Abortion, Casuistry, and Dancing on the Head of a Pin

I have elsewhere argued that Savita Happlanavar's tragic death cannot be pinned on either Irish law nor on Catholic teaching. It may be that Irish law concerning abortion, miscarriage, and care for women who are undergoing miscarriage and who are in danger of Septicemia (or other life-threatening situations) needs to be clarified, though as it currently stands we have:

The decision to induce labour early would be fully in compliance with the law and the current guidelines set out for doctors by the Irish Medical Council. Those guidelines allow interventions to treat women where necessary, even if that treatment indirectly results in the death to the baby. If they aren't being followed, laws about abortion won't change that. The issue then becomes about medical protocols being followed in hospitals and not about the absence of legal abortion in Ireland.

This tragedy occurred in the Hospital of the Galway University, a part of the state university system (thus, not run by the Catholic Church). We don't know whether or not the staff involved is Catholic and pro-life, indeed from the various news sources we do not know who was involved at all, and I suppose we won't know until the results of the investigation have been released. Thus, there is little reason to believe that Catholic moral teaching is directly involved in this case.

Suppose, for the sake of argument, that it is involved, or that it will come into play in some future case. Perhaps in the rosy future conscience rights will actually be respected [1] in the United States rather than subjugated. Would a faithful Catholic doctor who knows the teaching of the Church actually have responded the way that the staff at Galway Hospital allegedly did respond? Would he be able to induce early labor in this case to save the mother's life?

First, it should be noted that inducing labor does not actually guarantee that Mrs. Halappanavar's death will be prevented. It seems to me that she needed antibiotics and whatever else is standard treatment for this kind of infection. Whether or not this requires the removal of the baby from the uterus is unclear to me—though the opinion is frequently cited that at the least evacuating the infected amniotic fluid and placenta was necessary [2].

Supposing, in any case, that the only way to remove the amniotic fluid and the placenta is to also deliver the baby, who would almost surely die [3], what then? Church teaching includes the principle of double effect. According to this principle, both the lives of the mother and child must be treated as equally valuable, and both of which must be saved, but if the only way to save the one is to lose the other, whereas inaction will cause both to be lost, it is morally permissible—even required—to take action to save one life even if it hastens the loss of the other. Applying this principle to this case, if inducing labor is the only way to save Savita Halappanavar's life, and if (as was the case) doing nothing results in the deaths of both the mother and the baby, then it is morally imperative that labor be induced to save the mother's life.

I do not know if the Irish people are familiar with the documents of the American bishops—though most of the commentary which I have seen on the matter seems to assume that they are. The most cited applicable document, then, is the USCCB's document Ethical and Religious Directives for Catholic Health Care Services, which states 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...

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.

Abortion is never permissible, but other treatments which have as their end the cure of a "proportionately serious pathological condition" are. Life-threatening septicemia is certainly such a condition, though the standard examples used are ectopic pregnancies, the removal of a malignant tumor from the womb, or even chemotherapy to combat cancer: all of which generally have the unfortunate side-effect of killing the child. Inducing labor in this case would be no different. I have heard that some theologians disagree e.g. in the case of ectopic pregnancy; without questioning their good intentions, their reasoning seems muddled, and has most certainly been contradicted by the bishops of the USCCB, to say nothing of Pope Pius XII:
"If the saving of the life of the future mother … 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 fetus, 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."

So the teaching of the Church seems pretty clear here, and cannot be faulted for causing the death of Savita Halappanavar. There is, however, one objection which I have seen made by a pro-life Catholic to the clarity of this teaching. The argument is made quite cogently—though I think incorrectly—by Mr John Smeaton, citing mainly the same USCCB document which I have cited, and then citing a few decrees by the Holy See from the turn of the 20th century.

His argument focuses primarily on what he calls the "intrinsic wrongness of inducing babies before viability," which he says is taught by the Church (emphases his):
"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..."

"49. For a proportionate reason, labor may be induced after the fetus is viable."
Savita was in the 17th week of pregnancy. There is no scientific evidence that unborn children are capable of surviving outside the womb at such a young age. If the doctor in Savita's case had agreed to induce her child, he would have been performing an abortion. The principle of double-effect would not have justified inducing Savita because:

  • the termination of pregnancy before viability (which would certainly have killed the child) would have been directly intended, and would not have been (as double-effect requires) an indirect and unintended effect
  • the sole immediate effect of the inducing would have been the termination of pregnancy before viability, thus killing the child
  • there are alternative ways of managing these highly distressing cases (see my blog on the International Symposium on Maternal Health held in Dublin in September).

The last bullet point is worth re-iterating here, which is that it may be possible to have saved Savita Halappanavar's life without inducing labor. I am focusing on the hypothetical situation in which it is not possible to do so—under the assumption that such a scenario could exist [4]. The question becomes whether or not there is anything intrinsically special about inducing labor prematurely which makes it different from, say, removing the fallopian tube in an ectopic pregnancy (which is morally permitted). I think that it is not, and that inducing labor in the case I am talking about is different than in the cases which the USCCB document and the Holy See are referring to.

