(www.RemnantNewspaper.com) There are few words more terrifying for a woman (and her husband) than “tubal pregnancy”. Whenever these words are uttered to an expectant mother and father, it means the loss of hope, and not just physical pain, but the very real emotional pain of having to face the loss of an unborn child, and fear that the mother might die as well. To make matters worse, Catholic parents are thrown headlong into a murky moral dilemma that, more often than not, they will have face alone, having to make snap decisions on the spot without the benefit of sound moral or spiritual counseling, and with little or no preparation to make sound moral choices.

Even though there has been disagreement over the years concerning the right and wrong thing to do in the case of an ectopic pregnancy, Catholic parents and their doctors can turn to their Catholic faith for guidance. While no parent wants to contemplate the possibility of an ectopic pregnancy, it is something, nevertheless, that is faced by 1 in 70 pregnant women.  Knowing the facts about ectopic pregnancy, and how Catholic moral principles can be used to navigate the murky waters surrounding it, may not mitigate the emotional and spiritual pain, but it can still serve by helping parents avoid making an on-the-spot decision that they will come to bitterly regret. Knowing that you, as a mom or dad, did everything you could to achieve the greater good, preserve the life of both mother and child, and that you sought the will of God throughout the course of the tragedy, will facilitate healing afterwards.

Doctors and medical professionals also have a particular obligation to understand the moral dilemmas faced by their Catholic patients and their families. By coming to a more thorough understanding of Catholic moral teaching regarding the sanctity of life, and everyone’s moral obligation to safeguard human life from conception to natural death, medical professionals are better equipped to provide all the ethical information their patients will need when it comes time for them to make decisions while under extreme physical and emotional duress.

Ectopic Pregnancy and the Catholic Church’s Teaching Regarding the Unborn

An ectopic pregnancy is any pregnancy that occurs outside of the uterus. An ectopic pregnancy occurs when the movement of a fertilized egg is blocked or slowed in the fallopian tube, causing the egg to implant in the tube. This is commonly called a “tubal pregnancy”, but ectopic pregnancies can occur, on rare occasions, in the ovary, around or behind the uterus, or in the cervix.

There are various reasons why a fertilized egg can be blocked or slowed in the fallopian tube, to include a birth defect in the fallopian tubes, endometriosis (uterine lining tissue occurring in the fallopian tubes), complications caused by a ruptured appendix, and scarring from past infections or surgeries. The risk for ectopic pregnancies is significantly increased by age (over 35), in vitro fertilization, having multiple sexual partners, smoking, and getting pregnant while using certain intrauterine artificial contraception devices or after having a tubal ligation. Also reconstructive surgery to the fallopian tubes significantly increases the chances of an ectopic pregnancy.

An ectopic pregnancy is always a life-threatening condition to mother and child. Without the removal of the developing cells a rupture will occur, and the resulting hemorrhaging will kill the mother. Obviously, therefore, the baby cannot survive in such a condition, either. An ectopic pregnancy must be treated immediately in order to save the life of the mother, but the death of the unborn baby is always a consequence of all current ectopic pregnancy treatments.

The Catholic Church has always taught, since the first century (the Didache, II. 2), in fact, that every procured abortion is a grave moral evil, and this teaching has not changed, nor can it be changed. Any direct abortion, which is willed either as an end in itself or as a means to some other end, even to save the life of the mother, is grave matter that is contrary to the moral law (Denzinger, 1183f and 1890a-c). Thus, an ectopic pregnancy cannot be treated by a direct abortion, even if the abortion is performed to save the mother’s life.

Must the Mother Die?

Does this mean that an ectopic pregnancy must be left untreated, resulting in the death of both mother and child? This is clearly an unacceptable moral conclusion, especially if the means are available to the save the life of the mother. The principle of double effect can and should be applied when considering ectopic pregnancy.

St. Thomas Aquinas lays out the foundations of the principle of double effect in his Summa Theologica (IIa-IIæ Q. 64, art 7):

Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention. Now moral acts take their species according to what is intended, and not according to what is beside the intention, since this is accidental.

