case of pregnancy at term in a woman with a contracted pelvis the
foetus would be a contributing instrument of death to the mother,
supposing there were no artificial means of delivering her, but such a
child is not an aggressor even materially unjust. The child itself is
normal, it has a natural right to be where it is, it did not put
itself where it is; the mother's contracting uterus crushing the child
against her narrow pelvic arch is the direct agency that kills the
woman, and the child is only an inert instrument used by the
contracting uterus. In such a case the mother might be considered an
aggressor materially unjust against the life of the child rather than
that the child is the aggressor.
Lehmkuhl (_Compendium Theologiae Moralis_, 1891, p. 238) says:
"Medicus graviter peccat ... si media abortus procurat: nisi quando ad
salvandam matrem ex probabili opinione liceat." On page 188 he says:
"Ex consulto abortum inducere, etiam liceri videtur in praesenti vitae
{20} maternae discrimine, quod per solam foetus immaturi ejectionem
avert! possit . . . Idque videtur applicari posse ad matrem quae tarn
arcta est ut tempus praematuri partus exspectare non possit."
By _foetus immaturus_ here he means an unviable foetus, as is evident
from the context. If this probabilism of Father Lehmkuhl's stands (but
it does not), a decision in most of the cases that occur in ectopic
gestation would be easily made, but even he himself would not take
responsibility in the matter, and that before the decision of the Holy
Office which defined abortion. Since this decision, made July 24,
1895, Lehmkuhl has entirely withdrawn his opinion.
On May 4, 1898, the Holy Office published the following decree, which
was approved by the Pope:
BEATISSIME PATER,--Episcopus Sinaloen. ad pedes S. V. provolutus,
humiliter petit resolutionem insequentium dubiorum:
I. Eritne licita partus acceleratio quoties ex mulieris arctitudine
impossibilis evaderet foetus egressio suo naturali tempore?
II. Et si mulieris arctitudo talis sit, ut neque partus prematurus
possibilis censeatur, licebitne abortum provocare aut caesariam suo
tempore perficere operationem?
III. Estne licita laparotomia quando agitur de pregnatione
extra-uterina, seu de ectopicis conceptibus?
Feria iv, die 4 Mali, 1898.
In Congregatione habita, etc . . . EE. ac RR. Patres rescribendum
censuerunt:
Ad I. Partus accelerationem per se illicitam non esse, duromodo
perficiatur justis de causis et eo tempore ac modis, quibus ex
ordinariis contingentibus matris et foetus vitae consulatur.
Ad II. Quoad primam partem, _negative_, juxta decretum, Feria iv.,
24 Julii, 1895, de abortus illiceitate.--Ad secundam vero quod
spectat: nihil obstare quominus mulier de qua agitur caesareae
operationi suo tempore subjiciatur.
Ad III. Necessitate cogente, licitam esse laparotomiam ad
extra-hendos e sinu matris ectopicos conceptos, dummodo et foetus et
matris vitae, quantum fieri potest, serio et opportune provideatur.
In sequenti Feria vi., die 6 ejusdem mensis et anni . . . SSmus
responsiones EE. ac RR. Patrum approbavit.
{21}
The third question proposed by the bishop is:
"Is laparotomy licit when performed for extrauterine pregnancy or
ectopic gestation?"
The approved answer of the Holy Office to this question is:
"In a case of necessity, laparotomy for the purpose of removing an
ectopic foetus (_conceptus_) from the abdomen of the mother is licit,
provided the lives of both the foetus and the mother, as far as is
possible, are carefully and fitly guarded."
The expression, "dummodo et foetus et matris vitae, quantum fieri
potest, serio et opportune provideatur," is capable of various
translations and interpretations.
The words might have this meaning: "In a case of necessity you may do
laparotomy and remove an ectopic gestation, provided you do not kill
either the mother or the foetus." If that is the interpretation, the
decree means that we may never remove an unviable ectopic foetus when
we know that the foetus is alive, because removal will kill it.
The sentence can also be translated in this sense: "In a case of
necessity, you may do laparotomy and remove an ectopic foetus from the
mother, provided you take full care to save mother and child if that
is possible."
