What should a woman do if she becomes pregnant with an ectopically-placed embryo?
The purpose of this essay is not to give therapeutic advice. It is rather to offer moral instruction on adopting alternatives consistent with moral principles.
The term “ectopic pregnancy” refers to a pregnancy that is not in the uterus. More than 95% of such pregnancies occur in the fallopian tubes, but they also can occur in the abdominal cavity, ovaries or cervix.
Because there is presently no known procedure for transplanting an ectopic embryo into his or her mother’s uterus, ectopic pregnancies almost always result in the embryo’s death.
They also can be extremely dangerous to the mother. If not treated in a timely fashion, they can result in the rupturing of the organ into which the embryo has implanted, causing severe hemorrhaging and sometimes death.
Consequently, couples facing this tragic condition mustn’t tarry in making good treatment decisions. They must face squarely the distressing question of which option among a series of dolorous options they will adopt.
Catholic moral teaching gives minimal guidance on the question. The Ethical and Religious Directives for Catholic Health Care Services teach that “no intervention is morally licit which constitutes a direct abortion” (no. 48); but procedures and medications aimed at healing the pathological condition may be used, “even if they will result in the death of the unborn child,” presuming there are very serious reasons for doing so and that the treatment “cannot be safely postponed until the unborn child is viable” (no. 47).
These directives derive from the moral norm, held and taught from the earliest days of Christianity, that the intentional killing of the innocent, whether as an end or a means of one’s action, is always gravely wrong. Whatever procedure we use, therefore, mustn’t constitute intentional killing.
Unfortunately, the death of the embryo is unavoidable with or without intervention. But risk to the mother can be minimized. Therefore, the principal therapeutic concern of decision makers and the primary responsibility of practitioners is the life and health of the mother. She should not be subject to more harm than is necessary to resolve the condition.
There are five common therapies for treating ectopic pregnancy: expectant therapy, milking and squeezing, salpingectomy, salpingotomy and use of the drug methotrexate.
In the first, “expectant therapy,” no procedure is carried out; the pregnancy is followed closely by medical professionals with the hope that it will resolve itself by spontaneous abortion, which occurs in over half the cases. Hospital admission on short notice must be guaranteed so emergency care can be given in case of a ruptured tube.
In the procedure known as “milking,” the tube is grasped close to the site of the embryo and compressed, and then the compressing is advanced in the direction of the implantation site. The embryo is squeezed out of the tube by the pressure.
The third, “salpingectomy,” is a surgical procedure where the portion of the fallopian tube in which the embryo is implanted is removed and the two ends of the tube reconnected.
In a “salpingotomy” a slit is made in the fallopian tube at the site of the embryo’s nesting; the embryo is removed with a scalpel or forceps along with some of the damaged surrounding tissue.
Finally, “methotrexate” is a drug that interferes with the growth of the tissue that connects the embryo to the implantation site. This causes the embryo to be expelled.
Some moral theologians believe that the fourth and fifth procedures are immoral because in the case of salpingotomy the action is carried out on the body of the embryo, and in the case of methotrexate the mode of the drug’s activity is on the body of the embryo. Consequently, they argue, both procedures constitute an intentional attack on innocent human life.
I believe these arguments are erroneous; and when they are used to advise women with ectopic pregnancies, they exclude medical alternatives that might be least harmful to the women.
The norm against intentional killing prohibits any procedure that has as either its end or means the killing (or mutilation) of the embryo. But in the case of all five procedures above, including the salpingotomy and methotrexate, the end of the act is to protect the mother from serious harm posed by the growth of the ectopic embryo; and the means, morally speaking, to remove the embryo from its dangerous site in the woman’s body. Each procedure brings about death with equal foreseeability, although each brings it about in a physically different way. And in each case, what is chosen is not chosen because it is lethal to the embryo, but rather because it is effective for removing the embryo in the least invasive way. The embryo’s death contributes nothing to the end being sought, is of no positive interest, and so is not sought; only removal is sought.
Simply said, the end is the health of the mother, the means the removal of the embryo. Removal is chosen, not death. Death is a tragic, foreseen, unavoidable and unintended side-effect of the therapeutically-vital choice to remove the embryo.
Moral theologians should not give clinical advice. So I won’t. Skilled specialists should be consulted on which of the five procedures is medically indicated given a particular woman’s unique situation, health and options.
Since in each case the end is the same, and since in each the means constitutes a removal and not, morally speaking, a “killing”; and since at present we have no alternative available that is life-affirming for the embryo; it follows that the nature of the intervention—whether evasive, surgical or chemical—should be decided according to what is least harmful to the mother.