even if the possibility of success was infinitesimal; I'm still not sure if such a possibility might exist in some cases, but since no known child has yet survived delivery before 22 weeks I think it's safe to assume that 17 weeks would be too far away from that marker for a realistic attempt to save the baby to be made.  (At least for now; medical technology may eventually make such an early survival possible, via "artificial womb" technology or some such thing.)


Paul C. said...

Red Cardigan: "But a delivery of this sort is, quite simply, not an abortion."

That statement does not appear to be correct. For example see the posting here, by the SPUC director in the UK. The intended and deliberate delivery of a non-viable child is an abortion.The rulings have been that way since at least 1895. (See here).

Red Cardigan said...

Paul, I'm basing my definition on two things: Thirsty Gargoyle's in-depth discussion of Irish law on the matter, and the fact that the Church has already ruled this way regarding ectopic pregnancies (e.g., to remove the tube or organ containing the embryo is an indirect and unintentional killing of the embryo which is not sought for its own sake and is deeply regretted, while abortion is defined as the direct and intentional killing of an unborn child). I am, of course, open to further discussion of this from the perspective of Catholic moral theologians and will always defer to them, but Thirsty Gargoyle's parsing makes sense to me in accordance with the principle of double effect.

However, the simple truth is that even an induction of labor and the early delivery of this poor unborn child would likely not have saved his or her mother, who was already in an advanced stage of infection if the medical reports are accurate. Again, the "abortion would have saved her!" cries are a red herring; she died because someone along the way gave her negligent care, unless all the reports we've seen so far are simply not truthful at all about the details of what happened here.

vera said...

Excellent summary of what surrounds this very tragic story. It indeed sounds like a case of extreme negligence. Thank you for digging all this up!

As for whether or not inducing labor while knowing it will kill the fetus is or isn't an abortion... seems to me like weasel words. Sounds like the church is tapdancing around the words so that abortions meant to save the health/life of the mother (e.g. ectopic) can be performed and called something else.

On the other hand, it is true there is a difference btween killing the fetus for medical reasons while the parents very much want it, and killing it... well, out of inconvenience. So on that level, the church has a point...

Hm... Will keep chewing on it. Meanwhile, I hope this story gets out and the death of this woman doesn't become a tool for antireligious bashing, and pro-choice posturing.

Rebecca in ID said...

There is actually some disagreement among theologians about the ectopic pregnancy situation. In order for double-effect to make sense, you have to say that the fallopian tube is itself threatening the life of the mother, and then the removal of the fetus is an unintended side effect of removing the fallopian tube. Some theologians say that no, it is not the fallopian tube but the growing fetus that is dangerous, and thus it would be an act of abortion. I have always understood that inducing labor in the case of a viable infant is indeed abortion, because it is the presence of the infant in the womb which is life-threatening. It is not like you have a cancerous organ or something; it is the child's presence and the side effects of that which are dangerous. Thus, removing the child from the necessary conditions for its life, is abortion. However, a great majority of conditions which are called "life-threatening" and often result in automatic induction of labor by the hospital, are not, or the risks are much less severe than often stated. I think it is important to recognize that it is possible that a pregnancy *could* result in death; it may at some point happen that a mother has a choice to abort (or abort by induction) or to die. Difficult moral situations also come up in war, too, or just in life, and it is possible that sometimes you might save your life by doing something wicked (like pushing a child off your lifeboat, if the child's presence threatens your own safety).

Red Cardigan said...

Well, sure, Vera, but sometimes the exact words really are important, and this is one of those times. I always go back to two really important words we use to define abortion: abortion is the direct and intentional taking of the life of an innocent unborn human being. The part that I'm not qualified to discuss here is whether an induced delivery, or what's being called an "evac" at Thirsty Gargoyle's blog, is a direct and intentional killing under these kinds of circumstances.

