Is Abortion Justifiable in the Hard Cases? Part III
[Today’s post is the third in a three-part series on “hard cases” by SPL member Clinton Wilcox. For the first post, on fetal disability, click here. For the second, on pregnancy from rape, click here.]
In fact, Alan Guttmacher, past president of Planned Parenthood, acknowledged: “Today it is possible for almost any patient to be brought through pregnancy alive, unless she suffers from a fatal illness such as cancer or leukemia, and, if so, abortion would be unlikely to prolong, much less save, life.”  A powerful quote, especially considering Dr. Guttmacher wrote it in 1967.
But what about the rare cases in which the pregnancy does become life-threatening? The most common example of this is an ectopic pregnancy, in which the human zygote implants itself somewhere other than the uterus, most commonly in the fallopian tube. If the zygote implants itself in the fallopian tube, this is highly dangerous to the mother. Once the embryo grows big enough,
the fallopian tube will burst, causing the mother to hemorrhage internally. This is an extremely dangerous situation for the mother, and almost always fatal for the embryo.
Some pro-choice advocates claim that we should keep abortions legal because abortions are always an act of self-defense — the pregnancy may end up threatening her life. However, very few women die in childbirth and pregnancy. Additionally, we can’t justify abortions because of the extremely unlikely possibility of the pregnancy becoming life-threatening, otherwise we could justify infanticide in the off chance they may grow up and kill their parents.
I take the position that life-saving abortions are morally permissible as long as the child is not yet viable. Once the child becomes viable, a caesarian section should be performed to save both mother and child. This is not only the ethical choice, it is also faster and safest for the mother. Late-term abortions are a three-day procedure, and a c-section takes about thirty minutes. This is a position consistent with my pro-life views. The mother and child are equally intrinsically valuable human beings. The mother and child should both be treated as patients, and it’s not always possible to save both.
Ectopic pregnancies don’t always implant in the fallopian tubes. If the embryo implants elsewhere and it is generally safe to continue the pregnancy, I don’t think abortion would be justified in that case (although constant physician observation may be required). But if the unborn implants in the fallopian tube, I believe that abortion is justified. There has been a case in which a zygote implanted inside his mother’s fallopian tube, later bursting the tube and implanting himself in the uterus, later to be born completely healthy.  However, I don’t think we can justify leaving ectopic pregnancies in the fallopian tube hoping that the woman and child will both survive. What would you think of a father who learns his son has pains in his appendix, waiting until the appendix bursts to finally seek medical treatment? With technology the way it is now, there’s a good chance of surviving a burst appendix. But the father would be negligent in waiting until his son’s appendix bursts to seek medical help. Since tubal pregnancies are dangerous and potentially fatal, I don’t believe a doctor is justified in leaving the embryo to develop there.
It is a tragedy when this happens, but to the best of my knowledge there is no way to transfer the developing embryo from the fallopian tube into the uterus for it to implant. If that were medically possible then that would be the ethical course of action. Since there is little evidence that this transfer could be done right now, abortions are justified in that instance. Sometimes the embryo dies on its own, before putting the tube at risk. In that case, there is no moral dilemma.
Life-saving abortions can be justified through three lines of reasoning.
— Triage is when two people are mortally wounded and only one can be saved. Say two soldiers are on a battlefield, dying of bullet wounds. The medic will survey the two dying soldiers, determine which one stands a greater chance of survival, and save that person. If he works on the more severely injured person he may lose them both. By saving one he is not declaring that the other is not human or not valuable. In the case of a life-threatening pregnancy, the child can’t survive without the mother and the mother stands a 100% chance of survival. Since it is better to lose one life than two, the doctor will save the mother who has the best chance of survival.
Double effect — Double effect reasoning is a set of ethical criteria that we can use for evaluating the permissibility of acting when one’s otherwise legitimate act would also cause an effect one would normally be obliged to avoid. 
In this case, the legitimate act is saving the life of the mother and the act one would normally be obliged to avoid is the death of an innocent human being. Essentially, four conditions must be met before an act is morally permissible:
1) The nature-of-the-act condition. The action must be either morally good or indifferent.
2) The means-end condition. The bad effect must not be the means by which one achieves the good
effect. (This is because the ends do not justify the means.)
3) The right-intention condition. The intention must only be the achieving of only the good effect, with the bad effect being only an unintended side effect.
4) The proportionality objection. The good effect must be at least equivalent in importance to the bad effect.