The principle of double effect is employed in moral reasoning when an action one thinks one ought to do in a given circumstance has both good and bad effects, causing an ethical dilemma. An action that has bad consequences can be morally permissible if the good effect is intended, and not the bad effect. However, St. Thomas is careful to add in the same article that a justification of the unintended effect is conditional. It must be proportional to the intended good consequence. In other words, the good effect must be equal to or greater than the unintended bad effect.

Here is the New Catholic Encyclopedia on the rules for determining whether or not the action one thinks one ought to do when both good and bad consequences will follow:

1. The act itself must be morally good or at least indifferent.

2. The agent may not positively will the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary.

3. The good effect must flow from the action at least as immediately (in the order of causality, though not necessarily in the order of time) as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed.

4. The good effect must be sufficiently desirable to compensate for the allowing of the bad effect. (1021)

In the case of an ectopic pregnancy, the action that is directly willed is to save the life of the mother by the removal of a pathological mass of tissue (not unlike a malignant tumor), which unfortunately contains, but not exclusively, an unborn baby, which has implanted in the wrong place. The bad effect, the death of the unborn baby, is not directly willed. Just as it would be morally permissible to remove a cancerous tumor from the mother, even if such treatment will kill the unborn child, so it is also morally permissible to remove a pathological and abnormal mass of tissue that contains an unborn child in order to save the life of the mother. The death of the child is an unwilled, indirect and unfortunate effect of a treatment used to save the mother’s life, and is further proportional in that if no action were taken, not only would the mother die but so would the unborn child.

Therefore, according to the principle of double effect, treatment of an ectopic pregnancy that results in the unintended death of the baby can be morally permissible. However, not all treatments are morally permissible. It is in evaluating the various treatments offered by modern medicine that we find confusion and moral uncertainty.

Moral Considerations of Various Treatments for Ectopic Pregnancy

Surgical removal of the pathological tissue that contains the unborn baby is the least problematic treatment from a Catholic moral perspective. This treatment usually consists of the use of mini-laparotomy or laparoscopy surgery to confirm the ectopic pregnancy, remove the abnormal tissue mass containing the unborn child, and repair (salpingostomy) or remove (salpingectomy) the fallopian tube. This surgical procedure is intended to directly treat a pathology, thwart life-threatening conditions such as hemorrhaging or damaged tissue, and to stabilize the mother, all of which is done to save the life of the mother. This directly willed effect, to save the life of the mother, is proportional to the unintended bad effect.

Surgery also has the positive intention of confirming the ectopic pregnancy. One of the aspects of ectopic pregnancy that exponentially complicates treatment and moral reasoning is that an ectopic pregnancy can be very difficult to diagnose. Symptoms of an ectopic pregnancy can include more than normal vaginal bleeding, cramping and lower back pain. However, these can also be common symptoms of normal pregnancies.

Early diagnosis of ectopic pregnancy is usually limited to monitoring hCG (human chorionic gonadotropin) levels in the blood and ultrasound examinations. In a normal pregnancy hCG levels should double roughly every forty-eight to seventy-two hours. If hCG levels are low, or fail to double normally, this can indicate an ectopic pregnancy, but not necessarily. Early ultrasound examinations are also used to diagnosis ectopic pregnancies. At an hCG level of 1300 to 1500 international units per milliliter (mIU/ml), at the very least the gestation sack containing the fetus should be visible to a vaginal ultrasound examination. If the gestation sack is not seen on the ultrasound, this could indicate an ectopic pregnancy, but not necessarily. There are other reasons that the gestation sack may not be visible.

