Catholic Medical Quarterly Volume 64(1) February 2014
in vital conflict cases:
really morally permissible?
Anthony McCarthy SPUC
The induction of pre-viable unborn babies in order to save the mother’s life cannot be seen as morally acceptable. Either it involves an invasion of the baby’s bodily integrity of an impermissibly harmful kind or - at very least - it constitutes an expulsion of the baby from a place where it has a fundamental right to be.
Readers of the Catholic Medical Quarterly will be aware of the great work that MaterCare International has done throughout the world, in the most difficult of circumstances and in an area where harmful ideologies undermine efforts to help women and children.
Faced with the recently highlighted problem of second trimester septic threatened inevitable miscarriage, MaterCare issued a statement published in the CMQ  setting out its position with regard to the ethical handling of such cases. Such was the seriousness with which MaterCare took the issue that they generously invited those holding opposing views to address their 2013 conference in Rome as part of a panel discussion. I was honoured to be one of those so invited.
In setting out my objections to a part of the statement put out by MaterCare, I hope to clarify which moral principles are at stake in the induction of labour pre-viability in cases of vital conflict. I will then say how these moral principles are to be applied in concrete situations, and will end with a series of relevant citations from Catholic Church sources.
The MaterCare Statement tells us that “severe second trimester septic abortion in practice is a life-threatening complication which usually results in the death of the unborn child and the mother if not treated vigorously.” We are told that “current practice is to treat with antibiotics and to induce premature labour”. In other words, the doctor treats the woman with the aim of making her go into labour and expel the pre-viable unborn child from her body, the effect of which will be the death of the child. The practice is morally justified, according to the statement, in cases where “failure to intervene may result in the death of both the mother and the baby.” MaterCare agrees with Professor John Bonnar, an Irish obstetrician, that “there is a fundamental difference between abortion carried out with the intention of taking the life of the baby, for example for social reasons, and the unavoidable death of the baby resulting from essential treatment to protect the life of the mother.”
The distinction being made here is between an intentional act aimed at ending of the life of a mother’s unborn child (described as abortion) and an intentional act aimed ‘merely’ at bringing about an early induction of labour where the mother’s pre-viable unborn child will inevitably die. The immediate end aimed at in the second case is induction of labour to expel a pre-viable child (which will result in his/her death). The intended act of expelling the baby has the ultimate intended goal of saving the mother’s life. The claim is that the second case is quite different from the first case because in the second case it is no part of the intention of the medical staff that the baby’s death be brought about. Rather, the baby’s death is a foreseen but unintended side-effect of the intended expulsion. Indeed, if the baby were somehow miraculously to survive such premature expulsion from his/her mother, the doctor and mother would rejoice, as ending the baby’s life was never part of their intention.
Professor Bonnar confuses the issue slightly when he compares saving the mother’s life through the induction of a pre-viable unborn child with intentional abortion “for social reasons”. A more helpful comparison would be between a deliberate induction with the further aim of killing the unborn child in order to save the mother’s life (ultimate intention), and a deliberate induction also with the ultimate aim of saving the mother’s life but without the intervening intention to end the life of the child as a means to saving the mother.
The first case is clearly, uncontroversially an abortion and is condemned by the Catholic Church as an “unspeakable crime”. Deliberate killing of the innocent is condemned as absolutely morally wrong and there are no exceptions to this norm. This means that an abortion, understood here as a deliberate act undertaken with the aim of killing an innocent unborn child, is absolutely morally wrong even when carried out with the further end of saving a mother’s life. In contrast, MaterCare are claiming that if there is no intention to kill the baby, a deliberate pre-viability induction is not a deliberate killing of the innocent and is thus not wrong in certain cases such as that of threatened inevitable septic miscarriage.
Over one hundred years ago, Catholic physicians sought ethical guidance from the Church on the subject of craniotomy: a term covering operations carried out when a baby’s head is too large to allow normal delivery and which involve using instruments to crush the baby’s skull (sometimes after emptying that skull) so as to allow the child’s removal from the birth canal, thus saving the life of the mother who would otherwise have died along with her baby.
Some influential Catholic thinkers have defended the moral acceptability of this procedure in principle, where the mother’s life (as well as the baby’s) is otherwise likely to be lost. For example John Finnis, Germain Grisez and Joseph Boyle have written that “a doctor could do a craniotomy, even one involving emptying a baby’s skull, without intending to kill the baby – that is, without the craniotomy being a direct killing.” They justify this statement by arguing that from the perspective of the acting person, the craniotomy’s “physical character as a lethal crushing and emptying”  is not intentional killing of an innocent because “done for the purpose of saving at least the mother’s life, the object of the act [immediate end] is to reduce the size of the baby’s head so that the baby or its corpse can be removed from the birth canal.” And if the procedure is not an intentional killing it might, in certain extreme circumstances, be permissible, the authors seem to be suggesting.