Most life-saving abortions satisfy all four conditions. 1) The action is saving the mother’s life, which is morally good. 2) In most life-saving abortions (removing a cancerous uterus or the fallopian tube in which a zygote implanted itself) you don’t achieve the saving of her life by directly killing the embryo, itself. 3) The intention is only to save the mother’s life, not to kill the unborn human. If there were a way to save the unborn human, that would be the ethical course of action. And 4) The good effect is equal in proportion to the bad effect. You are saving the woman’s life although the unborn child will die, and the unborn child will die even without doctor intervention.
If the woman has a cancerous uterus and can’t wait for the child to become viable, the ethical thing to do would be to remove the uterus, with the unintended (but foreseen) side effect that the unborn child will die. This would only justify one method of action during ectopic pregnancy (though the other methods can be justified using the other lines of reasoning — triage and third-party defense of an innocent aggressor).
Third-party defense of an innocent aggressor
— The preborn human has no intention of implanting itself in the wrong place or threatening the mother’s life. They have become an innocent aggressor. If the woman were to have the abortion herself, this would be justified by self-defense. But does the doctor have a right to step in? I would argue that he does.
Consider the case of a man at a bar who, unbeknownst to him, has his drink spiked with a hallucinogenic drug. He flips out and next thing you know is aiming a gun at five people, threatening to shoot. The police arrive and an officer has a shot, but a fatal one. I think the police officer would be justified in taking the fatal shot to protect the people whose lives are at risk.
As I indicated earlier, pregnancies are generally very safe. Most abortions cannot be justified as self-defense. But in a case where the woman will die if the pregnancy is left alone, then defense measures are justified.
Let’s have a look at the three different methods used to treat ectopic pregnancies. Some pro-life people I have talked to justify these by claiming that they are not really abortions, since medically they are called something else (Methotrexate, salpingectomy, salpingostomy). However, this does not affect the morality of the situation. They still result in the death of the preborn human. Plus, we can make the argument that all abortions are called something else (e.g. Dilation & Evacuation, RU-486, etc.). Even miscarriages are called “spontaneous abortions.” Shakespeare once wrote, “that which we call a rose by any other name would smell as sweet.”  Well, that which we call an abortion by any other name would still result in the death of an innocent human being.
Sometimes an ectopic pregnancy may correct itself. If it doesn’t and if no intervention is taken the embryo will grow large enough that the tube will rupture, causing hemorrhaging in the woman and a severe risk of death. I do not believe a doctor is justified in waiting around to see what will happen, since the tube rupturing severely harms the woman (possibly fatally). To expound on an analogy I used earlier, suppose a boy approaches his father complaining of pain in his abdomen. The father realizes his son may have appendicitis, but decides it’s not an emergency so he waits. The son’s appendix soon bursts and his father rushes his son to the hospital. With today’s technology his son has a good chance of survival, but the father was still negligent in his parental duties by waiting until the son’s appendix burst to seek medical attention.
— In this procedure, the section of the tube with the zygote inside it is removed and the embryo dies on its own. This is seen as satisfying double effect since you are not directly killing the embryo, you are allowing it to die on its own. This satisfies the second criteria, where the bad effect (the death of the embryo) is not used as a means to bring about the good effect (saving the woman’s life).
— In this procedure, an incision is made in the fallopian tube and the embryo itself is removed. This has the added advantage of preserving the woman’s fertility. Christopher Kaczor actually argues that this procedure likewise satisfies double effect. The effect of removing the embryo itself from the fallopian tube is not an intrinsically evil act, otherwise we would have to oppose removing it to attempt to transfer it into the uterus, if such a procedure ever becomes perfected. 
— Methotrexate is a drug that inhibits the cellular reproduction in rapidly growing tissue; it is also used to treat some forms of cancer. It works by inhibiting the growth of the trophoblast, the forerunner to the placenta and the embryo proper. 
Now, I personally believe that salpingectomy does not, in fact, satisfy the principle of double effect. Even if you are not directly killing the embryo itself, you are still the agent responsible for its death by removing the fallopian tube. You are removing it from the only environment in which it can live, which will result in its death. Someone might respond that you are simply removing the tube, which has been damaged and will result in hemorrhaging if left untreated. But I find this unconvincing. The reason the tube is damaged and will burst is because the embryo has implanted itself there and will burst it when it grows large enough. The embryo is the agent, not the fallopian tube, that is threatening the woman (albeit unintentionally).