There are only two reliable methods of diagnosing an ectopic pregnancy: either the tube has burst and is causing hemorrhaging, which is visible to ultrasound imaging (other symptoms of a rupture is fainting, intense abdominal pain, low blood pressure, pain in the shoulder area, and intense pressure on the rectum), or confirmed in the course of a mini-laparotomy or laparoscopy. In some rare cases, a rupture can occur without immediate hemorrhaging or other symptoms. For these reasons, even without a rupture, exploratory surgery is morally permissible if an ectopic pregnancy is strongly suspected. However, such an exploratory surgery, like all surgeries during pregnancy, runs the very real, though unintended, risk of injuring or killing the unborn baby. Uncertainty in regards to the diagnosis is an important consideration in moral reasoning as we consider other treatments.

This uncertainty brings us to a second treatment consideration, which is to wait and see. The “wait and see” approach works on the premises that many pregnancies may start out as ectopic, but naturally work themselves out. The fertilized egg could be slow in passing through the fallopian tube, causing hCG levels to rise at a slower rate. Ultrasound examinations may not give an accurate picture. Because of this uncertainty in diagnosis, and considering that an exploratory surgery may harm a healthy pregnancy, it can be decided to wait and see if a rupture takes place.

While this course of action is morally sound, if a rupture does occur along with life threatening hemorrhaging, to continue to “wait and see” will only result in the death of the mother and the unborn child, thus making continued delay of immediate treatment irrational, to say the least. It must be noted, that in extremely rare cases ectopic pregnancies have been known to proceed without hemorrhaging or other life threatening complications to a point that the fetus was viable and could be surgically removed alive. While extremely remote, I think that even this small possibility justifies the “wait and see” approach, at least up until such a time that a rupture occurs that directly threatens the life of the mother and the unborn child.

The third and most common form of treatment for ectopic pregnancies is the administration of methotrexate (MXT). The use of MXT is so common due to its convenience. MXT was developed as a treatment for cancer, and is still used as part of chemotherapy in the treatment of leukemia, lymphoma, breast and other cancers. Because MXT inhibits the metabolism of folic acid, which is necessary for cell division and the growth of the fetus, MXT is used to terminate early pregnancies. Without the normal metabolism of folic acid, the unborn child is unable to develop, dies, and the mother’s body disposes of the dead tissue. If used to terminate an ectopic pregnancy, it is administered by injection, and accompanied by routine monitoring to ensure that the blood hCG level decreases, reflecting that the pregnancy has been terminated and that the tissue in the fallopian tube is dissolving.

The use of MXT as a treatment for ectopic pregnancy is extremely troublesome from a Catholic moral perspective. MXT is an abortifacient. The administration of MXT is primarily for the purpose of terminating the pregnancy. Thus, it would seem that the use of MXT to terminate the pregnancy is in direct contradiction to the Church’s teaching, namely that any direct abortion, which is willed either as an end in itself or as a means to some other end, even to save the life of the mother, is grave matter for sin, and is contrary to the moral law, as sated above.

However, can the principle of double effect make the use of MXT permissible in the case of an ectopic pregnancy? In order for the principle of double effect to be valid, the good effect must be produced directly by the action, not by the bad effect. The use of MXT directly produces the bad effect, the death of the unborn child, which in turns causes the mother’s body to dispose of the pathological tissue. Obviously this is a case of the ends justifying the means, which is never allowed. MXT circumscribes the pathology by terminating the pregnancy. In the use of MXT, a direct chemical abortion is willed as a means to an end, and such an action is, indeed, contrary to the moral law. Double effect, therefore, cannot be used as a justification for the use of MXT because the bad effect, the destruction of the fetus, the death of the unborn child, is directly intended.

It has been argued that the use of MXT is simply a chemical substitute for surgery. Instead of surgical instruments, chemicals are used to the same effect. This is not a sound argument, though, because the use of MXT first seeks to destroy the life of the unborn child, and then as a consequence of that action, the body disposes of the pathological tissue. Surgery, on the other hand, produces first the removal of the pathological tissue containing the fetus, which in turn causes the unintended death of the fetus. Also, because the pathology has been circumscribed, rather than treated directly, there is no guarantee that the pathology has been completely removed or the medical condition that caused the pathology repaired.