The authors do, however, concede that “even when bringing
about a person’s death is not direct killing, doing so is often
gravely wrong. We do not deny that there might be reasons for
condemning the practice of craniotomy other than that it is
direct killing.” Despite this important admission, the
authors do not pursue the question of such possible alternative
reasons for condemning craniotomy and appear to want to exclude
craniotomy from the clearest categories of exceptionless moral
There are a number of things which need to be said about all this. Many readers may find such arguments justifying craniotomy extraordinary, and may object that craniotomy just is a direct killing of an innocent new human being and therefore obviously wrong in itself. David S. Crawford, for example, makes the point that we are not mere ‘parts’ or ‘assemblages’ and that to ‘narrow’ a skull is to ‘narrow’ a person and that “the choice is to change the baby into something other than a baby, for it is only a new substantial form - that of a corpse – that would be compatible with delivery. But this is just another way of saying that the doctor is in fact choosing to kill the baby.” 
Is David Crawford right to say that death must necessarily be intended in all cases of craniotomy? Perhaps he is wrong, and death need not be intended as such; however, even if we don’t want to say that the doctor must necessarily intend to kill the baby, we can certainly say that he intends, as the moral object of his act (his immediate end), a bodily invasion on the unborn child of a kind which is in fact lethal. And isn’t such an act unjust to the child? After all, his/her bodily integrity is grossly violated and he/she is deliberately deprived of what he/she relies on to continue to exist. The baby’s skull is indeed, as Crawford says, ‘the person’ and not a mere part. And that person is violated by a deliberate invasion of his/her body of a lethal kind. Such a deliberate act is necessarily unjust to the innocent person at whom it is directed and is always and everywhere absolutely wrong. Similarly a doctor operating on a dying, unconscious person in order to extract a vital organ to give it to someone else might not be intending to kill the person by lethally cutting into him/her – but is necessarily committing a gross lethal bodily violation of the person that cannot be anything other than intrinsically unjust.
For reasons of this kind, craniotomy can never be a morally acceptable procedure when carried out on a live baby. And we can say the same about obstetricial procedures more widely practised today, such as D&C’s or D&E’s in vital conflict situations. Here again, there will be, at very least, a deliberate and in effect lethal invasion of the baby, including his/her placenta which is a temporary part grown by, and genetically identifiable as, the baby him/herself. Any foetal part that is targeted for invasion/pulling/scraping away is something which, as Crawford says, “contains the whole of the person because the formal cause of the whole is present in every part.”
Induction of pre-viable babies
Bearing all of the above in mind we can now tackle the vexed question of the moral acceptability of inducing pre-viable babies in ‘vital conflict’ situations. If the deliberate induction of pre-viable babies involves a bodily invasion (ie a violation of the baby’s bodily integrity offering no benefit to the baby but doing the baby serious harm) we are dealing with an unjust act directed at an innocent victim. This is a kind of act that is wrong if committed on an innocent person outside the womb, and it could be argued that there are additional reasons why such acts might be wrong in the context of the unique and special activity known as human pregnancy.
However, a much more difficult question arises when we talk about pre-viable inductions apart from any bodily invasion of the foetus – if indeed that is possible to envisage (in fact detachment would seem to necessitate the rupture of foetal tissues such as the placenta and amniotic sac, however that rupture is achieved). Leaving that aside, in order to focus on the issue of removal itself, let us look simply at a supposedly non-invasive deliberate removal of the baby in a case where the mother is at serious risk and the baby will die soon whatever happens.
In such a case, the baby cannot be said to be an ‘aggressor’ as it is has no harmful intent towards the mother - hence the need to avoid all lethal violence towards it. However, the induction method mentioned above is supposed to be a mere ‘removal’, not involving any violation of the baby’s bodily integrity. By analogy, on a crowded lifeboat someone might be pushed off the boat in order to save other people in it. The person will fall into the sea and drown and we may know with certainty that this will happen. However, such an act need involve neither an intention to kill nor an intention to violate bodily integrity, of a kind that would immediately rule it out. The person’s death is a foreseen but unintended side effect of the action.
Now, if one thinks that pushing someone off the boat in this way is always morally wrong (whether because one sees it as a direct intentional killing – despite the description above - or because one sees it as otherwise inherently unjust) then one will not be appealing to the principle of double-effect which presupposes that the immediate act under consideration is morally good in itself, or at least ‘neutral’. And one might go on to say by analogy that the deliberate induction of a pre-viable unborn baby – throwing it out of a protective environment to benefit another - is always wrong and therefore that the principle of double effect is inapplicable to it as the act is already wrong in itself.
