Part 3

Mark the words "right of another," at the end of the quotation. In a 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 Since this decision, made July 24, 1895, Lehmkuhl has entirely withdrawn his opinion.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.

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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.

Génicot (_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.

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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.