For example, the use of MXT does not treat a damaged fallopian tube that may have been the cause of the ectopic pregnancy. Because a damaged fallopian tube is left untreated, another ectopic pregnancy could result. In addition there is a risk that the body will not dispose of the dead tissue, which can cause further damage and even ruptures long after the administration of the drug. If the tube has already ruptured, the administration of MXT is useless, and is liable to cause further complications.

It should be highlighted that among all the medical problems incumbent with the use of MXT, which makes it not just immoral but impractical and even dangerous, there is the risk of using MXT prematurely. Because of the convenience of using MXT, and because of the uncertainty in diagnosing ectopic pregnancies, MXT is often used as a preventative rather than as a treatment, and this behavior can have very severe moral and physical consequences. The use of MXT in a miss-diagnosed ectopic pregnancy can result in the termination of a perfectly healthy pregnancy, or, because MXT is a highly teratogenic drug, it can result in severe birth defects if the baby should survive its administration. MXT is a “cell toxic” drug, and can have serious and broad adverse side effects for the mother. All this indicates that the morally problematic nature of using MXT as a treatment for ectopic pregnancy is reflected in the physically problematic nature of MXT on the mother and unborn child.

We can, conclude, therefore, that the use of MXT as a treatment for ectopic pregnancy is not morally permissible, and this is reflected in the physical dangers incumbent in its use.

The Dangers of Reparative Surgery

The advance of medical science has further confused moral reasoning in regard to reparative surgery of damaged fallopian tubes. The most common form of reparative surgery is the repairing of damaged fallopian tubes in the course of treating an ectopic pregnancy (salpingostomy). Another common reparative surgery is tubal ligation reversal procedures. In both cases there are important moral and practical aspects that need to be considered.

In the first case, many Catholic moralists in the past have argued that a salpingostomy was immoral for two reasons: (1) an ectopic pregnancy indicated a terminal abnormality of the fallopian tube, that should, therefore, be removed, and (2) the removal of the fallopian tube was the only way to justify double effect in the case of an ectopic pregnancy, as the tube, considered the pathology, contained the unborn child.

We now know, however, that there are causes for ectopic pregnancies other than damaged or defective fallopian tubes. Furthermore, medical science has progressed to such a point that reconstructive surgery can adequately repair these same defects. Doctors do not act wrongly in seeking to use their skills, knowledge and technology (all of which are gifts from God) to restore to the mother’s body a function that naturally occurs otherwise.

Furthermore, double effect does not negate the responsibility of the parties involved to mitigate to the best of their ability the bad consequences incumbent upon the moral action. If, for example, the doctor can remove the pathological mass containing the fetus, and is reasonably sure she can adequately repair the fallopian tube, there is no moral imperative that the fallopian tube be removed. Double effect does not require that the doctor sterilize the mother, especially since we know that it isn’t the fallopian tube that contains the unborn child, but primarily a pathological tissue mass, which happens to be inside the tube, that contains the unborn child. In fact, it would seem to be the more Catholic and “open-to-life” action that the doctor does everything in her power to safeguard the fertility of the mother, so that there might be future children born to her.

However, seeking to repair the fallopian tube is not unconditional. First, the tube may not be salvageable. Secondly, even if the tube can be saved, if the mother has suffered more than one ectopic pregnancy in the same fallopian tube this may truly indicate that the defective tube is beyond repair. In order to avoid future ectopic pregnancies or other complications, the tube should to be removed, if but for medical reasons notwithstanding the moral implications. In any case, a salpingostomy, the repairing and saving of a fallopian tube in which an ectopic pregnancy has taken place, should no longer be considered immoral, in and of itself. It stands to reason that removing the fallopian tube in which an ectopic pregnancy has taken place (a salpingectomy) is not required to make double effect a valid justification for the death of the unborn child.

