Breaking News*: The Magisterium Explicitly Addresses Ectopic Pregnancy

January 12, 2009 § 23 Comments

I’ve expressed the opinion before that while I think salpingectomy (removal of the baby-and-fallopian-tube together) may be licit in some circumstances, I am not convinced that it is licit to perform that operation immediately upon determining that a pregnancy is ectopic. For those who think I must have off the wall theological opinions contrary to the teaching of the Magisterium for having doubts about using specific techniques to resolve ectopic pregnancy at just any old time during the pregnancy, despite a mild consensus of theologians – who are not the Magisterium – contrary to my own views, I give you the following Magisterial statement specifically addressing the issue:

To the Question:
“Whether it is at any time permitted to extract from the womb of the mother ectopic fetuses still immature, when the sixth month after conception has not passed?”

The reply is:
“In the negative, according to the decree of Wednesday, the 4th of May, 1898, by the force of which care must be taken seriously and fittingly, insofar as it can be done, for the life of the fetus and that of the mother; moreover, with respect to time, according to the same decree, the orator is reminded that no acceleration of the birth is lict, unless it be performed at the time and according to the methods by which in the ordinary course of events the life of the mother and that of the fetus are considered.”

From the reply of the Holy Office to the Dean of the faculty of theology of the University of Marienburg, March 5, 1902

* For Catholics, a century-old decree is breaking news, hah.

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§ 23 Responses to Breaking News*: The Magisterium Explicitly Addresses Ectopic Pregnancy

  • I thought ectopic pregnancies occured in the <>fallopian<> tubes.The ban on removing ectopic fetus’ from the <>womb<> would appear to be speaking of a different situation ?Maybe medical understanding of ectopic pregnancies has advanced since 1902 so that what we’re talking of is not quitethe same thing as the Holy Office 1902 was talking about ?God Bless

  • zippy says:

    Chris:I think it is safe to interpret a 1902 decree by the Magisterium as using the term “womb” to refer to inside the mother generally; just as those documents refer to operations which involve opening up the abdomen as “laparotomy” generally, and “caesarian” to refer to removing the baby alive via “laparotomy” generally. They certainly understood the existence of and consequences of ectopic pregnancy, if not all of the medical details we do today.

  • Jeremy says:

    My understanding of an ectopic pregnancy is that it will lead to the death of the fetus, and could lead to the death of the mother. If that is the case, then the decree makes no sense. What am I missing?

  • zippy says:

    <>If that is the case, then the decree makes no sense. What am I missing?<>Perhaps the fact that we are all in the process of dying, which in no way excuses killing the innocent.Also, if the woman has access to modern medical facilities it is rare to die from a rupture; so technically it doesn’t need to be treated at all, but can be left to resolve itself, with only a small fatality risk to the mother. Half or more will resolve themselves with no complications, IIRC, though I am no expert.I’ve read the claim that 5% or more of ectopic pregnancies survive to term if they are left to themselves, though I haven’t vetted that claim.So it may be that modern people are less informed about ectopic pregnancy in some ways than those who lived a century ago, because of our prejudices, and our penchant to treat a risky situation as definite because we don’t like leaving risky situations up to God and accepting the outcome.In any event my personal view is that treating them with salpingectomy is probably licit when we know that the tube is on the verge of rupture or has ruptured; and probably not before. For thinking this I have been labeled a dissenter from the Magisterium, from which it follows that all of my opinions on the morality of matters of life and death can be discounted.

  • Lydia McGrew says:

    Thing is, though, it seems to me that the “is it in principle possible to save the innocent” idea from the former post whereby removing the tube with the child might be licit would by the same reasoning have to apply to simple “expulsion” abortions of very young fetuses. For it is “in principle possible” that we should someday develop technology that would allow such children to be saved after being expelled from the womb. Only we don’t have it now. And by the same token, we have no possible way now to save a child removed in the fallopian tube, and he ends up being dead on arrival just like the child expelled from the womb in, say, the eighth week after the mother takes a drug producing strong contractions and simple miscarriage.