Still, the unborn child did, tragically, die even before his or her mother did, and there's really NO evidence from the reports of this case that directly and intentionally killing him/her would have made a difference. The child's body was removed after his/her heart stopped beating, but the removal of the baby's body didn't, alas, make a difference to a woman who had not apparently been given antibiotics during the previous two to three days! That remains the outrageous part of this to me, more so than hypothetical discussions concerning whether or not labor could have been induced.

Red Cardigan said...

Rebecca, I realize that these are complex discussions and I'm certainly not prepared to say that it should be open season on pre-viable babies if the mother's health is at risk--hope that goes without saying! :)

But what's got me confused about this situation (again, if the removal of the child would have helped, which is doubtful considering the problems with this mother's care) is this sort of conundrum:

1. The child's death may result from the removal of the child, but the child's death is not desired or wanted, and the child's death in and of itself will not help anything. If by the miracles of modern medicine it someday becomes possible to save *some* fetuses at 17-18 weeks, then provided a really good attempt is made to do so, removing the child wouldn't be wrong at all.

2. In fact, though, in this case, we're told that a miscarriage was in progress. The child was actively dying. Do the sorts of considerations which apply to those actively dying apply here? (I'm honestly just asking--I don't know what to think about this.)

3. In the ectopic pregnancy situation, the fallopian tube IS threatening the mother's life because it is going to rupture. Yes, the presence of the child is what will make it rupture, but the tube itself is no longer benign. Again, I hope that moral theologians can agree that abortion is the direct and intentional killing of an unborn human being; removal of a section of the fallopian tube in the presence of ectopic pregnancy would seem to me not to meet that basic definition.

Again, I'm hoping to be sensitive and thoughtful in discussing these things; the Church always has the final word.

Red Cardigan said...

I've added another update, because I'm still thinking about this...

Was Savita miscarrying, or was this preterm labor/premature rupture of membranes? If the fetus is still healthy, there are lots of PPROM options--and the first recommendation is antibiotics to ward off infection! If that had been done immediately, this poor woman might have made it to 22-24 weeks and delivered a living premature baby who might have had a chance of survival. Failure to treat the mother properly cost two lives, if this story does turn out to be what I suspect it is.

Rebecca in ID said...

Red, I agree that the situation seems one of obvious malpractice and the headlines were not only sensational but way off track.

What you say about the fallopian tube is what the theologians argue, and it may well be the case. I don't know for sure what the answer is. The Church has not finally spoken on this situation specifically. The reason I brought it up was to make clear the distinction between directly intended or not. You seem to be thinking of directly intended as "what the person really wants". But that is not what "directly intended" means. For example, say I'm sharing a life boat with a child and the both of us are too heavy for it. Well, I could push the kid out, and I don't really want the kid to die, I just want to save my life. In fact, I might pray that the child would miraculously survive the icy waters without the life boat. But as a matter of fact, I have directly intended an action, the pushing of the child off the lifeboat, which I am morally certain will end in the child's death. I am choosing the pushing of the child (which is called "killing") in order to save my own life. Likewise, with regular old surgical abortions, my guess is that rarely does the mother "really want" the death of the child; there is always some other good they are aiming for or evil they are trying to avoid. With double-effect, you just have to think simply about what the action is that you are doing. With the case of a cancerous uterus, for example, the direct action would be the removal of a diseased organ to save the whole body. The side effect if the woman were pregnant, not directly intended, would be the death of the child in the womb. With inducing premature labor on the other hand, the action is getting a baby out of its mothers womb. In the case of pre-viability, this is not just removal to another place, but killing, just as pushing the child off the lifeboat was killing. The child still needs the womb to survive and you have moral certitude of that. Therefore, your direct intent is to kill, *even if you really didn't want to do that, even if you'd be thrilled if the baby could live after all*. Does that make sense?

As for miscarriage--usually when a woman is going through a miscarriage, the baby has died some time before, perhaps a week or two, or even more. Usually the baby is not dying right then, though that is possible. If it were the case, you still can't hurry along someone's death even when they are dying. You don't have to take extraordinary measures to keep them alive, but you can't do something to make them die faster in order to help someone else. Sometimes someone gets extra morphine but the intent has to be to manage pain rather than to hasten death.