A second reparative surgery that demands our consideration is tubal ligation reversal procedures sought out by women who have undergone tubal ligation sterilizations. As a matter of course, tubal ligation sterilization is contrary to the moral law, and gravely sinful. However, it is such a common feature of modern life that many women entering the Church or those who are “re-verts” to the faith have had tubal ligations. Sadly, this is often the case with women who come over from mainstream Catholicism to traditional Catholicism. Often enough, these women and their husbands bitterly regret sterilizations and seek in one fashion or another to have more children. As new medical advances emerge, tubal ligation reversals are becoming less expensive, and thus more commonly sought out as a fertility procedure for these women. Often, in vitro fertilization is offered by the medical establishment as a means for sterilized women to have children. Obviously, in vitro fertilization is morally unacceptable. Therefore, tubal ligation reversal is definitely the better alternative, but it is not without its problems.

Most troublesome is that tubal ligation reversal significantly increases the chances of ectopic pregnancy. Most women who have the procedure will experience one or more ectopic pregnancies and the likelihood of ectopic pregnancy only increases as time passes after the reversal procedure (this latter point is contested by some doctors in the field). Husbands and wives who are considering tubal ligation reversal should put this in the balance along with other possible risk factors as part of their discernment process.

Pressure from medical professionals to act immorally is common, especially in regards to the use of MXT. All tubal ligation reversal clinics that I know of promote early diagnosis of ectopic pregnancy and the use of MXT as a treatment for suspected ectopic pregnancies. Unless a couple is well versed in the uncertainties of early diagnosis and the moral and physical dangers of MXT, they may be persuaded by the nurses and doctors to act in a manner contrary to their Catholic faith.

Because tubal ligation reversal significantly increases the chance of having an ectopic pregnancy, and because of the moral quicksand surrounding ectopic pregnancy, pastors and spiritual directors should be hesitant to promote the procedure, especially for those just entering the Church. Even though sterilization is a grave sin, and even though it is a decision that so many couples come to regret, jumping into a tubal ligation reversal procedure may turn out to cause even more physical and spiritual damage. The woman and her husband who are new to the Church may not be equipped to make all the necessary moral considerations, and may be pressured by pain, fear of death and the council of medical professionals to make a moral decision they will regret more than the initial sterilization.

It should be remembered that having a tubal ligation reversal procedure is not necessary for obtaining God’s forgiveness for the sin of self-sterilization, or for entering the Catholic Church. Priests place an undue burden on their flock, and expose them to unnecessary physical and spiritual danger, if they in any way suggest that this procedure is necessary as a penance for sterilization.

There are, of course, many beneficial effects of reparative surgeries and tubal ligation reversal procedures beyond simply being able to get pregnant. Women have reported better emotional and physical well-being after reparative surgery, not to mention the reversal of most or all of the adverse effects of sterilization (i.e. tooth decay, hair loss, weight gain, sever pain or prolongation of menstrual periods, etc.). Setting things aright, as God intended them to be, has many positive effects, not to mention the very real possibility of having perfectly normal and healthy pregnancies. The decision to have a tubal ligation reversal or other reparative surgery is an admirable and courageous choice if weighed prudently. Husbands and wives, and their pastors, in their efforts to be open to life, should investigate all avenues, including the possibility of adoption, and take seriously the moral quicksand surrounding ectopic pregnancy before coming to a decision about having a morally permissible reparative fertility treatment.

Why Should My Child Die Do I Can Live?

For those trying to get pregnant, who are not just passively open to life but actively seeking new life, the emotional and spiritual trauma of an ectopic pregnancy is absolutely devastating. Parents are given an impossible choice, either Mom will live and the baby will die, or both Mom and the baby will die. No matter what, it’s a lose-lose proposition.

Inevitably, even if all the right moral decisions are made, and even if the doctors and medical professionals are as supportive of those decisions as possible, the death of a mother’s unborn child will throw her headlong into sorrow the likes of which could only be experienced by a mother who has lost a child. Coupled with this sorrow will be the knowledge that the child died as a necessary consequence of actions taken to save the mother’s life. As a result, Mom will experience guilt as well as sorrow. She will ask the unanswerable question: “Why should my child die so I can live?”

