Part 2
Dr. Hirst said: "In almost all cases of advanced gestation the differential diagnosis can be made. In early cases it is not always possible unless conditions be favourable."
Dr. Howard A. Kelly said: "The differential diagnosis between intra and extrauterine pregnancy can usually be made from the sixth week up to the end of pregnancy. It is more easily made from the tenth to the twelfth week on." Writing in the _American Text Book of Obstetrics_ (Philadelphia, 1896), he says: "In the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. . . . {9} The diagnosis of ectopic gestation after the death of the foetus is largely dependent upon the clinical history; if this be deficient, the diagnosis is frequently impossible."
Dr. Lusk said: ".... The frequent discovery of the dead ovum in a tube when there has been no suspicion of pregnancy shows the difficulty of a diagnosis." In his text-book (_The Science and Art of Midwifery_, New York, 1890) is this remark: "Sometimes the diagnosis can only be decided by the introduction of the sound or a finger into the uterus, the physician assuming the risk of premature labour, should he find his supposition of extrauterine pregnancy an error." This means that sometimes the diagnosis is impossible without running the risk of causing abortion of a normal uterine pregnancy.
Dr. Thomas said, "After the second month the diagnosis is perfectly possible." This was also the opinion of Dr. Mordecai Price; and Dr. Joseph Price holds that the diagnosis can be made "after the third month, by exclusion." Dr. John F. Roderer, quoting Lawson Tait, says that "the diagnosis between intra and extrauterine pregnancy can not be made with certainty before rupture, nor can it be determined exactly whether an enlargement of the tube is either an ectopic pregnancy or some form of tumour."
Dr. Goodell's opinion was, "A differential diagnosis can rarely be made positively at any stage of extrauterine pregnancy."
The diagnosis, then, is difficult; and for the ordinary practitioner, the average physician, who does perhaps ninety-five per centum of the medical work of the world, the diagnosis is often impossible. There is no greater expert than Dr. Thomas Addis Emmet, and he says the diagnosis is difficult. Others hold that the diagnosis can be clearly made, and they speak truly as regards themselves, but ordinary skill finds the diagnosis almost impossible in many cases. Mordecai Price (_The Pennsylvania Medical Journal_, vol. viii. p. 223) in one year saw four cases which he and other physicians diagnosed as ectopic pregnancies with rupture of the tube. When the abdomen had been opened, uterine pregnancy was discovered with a ruptured tube in each case, and all the women died.
{10}
The first positive diagnosis of unruptured tubal pregnancy was made by Veit in 1883, and the first one made in America was by Janvrin in 1886, eight years before Father Holaind's article was written. Before 1883, only eleven years in advance of the same article, when Lawson Tait performed the first coeliotomy for the purpose of checking hemorrhage from a ruptured tubal gestation, extrauterine pregnancy was as mysterious as the old "inflammation of the bowels," which turned out afterward to be appendicitis. Hence common skill in the difficult diagnosis of ectopic gestation can not be looked for.
The doctrine given in all the leading medical works at present concerning the treatment of extrauterine pregnancy is this:
1. As soon as an extrauterine pregnancy is discovered remove the foetus through an opening made in the mother's abdominal wall. Do not use electricity or the injection of poisons into the foetal sac, or the incandescent knife. Emmet and a few others approved of the use of electricity at times, but this is against the teaching of the great majority of writers at present. The reason for removing the foetus at once is that it is apt at any moment to cause rupture and fatal hemorrhage before surgical aid can be effective.
2. In a case of rupture with free hemorrhage and collapse the only operation advised is an immediate coeliotomy to stop the bleeding by ligatures. The rupture should not be approached through the vaginal wall according to the common doctrine, but through the abdominal wall.
3. If there is a rupture in which the bleeding is confined and there is no collapse, do not operate at once unless the haematocele increases steadily or shows signs of suppuration. Sometimes evacuation of the haematocele through the vaginal wall is possible.
4. In the later months of an extrauterine pregnancy, whether the case is intraligamentous or abdominal, perform coeliotomy as soon as the diagnosis has been made, and remove the foetus, because there is always danger of sudden and fatal hemorrhage before the surgeon can reach the source of the bleeding. What is to be done in a case where the surgeon is certain before operating that the foetus is {11} dead, has interest only for the physician, and it involves no moral question.
Operating for extrauterine pregnancy maybe a simple coeliotomy, if any coeliotomy is really simple, but it commonly is the most dangerous operation for the mother that the gynaecologist is called upon to perform.