If that is the signification, it is evidently very different from the
first interpretation. It would mean: do the laparotomy, remove the
foetus, and if you possibly can save both mother and foetus do so, but
if you can not, take the best means you can to save one or the other.
If the decree refers only to cases in which the foetus is viable, it
would appear to be unnecessary--we need no decree of the Holy Office
to let us do a laparotomy to remove a viable foetus. If it does not
refer to a viable foetus, it refers to an unviable foetus, but to
remove an unviable foetus is to either kill it or to hasten its death.
Genicot (_Institutiones Theologiae Moralis_, Louvain, 1902, vol. i. p.
358) has this interpretation of the decree:
"In conceptione extra-uterina licebit sane recurrere ad laparotomiam
similemve operationem, quando aliqua etiam tenuissima spes affulget
salvandi infantem, simul ac mater fere certo liberabitur. . . . Ubi
vero nulla spes hujusmodi {22} affulget, neque in hoc casu licebit
abortum directe inducere, etiamsi foetus certo moriturus sit antequam
in lucem edatur, et baptismum recipere nequeat. Etenim S. Inqu., dum
provocat ad responsum 19 August, 1888, satis indicat abortus
inductionem a se haberi tamquam operationem directe occisivam foetus
ideoque semper illicitam."
There is no question of an _abortion_ in a laparotomy for extrauterine
gestation; abortion is altogether a different operation in method and
nature. Secondly, the other decree of the Holy Office to which he
refers speaks of a direct killing of the foetus, but there is no
direct killing of the foetus in the operation for ectopic gestation,
nor is the indirect hastening of the foetus's death a means to an end.
The decree on abortion is so clear it leaves no room for doubt.
Cardinal Monaco, in the _Epistola ad Archiepiscopum Camarcensem_,
August 19, 1889, says the Holy Office decreed that "In scholis
catholicis tuto doceri non posse licitam esse operationem chirurgicam
quam _craniotomiam_ appellant, sicut declaratum fuit die 28 Maii,
1884, et quamcumque chirurgicam operationem directe occisivam foetus
vel matris gestantis."
Note the words "_directe_ occisivam." Craniotomy is a direct killing,
and a direct killing used as a means to an end; moreover it is an
altogether unnecessary killing. Artificial abortion in the case of an
unviable foetus is also a direct killing as a means to save the
mother's life, but the removal of an unviable ectopic foetus is
neither a direct killing, nor is it a means toward any end.
Since the meaning of the decree concerning laparotomy in extrauterine
pregnancy is by no means clear, we may discuss the question until the
law has been fully promulgated, ready to conform to the real meaning
of the decree whenever it is explained. In that spirit we may now
consider the cases that occur in ectopic gestation.
Case I. A surgeon is called in to treat a woman and he finds her in a
state of collapse. He makes a diagnosis of tubal pregnancy, which has
gone on to rupture with hemorrhage, and the bleeding will evidently be
fatal to the mother unless it is checked. Practically the only chance
of saving the {23} mother's life is coeliotomy and the ligation of her
open arteries. Dr. Howard Kelly (_Operative Gynaecology_, vol. ii. p.
437) says: "When the hemorrhage is sudden and excessive the patient
falls in collapse; but, in spite of these alarming symptoms, she may
survive a succession of similar attacks and the foetus and sac may
continue to develop." This exception complicates the case slightly. If
the surgeon were absolutely certain that the only possible chance to
save the woman's life is coeliotomy and haemostasis, the case would be
somewhat different from one in which there is some chance of escape by
spontaneous haemostasis. That chance, however, is so slight, and so
far beyond any means we have for forecasting, that it is mere luck,
and it is to be neglected. The surgeon may safely consider the patient
in the gravest actual danger.
(a) Before he opens the abdomen he can not tell whether the foetus is
alive or not; but the stronger probability is that it is not, and the
certainty is that it has no chance at all to remain alive more than a
few minutes or hours, unless the surgeon is willing to trust to sheer
luck in the expectation that he may happen to have one of Dr. Kelly's
exceptions before him.
