A Catholic Approach to Tubal Pregnancies

CUF
From the Jan/Feb 2004 Issue of Lay Witness Magazine

ISSUE: What is an ectopic, or “tubal,” pregnancy? What moral principles must be taken into account in treating a tubal pregnancy? What alternatives are available that respect both the mother’s life as well as the life of her unborn child?

RESPONSE: A woman’s egg or ovum descends from an ovary through the fallopian tube to the uterus. While on this path, the egg is fertilized and naturally continues this descent and implants in the uterus. Sometimes, however, the egg is impeded in its progress and instead implants somewhere along the way. This is called an ectopic pregnancy. “Ectopic” means “out of place.” Ectopic pregnancies are often called “tubal” pregnancies because over 95 percent occur in the fallopian tubes. (fertilized eggs can also implant in the abdomen, ovaries, or within the cervix).

A mother facing a tubal pregnancy risks imminent rupture of the fallopian tube. While the doctor would opt for the least risk and expense to the mother, all the options presented to her involve terminating the pregnancy. The mother, however, must respect both her life and that of her child.

There is no treatment available that can guarantee the life of both. The Church has moral principles that can be applied in ruling out some options, but she has not officially instructed the faithful as to which treatments are morally licit and which are illicit. Most reputable moral theologians, as discussed below, accept full or partial salpingectomy (removal of the fallopian tube), as a morally acceptable medical intervention in the case of a tubal pregnancy.

As is the case with all difficult moral decisions, the couple must become informed, actively seek divine guidance, and follow their well-formed conscience.

DISCUSSION: According to the Centers for Disease Control (CDC),[1] ectopic pregnancies have increased in frequency and now number roughly 100,000 a year.

Though detection and treatment have greatly improved, ectopic pregnancies still pose a serious health risk to the mother. Ectopic pregnancies are the leading cause of maternal deaths in the first trimester. While they often end in early miscarriage, waiting indefinitely for miscarriage to occur poses a grave threat to the mother. By ten weeks (in the case of a tubal pregnancy), the fallopian tube will likely rupture, causing severe hemorrhaging that can result in death. Such cases most often occur when the ectopic pregnancy is not diagnosed. Hence, most deaths caused by ectopic pregnancies each year are among minority groups and the poor whose access to prenatal care is limited.

Who are at risk for an ectopic pregnancy? All women are susceptible. However, there are factors that can increase the risk, namely: smoking, sexually transmitted diseases, tubal sterilizations, fertility drugs, and previous occurrences.

Moral Principles

In the case of an ectopic pregnancy, the lives of both the mother and child are placed at risk. The moral teachings of the Church call for medical treatment that respects the lives of both. Most recently, the U.S. Conference of Catholic Bishops reiterated these principles:

In the case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.[2]

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.[3]

On one hand, there can be no direct attack on the child (direct abortion) to save the life of the mother. On the other hand, the life of the mother is equally valuable and she must receive appropriate treatment. It might be that the only available remedy saves the life of the mother but, while not a direct abortion, brings about the unintended effect of the death of the child. Morally speaking, in saving the life of the mother, the Church accepts that the child might be lost.

This principle applies in other pregnancy complications as well. With severe hemorrhaging, for example, if nothing is done, both will die. In respecting the life of the mother, the physician must act directly on the uterus. At that time the uterus loses its ability to support the life of the embryo. The mother’s life is preserved and there has been no intentional attack on the child. The mother and the uterus have been directly treated; a secondary effect is the death of the child.

Another example arises in the treatment of uterine (endometrial) cancer during a pregnancy. The common treatments of uterine cancer are primarily hysterectomy (surgical removal of the uterus) and sometimes chemotherapy or radiation therapy. Again, taking the life of the baby is not intended, but a hysterectomy does mean the removal of the womb and the death of the child. Yet, if a hysterectomy must be performed to save the life of the mother, the Church would deem the procedure morally licit.

Thus, a moral distinction must be made between directly and intentionally treating a pathology (a condition or abnormality that causes a disease) and indirectly and unintentionally causing the death of the baby in the process.