The discussion of the moral questions that arise in cases of ectopic gestation which began in volume ix. of the _American Ecclesiastical Review_ was very valuable, but as the moralists had not full data to work on their decision as a whole is not satisfactory. The original cases presented are in part obsolete in the medical practice of to-day, and important physical conditions were not disclosed in some of the other parts of the cases. Father Holaind tentatively agreed with Father Lehmkuhl in one decision, Fathers Eschbach and Sabetti directly attacked Father Lehmkuhl's reasons, and Father Aertnys indirectly opposed Father Sabetti's chief argument. These men are all eminent authorities, but as each, except Father Holaind, was dissatisfied with the arguments advanced by the others, and as their data were incomplete, we can not rest the case on their decision.
In Father Holaind's fifth question, if I understand it correctly, he seemed to think it possible to baptize a foetus through the opening in the mother's abdominal wall while it lies in the abdominal cavity before surgical removal. He mentions antiseptic precautions in the baptism, which would have no meaning if the foetus were out of the abdomen.
Baptism would not be possible in that case: the priest could not get at the foetus, he ordinarily could not even see it, and certainly no surgeon would permit the attempt. There would be no time for the attempt in a rupture case, even if the foetus could be seen; and there would be no advantage gained by baptizing the foetus in the abdominal cavity where the conditions gave time to do so. If it is alive it will live long enough for baptism after removal from the abdomen, provided, of course, it is baptized immediately in the operating room. That it does not breathe is no proof of immediate death. It is not unusual for a full-term child not to breathe for even an hour or longer after birth.
{12}
If Father Holaind had not in view baptism within the abdominal cavity, the question has this meaning: What is the most effective method after the foetus has been removed from the abdomen to open its enveloping membranes so as to give it a chance for a life lasting long enough to allow baptism?
The best method is to slit the membranes with a scalpel or scissors as quickly as possible. The envelopes, cord, and placenta are essential parts of the foetus itself, and they grow from itself, not from the mother. They take the place of the lungs and the alimentary tract, which do not come into action until after normal birth. It would be worth discussing whether a baptism on the intact foetal envelopes is valid, were it not that we may not apply probabilism in such a case. The remaining matter brought out in Father Holaind's questions will be considered in the course of this article.
Before presenting the cases of ectopic gestation that occur in medical practice, the fundamental ethical principles that are to be applied in judging the morality of the surgeon's interference should be given.
The morality of any action is determined, (1) by the object of the action; (2) by the circumstances that accompany the action; (3) by the end the agent had in view.
1. The term _object_ has various meanings, but here it means the deed performed in the action, the thing which the will chooses. That deed by its very nature may be good, or it may be bad, or it may be indifferent morally. In themselves to help the afflicted is a good action, to blaspheme is a bad action, to walk is an indifferent action. Some bad actions are absolutely bad, they never can become good or indifferent (blasphemy or adultery, for example); others, as stealing, are evil because of a lack of right in the agent: these may become good by acquiring the missing right. Others are evil because of the danger necessarily connected with their performance,--the danger of sin connected with them, or the unnecessary peril to life. An action to have the moral quality must be voluntary, deliberate; and mere repugnance in doing an act does not in itself make the act involuntary.
2. Circumstances sometimes, though not always, can add a {13} new element of good or evil to an action. The circumstances of an action are the agent, the object, the place in which the action is done, the means used, the end in view, the method observed in using the means, the time in which the deed is done. If a judge in his official position tells a sheriff to hang a criminal, and a private citizen gives the same command, the actions are very different morally because of the circumstances of the agent giving the command. The object--it changes the morality of the deed if a man steals a cent or a thousand dollars. The place--what might be merely a filthy action in a house might be a sacrilege in a church. The means--to support a family by labour or by thievery. The end in view--to give alms in obedience to divine command or to give them to buy votes. The method observed in using means--kindly, say, or cruelly. The time--to do manual labour on Sunday or on Monday. Some circumstances aggravate the evil in a deed, some extenuate it. Others may so colour a deed that they specify the deed, make the action some special virtue or vice. The circumstance that a murderer is the son of the man he kills specifies the deed as parricide.
The end also determines the morality of an action (see St Thomas, _Sum. Theol_. I. 2., q. xviii., a. 4 and 7). Since the end is the first thing in the intention of the agent, he passes from the object wished for in the end to choosing the means for obtaining it. Without the end the means can not exist as such. There are occasions when an end is only a circumstance: for example, if it is a concomitant end. When an end is a, _finis extrinsecus operantis_, when it is in keeping with right reason or discordant thereto, it may become a determinant of morality.
In every voluntary, or human, act there is an interior and an exterior act of the will, and each of these acts has its own object. The end is the proper object of the interior act of the will; the exterior object acted upon is the object of the exterior act of the will; and as this exterior act specifies the morality, so does the interior object--which is the end--specify it, and even more importantly than the exterior object does.
