Catholic Medical Quarterly Volume 64(2) May 2014

Correspondence

Saving Mothers, Protecting Babies.

Dr Seán Ó Domhnaill

Summary

Regarding the article on previable induction (CMQ 2014(1)13-17). The Catholic physician is directed to completely avoid the direct killing of the unborn child, and also to preserve the lives of both mother and child to every extent possible.

Catholic moral teaching tells us that, in carefully defined circumstances, it can be morally acceptable to induce an unborn baby before viability in order to save a mother’s life, but that it can never be permissible to directly end the life of an unborn child.

 

 

Introduction

It is a core contention of the global pro-life movement that abortion is not required to save a mother's life, and that, therefore, mother's lives are not put at risk where abortion is banned.

This contention is hugely important to the pro-life position. As much as abortion campaigners claim otherwise, pro-life medical experts have shown that the principle of double effect combined with expectant management and tailored therapeutic interventions generally ensure that life-threatening conditions arising in pregnancy can be suitably treated.

The Principle of Double Effect allows doctors to intervene to save the life of a mother without recourse to abortion. It is championed by pro-life groups, is in accordance with Catholic teaching.

The core issue

In the U.S., abortion supporters in the American Civil Liberties Union have lodged a major lawsuit against the Catholic Church, claiming that Catholic ethics caused a woman’s life to be endangered. At the heart of this lawsuit is the false claim that Catholic teaching can never permit the delivery of a pre-viable unborn baby where the life of the mother is at risk. A very small number of commentators also erroneously make the same claim from a pro-life perspective, and selectively quote from Catholic directives to bolster that claim. However well meaning, this error can only damage the cause of protecting life.

Thankfully, the US Conference of Catholic Bishops have issued Directives to guide healthcare practitioners on this issue, and senior Catholic obstetricians and ethicists have also provided necessary clarity for the faithful.

After the tragic death of Savita Halappanavar in Ireland in 2012, Dr Robert Walley of MaterCare International, a medical body committed to carrying out the work of Evangelium Vitae (the Gospel of Life), wrote lucidly and with great insight on this matter.

He pointed out that severe sepsis arising in the second trimester "is a life - threatening complication which usually results in the death of the unborn child and of the mother if not treated vigorously. Such clinical situations, although not common, present the obstetrician with serious ethical dilemmas".

"In considering the treatment options the following rights must be taken into consideration," he continued.

He named these as the right to life, the right to respect, the right to treatment, the right to skilled care and the right to compassionate care. He further emphasised  that: "As far as the right to life is concerned, every human being is absolutely equal to all others and this right is applied universally. The moral norm prohibits the direct taking of the life of an innocent human being."

Dr Walley also pointed out that "Every mother and every child has the right to the treatment and care needed to try to ensure the survival of each of them during pregnancy and childbirth; nothing must ever be done deliberately and directly which causes or which is intended to cause the death of either of them, nor must anything morally upright be deliberately omitted in order to provoke the death of either; essential obstetrical care must always be provided."

Dr Walley then confirmed that the correct practise in a case such as Ms Halappanavar's was to “treat with antibiotics and to induce premature labour".

"Such an approach is justified ethically by the Principle of Double Effect, (a time honoured principle based on Aristotelian principles), which states that is morally permissible to carry out a procedure that has two effects, one good and the other bad which are practically inseparable."

Dr Walley is an emeritus Professor of Obstetrics and Gynaecology at Memorial University of Newfoundland, and a Consultor to the Pontifical Council for Health. He was also awarded the Pro Ecclesia et Pontifice medal by Pope Benedict for his services to mothers and babies.

In a recent article on the same subject, Fr. Tadeusz Pacholczyk, Director of Education at The National Catholic Bioethics Center offered further insight, and spelled out the correct interpretation of the Ethical and Religious Directives for Catholic Health care Services, issued by the U.S. Conference of Catholic Bishops.

An examination of the Directives, and an understanding of the Principle of Double Effect, is vitally important to a full appreciation of whether delivery of a non-viable unborn baby is ever permissible.

Naturally, it is important not to fall into the error of saying that the delivery of a non-viable baby, directly procured in order to save the mother's life, will automatically be morally acceptable, but the Directives issued by the US Catholic Bishops make it clear that the induction of pre-viable unborn babies in order to save the mother’s life is morally permissible in certain circumstances.

Fr Pacholczyk explains that the lawsuit against the US Bishops referred to above alleged that the Directives for Catholic hospitals resulted in negligent care of a pregnant woman named Tamesha Means.