  • Lydia McGrew says:

    Please understand that I’m not actually disagreeing with the “in principle possible to save the innocent” idea. I’m just saying that what counts as “in principle possible” has to take into account the actual physical circumstances, including present medical knowledge and technology where that’s relevant, if it’s to be ethically valuable.

  • Paul says:

    The 1902 ruling applies to the <>direct<> removal of a foetus. For some time the ruling was thought to always apply. It’s the subsequent book by Bouscaren (“Ethics of ectopic operations”) which analyzed the situation under the principle of double effect, with an <>indirect<> removal of the foetus, that led to current teaching.

  • zippy says:

    Paul: I am definitely open to seeing something from the Holy Office/CDF endorsing some newer interpretation, if such a document exists.Lydia:A couple of things, briefly.Inducing premature delivery is <>not<> intrinsically immoral. In itself it does not constitute a killing behavior. A non-intrinsically killing behavior is still murder when done with the purpose of killing, of course. (When I get back to my library I can look up the reference in Denzinger for any Catholic who objects, not that a Magisterial appeal would move you Lydia).Second, I am not trying to draw a line here between which behaviors are intrinsically killing behaviors and which are not. I’m just trying to show that some behaviors are in fact intrinsically killing behaviors, and are therefore murder no matter why one chooses them. This in turn becomes a refutation by counter-example of what Bill Luse calls the dictatorship of intention. Once it is clear that certain concrete behaviors in themselves are always wrong to choose, no matter why one chooses them, the dictatorship of intention falls. That doesn’t in the least exonerate other behaviors chosen with the intent to kill the innocent.

  • James says:

    Something from the National Catholic Bioethics Center:Managing Tubal Pregnancies: Part I Ectopic Pregnancies A persistent, vexatious, and increasingly serious problem is the management of ectopic pregnancies, especially the tubal variety. In an ectopic pregnancy, the embryo implants not in the uterus, as it should, but in a place incapable of effectively supporting its full development. Often these pregnancies occur in the fallopian tube before the embryo reaches the uterus. Modern diagnostic techniques enable physicians to detect tubal pregnancy earlier than heretofore. It has been estimated that about 64% of tubal pregnancies resolve spontaneously, making it unnecessary to do anything (J. Rock, “Ectopic Pregnancy” in TeLinde’s Operative Gynecology, 1992, p. 420). Often, however, the trophoblastic cells (those cells which lead to the formation of the placenta and the chorionic and amniotic membranes), by exercising their proper function of establishing nutritional contact with the maternal tissue, injure the lining of the tube. The developing embryo rapidly erodes through the lining and grows into the adjacent layers of the tube (extra luminal growth). Eventually, this causes hemorrhaging and rupture of the tube. Rapid embryonic growth in a site incapable of supporting it all but guarantees the death of the child and seriously jeopardizes the life of the mother, unless there is some intervention. It would be morally ideal to transplant the ectopic embryo to the uterus. Two successful transplants have been reported (1917, 1990), but physicians do not consider this a realistic option at present. If the ectopic pregnancy does not spontaneously resolve itself, there are several available treatments: 1) salpingectomy-removing either the whole tube or just its damaged segment and reconnecting the remaining portions; 2) salpingostomy-making a slit in the tube through which the damaged tissue (including the embryo) is pressed out (leaving the tube substantially intact); or 3) administering methotrexate-a cytotoxic drug which prevents the trophoblastic cells from maintaining the attachment of the embryo to the fallopian tube. Moral Principles When evaluating these medical procedures, we must accept the relevant teaching of the Magisterium, especially the general teaching that all innocent human life is sacred and has an inherent dignity from the first moment of conception due to its creation in the image of God, redemption by Christ, and call to eternal life with God. No one may knowingly and deliberately kill an innocent human being at any stage of development. This is an exceptionless moral norm. The use of technical medical terms, such as zygote, embryo, and fetus, should not mask the fact that we are always speaking of a child, a human person. When both mother and child are in danger, it is in no way justifiable to kill one in order to save the other. One may not do evil in order to achieve a good end (see Rom. 3:8). Specific teaching regarding ectopic pregnancies is expressed in the Ethical and Religious Directives for Catholic Health Care Services (1995). Directive #48 states: “In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.” Abortion is defined as “the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus” (ERD #45). Direct abortion is distinguished from indirect abortion: 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. (ERD #47) Are the proposed medical treatments to be understood as direct or indirect abortion? Salpingectomy In the past, tubal pregnancies often were diagnosed only after the tube had been seriously damaged by the developing child. Under these conditions, salpingectomy has been deemed morally acceptable. One may remove the whole tube or a segment thereof even if it is foreseen that the child will die as a consequence. This protects the mother’s health and life, without denying the equal right to life shared by the child. The moral object of the surgery is to remove damaged tissue, a “proportionately serious” (i.e., life-threatening) pathology, despite the foreseen but unintended consequences for the child. This causes an indirect abortion, analogous to the often-discussed case of the ‘cancerous uterus.’ Salpingectomy may leave the woman infertile on the affected side even if the tube is only partially removed and resectioned. This undesirable side effect has encouraged development of less invasive treatments, such as salpingostomy and methotrexate therapy. These procedures present the possibility of resolving the pregnancy at a lower cost, with quicker recovery, and with a higher likelihood that the woman retains her fertility. Are these newer treatments morally equivalent to salpingectomy? A Closer Look at Tubal Pregnancy In a tubal pregnancy, the child attaches in an abnormal site and causes injury to the fallopian tube such that increasingly serious damage and actual rupture will take place within a few weeks. Can the embryo be considered effectively attached when in a short time its demise will take place? One could argue that from the outset implantation has not been successful because the child was doomed to death from the beginning by attaching in an abnormal site, a site where it could not-except for very rare cases-be brought to term. This abnormal site is progressively deteriorating as the wall of fallopian tube is being destroyed by the continued activity of the trophoblast. “Effective implantation” should mean not only that here and now the system is able to provide adequate nourishment and oxygenation but also that this will continue until the child is born alive. Although there is no guarantee that a uterine pregnancy will proceed to term free of unforeseen accidents or disease, it is reasonably expected to go to term, whereas in a tubal pregnancy there can be no such expectation. Implantation in the fallopian tube is life-threatening not only for the child, but also for the mother. As the child grows in a part of the mother which cannot support pregnancy, her fallopian tube suffers progressive damage which ultimately endangers her life. In this sense, implantation in the fallopian tube amounts to a pathological condition for the mother. Salpingostomy This article argues that salpingostomy at least is a morally acceptable treatment of this pathology in the mother, not a direct abortion. The attachment of the embryo at this location (where it cannot survive to term and where it will soon produce life-threatening difficulties for the mother) constitutes a sufficiently serious pathology which can be treated in anticipation of irreversible structural damage. Methotrexate involves more complicated medical facts and will have to be addressed in another article. Let me state clearly that this analysis of salpingostomy is proposed for theological consideration and welcomes clarification or correction from the Magisterium. Other theologians have come to a different conclusion (see William E. May, “The Management of Ectopic Pregnancies,” in The Fetal Tissue Issue, Cataldo and Moraczewski, O.P., eds., The Pope John Center, 1994, p. 121-147). According to surgeons who perform salpingostomies, careful inspection of the affected tube reveals an enlargement of the tube itself at the location of the ectopic pregnancy. This enlargement of the tube corresponds to the growth of the ectopic pregnancy and has been so identified by histological examination of tubal tissue obtained by salpingectomy. In other words, the implanted embryo is not merely sitting, as it were, on the surface of the inner lining of the tube, but is embedded in the tissue of the tube. This observation supports the claim that the embryo’s attachment to the tube constitutes a pathological condition. A pair of forceps (or other suitable instrument) is used to remove the pathological tissue in such manner that part of the tubal wall remains, although thinned out by the procedure. This maneuver extracts a sizable amount of damaged tubal tissue, but the tube is subsequently able to repair itself so that the woman’s fertility is not impaired by the surgery. Of course, and unfortunately, along with the removal of the pathological tissue-the tissue damaged by the ingrowing trophoblastic cells of the embryo-the embryo proper is also removed. Although foreseen, one does not choose or select or will the death of the embryo either as an end in itself or as a means to a further good end, namely, the health and life of the mother, including protection of her ability to conceive another child. Salpingostomy is the removal of damaged tissue and detachment of the trophoblast (of the embryo) from the abnormal site. The specific focus of the surgical action is the removal of damaged tubal tissue and damaging trophoblastic tissue, not the destruction or death of the embryo, even though one foresees that by taking that action the embryo’s death will take place. Will this position be used to justify abortions? There is, of course, a valid concern here that a proposed solution to a difficult moral problem may, at the same time, be misused to justify procedures which are clearly evil, namely, direct abortions. Might this be the case here? I think not, for the following reasons: 1) The argument begins from the fact that the implantation of the child is clearly in an abnormal site. Uterine pregnancies are not so considered even if at times the embryo may not be located in the best site in the uterus for optimal development and delivery. 2) In a tubal pregnancy, serious damage is done to the tube which generally does not occur to the uterus in case of uterine pregnancies. 3) In tubal pregnancies there is no rightful expectation of an eventual live delivery whereas that is usually the case in uterine pregnancies. Conclusion From a moral point of view, the initial steps upon diagnosing a tubal pregnancy should be medically conservative, such as expectant therapy coupled with careful monitoring. If the tubal pregnancy continues and the medical judgment is that it will not resolve spontaneously then other treatment modalities-as medically indicated-may be used so long as they do not constitute a direct lethal attack on the embryo. In light of the above moral analysis-if valid-a salpingostomy could be performed if there is a desire also to retain the reproductive potential of the patient. But it would be important in the use of any procedure that the patient and the physicians not intend the death of the embryo/child even if such is clearly foreseen. The object of the moral act is the termination of a process causing serious injury to the mother because of the abnormal site in which the child cannot be effectively supported, ultimately leading to the death of the child. (Click here for the August, 1996 continuation of this article) Rev. Albert S. Moraczewski, O.P.