The will uses the body as an instrument on the external {14} object, and the action of the body is connected with morality only through the will. We judge the morality of a blow, not by the physical stroke, but from the intention of the striker. The exterior object of the will is, in a way, the matter of the morality, and the interior object of the will, or the end, is the form. Aristotle (_Ethics_, lib. v., cap. 2) says: "He that steals that he may commit adultery, is, absolutely speaking, more an adulterer than a thief." The thievery is a means to the principal end, and it is this principal end that chiefly specifies or informs the action.
The means used to obtain an end are very important in a consideration of the morality of an act. There are four classes of means,--the good, the bad, the indifferent, and the excusable.
Good means may be absolutely good, but commonly they are liable to become vitiated by circumstances,--almsgiving is an example. Some means are bad always and inexcusable,--lying, for example. The excusable means are those which are bad, but justifiable through circumstances. To save a man's life by cutting off his leg is an excusable means.
The existence of excusable means whereby some good actions are effected does not establish the assertion that the end justifies the means. The end sometimes may incriminate or sanctify indifferent means, but it does not in itself justify all means. The means, like other circumstances, are accidents of an action, but they are in an action just as much as colour is in a man. Colour is not of a man's essence, but you can not have a man without colour.
The effect of an action, the result or product of an effective cause or agency, may in itself be an end or an object or a circumstance, and it has influence in the determination of morality. Sometimes an act has two effects, one good and the other bad; and that such an action be lawful it is necessary (1) that the action itself be good or indifferent; (2) that the good effect be intended and the evil effect be not intended (chosen) but only reluctantly permitted; (3) that the evil effect be not a means to secure the good effect; (4) that there be present a motive sufficiently grave to excuse or counterbalance the bad effect. {15} St. Thomas (_Sum. Theol_. 2. 2. q. 64, a. 7) Speaking of killing a man in self-defence, says: "Nihil prohibet unius actus esse duos effectus, quorum alter solum sit in intentione, alius vero sit praeter intentionem. Morales autem actus recipiunt speciem secundum id quod intenditur, non autem ab eo quod est praeter intentionem, cum sit per accidens."
That an act, therefore, be morally good, or justifiable, (a) the whole train of the tendency of the will must be good; that is, (1) the object, (2) the end, (3) and the circumstances must be good; or (b) the intention should be good, and the remaining elements in the train of will-tendency are to be indifferent. That an act be morally bad it is enough that the object, the end, or the circumstances be inexcusably bad.
There may be honest doubt as to the existence of evil in the circumstances or the end, and here enters the matter of probability; but apart from this, some general rules of morality that govern all cases may be formulated:
1. An intention or end which is gravely evil always makes the entire action evil and unjustifiable.
2. An intention or end which is slightly evil, if it is the entire end of an action, makes the whole action evil but not gravely evil--makes it, say, a venial sin and not a mortal sin.
3. If an intention or end which is venially evil accompanies secondarily a good intention or end, and is rather a motive than the real effective agent in attracting the will, this venial evil does not vitiate the whole goodness or righteousness of the main action. Compare the remarks made above in discussing an action that has a double effect, partly good and partly bad.
4. Circumstances that are gravely evil practically vitiate the entire action, but circumstances which are venially evil do not always vitiate the entire action.
Much might be said here concerning conscience as a judge of the morality in an act, but this discussion is not necessary for our present purpose. Like other men, physicians often confuse conscience with inclination, or at best with unfounded opinion. When conscience is to be a rule of action it must {16} have at the least moral certitude; or, what is different but practically the same thing, the opinion of conscience must be at the least genuinely probable. The term "probable" is used here in a technical sense, and it will be so used throughout the remainder of this article.
The doctrine of Probabilism is connected with the promulgation of law. A law, according to St. Thomas (_op. cit._ I. 2., q. 90, a. 4) is: "Ordinatio rationis ad bonum commune ab eo qui curam habet communitatis promulgata." Sometimes it is not evident whether or not a law binds in a particular case, and in such a condition, that is, in which there is question solely of the existence, interpretation, or application of a law, we may follow a probable opinion which assures us the act is licit, although the opinion which says the act is illicit may be just as probable or even more probable. This is the fundamental proposition of Probabilism, which is the doctrine especially of St. Alphonsus Liguori, but it was held centuries before his time. As the church has never condemned this doctrine, but rather tacitly approved of it, Catholics may safely follow it, and those that are not Catholics will find it very reasonable.
A law which is doubtful after honest and capable investigation has not been sufficiently promulgated, and therefore it can not impose a certain obligation because it lacks an essential element of a law. When we have used such moral diligence of inquiry as the gravity of a matter calls for, but still the applicability of the law is doubtful in the action in view, the law does not bind; and what a law does not forbid it leaves open.