(b) The operation to save the mother is this: as quickly as possible
he makes a vertical slit from four to six inches long through the
woman's belly-wall. Then commonly the free blood begins to run out, or
it may even spurt out some feet into the air. The surgeon can see
nothing for the blood and the presence of the entrails. If the blood
is not freshly welling up he bails it out with his hands or a ladle;
if it is spurting he at once thrusts in his hand, feels for the foetal
sac, lifts it up, and puts on clamps near the uterus on one side and
near the pelvic brim on the other. This stops the hemorrhage, and he
can then work more leisurely, but unfortunately this also stops the
flow of blood to the foetus. He can not first examine the foetus and
then stop the hemorrhage. He can not back out even if he finds a live
foetus without letting the mother die on the table.
(c) If the placenta is already loose from the Fallopian tube the child
is dead or it will die in a few seconds or minutes. If it was not
loose the lifting out may tear it loose, and this {24} tearing loose
will hasten the death of the foetus a few minutes (but give a chance
for baptising it).
(d) If the lifting out does not tear loose the supposedly fixed
placenta, the foetus either will die anyhow if the mother dies, or it
will die if the mother lives, because to save her the surgeon must put
ligatures just where the flow of blood will be shut off from the
foetus. Commonly there is no time to even look for the foetus until
after the maternal arteries have been closed.
(e) The same conditions could exist in the rupture of a pregnancy in a
rudimentary uterine horn as in a rupture in tubal gestation.
What is the surgeon to do in a case like this? Fathers Holaind (_Amer.
Eccl. Rev._, January, 1894, in a note on p. 39), Lehmkuhl and Sabetti
say: do coeliotomy, ligate the mother's arteries, remove and baptise
the foetus.
The analysis of the case is this: (i) The _action_ is the stopping of
a fatal hemorrhage in a woman, and possibly, though not certainly, an
indirect incidental hastening of a foetus's inevitable death.
(2) The _object of the action_ is the haemostasis, which is good, and
the possible indirect hastening of the foetus's death, which is evil,
but, as we shall see, excusable evil.
(3) The _end of the action_ is to save the mother's life--a good end.
(4) The _circumstances are_: (a) that possibly, through mere luck, the
woman's condition is not necessarily hopeless: a few women have
escaped in this seemingly imminent peril--but that chance of escape is
not soundly probable; the stronger probability by far is on the side
of a fatal issue; therefore the chance for escape may be neglected,
and the woman's case may be regarded as hopeless if operation is
foregone.
(b) The quickest possible work on the surgeon's part is necessary, and
there is no time or chance to examine the foetus's condition before
tying the maternal arteries. Before he opens the mother's abdomen he
can tell nothing whatever of the foetus's condition, but the
probability is all in favour of the fact that the foetus is already
dead or moribund.
(c) The _means_ are coeliotomy, and the ligation of the {25} uterine
and ovarian arteries to stop the mother's bleeding. This ligation, in
the contingency that the foetus is still attached to the Fallopian
tube, will also shut off the blood from the foetus, yet the uncertain
shutting off of the foetal blood-supply is not intended by the surgeon
as a means toward his end in any degree direct or indirect, but it is
an evil circumstance associated with the action which may hasten the
foetal death--even here the hastening is uncertain.
(5) The _action has two effects_,--one, the saving of the mother, is
directly intended and evidently good; the other, the possible indirect
hastening of the foetus's death, may or may not be evil. The moral
centre of the whole case is this possible hastening of the foetus's
death. If that possible hastening is licit the whole action is licit;
if it is not permissible it will vitiate the entire action.
Suppose that there is no doubt that the ligation of the maternal
arteries in this case really hastens the foetus's death some minutes:
it would still be an indirect volition. Father Lehmkuhl also calls it
indirect and licit. Father Sabetti denied that it is indirect, but he
held that it is licit for another reason. Sabetti said (_Aner. Eccl.
Rev_., August, 1894): "It is evidently false to say that a means which
is _directly_ adopted for obtaining an end is only _indirectly_
contained in the intention of the agent who so adopts it." That is
true, but the minor proposition in a syllogism drawn from that
statement is to be emphatically denied. The cutting off of the foetal
blood is a fact associated with the means, not a means direct or
indirect toward the end, which is to save the mother--the means to
save the mother is the stopping of her bleeding.