  • zippy says:

    I’d appreciate it if folks would briefly excerpt articles to combox-appropriate size and provide links rather than posting substantially whole articles. I’ll let it stand for now — it is a good example of where refusing to qualify the choice of some kinds of behaviors in themselves as morally evil, independent of the reasons why they are chosen, will take you: straight to consequentialism. Hacking apart the living body of the child is not a “direct abortion” as long as it is done for a good enough reason.

  • Paul says:

    The case of salpingostomy is hard to decide, because the answer may depend on the details of the operation. Googling the operation did not provide enough details as to whether the method of removal of the foetus is actually likely to kill it. It seemed possible.Zippy, while it would be good to have a ruling from the Holy Office/CDF, we do have a policy in place which is accepted by the Magisterium.

  • William Luse says:

    The description of salpingostomy given in the quoted article sounds like flat-out murder to me.

  • Rodak says:

    This comment has been removed by the author.

  • zippy says:

    Paul:<>we do have a policy in place which is accepted by the Magisterium.<>I’m still waiting for an actual Magisterial document superseding this one on the particular point. There may be one, but I haven’t seen it. It looks to me like we have a policy in place which is accepted by (non-magisterial) theologians, a policy which has not been expressly condemned (again, since it is condemned by this document) by the Magisterium since the issuance of this document.That some theologians accept a practice and the Magisterium hasn’t gone out of its way to reiterate its condemnation of that practice is interesting, but hardly constitutes settled matter.Rodak:<>“This understanding of direct and indirect intent is an essential element of the principle of double effect.”<>The quoted language is true — if and only if double-effect applies to the particular act. That is why much of what passes for modern reasoning about double-effect is question-begging. People are applying double-effect analysis to every act without first determining that the act is not evil in its object; but double-effect can only be applied to acts which are <>not<> evil in their object. When the behavior chosen is in itself intrinsically immoral, the act is evil no matter why the acting subject chooses to do it; so it is invalid to “back door” the “intended/indirect voluntary” (or “directly intended/indirectly intended”) language into the discussion until <>after<> it is determined that the act is not evil in its object.