However, what if someone were to hold that sometimes it might be permissible to push someone off a boat – let’s say, someone already very close to death – in order to save other lives? The deliberate pushing is here seen as something not morally wrong in itself, and so as potentially justifiable according to the principle of double effect (i.e. the death of the passenger is a side-effect of an otherwise justified choice to ‘remove’). And if that is the case, isn’t the pre-viable induction of labour a similar kind of ‘removal’ done in order to save a life?
One answer to that question might be to return to the special nature of pregnancy: doesn’t the baby have a right to be in the womb of the woman at this stage of his/her life? a right that is fundamental in a way that is not the case with the person on the lifeboat. Indeed, one of the problems in ethics discussions these days is the frequent assumption that the ‘physical’ or ‘bodily’ nature of certain situations has no serious relevance to moral thinking. Yet to ignore the meaning of our bodies, their complementarity, the nature of pregnancy and the dignity of our deepest physical, spiritual and familial bonds, is to ignore the very reality which grounds and gives rise to all our moral norms. Sexual ethics and medical ethics, above all, need to pay attention to our embodied natures and not fall into the modernist trap of seeing ethical thinking too much as something concerned with what we choose as our ‘further’ ends while ignoring the realities of nature and its teleology and the physical structures we choose more immediately. Sexual ethics and medical ethics have both suffered at the hands of otherwise orthodox ethicists who lead others into error by failing to see that some chosen acts are identified partly in relation to their bodily kind. For example, masturbation is an act of an (im)moral kind regardless of the motive or further intention of the one doing it – and that kind of thinking can equally be applied outside the area of sexual ethics.
In short, I want to claim that the induction of pre-viable unborn babies in order to save the mother’s life cannot be seen as morally acceptable. Either it involves an invasion of the baby’s bodily integrity of an impermissibly harmful kind or - at very least - it constitutes an expulsion of the baby from a place where it has a fundamental right to be. As Helen Watt has argued:-
“...pregnancy is a special case: the duty not to evict or withdraw support in pregnancy is, uniquely, absolute. At this stage in the mother-child relationship, it is crucial that this relationship be seen as literally unconditional: ‘till death [or birth] do us part’. Such unconditionality enables the mother to bond effectively with the child she is carrying, whose life is accepted as inextricably bound up with her own. While later on, parenthood is a matter of a gradual ‘letting go’, introduction to other carers, and encouragement to independence, it is important that both women and children feel that there was one time at which the child was unconditionally supported. Pregnancy should involve a unique commitment to the child, whose presence is accepted as a ‘given’: any deliberate removal of the child, or willingness to do so in certain circumstances, goes against that unconditional commitment.”
In the light of all of the above, I am claiming that the deliberate induction of pre-viable babies, like the use of a morning-after pill for pregnancy-disrupting purposes, is always morally wrong and can rightly be called ‘abortion’ – a term which should not be restricted to deliberate killing of the unborn, but should be seen to cover also lethal bodily invasions and deliberate expulsions of pre-viable unborn children of a lethal kind.
Finally, we should also listen carefully to what the Catholic Church has told us on these questions. I will end this article with a list of statements from Church authorities for the information of readers (emphasis has been added throughout). At very least, it is for those claiming that deliberate induction of pre-viable babies can be morally acceptable to show that the Catholic tradition allows for their position. Taken together, these quoted passages dealing with abortion, including in vital conflict cases, certainly appear to rule out in a definitive way any recourse to deliberate induction of labour in the case of a pre-viable baby. That the guidance of the Holy Spirit can help us develop our philosophical thinking on these disturbing and difficult matters is both a consolation and a blessing.
Catholic Church teaching on deliberate induction
pre-viable unborn children – some sources
Pope John Paul II:
“Especially in the case of abortion there is a widespread use of ambiguous terminology, such as "interruption of pregnancy", which tends to hide abortion's true nature and to attenuate its seriousness in public opinion. Perhaps this linguistic phenomenon is itself a symptom of an uneasiness of conscience. But no word has the power to change the reality of things: procured abortion is the deliberate and direct killing, by whatever means it is carried out, of a human being in the initial phase of his or her existence, extending from conception to birth.”(Evangelium Vitae 58)
As Evangelium Vitae 62 approvingly records,
“Pius XII excluded [in his Address to the Biomedical Association "San Luca" of 12 November 1944] all direct abortion, i.e., every act tending directly to destroy human life in the womb "whether such destruction is intended as an end or only as a means to an end".