Red Cardigan said...

Well, not to split hairs too much, Rebecca, but I'm not saying "directly intended" but "direct and intentional," and I'm only saying that about abortion. In other words, for an act to be abortion specifically, the child must be directly killed and the intent must be to kill the child. Removing a cancerous uterus from a pregnant woman will result in the child's death just as much as pushing a child out of a lifeboat will, but the unborn child's death is an indirect result of removing a cancerous uterus from a pregnant woman, not the result toward which the act is aimed. And, again, removing the uterus in that circumstance is intended to remove the cancer and save the woman, not to kill the child, even if the death of the child is an unavoidable result.

Is removing a pregnant woman's cancerous uterus an abortion? No, not as the Church defines abortion. If, in your lifeboat example, the lifeboat is on fire and the fire can't be put out (and maybe the whole thing is going to explode), pushing the child out of the boat and jumping in yourself will not be murder or suicide, either, even if the child is too young to swim and has no chance in the water, and your own chance of survival is very slim.

And that's why I added the update (#3) above when I better understood what the Gargoyle and his readers and commenters were getting at when they used the term "evac." I misunderstood what they were getting at before (and honestly, I should know better!). Delivering a pre-viable baby from a perfectly healthy uterus would be a form of abortion; the problem here is that the septicemia of pregnancy means by definition that the placenta, amniotic fluid, remains of the amniotic membrane, etc. are badly infected and might have to be removed--but, of course, removing these things and completely emptying the badly-infected uterus, or even doing an emergency hysterectomy if things have gotten that bad, will also kill the unborn child.

And that makes sense to me--not that this would be the only or even the best option, but that it would be a permissible option if the infection has progressed to the point where healing will not take place without the removal of the infected fluids and tissues--and even the uterus if things have gone that far. It is sometimes necessary when infections are raging to remove whole limbs (as we've seen in the staph infection horror stories in the news) to try to help the patient survive, so this wouldn't be some sort of "excuse" to kill the baby, either.

But we come back to the glitches in this story, again. If this had been a true miscarriage, the baby would probably already have died. It really does look like a badly mismanaged preterm labor situation where life-saving antibiotics were withheld for no discernible reason from the outset. I'll be interested to read opinions from Catholic bloggers with medical experience, because I think that there were plenty of morally sound options here that were never even offered or investigated.

Paul C. said...

I am dubious, given the prior rulings of the Holy Office, that a fetal evacuation would ever be permissible. However, it is difficult to give a reply one way or another without some fairly exact definition of exactly what kind of "fetal evacuation" is to be analyzed.

In the case under discussion, given that the mother was 17 weeks pregnant, what happened was likely a D&E (involving dismemberment), which is definitely a direct abortion, and not capable of being rescued by any kind of appeal to double effect.

Tony said...

3. Someone pointed out to me that in the United States it is standard procedure not to allow a pregnant woman who is leaking amniotic fluid to go more than a certain number of hours before inducing labor precisely because of the risk of infection;

I have to disagree with this. My wife broke water 10 weeks early, so they put her on bed rest in the hospital monitoring her labor and stopping it with Breathene (asthma medicine). Also she got two shots of Metamethazone to develop the baby's lungs. At 7 weeks early (three weeks later) she spiked a temperature and our first child was delivered C-section.

vera said...

I saw another story this morning, and all they are quoting (again) is the husband who blames the church. I think there are too many unclear things in this case, the doctors or nurses have not made a statement, and I have even wondered if the husband in his naturally angry and grieving state has been coopted by the pro-choice forces (who could be just Irish, or even financed by EU). Let's follow this closely... I am smelling big-time propaganda. It could be that all the forces who have been pressuring Ireland to change this, have been looking for just such a case...

vera said...