I would actually argue that salpingectomy is morally impermissible in treating ectopic pregnancies. First, it is causing unneeded harm to the woman. By removing the fallopian tube, you are reducing the chance of her conceiving another child in the future by 50% (and if she had one before, you are effectively sterilizing her). Second, the embryo will die regardless of which method you use. Even if you don’t kill the embryo itself, you are still responsible for its death by removing it from its natural environment. So you are effectively responsible for the embryo’s death in any case. It seems that due to the unneeded harm and the fact that the embryo will die anyway, salpingectomy is actually morally worse than salpingostomy and using Methotrexate.
There’s some evidence to suggest that transferring an embryo implanted into the wrong place may be possible.  If this is correct, then this may change the ethics of the situation. Some may argue that this course of action would be morally required to be taken. Others, like Christopher Kaczor, argue that, as with saving other humans, this action may not be morally required. As he writes, “we need not make use of every treatment available in every circumstance. In each case, the burdens and benefits of the treatment must be considered, and treatments that are more burdensome than beneficial may be foregone.” 
So I would argue that abortions are morally permissible if the woman’s life is in immediate jeopardy but the child is not yet viable. Regarding the other hard cases, fetal disability/defect, rape, and incest, abortions are not morally permissible. On top of that, even if they were, they could not be used to justify general abortion-on-demand. Saying that we should make abortion legal because of a rare instance it may be justified is like saying we should eliminate all traffic laws because you may have to break one rushing a loved one to the hospital. 
to the study), and less than 1% of women die in childbirth (8.8 in 100,000, according to the study). A woman’s risk of dying by having an abortion rises exponentially as the pregnancy continues.
 Shakespeare, William, Romeo & Juliet, Act II, Scene II.
 See Kaczor’s article for more on this.
 L. Shettles, “Tubal Embryo Successfully Transplanted in Utero,” American Journal of Obstetrics and Gynecology, 163 (1990): 2026.
 See Kaczor’s article.
 Scott Klusendorf makes this observation in The Case For Life, (Crossway Books: Wheaton, Illinois, 2009), p. 175.
I agree that it's silly to insist on taking out the fallopian tube, just so the doctor can feel less guilty about "directly" killing the embryo. The embryo is going to die; the doctor's role is to make the best out of a bad situation. And that is why I disagree with you about the importance of language; I do NOT call ectopic pregnancy treatment "abortion." Abortion violates the right to life; in the case of an ectopic pregnancy, the right to life simply cannot be vindicated.
See also: http://www.youthdefence.ie/campaigns/set-the-record-straight/
I know that it wasn't done through malice, but I'm disappointed that this post doesn't make the distinction between medical treatment and abortion.
This statement from the American Association of Pro Life OB/GYNs is very clear that medical or surgical treatment for ectopic pregnancy is not abortion. http://www.aaplog.org/position-and-papers/what-is-aaplog%E2%80%99s-position-on-treatment-of-ectopic-pregnancy/
A ban on abortion does not – an should never – preclude women from accessing medical treatments while pregnant.
Take for example Ireland (where abortion is banned). Medical treatments for pregnant women are not withheld (nor should they ever be) because of the ban on abortion. A pregnant women is able to access any medical treatment she requires even if fetal death is a sad side-effect of the treatment.
It's unfair and untrue to claim that women who've had treatment for ectopic pregnancy (or any other treatment during pregnancy that runs the risk of fetal death) that they had abortions: they have not.
In communicating with the general U.S. public, you have to keep in mind that people do think of things like treatment for ectopic pregnancy as abortions. Including women who have had them. These women feel extremely threatened by the prospect of banning abortion because they believe that would mean allowing them to die.
If you're going to say "no abortions, no exceptions," you'd sure as hell better first make sure that the people with whom you are trying to communicate understand that you don't include life-saving treatment for the mother under the category of "abortion." And that's not easy to get across because it conflicts with the extremely common vernacular use of "abortion" as meaning basically "any procedure that kills the fetus."
Or the equal colloquial definition of abortion as "termination of a pregnancy," which would also include removing the zygote during ectopic pregnancy.
Thank you for reading, and for your response, Kelsey. The thing is, I wanted to be as thorough as possible in this article. i did briefly address why I'm including ectopic pregnancy, even though some people don't consider it an abortion. Not considering it an abortion still doesn't change the morality of the situation, because many people don't believe the end ever justifies the means. I know many people who don't believe that abortions are EVER justified, even in life-threatening situations (like ectopic pregnancy). So I really included it for the sake of being thorough with my treatment of the issue.