Dad, too, will feel at least a portion of Mom’s sorrow and guilt, and it will be beyond his power, at least immediately following the tragedy, to console her or make the pain go away. He will feel hopeless and inadequate as he attempts to deal both with his own grief and guilt and that of his wife.

Like all tragedies in this “veil of tears”, there are no easy answers for those attempting to recover from an ectopic pregnancy. All the crosses of this life, the big and the small, are invitations from Our Blessed Lord to enter into the mystery of His Passion, to share in His sufferings and death. God gives us a share in the Cross, to each according to the measure of her character, so that each of us may rejoice with Him in the glory of the Resurrection. The best remedies are time, prayer, and the understanding, the wisdom, that is gained thereby.

As a practical note to the OBGYNs and gynecologists: please realize that not all your patients will have happy endings to their pregnancies. Small gestures go a long way in helping your patients (and their families) to physically, emotionally and spiritually recover from an ectopic pregnancy. For example, reserve at least one examination room in your office that isn’t plastered from floor to ceiling with pictures of happy mothers holding their new-born babies, so you can have a room wherein to perform follow-up examinations of women whose pregnancies ended in tragedy. Also consider keeping advertisements for artificial contraception devices out of the sight of mothers grieving the loss of their unborn child, or better yet, get rid of them altogether! Promoting a love for life that is especially central to the Catholic faith, is the healthiest long-term treatment you can provide your patients.

Finally, for all involved, knowing that you did all you could to preserve life, achieve the greatest good, and remain obedient to the will of God will be a soothing thought once you are able, after time and much prayer, to reflect back on the experience of your ectopic pregnancy. You can at least take some consolation in the fact that you need not have any regrets pertaining to your moral decisions during that time of personal crisis.  

Bibliography

Aquinas, Thomas. Summa Theologica II-II, Q. 64, art. 7, “Of Killing”, in On Law, Morality, and Politics. Baumgarth WP, Regan RJ, eds. Hackett Publishing Co. Cambridge. 1988.

Cavanaugh, TA. Double-Effect Reasoning: Doing Good and Avoiding Evil. Claredon Press. Oxford. 2006.

Connell, FJ. Double Effect, Principle of. Found in: New Catholic Encyclopedia (Volume 4). McGraw-Hill. New York. 1967.

Denzinger, H. The Sources of Catholic Dogma. Deferrari, RJ tran. Loreto Publications. Fitzwilliam. 2007.

Gorman, MJ. Abortion and the Early Church: Christian, Jewish and Pagan Attitudes in the Greco-Roman World. Stock Publishers. 1998.

Houry DE, Salhi BA. Acute complications of pregnancy. Found in: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7^th ed. Mosby Elsevier. Philadelphia, PA. 2009.

Lobo RA. Ectopic pregnancy: Etiology, pathology, diagnosis, management, fertility prognosis. Found in: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5^th ed. Mosby Elsevier. Philadelphia, PA. 2007.

Newman, ME tran, Burghardt WJ, Quasten, J eds. Ancient Christian Writers: The Didach, The Epistle of Barnabas, the Epistles and the Martyrdom of St. Polycarp, the Fragments of Paias, the Epistle to Diogen. Paulist Press. 1948.

Internet Resources

Catholics United for the Faith: Faith Facts, Answers You Need: Ectopic for Discussion: A Catholic Approach to Tubal Pregnancies. http://www.cuf.org/faithfacts/details_view.asp?ffID=57

Drugs.com: Methotrexate. http://www.drugs.com/monograph/methotrexate.html

Patient.co.uk: Ectopic Pregnancy. http://www.patient.co.uk/doctor/Ectopic-Pregnancy.htm

Scott, Rev. PR, SSPX: Society of Saint Pius X – Catholic FAQs, Morality: Does the Church approve of surgery for an ectopic pregnancy? http://www.sspx.org/catholic_faqs/catholic_faqs__morality.htm#ectopicpregnancy