First, consider how an abortion might be attempted. By this, I mean the obvious evil of abortion for the sake of killing the child, which is what all abortions ultimately are. There are chemical abortions, starting these days with RU-486 [5], but also including saline injection and for that matter taking "potions" as proscribed against by the early Church. Then there are the various methods by which the unborn child is savagely dismembered in the uterus—or, in the case of partial birth abortion, when 3/4 of him is already delivered—in which the child is often cruelly torn limb-from limb, dying sometime after this dismemberment process is well underway. Then there is the method of inducing a "miscarriage," that is, of induing the child to be born prematurely, and then left to die. If this latter is done pre-viably—which at the time of Pope Leo XIII (1889) would have meant about the 6th month of pregnancy—then the baby will die upon being born.

We are very good at fooling ourselves—that is, at silencing our own consciences. In the words of Professor J Budziszewski, abortion is one of those things which "we can't not know" is morally wrong, so we have to fool ourselves when committing it. We might, for example, play little casuistic games with ourselves to show that we don't really intend to kill the unborn child, even when that is the sole immediate effect of an abortion [6] (as it usually is), or that the child isn't really a person, or not really innocent.

One such game that might conceivably be played is to say, "it's not an abortion!" when we know that it is. Many a person has recognized that abortions typically involve either actively tearing a baby limb-from-limb or burning his skin off alive (as in saline injection), and that these things are the actions of a moral monster. Yet, this does not change the reality that a woman is pregnant with a child she does not want—and for whatever reason does not want to give up for adoption—so inducing pre-viable labor would seem to give her an "out." Induce the labor, deliver the child, and then leave him to die, or (since he's pre-viable) even cradle him in his last few moments (he'll die whether left or not).

It seems to me as likely as not that the prohibition against deliberately delivering a pre-viable infant is to combat just such a scenario.

I noted before that I think there is a difference between inducing pre-viable labor in the case outlined by Mr Smeaton—and by the USCCB, the Holy See, and for that matter by myself above—and a case like Mrs Halappanavar's. The difference is this: in the Halappanavar's case, the child was already miscarrying, already dying, whereas in the case that a moral proscritpion is made against inducing labor, the assumption is that the child is healthy, that inducing labor will kill him but that he would otherwise live. In the case of Savita Halappanavar inducing labor could conceivably save the mother's life (when it would otherwise be lost). Moreover, the baby's heartbeat had stopped within two days of her being admitted to the hospital—he was already dying. And finally, the immediate end was not so much to induce labor to remove the baby—though the case might I suppose be made that this is the only way we could hope to save the baby, by removing him from the "toxic environment" which was the infected womb—but rather that the immediate end was to remove the infected amniotic fluid and placenta, which actually were a threat to the mother's life.

These three observations suggest to me three analogies to which this might be likened. In order, they are self-defense; life-support removal at the end of a person's life; and the removal of an ectopic pregnancy, or, better still, of a malignant tumor from the womb. None of these scenarios is considered murder, all are (or can be) morally licit, and yet in each scenario a person dies as a direct result and immediate of the action taken.

Concerning self-defense, the Catechism of the Catholic Church, citing Saint Thomas Aquinas, states:
"'The act of self-defense can have a double effect: the preservation of one's own life; and the killing of the aggressor...The one is intended, the other is not'....Therefore it is legitimate to insist on respect for one's own right to life. Someone who defends his life is not guilty of murder even if he is forced to deal his aggressor a lethal blow....Legitimate defense can be not only a right but a grave duty for someone responsible for another's life" (CCC 2263-2265).

Even in this case, the child is not exactly an aggressor, it is true, but if by allowing him to remain in the womb the life of the mother is guaranteed forfeit, then defense of the mother's life allows for the child to be removed. Moreover, if the lives of both mother and child will be lost by allowing the child to remain in the womb, but the former might be saved otherwise, then it seems to me that it is a "grave duty" (though an unfortunate one) to remove the child from the womb, e.g. by inducing labor.

Concerning my second analogy, the womb is effectively a great life-support system for a child—though at the beginning of life ratehr than its end. Here the Catechism states that
"Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of 'over-zealous' treatment. Here one does not will to cause death; one's ability to impede it is merely accepted. The decision decisions should be made by the patient if he is competent and able or, if not, by those who are legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected" (CCC 2278).

In essence, then, the medical procedures are analogous to the child's remaining in the womb. If this will cause the mother to die, then it is clearly a "burdensome, dangerous" "procedure." Applying this reasoning, it is permissible to induce labor. Indeed, the USCCB's Ethical and Religious Directives for Catholic Health Care Services notes that
56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.

57. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.

58. In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.” For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort."

If the womb is like a life-support system—a respirator, for example—and the amniotic fluid and placenta have become infected, even toxic to the baby, and if the baby is dying anyway, it seems to me that inducing labor is justified by the USCCB's Directives. This is analogous to removing life-support (not food and water, just the respirator) from the terminally ill, which again seems to be permissible in the case "extraordinary or disproportionate means of preserving life," meaning "those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden." In this case, the "patient" (the baby) is "not competent to make this decision, so it falls to the mother and father—and the loss of the mother's life is certainly an "excessive burden." To extend the analogy further, the "life support system" was failing, so unplugging it doesn't kill the baby, though it may hasten death.