Thank you for reading and responding, Evelyn. I'll tell you what I just told Kelsey in a response: The thing is, I wanted to be as thorough as possible in this article. i did briefly address why I'm including ectopic pregnancy, even though some people don't consider it an abortion. Not considering it an abortion still doesn't change the morality of the situation, because many people don't believe the end ever justifies the means. I know many people who don't believe that abortions are EVER justified, even in life-threatening situations (like ectopic pregnancy). So I really included it for the sake of being thorough with my treatment of the issue.
Even miscarriages are considered "spontaneous abortions" in the medical field, even though the death of the unborn child was neither desired nor intended. In fact, many people include standard abortions as medical treatments.
Kelsey, in the case of ectopic pregnancy, whether or not the treatment is termed abortion, it *does* vindicate the mother's right to life, when there is no way to honor the child's.
Thanks Clinton for your honest and thoughtful analysis of lifesaving abortions. Some prolifers deny these situations exist and employ all manner of mental gymnastics to deny that they are ever a problem.
Some even go so far as to deny the extent of maternal mortality around the globe–after all, if pregnancy is women's "natural" function, it can never injure or kill them, right?
But if prolife means every life, we need to be prepared to save the woman's life when the baby's cannot be saved–and both lives when both can be saved. Also to respect women's lives by ensuring access to voluntary family planning, which also saves women's and children's lives.
Preterm births are dangerous for both mother and child, so they are not a panacea. They are at greater risk for "…respiratory, gastrointestinal, immune system, central nervous system, hearing, and vision problems. Longer-term problems may include cerebral palsy, mental retardation, visual and hearing impairments, behavior and social-emotional concerns, learning difficulties, and poor health and growth."
Like the second post in this series, this essay assumes Catholic belief on the part of the reader. That assumption should have been flagged at the outset.
Marysia, thanks so much! I believe in absolute honesty in this issue, on both sides of the fence. The problem is that many pro-life people think that if we find any sort of common ground with pro-choice people, we're compromising our views. That couldn't be further from the truth. I believe in finding common ground without compromising our views, and I am pursuing a career in pro-life apologetics doing just that. 🙂
I agree that being pro-life means respecting every life, the mother's as well as the unborn child's. In this case, there's simply no way to save the unborn child, and I don't believe we can justify forcing the mother to give up her life for the sake of a child who most likely isn't going to survive, anyway.
156, just so you know, I am not Catholic. Would you mind elaborating? If you're referring to the doctrine of double-effect, yes, that was proposed by a Catholic theologian/philosopher, but the reasoning does not assume a Christian worldview.
156, would you rather kill the child outright, or deliver them prematurely with possible health problems?
Although, I should add that I *am* Christian, I'm just Protestant. But I don't try to assume any worldview when I write these articles. As you see, I haven't made any blatantly religious arguments on any of my posts that I give to this site. I do write pro-life articles from a Christian perspective for Christian blogs, but not for Secular Pro-Life.
Waiting for 156 to leave 10 more comments on the next blog rather than actually continue the conversation (read: accusation) that he initiated….One of those, "I say what I want then I ignore everyone else" type.
Well, at least that way he never has to re-think his position if he can be shown to be in error.
"156, would you rather kill the child outright, or deliver [him or her] prematurely with possible health problems?"
Writing strictly about morality and with the assumption that knowledge is absolute, I am not sure. I think different people could derive different reasonable conclusions depending on the circumstances. I do not share the Catholic and Hindu beliefs that life should be preserved at all costs.
In doing research on this issue, I was not able to find any examples of babies being saved from ectopic pregnancies using Caesarean section. Google did, however, provide page after page of links to stories about how Caesarean section can cause a later pregnancy to be ectopic. Can you show me any examples of life-threatening pregnancies being saved by Caesarean section?
As right-to-lifers, I think we should focus on the causes of ectopic pregnancies. According to WebMD, they include smoking, surgery on the fallopian tubes or in the
pelvic area, fertility drugs, fertility treatments including in vitro fertilization, use of an intra-uterine device, sexually-transmitted diseases, unsuccessful tubal ligation, tubal ligation reversal, exposure to DES, pelvic inflammatory disease (often caused by a sexually-transmitted disease, endometriosis, congenital abnormality of the fallopian tubes, history of ectopic pregnancy. Many of these causes can be easily prevented at the individual or societal levels. For other causes, we could advocate research into their causes and possible preventions.
Here are my links for that last post.
"Would you mind elaborating?"
I already elaborated on the second part of the series.