This is not hair-splitting in the opprobrious sense of that term. The
bases of all sins are absolutely abstract principles, and because
abstract principles can not be pinched or weighed, they have often
little meaning for the opposition in an argument. There is only the
width of a hair between Heaven and Hell at many places along the
frontier, and there is only the difference between a direct or an
indirect volition separating murder and a good deed. The best ethics
frequently consists in delicate hair-splitting; and despite the
protests of sentimentalists, one of the most valuable benefits of
Moral Science is {26} to show us how to handle moral poisons for good
purposes, as a physician uses the material poisons, opium and aconite.
If the foetus in this case of rupture in ectopic gestation were a
materially unjust aggressor on the mother's life, the indirect
hastening of its death would be justifiable according to all
moralists, and the direct hastening would be licit according to
Cardinal de Lugo, who was, in the opinion of St. Alphonsus, "post D.
Thomam inter alios theologos facile princeps"
(_Th. Mor._, lib. 4. n. 552).
Sabetti held that the foetus is a materially unjust aggressor. His
reason for this opinion is that the extrauterine foetus is not in a
position in which it has a right to be. If it were in the uterus, its
natural position, it would have a right to its position. Ectopic
gestation is a disease, not a physiological condition.
Father Aertnys (_Amer. Eccl,_ Rev., July, 1893) denies that the foetus
is an aggressor materially unjust. He says: "Nequaquam enim mortem
intentat matri, sed actione, quam non ipse sed corpus matris producit,
conatur ad lucem pervenire, et iste conatus non nisi ex naturali
concursu rerum fit matri causa mortis. Infans ergo non est _aggressor_
et multo minus est _aggressor injustus_. Hinc nego paritatem cum
homine mente capto, qui delirans alteri mortem intentat; hic enim agit
motus a sua voluntate, licet absque culpa, et ponit actiones in se
injustas, utpote ad necandum directe intentas."
In the same periodical (January, 1894) while repeating this statement
he says: "Sive in utero existat sive alibi reconditus sit [sc.
foetus], nequaquam mortem intentat matri, siquidem non ipse actione
propria conatur egredi, sed corpus matris infantem expellit et haec
expulsio a matre emanans fit matri causa mortis."
What Father Aertnys says in these two passages is true of an
intrauterine foetus, but it is altogether erroneous when applied to an
extrauterine foetus, of which alone there is question here. In
extrauterine pregnancy the uterus or any other part of the maternal
body does not "try to expel" the foetus; the uterus has nothing at all
to do with the case--the very name of the condition is _extra_-uterine
pregnancy. If an ectopic gestation {27} goes on to term (a very rare
happening), there will be false labour and uterine contractions, and
these cease after a time without effect one way or the other; but in
all cases of rupture and the like the uterus is outside the question
and the mother is passive. There is no attempt by the mother in
extrauterine pregnancy at expulsion either before rupture or at any
other time unless the dead foetus putrefies, and the maternal tissues
"try to expel" it as a foreign body by breaking down into an abscess.
The foetus simply grows, and its bulk bursts the tube. If it were in
the uterus, the uterus would enlarge synchronously with the foetus and
there would be no rupture, but the tube will not give beyond a certain
point, therefore it bursts.
In normal uterine pregnancy at term the uterus and other maternal
muscles are the active factors in expelling the foetus--the foetus is
passive. In ectopic gestation the foetus is active, the mother is
passive, and there is no attempt at expulsion from either side. In
this case the foetus in the tube through the action of its own vital
principle draws nourishment from the mother and grows gradually larger
till it bursts the tube (it may even move its arms and legs if
advanced), and this rupture tears open arteries wherethrough the
mother bleeds, commonly to death. This is evidently material
aggression.
Father Aertnys says the foetus differs from the murderous lunatic in
this, that the madman is moved by his will, although blamelessly, in
doing unjust actions directly intended as homicidal. The fact that the
lunatic uses his will has no weight whatever in permitting me to
defend my life against him, it is an accidental thing outside the
question; but Father Aertnys in mentioning the madman's will means
solely, if I understand him, that the madman is really an active
aggressor. The foetus, however, is also an active aggressor without
using its will. I might fall from a height toward a man and certainly
endanger his life while I was not using my will at all, not conscious
of the man's presence under me, or even while I was using all the
power of my will against the result. In any of these cases I should be
a materially unjust aggressor; and if in trying to prevent my body
from killing him the man killed me, he would be blameless.