This distinction is derived from a moral principle called “double effect.” When a choice will likely bring about both an intended desirable effect and also an unintended, undesirable effect, the principle of double effect can be applied to evaluate the morality of the choice. The chosen act is morally licit when (a) the action itself is good, (b) the intended effect is good, and (c) the unintended, evil effect is not greater in proportion to the good effect. For example, “The act of self-defense can have a double effect: the preservation of one’s own life; and the killing of the aggressor. . . . The one is intended, the other is not” (Catechism, no. 2263, citing St. Thomas Aquinas).

Proposed Treatments

Catholic Theologians typically discuss the morality of three common treatments for ectopic pregnancies according to the principle of double effect.[4] One approach utilizes the drug Methotrexate (MTX), which attacks the tissue cells that connect the embryo to its mother, causing miscarriage. A surgical procedure (salpingostomy) directly removes the embryo through an incision in the fallopian tube wall. Another surgical procedure, called a salpingectomy, removes all of the tube (full salpingectomy) or only the part to which the embryo is attached (partial salpingectomy), thereby ending the pregnancy.

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

The majority of Catholic moralists, while rejecting MTX or a salpingostomy, regard a salpingectomy as different in kind and thus licit according to the principle of double effect. What is the difference?

A partial salpingectomy is performed by cutting out the compromised area of the tube (the tissue to which the embryo is attached). The tube is then closed in the hope that it will function properly again. A full salpingectomy is performed when implantation and growth has damaged the tube too greatly or if the tube has ruptured. These moralists maintain that, unlike the first two treatments, when a salpingectomy is performed, the embryo is not directly attacked. Instead, they see the tissue of the tube where the embryo is attached as compromised or infected. The infected tube is the object of the treatment and the death of the child is indirect. Since the child’s death is not intended, but an unavoidable secondary effect of a necessary procedure, the principle of double effect applies.

Dr. T. Lincoln Bouscaren,[5] an early 20th-century ethicist and canon lawyer, argues that though the pathological condition is caused by the presence of an embryo in the fallopian tube, nonetheless “the tube has become so debilitated and disorganized, or destroyed by internal hemorrhage, that it now constitutes in itself a distinct source of peril to the mother’s life even before the external rupture of the tube.”[6]

Bouscaren admits that this is a “fine distinction,” but he essentially argues that the infection in the tube, though related to the pregnancy, is sufficiently distanced from the pregnancy to constitute a pathological condition of its own. He maintains that the inevitable rupture is the final end of a single pathology, i.e., a diseased and ever-worsening tube.

Dr. Bouscaren arrives at the same conclusion as the majority of Catholic moralists, that both the partial and full salpingectomy is licit. Some critics of this conclusion argue that salpingectomy is morally indistinguishable from salpingotomy or MTX. Therefore, Dr. Bouscaren’s explanation is helpful and would benefit from further elaboration by contemporary moral theologians.

There are two circumstances that make the use of any of these treatments morally acceptable. The first occurs when an ectopic pregnancy has been diagnosed, but no signs of life exist. The morality of treatment for ectopic pregnancies concerns the absolute value of human life. Conversely, there is no such moral consideration if the embryo has succumbed—there is no taking of human life (assuming a reasonable effort has been made to detect life).

The second circumstance occurs when the fallopian tube ruptures, whether or not the embryo is alive. A ruptured tube presents an immediate threat to both mother and child. If nothing is done, both will die. The doctor is morally obligated to act, even though only one life can be saved. The rupture is the cause of the child’s death, not any procedure the doctor performs. These two circumstances, miscarriage and rupture, present fundamentally different moral questions from instances in which both mother and child are alive and the fallopian tube itself does not pose an immediate threat to the mother’s life.

Wait and See

Catholic moralists generally assume in their discussion of treatments for ectopic pregnancy that treatment will not be postponed. Perhaps most moralists believe there is no reasonable possibility to save the child. There are options, discussed below, but the availability of these options is virtually non-existent at this time. Other options are generally not even considered, because the standard protocol calls for only one of the three treatments that have been discussed thus far.

Surgical treatments, however, increase the risk of future ectopic pregnancies and/or reduce fertility, and there are situations in which postponing surgical intervention can be medically advantageous. “Expectant therapy” (or “expectant management”) is basically close observation in the hope that the pregnancy will resolve itself naturally. A combination of reduced hormone levels (movement toward miscarriage) and location of the embryo in a less constrictive part of the tube can indicate a decreasing chance of rupture.

