Catholic Medical Quarterly Volume 64(2) May 2014

Correspondence

Author's response.

Anthony McCarthy

Sir,

I am grateful to Drs James Gerrard, Ian Jessiman, Michael Jarmulowicz and Seán Ó Domhnaill for raising their concerns about my article (CMQ 2014(1)13-17) on the difficult subject of vital conflicts.

Dr Gerrard takes issue with my phrase “threatened inevitable septic miscarriage”; however, its use (as with the term “life-threatening illness” which covers threats both evitable and inevitable)  has no bearing on the ethical arguments.  He rejects my analogy of pushing a person off a lifeboat, which in fact I made partly to highlight the special nature of pregnancy, which is in many ways disanalogous to being on a lifeboat - whether or not one is already dying, as in one lifeboat case I mentioned.  To highlight the fact that the baby is already doomed, Dr Gerrard talks of the uterus as being like a poisoned room, and claims that it does not cause death if a baby is taken from a poisoned room to a cold one.  In fact, death is caused by whatever in fact causes it (as I argue below);  and in any case, I am opposing the targeted removal of pre-viable babies even when the uterus isn’t a poisoned environment and the baby has some chance of survival if left where it is a few more weeks, despite a very real threat to the mother.  Does Dr Gerrard think that deliberate pre-viability removals are justified in these cases too?

Whatever the answer to that question, even when we do have a “poisoned room” situation, we are surely still not justified in harmfully invading the bodily integrity of a person in order to remove that person from such a room to benefit someone else.  And in the case of pregnancy, we are not just deliberately displacing the baby by means which harmfully invade the fetal tissues but are displacing the baby from his or her natural home to a certain death.  Remember, this procedure is being carried out with no intention of benefitting the baby – i.e. the person on whom the destructive procedure is intentionally carried out. And the procedure of removal does cause the baby’s death and does so regardless of whether the baby is about to die or not.

Contrary to Dr Gerrard’s claim, the mother is very much present in my piece, such as in the quotation on the pregnancy relationship and its unconditional nature and (more importantly) the cited passages from the CDF/Holy Office, and from Popes known for their defence of mothers and children. Ignored too are the following 2009 USCCB Directives quoted in the article:

“45. Abortion (that is the directly intended termination of a pregnancy before viability or the directly intended destruction of a viable foetus) is never permitted...49. For a proportionate reason, labour may be induced after the foetus is viable.

Given that Dr Gerrard quotes Directive 47 of the Ethical and Religious Directives as authoritative he needs to address the Directives cited above which contextualise 47 and make quite clear what is and is not permitted according to the Directives (not to mention some of the other cited texts).

Dr Jessiman claims that doctors in a case of inevitable miscarriage

“are not intending to terminate a normal pregnancy but to assist, facilitate or encourage a natural (if pathological) process already begun (albeit possibly ‘arrested’).  (I exclude instrumental delivery unless the miscarriage is already incomplete and the foetus is dead).”

Dr Jessiman’s point with regard to “facilitating” a natural process in the case of miscarriage is worrying. After all, a case of euthanasia could be justified on similar grounds where a patient is terminally ill. The “facilitator” of such a death is also assisting in a natural process but is, in that case, deliberately ending the life of the patient – an act which pro-life ethics and the Hippocratic Oath condemns.   And in the case of deliberate pre-viability ending of pregnancy, the ending of pregnancy, if not the death itself, is most definitely intended.  The pre-viable baby is lethally targeted in a procedure which is destructive and cannot be said to “treat” the baby in any way beneficial to him or her.  Moreover, the procedure removes the baby from that very special place which can be reasonably regarded as the baby’s home:  if we lethally target and wrench the baby from that place we are responsible for what we target and for the lethal effects of that targeting. That said, I welcome Dr Jessiman’s clarification, not made by the other correspondents, that he is not defending the use of instruments unless the baby is already dead – presumably because he would see such use as a harmful attack on the child.

This contrasts with the more disturbing letter from Dr Michael Jarmulowicz who in the context of ectopic pregnancy treatment with methotrexate appears to leave open the possibility of it being morally acceptable for someone to carry out what he admits is a “direct attack on the developing fetus” (bearing in mind that the trophobast is part of the fetus him or herself).  We are a long way here from triage situations, or from the therapeutic targeting of the mother’s body alone, as with hysterectomy for uterine cancer or salpingectomy for a tube already damaged by ectopic pregnancy.  Nor is it necessary, as I stressed in my article, to claim that an intention exists to harm or kill the baby in order to exclude absolutely such wrongful targeting of the baby’s own tissues.[1]

It is not so much a question of what causes death (after all, salpingectomy certainly causes death) as of how death is caused, even if the baby was going to die anyway of other causes.  Is death caused by illicit targeting of the baby’s own tissues and/or by his or her illicit targeted removal from the mother’s body?  Is it physically possible to remove a pre-viable baby from the uterus without harmful invasion of the baby’s own tissues, whether achieved via instruments or via drugs inducing labour?

Dr Jarmulowicz alarmingly gives us an analogy for pregnancy very similar to those standardly used by abortion advocates (most famously, the philosopher Judith Jarvis Thomson).  He compares ending the pregnancy with disconnecting a person from an ITU in a case of fire.  However, pregnancy is not a technological linkup, even if we accept that deliberate pre-viability induction/removal is a benign non-invasive unplugging, which seems very doubtful.  The special nature of pregnancy and its multifarious bonds of crucial ethical significance is not acknowledged here.  If we were to accept Dr Jarmulowicz’s analogy then it seems that pregnancy is in no way “special” for purposes of removal,  and if pregnancy is not special then a doctor  could presumably deliberately induce labour pre-viability not only to save a woman’s life but to stop her going blind, for example. After all, in a different case where miscarriage was not intended, but a mere side-effect of treatment to prevent blindness, we might indeed be willing to accept such a side-effect of legitimate treatment of the woman’s body alone.

Finally, Dr Sean O Domhnaill merely restates the MaterCare position, which was criticised in my article, and then quotes from a US bioethicist whose points do not address the kind of criticisms made in the article; he also passes over in silence the phrase "termination of pregnancy" in paragraph 45 of the USSCB document mentioned above which very explicitly condemns "directly intended termination of pregnancy" (instead of referring to "directly intended destruction of a pre-viable fetus" immediately before its reference to "directly intended destruction of a viable fetus"). To argue that pre-viability inductions are morally justified where sepsis has arisen because the "focus of the intervention is the expulsion of the infected membranes" is to ignore the fact that the membranes are part of the baby: targeting the unborn baby in a destructive way cannot be justified (any more than if a mother were targeted to benefit a viable baby in a way destructive to her). We need to remember that salpingectomies, as we saw above, are not like pre-viability inductions as they, in this case therapeutically, target the mother and not her baby. I draw your readers' attention again to the relevant Church teaching, cited in my original article and left unaddressed by my respondents. The issues are difficult and distressing, but the arguments put forward on this side have not been refuted, are, I hope, clearly put and are, I believe, fully in line with the quoted statements from Church sources in this area.

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