Ms. Means’ water broke at 18 weeks of pregnancy, leading to infection of the amniotic membranes, followed by the miscarriage of her child

Fr Pacholczyk in the December, 2013 installment of his syndicated column “Making Sense of Bioethics” writes that:

"The lawsuit not only suggests that she should have been given a drug to induce labor early on, but claims this wasn’t possible precisely because the hospital was Catholic and bound by the directives.  It further asserts that Catholic hospitals are not able to terminate a woman’s pregnancy by inducing premature labor 'even if necessary for her health,' because to do so would be 'prohibited' by the directives.

"In point of fact, however, the directives would not prevent the early induction of labor for these cases. Not infrequently, labor is induced in Catholic hospitals in complete conformity with the directives."

The two Directives under discussion are Directive #45 and Directive #47 which state that:

45. "Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) 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."

“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.”

What the Directives tell us then is that, while the direct killing of an unborn child is never permitted, an intervention which is directed towards an organ or the body person of the mother may be permissible before the baby is viable in order to save the life of the mother.

This is the key issue. In the same manner that morally-licit treatments for an ectopic pregnancy target the fallopian tube and not the baby, or treatment for cancer of the uterus is targeted at removing the cancerous womb and not at harming the baby, the induction of labour before viability can be permissible when sepsis arises in pregnancy, because the focus of the intervention is the expulsion of the infected membranes.

No pro-life physician is arguing that a blanket approval of induction prior to viability would be permitted: rather that it is vital to understand that the Principle of Double Effect, and the teachings of the Catholic Church, permit the induction of the unborn child before viability in rare circumstances.

Fr Pacholczyk explains that "Deciding about whether to induce labor involves the recognition that there are two patients involved, the mother and her child in utero, and that the interests of the two can sometimes be in conflict.

"In certain situations — for example, when the child is very close to the point of viability and the pregnancy is at risk — it may be recommended to delay early induction of labor in the hope that the child can grow further and the pregnancy can be safely shuttled to a point beyond viability, allowing both mother and child to be saved. Sometimes expectant management of this kind is not possible. Each case will require its own assessment of the risks, benefits, and likely outcomes before deciding whether it would be appropriate to induce labor.

"When a woman’s water breaks many weeks prior to viability and infection arises, long-term expectant management of a pregnancy is often not possible. In such cases, induction of labor becomes medically indicated in order to expel the infected membranes, and prevent the infection from spreading and causing maternal death.

"Early induction in these cases is carried out with the foreseen but unintended consequence that the child will die following delivery, due to his or her extreme prematurity. Such early induction of labor would be allowable because the act itself, i.e., the action of inducing labor, is a good act (expelling the infected amniotic membranes), and is not directed towards harming the body-person of the child, as it would be in the case of a direct abortion, when the child is targeted for saline injection or dismemberment.

"The medical intervention, in other words, is directed towards the body-person of the mother, using a drug to induce contractions in her uterus. One reluctantly tolerates the unintended loss of life that occurs secondary to the primary action of treating her life-threatening infection.  On the other hand, direct killing of a human being through abortion, even if it were to provide benefit for the mother, cannot be construed as valid health care, but rather as a betrayal of the healing purposes of medicine at its most fundamental level," he wrote.

A 2010 statement from the US Bishop's Committee on Doctrine also deals with the Distinction between Direct Abortion and Legitimate Medical Procedures.

It states that: "As the Church has said many times, direct abortion is never permissible because a good end cannot justify an evil means." It then explains an intervention is morally justified when an "urgently-needed medical procedure indirectly and unintentionally (although foreseeably) results in the death of an unborn child" but where that surgery "directly addresses the health problem of the woman, i.e., the organ that is malfunctioning", rather than directly terminating the life of the innocent unborn child.

This important distinction is also reflected in the Dublin Declaration which states that:

“As experienced practitioners and researchers in obstetrics and gynaecology, we affirm that direct abortion – the purposeful destruction of the unborn child – is not medically necessary to save the life of a woman.
We uphold that there is a fundamental difference between abortion, and necessary medical treatments that are carried out to save the life of the mother, even if such treatment results in the loss of life of her unborn child.
We confirm that the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women.”

The Declaration has already been signed by more than 700 maternal healthcare specialists and medical practitioners worldwide.

Conclusion

The best medical care protects both mother and baby. Abortion has no place in modern obstetric care, where, as we can see, women's lives are not put at risk and doctors strive to provide the best maternal healthcare possible. Catholic teaching can permit induction of the pre-viable unborn baby in certain circumstances to save the life of the mother, avoiding at all times, the morally unacceptable act of direct abortion. We must not allow abortion advocates to deliberately confuse legitimate life-saving medical treatments with abortion - and we should certainly not add to that confusion ourselves.

Click here to see all articles and letters in this debate

Dr Seán Ó Domhnaill is a Consultant Psychiatrist in Co Kildare, Ireland.