Can anyone clarify the Irish law? Does it really say that if there is a heart beat that a termination cannot be performed even if (assuming this is the case in a hypothetical case) the life of the mother is in danger directly from continuing the pregnancy?

Rebecca in ID said...

Okay, now I'm confused about whether we've understood each other or not, though maybe it doesn't matter. Anyway, all I'm saying is that whatever word you use, if you intend a direct act which kills someone whether by commission or omission, that is murder. I didn't quite get the boat on fire business but in the simpler example I gave, if the boat is not big enough for two of you and you push the child off in order to save your own life, that is killing. Removing a necessary hydrating tube from someone dependent on it, is killing. Refusing to feed a hungry infant, is killing. Removing a child from a womb when this is necessary for its survival, is killing. The most common example of that would be the usual procedure for when it is discovered that a child suffers from anenephaly--as soon as they find out, they often induce labor, pre-viability, because sometimes anencephaly results in too much amniotic fluid and there is some risk to the mother. This practice is killing; I had an acquaintance who went through that and the doctors and nurses were all very kind; they all grieved with her for the loss of her baby's life. But they weren't removing a diseased organ, they were removing a child, that was the direct intention. Removal of a diseased uterus is not killing, though it may have the known effect of the death of the infant. And you make a good point that it may be the case that in a case of infection, the aim is to remove diseased and dangerous tissue, or a diseased organ. That could be. The thing I wanted to make sure was understood is that removing the child from the surroundings necessary for life does not become a different act if it is done in order to reduce risk to the mother's life. It definitely is a more understandable reason than citing the psychological health of the mother, or other things, but the key is that we have to look at exactly what the act is, in itself, and as Catholics I think we have to be ready for the possibility that sometimes, there will be risk to the mother, that the risk could possibly be lessened if inducing pre-viable infants were a moral option, but that this is not a moral choice if it is a direct action rather than a side effect of another action.

Red Cardigan said...

Rebecca: please see my new post! Hope that explains my thinking better.

Tony, it sounds like they delivered your baby when your wife showed signs of infection (e.g., the temperature spike). This woman, Savita, presented in pain and was in a state of raging infection only two days later, so I have a hard time believing there were no signs of infection at the outset...

Red Cardigan said...

Paul, a D&E was not done. The baby's heartbeat stopped, and after the baby's death, his or her remains were removed--but by then the untreated infection had progressed so far that it wasn't possible to save this woman.

But, again, I think that the infection did not *begin* at the time of the removal of the baby's remains--the story doesn't support that, if the story is accurate.

eulogos said...

I think Paul is saying that the only way to get the baby, living or dead, out at that point would be D&E.

I dont' know if he is right or not. We can't automatically assume that labor can be induced any old time we want to do that. Prostaglandins are sometimes used for this purpose, misoprostol is used. It is possible that the child could have been delivered intact, certainly to die later.

In my opinion, this is also an abortion and illicit.

However, since the placenta and the amniotic membranes were infected, I suppose one could make the argument that those were being removed, analogous to the cancerous uterus. This wouldn't work for other "life of the mother" situations, such as the Kansas City, pulmonary hypertension, case, however.

Antibiotics don't usually work for sepsis like this because they don't all cross the placenta and even if they do, they don't get into the amniotic fluid and to all the tissues of the amnion, in sufficient concentrations. I have sometimes wondered if an infusion right into the amniotic fluid would work.

The best principle is to try to find a medical technique which will save both mother and child. Saying one will try to save a 17 week fetus after delivering it is to my mind dishonest. It is like hoping the child shoved out of the lifeboat will survive, only that child has more of a chance then a 17 weeker has with current technology.

I have to mention that this situation is rather suspicious to me as possibly being the result of an attempted self abortion. This (sepsis) is what doctors used to see which made them want to make abortion legal. That isn't the only situation in which this can happen, but it is a possibility in this case. You would think most women would be saying "Will my baby be ok, can you save my baby?" rather than asking for an abortion.

Susan Peterson