  • James says:

    Zippy,Sorry about posting the whole article. Access to articles at the National Catholic Bioethics Center is by subscription. So I didn’t think a link would work.The Center does accept unsollicited manuscripts and they do enjoy publishing works that argue contrary to what others have published at their Center on subjects not yet defined by the Magisterium. It might be an opportunity for you to address this article.

  • zippy says:

    Ah, thanks James.

  • Rodak says:

    <>it is invalid to “back door” the “intended/indirect voluntary” (or “directly intended/indirectly intended”) language into the discussion until after it is determined that the act is not evil in its object.<>I fully agree. But, then, I’m not among those having difficulty calling a spade a spade.

  • Paul says:

    The written Ethical Directives issued by the US Bishops — as commonly read by Catholic hospitals around the country, with no condemnation or correction by the Bishops — allow salingectomy when necessary. Hence there has been a ruling by the Magisterium. (If you disagree, you have only to write to your own Bishop to obtain a ruling from the Magisterium.)The 1902 ruling you quote is not totally clear. What is it about the 6th month that was seen (in 1902) as a necessary criterion to mention? As it stands, the ruling forbids something until the 6th month, whereafter it takes no explicit position on it.

  • zippy says:

    I don’t disagree that salpingectomy <>can<> be morally licit in some circumstances. Combox warriors have attempted to cast my opinions into the outer darkness because of my careful qualifications.I’m still waiting for something more recent of equivalent authority.

  • Anonymous says:

    I suffered an ectopic pregnancy in 2007, in which my fallopian tube ruptured and I slowly haemorrhaged.I would not be here today, and my three other children would be motherless, if I had not been treated. I underwent a salpingectomy. My tube and my much loved (but already dead) baby were removed. I suppose I don’t really have a point, sorry, but just wanted you to consider for a moment how heartbreaking it is for women (and I have since talked to many, many other women who have suffered too) and indeed their husbands who have not only lost a child, but had to face up to the possibility of losing their wife.I think of my baby constantly, and wish things were different. I hope to be blessed with another child, but that seems unlikely now.I’m sorry to intrude on what seems to be a very unemotional and intellectual discussion, but couldn’t read and not comment.My parish priest has never spoken to me about the ‘Catholic take’ on ectopic pregnancy, but knows how heartbroken I am, still. We have both prayed for the child (as have many others) and continue to do so.I sincerely hope no one in your families has to suffer an ectopic pregnancy, but if they do, I hope they stay safe and survive.I wish you all the best. Thanks for reading.

  • Lydia McGrew says:

    Anonymous, as a “hard-liner of the hard-liners” on this subject, I myself am on record as saying that when the embryo is dead, it is of course completely morally legitimate to perform surgery. I have also given an opinion (subject to correction from medical people) that when rupture and hemorrhage have occurred, the child is indeed dead. I would be willing to guess that even if there were a heartbeat before rupture (which there sometimes was not) there would not be afterwards. At that point the situation is no different from that of a woman who has suffered a miscarriage and has to have a D & C to remove the dead child so as to avoid an infection, only of course in the ectopic case the surgery is more urgent for the mother.God bless.

  • zippy says:

    Anonymous,I am very, very sorry for your loss. In addition to seconding what Lydia said, I want to thank you for vividly calling to mind the human side of what can often seem to be an abstract discussion. Underneath all the moral theology is charity toward real persons; all the moral theology is simply a comcomitant of that charity in the face of the God-breathed dignity of every person.

  • Anonymous says:

    Thank you so much for your replies, Lydia and zippy.I really do appreciate the fact that you see the human story behind the discussion.

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