Probabilism is not permissible when there is question of the worth of an action as compared with another, or of issues like the physical consequences of an act. If a physician knows a remedy for a disease that is certainly efficacious and another that is probably efficacious, he may not choose the probable cure, at the least in a grave illness. Probabilism has to do with the existence, interpretation, or applicability of a law, as I said, not with the differentiation of actions.
The term probable means provable, not guessed at, or jumped at without reason. There must be sound reason {17} adduced to constitute probability. The doubt must be founded on a positive opinion against the existence, interpretation, or application of the law. It must be more than mere negative doubt, more than ignorance, more than vague suspicion, especially must it be more than a sentimental impression. There is a mental condition, which easily passes over into disease, wherein a man habitually can not make up his mind. This flabbiness has nothing to do with Probabilism. The opinion against a law to constitute Probabilism must be solid. It must rest upon an intrinsic reason from the nature of the case, or an extrinsic reason from authority,--always supposing the authority cited is really an authority. Many men sitting upon the supreme bench in the Court of Science and called authorities by friends and newspapers, are only fools in good company.
The probability must also be comparative. What seems to be a very good reason when standing alone may be very weak when compared with a reason on the other side. When we have weighed the arguments on both sides, and we still have good reason left for standing by our opinion, our opinion is probable. The probability is, moreover, to be practical. It must have considered all the circumstances of the case.
The principles presented here have been arranged, as we said, with a view toward application in judging the morality of actions that may occur in cases of ectopic gestation, and we shall apply the doctrine of probabilism in the question, does the commandment "Thou shalt not kill" bind in certain cases of ectopic pregnancy? It is also necessary to add the principles underlying our duty to preserve human life.
1. It is never lawful directly or indirectly to kill an innocent man. "Insontem et justum non occides" (Exod. xxiii. 7). An _innocent_ man is one that has not by any human act done harm to another man or to society commensurate with the loss of his life. _Directly_ means to kill either as an end, say, for revenge, or as a means toward an end.
A man is a person, an intelligent being, therefore free, and autocentric; he belongs to no one except to God, who made {18} him; he is by that very fact distinguished from brutes or things which may belong to another. Now, if you kill a man, you destroy his human nature by separating his soul and body, you subordinate and sacrifice him wholly to yourself, make him entirely yours, which is unjust. Even the state has no right to kill an innocent man. A foetus in the womb, only a few hours old, is as much a human being as a man fifty years of age, and this natural law holds for the foetus as for the man.
2. It is, however, lawful _indirectly_ to kill a man provided this man is an unjust aggressor. Cardinal de Lugo (_De Just. et Jure_, 10, 149) and others hold you may even _directly_ kill an unjust aggressor. _Indirectly_ here means incidentally. An effect happens indirectly when it is neither intended as an end nor a means, but happens as a circumstance unavoidably attached to the end or means intended.
We may not, however, kill an innocent man even indirectly, because no end is proportionate to the sacrifice of an innocent man's life, but the case of an unjust aggressor differs from that of an innocent man. By an unjust aggressor is meant some one that outside the due course of law threatens your life or the equivalent of your life, or the life of some one you should or may protect. You may stop such an aggressor, and if you happen to kill him while trying to stop him, there is no moral wrong involved. This aggressor may be formally or only materially unjust: he may be a normal man with a formal intention to kill you or your ward, or a murderous lunatic that tries to kill you or your ward, but he must be _unjust_ either formally or materially.
It is natural for every being to maintain itself in existence, to resist destruction. This is a primary law of nature. As Father Holaind well said (_Amer. Eccl. Rev._, January, 1894): "The ethical foundation of self-defence is this: Justice requires a sort of moral equation, and if a right prevails it must be superior to the right which it holds in abeyance. At the outset both the aggressor and his intended victim have equal rights to life, but the fact of the former using his own life for the destruction of a fellow man places him in a condition of juridic inferiority with regard to the latter. If we may be {19} allowed so to express it, the moral power of the aggressor is equal to his inborn right to life, less the unrighteous use which he makes of it, whilst the moral power of the intended victim remains in its integrity and has consequently a higher juridic value. When the person assailed cannot defend himself, his right _can_ and sometimes _must_ be exercised by those who are bound in justice or charity to protect the innocent. At the dawn of human life the physician or surgeon stands as the natural protector both of the mother and of the child; he is beholden to both.
"The right of self-defence is not annulled by the fact that the aggressor is irresponsible. The absence of knowledge saves him from moral guilt, but it does not alter the character of the act, considered objectively and in itself; it is yet an unjust aggression, and in the conflict, the life assailed has yet a superior juridic value. The right of killing in self-defence is not based on the ill will of the aggressor but on the illegitimate character of the aggression. Now, an aggressor is _at least materially unjust_ whenever he perpetrates an act destructive of the right of another."