While there are anecdotal accounts of fetuses living to six months without the tube rupturing, postponing surgery indefinitely is dangerous, given the virtual certainty of rupture long before viability. So, it’s one thing to wait a short period of time for miscarriage to occur spontaneously. It’s quite another to forego intervention altogether in anticipation of a life-threatening tubal rupture. Such a high-risk course of action is rightly discouraged and can even be indicative of a reckless disregard for the life of the mother.

If Only

There is a case that took place in 1915 in which a doctor, in the process of removing a tumor from a uterus, discovered an early tubal pregnancy. The operation on the tumor had left an incision in the uterus. The doctor transferred the embryo to the uterus through the incision. The embryo implanted, and the mother eventually gave birth to a healthy baby. The same hospital allowed further attempts at embryo transferal. Only a very small percentage were successfully implanted and born. Of those, the majority did not live very long. Most died between the ages of six and 12 years. With such low odds of the birth of a healthy baby, it is rare nowadays for medical professionals to consider embryo transferal. Recently a doctor at a Catholic fertility institute attempted three embryo transferals with none surviving to birth.

Among future possibilities might be the development of the artificial womb. Some shudder at such an option because of its possible abuse by those who want a child but wish to avoid pregnancy. However, a morally deficient motivation doesn’t nullify the potential of the technology itself. No one would question life support for a child who is born prematurely and cannot live on its own. An artificial womb could theoretically provide adequate life support for a child at an earlier stage.

Prayerful Discernment

It is the task and duty of those in the relevant professional fields, especially Catholics, to seek for means by which life at whatever stage can be preserved, protected, and nurtured. Unfortunately, the thrust of contemporary medical technology has been to terminate the tubal pregnancy as directly as possible without any consideration of ways to save the life of the embryo. This renders the application of the “double effect” theory to tubal pregnancies problematic, as the intended good of preserving the mother’s health seems to be accomplished directly through the efficient taking of the child’s life. This can be especially disturbing to Catholic couples who face this situation.

While the Church has not spoken officially about the morality of specific treatment options, she does provide several principles rooted in the natural law concerning human life. In applying these principles, the great majority of moral theologians agree that the salpingectomy does not constitute a direct attack on the life of the baby and is morally licit. A couple may serenely choose this option in good faith without fear that they are violating Church teaching.

Because the salpingectomy is considered by most theologians to be morally acceptable, the issue becomes how long to wait before proceeding with this invasive treatment, given the grave health risk posed by the ectopic pregnancy. This will vary from case to case. Sometimes the immediate risk is low and allowing the miscarriage to occur naturally preserves the mother’s fallopian tube. Conversely, there are also cases in which the fallopian tube itself is so compromised that it must be immediately removed to preserve the life of the mother.

The course of treatment the woman chooses should be determined by her informed conscience. This means that she must strive to understand the natural law regarding the value of life—her own and the baby’s—and choose a course of action that will respect both. She must also become informed about alternative treatment and the facts related to her own condition. She can then prayerfully discern the course of action she will take.

——————————————————————————–

[1] Much of the statistical information in this Faith Fact was gathered from the CDC

[2] National Conference of Catholic Bishops. Ethical and Religious Directives for Health Care Services (Washington, DC: NCCB, 1994), 28

[3] Ibid., 47.

[4] Cf. William E. May, Catholic Bioethics and the Gift of Human Life (Huntington, IN: Our Sunday Visitor, Inc., 2000), 182-83.

[5] T. Lincoln Bouscaren, Ethics of Ectopic Operations (Chicago, IL: Loyola University Press, 1933).

[6] Ibid., 160-61.

Recommended reading:

Holy Bible (Catholic edition)

Catechism of the Catholic Church

Vatican II Documents

Catholic Bioethics and the Gift of Human Life by William May

Medicine and Christian Morality by Thomas J. O’Donnell, S.J

Other Available FAITH FACTS:

• Moral Conscience • Principle of Double Effect • Hope: The Pilgrim’s Virtue • Where Do We Go From Here: The Concept of Limbo • Canonical Misconceptions: Pope Pius IX and the Church’s Teaching on Abortion

Call 1-800-MY-FAITH (693-2484).

FAITH FACTS are a free membership service of Catholics United for the Faith.

Catholics United for the Faith
827 N. Fourth St., Steubenville, OH 43952
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www.cuf.org

© 2004 Catholics United for the Faith

Last edited: 12/3/2003

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