I turn then to my last analogy, which is the most obvious and the most easily comparable. It is and I think always has been morally licit to remove the fallopian tubes during an ectopic pregnancy, saving the mother's life even if this causes the baby to die [7]. The same is true of removing a malignant tumor from the womb, which may also cause the death of the child. The same is again true of undergoing chemotherapy to treat cancer, which again can cause the death of the unborn child. Inducing labor and removing the child from the womb in the case of toxicity should be viewed no differently. To return one last time to the USCCB's Directives document:
"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."

An extrauterine pregnancy mean an ectopic pregnancy, and the removal of the Fallopian tubes has been permitted in these cases as morally licit. It is not a direct abortion, and by extension neither is inducing labor—by C-section or with forceps-assistance—in the case where this is the only way to save the mother's life. Certainly, giving antibiotics is one form of permissible "treatment." So surely would be the removal of the infected amniotic fluid and placenta, even if this resulted in also delivering the pre-viable child [8]. As the Human Life International statement on Mrs Halappanavar's death notes, "The Church’s position in these difficult cases is always to save both patients – both mother and child."

Since this case happened in Ireland, it is worth hearing what the Irish bishops have had to say about this. His Excellency the Most Reverend Joe Fleming wrote that "Abortion is never the basis for a humane or compassionate solution." The good bishop writes that
"international experience indicates that once abortion is introduced, even for apparently very restricted or limited situations, it becomes more widespread than was first intended....The Constitution recognises 'the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect' that right. The clear intention, therefore, is to protect and cherish equally the lives of both the mother and her unborn child.

In fact, Ireland, without abortion, is recognised as one of the safest countries in the world to be a pregnant mother. This is something about which we should be proud and is a tribute to the excellent care provided by hospital staff who treat both mother and unborn child with equal dignity and respect as people in their own right. Clearly, if the life of the mother is threatened, by illness or some other medical condition, the care provided by medical professionals will make sure that she receives all the medical care needed.

In a small number of cases, however, the treatment given may unintentionally result in the death of the unborn child. But in such cases the life is never directly and intentionally taken and everything is done to save the child.

The key moral issue, therefore, for Catholics is that the life of the unborn can never be taken intentionally.

That should as always be our guiding principle: respect for human life—both the mother's and the child's. The Catholic Church allows for action to be taken to save one when inaction results in the loss of both—the principle of double effect—and all doctors, Catholic or otherwise, should be familiar with this principle as a basic part of their medical ethics training. While the Church—and, for that matter, Irish law—might be clearer in the particulars, or might better communicate them, the principle is quite sound.

[1] One argument I have heard made is that we ought to respect the conscience rights of medical professionals either way. For example, in a case where the law actually is ambiguous (let alone prevents necessary treatment from being applied), the doctors and nurses involved can apply treatment without fear of legal repercussions, assuming of course that there is no obvious evidence of medical malpractice.

[2] Evacuating the contents of the uterus, incidentally, could involve inducing labor—perhaps using forceps to assist in delivery—or a Dilation and Extraction abortion. The latter is not moral in any circumstances, as it involves mutilating the still-living child and is incredibly cruel to the baby (among other reasons). As Christina Dunigan notes,
Once an infection like that takes hold it's very difficult to get under control. That's why it's important in an obstetric infection to get the baby out as quickly as possible.

I could see the ban on doing it while there's still a fetal heartbeat if you're doing an extraction abortion, which involves dismembering a live baby in-utero. That's unspeakably cruel to the baby -- and I can't see how it could help the mother to have the baby's body converted to lots of sharp bone shards to scratch up her uterine walls and give the infection an even quicker way to get into her bloodstream.

Inducing labor or doing a forceps-assisted delivery makes perfect sense. It removes the baby from what is, essentially, a toxic environment of infected amniotic fluid, and gives the child the chance to know being held and loved before he or she dies.

[3] Savita Halappanavar as 17 weeks pregnant; the record for survival outside the womb is currently after 21 weeks of pregnancy.

[4] Insert your favorite joke or quip about debating angels danging on the head of a pin here.

[5] Now bought for you by faithful Catholic employers under the Obama administration's tyrannical HHS mandate.

[6] The effects of the mother's pain and guilt can linger on for the rest of her life, but the culture of death wants to sweep that under the rug: they are conveniently ignored. Also ignored is any link between cancer and abortion (or even birth control).

[7] This fact will change, however, if/when some method is developed which allows an ectopic pregnancy to be successfully and reliably treated without removing the Fallopian tube and thus killing the baby.

[8] National Review even quotes Fr Tadeusz Pacholczyk, Director of Education for the National Catholic Bioethics Council, as saying,
"“If it were the case, for example, that she suffered from a serious placental infection unable to be controlled by other remedies, it would have been allowable to induce labor under a proper application of the principle of double effect. Such an action would not constitute a direct abortion, but maternally directed therapy to remedy the infection, with the secondary, unintended effect that the life of the child would be lost."

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