Already in 1988, John Paul II had confirmed a response to a question put to the Pontifical Council for the Interpretation of Legislative Texts:
“Whether abortion, as referred to in c. 1398, should be understood only of the ejection of a foetus which is not yet viable, or also of the killing of the same foetus, whatever the way and at whatever the time, from the moment of conception, it is procured?”
The answer was:
“Negative to the first part, affirmative to the second”. Responsio: 19/01/1988 Approbatio pontificia: 23/05/1988 Promulgatio: 12/12/1988 (AAS 80 (1988) 1818). This answer was cited in the Congregation for the Doctrine of the Faith’s Instruction Dignitas Personae at footnote 46. Dignitas Personae also observes that fertility interventions should respect "the right to life and to physical integrity from conception to natural death"(12) and later (34) refers to cell lines resulting from an illicit intervention "against the life or physical integrity of a human being."
Pope Pius XII:
“Deliberately We have always used the expression "direct attempt on the life of an innocent person,""direct killing." Because if, for example, the saving of the life of the future mother, independently of her pregnant condition, should urgently require a surgical act or other therapeutic treatment which would have as an accessory consequence, in no way desired nor intended, but inevitable, the death of the foetus, such an act could no longer be called a direct attempt on an innocent life. Under these conditions the operation can be lawful, like other similar medical interventions - granted always that a good of high worth is concerned, such as life, and that it is not possible to postpone the operation until after the birth of the child, nor to have recourse to other efficacious remedies.” Pius XII, Allocution to Large Families, Nov. 26, 1951 (17).
This statement was quoted in “On Procured Abortion: Clarification from the Congregation for the Doctrine of the Faith” of 10 July 2009, which made the following observation:
“As for the problem of specific medical treatments intended to preserve the health of the mother, it is necessary to make a strong distinction between two different situations: on the one hand, a procedure that directly causes the death of the foetus, sometimes inappropriately called 'therapeutic' abortion, which can never be licit in that it is the direct killing of an innocent human being; on the other hand, a procedure not abortive in itself that can have, as a collateral consequence, the death of the child”.
Much earlier, the Holy Office (Congregation for the Doctrine of the Faith) had condemned craniotomy (1884), any surgical procedure “directly lethal” (directe occisiva) either to the mother or to the foetus (1889), and deliberate previability removal which, as the question was framed, involved no direct attack (1895) but a foetus too young to survive. The 1895 ruling referred back to the previous two rulings. In 1902 the Holy Office made clear that pre-viability removal of an ectopic pregnancy was also ruled out, and referred to an earlier ruling on ectopic pregnancy in 1898 which demanded that serious and opportune provision be made for the life of the foetus and the mother. The Holy Office explained that “no acceleration of the birth is licit, 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 foetus are considered” (on these rulings, see the discussion in John Connery, Abortion: the Development of the Roman Catholic Perspective (Chicago: Loyola Univ. Press, 1977) Chapter 15).
The United States Conference of
Catholic Bishops in its Ethical and Religious Directives for
Catholic Health Care Services 2009 Fifth Edition includes the
45. Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable foetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo. Catholic health care institutions are not to provide abortion services, even based upon the principle of material cooperation. In this context, Catholic health care institutions need to be concerned about the danger of scandal in any association with abortion providers.
46. Catholic health care providers should be ready to offer compassionate physical, psychological, moral, and spiritual care to those persons who have suffered from the trauma of abortion.
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
48. In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion. [Ft 31: Cf. Directive 45]
49. For a proportionate reason, labour may be induced after the foetus is viable.
- John Finnis, Germain Grisez, Joseph Boyle, “Direct” and “Indirect”: A Reply to Critics of Our Action Theory The Thomist 65 (2001) p.27. The paper lays out the authors’ action theory and uses craniotomy as an example to illustrate its application rather than as a current medical issue.
- Ibid. p29 fn 47.
- Ibid. p25.
- Ibid p27.
- David S. Crawford, Experience of Nature, Moral Experience: Interpreting Veritatis Splendor’s “Perspective of The Acting Person” Communio 37 (Summer 2010) p278.
- Ibid. p277.
- The topic is discussed in the following important and original paper - Helen Watt, Beyond Double Effect: Side Effects and Bodily Harm collected in David S. Oderberg and Timothy Chappell (eds), Human Values: News Essays on Ethics and Natural Law, (New York: Palgrave MacMillan 2007) p245. See also Helen Watt, Bodily Invasions: When Side Effects are Morally Conclusive, National Catholic Bioethics Quarterly, Spring 2011 p677-679. Helen Watt, Side Effects and Bodily Harm, Ethics and Medics, January 2011 p1-2 and the discussion of double effect in Stephen L. Brock, Action and Conduct: Thomas Aquinas and the Theory of Action, Edinburgh T&T Clark 1998).