{28}
Now, in the first place, the tubal foetus is an aggressor; and since,
secondly, its position is unnatural, monstrous, a disease, a thing not
intended by nature, it has no right to its position, and it is
therefore a materially unjust aggressor. Since it is an aggressor on
the very life of the mother in a place where it should not be, the
surgeon therefore may at the least stop the fatal bleeding it causes.
If the foetus dies as an unwished for, though permitted, consequence
of this haemostasis, the surgeon may lament this result, but he is
blameless.
The foetus was blocked in its unnatural position through a defect in
the mother, nevertheless it remains a materially unjust aggressor. If
I by an accidental blow had made a man insane, and later this lunatic
tried to kill me, I, or my legitimate protector, might lawfully kill
the lunatic in defence of my life. This is an exact parallel to the
case of the mother and the extrauterine foetus.
The extrauterine foetus is not like a foetus in a craniotomy case.
Where there might be question of craniotomy the foetus is not an
unjust aggressor even materially, as has been said: first, because it
is not an aggressor in any manner, it is altogether passive; secondly,
it has a perfectly natural right to be where it is. In ectopic
gestation with fatal rupture the foetus is, first, an active
aggressor; secondly, it has no right to be where it is. In craniotomy
the foetus is killed as a direct means toward the end that its head
may be reduced and extracted and the mother saved; in extrauterine
gestation with fatal rupture the foetus is incidentally killed as a
consequence of the haemostasis, and not as a means in any sense of the
term. In craniotomy the child is wantonly killed since there are other
means of saving the mother; in extrauterine pregnancy with fatal
rupture the hastening of the death of the child is unfortunately
associated with the only possible means we have to save the mother.
In Case I., therefore, we have an action that has an object partly
good and partly, very probably, not evil; the end intended is good;
the circumstances are justifiable or indifferent; consequently in Case
I. the surgeon may do coeliotomy, tie the uterine and ovarian
arteries, and if the foetus {29} happens to be alive he may
reluctantly and indirectly permit the hastening of its death after
attempting to baptise it.
Case II. The conditions presented in Case I. are the ordinary and most
common that the surgeon meets with in treating ectopic gestation, but
other conditions may be found.
Suppose the surgeon, before operation, diagnoses a case of ectopic
gestation, but that he can not tell whether or not the foetus is
alive. The probability leans toward the side that the foetus is alive,
because there is no indubitable history, as physicians say, of
maternal symptoms that indicate rupture.
Medical authorities tell him to do coeliotomy at once, ligate the
uterine and ovarian arteries, and remove the foetus. Would he
certainly or probably be justified in following out this medical
doctrine?
The mother is in actual, _very probable_ danger of death, but not in
actual, _certain_ danger of death. She may possibly escape if
operation is deferred; she has a negligible chance of escape if no
operation is performed after the death of the foetus; coeliotomy and
ligation of the uterine and ovarian arteries give her by far the
surest chance of escape, so sure an opportunity for escape when
performed early that it can scarcely be called a mere chance.
If operation is deferred the chances for rupture are about 22 per
centum, say, one and a half in five chances, and all ruptures are not
necessarily fatal. The chances of the mother's death, however, are
much higher than that, because death can come in ectopic pregnancy
from causes other than rupture. From 63.1 to 68.8 per centum (say,
66.3 per centum) of ectopic gestations treated by the expectant method
result in death to the mother--just two-thirds of the women die. A.
Martin in a series of 265 cases of ectopic gestation where the
expectant treatment was employed found a maternal mortality of 63.1
per centum; Parry in 500 similar cases found a mortality of 67.2 per
centum; and Schauta in 241 cases a mortality of 68.8 per centum.
In the 87 years between 1809 and 1896, 77 cases of coeliotomy for the
delivery of _viable_ ectopic foetuses were reported {30} in all
medical literature with a maternal mortality of about 58.3 per centum.
Between 1809 and 1888 there were 37 coeliotomies with a maternal
mortality of 86.5 per centum. Between 1889 and 1896 there were 40 such
operations, with a maternal mortality reduced to 32.5 per centum by
modern surgical methods.