Without an exhaustive review — which is not warranted without good answers to the second post –, I will elaborate on your end notes. They provided no support for your theses about the moral permissibility of abortion beyond Christian theology and philosophy.
Your first three endnotes do nothing to support your theses. If anything, they cloud the application of those positions to actual situations.
Your fourth endnote was to the testimony of a religious authority. It was the only basis you provided for why we should give any credence to the notion of "double effect," so I fail to see why you asserted that "the reasoning does not assume a Christian worldview."
Your fifth endnote was superfluous.
Your sixth endnote was to the testimony of a Catholic philosopher who only commented on the doctrine of double effect. See his books in the link below.
Your seventh endnote was also to the Catholic philosopher mentioned in the sixth endnote.
Your eighth endnote merely casts doubt about the relevance of your positions in actual decision-making.
Your ninth endnote was to the testimony of the Catholic philosopher mentioned in the sixth and seventh endnotes.
Your tenth endnote was to the testimony of someone whose only qualification is a Christian apologetics degree from a college whose mission "…is biblically centered education, scholarship and service—equipping men and
women in mind and character to impact the world for the Lord Jesus
Because all of your endnotes that support your main theses are to the testimony of Christian philosophers, I think I am quite justified in concluding that your essay assumes Catholic belief on the part of the reader.
"As you see, I haven't made any blatantly religious arguments on any of my posts that I give to this site."
No, I do not see that. You have made blatantly religious arguments in your posts to this site, as my comments below this post and the second post in the series demonstrate.
And in response to this ridiculous accusation that I always ignore other posters, please note that you have still not answered any of my questions under your second post in ten days.
No. In fact, your entire comment commits the genetic fallacy. My post does not assume a Christian worldview. All of my arguments are secular arguments, not reliant on a Christian worldview. If all of my endnotes are from Catholic/Christian philosophers, it's only because the best works written on the subject were from Christians. I defy you to find three better books on the pro-life position than The Ethics of Abortion by Christopher Kaczor (despite him being Catholic, his book was endorsed by atheist pro-choice philosopher David Boonin as the best book in print defending the pro-life position), Defending Life by Frank Beckwith, and The Case for Life by Scott Klusendorf.
I didn't answer your other post because we were arguing in circles, so there was no point in continuing.
You don't see that because you refuse to see that. You're the only person who's commented on my post that has accused them of presupposing a Christian worldview. They do not, but even if they do, you are merely committing the genetic fallacy by rejecting them based on that alleged reason.
I write blatantly religious articles, too. I don't post them here because they are not appropriate. You have not demonstrated that my reasoning is wrong, you are only rejecting them based on a presumed presupposition of the articles.
I did not make any claim that ectopic pregnancies can be saved through c-section. Would you please point out the specific quote in which I made this claim?
" I did not make any claim that ectopic pregnancies can be saved through
c-section. Would you please point out the specific quote in which I made
I never claimed that you did. Here is my question: "Can you show me any examples of life-threatening pregnancies being saved by Caesarean section?"
"…your entire comment commits the genetic fallacy."
If you had made an argument based on reasoning or facts that happened to be borrowed from religious authorities, I might agree. But you did not do so. What you did was say that we should accept your assertions merely because they were offered by people whose only qualifications are knowledge of evangelical or Catholic theology. You said, essentially, that we should accept the principle of double effect and other such notions merely because a Catholic or evangelical authority proposed them. That is a religious argument, not merely an argument with religious origins.
"You're the only person who's commented on my post that has accused them of presupposing a Christian worldview."
They do not just presuppose a Christian worldview. They are based on Catholic and evangelical dogma. Nobody outside of those religions will accept such dogma unless they accept the religion. And whether anyone else has made similar comments is irrelevant.
"I didn't answer your other post because we were arguing in circles, so there was no point in continuing."
What are you talking about? I posted one comment in response to your article. There was no argument.
Hmm. I must be thinking of someone else. I'll go check and respond.
It's not irrelevant. You can't just dismiss someone's posts because they are a Christian. My posts are not based on "religious dogma," and you're still committing the genetic fallacy. I just watched an atheist debate another atheist on abortion, and she made many of the same arguments that Christian/Catholic pro-life philosophers do, the same ones that I read. My articles don't presuppose anything.
I said nothing of the sort. Whether you accept double-effect reasoning or not is up to you. I never said you should accept them because they come from a Catholic or otherwise religious authority. You are dismissing them simply because the reasoning was proposed by a Catholic, which is the genetic fallacy. There is nothing in the reasoning that would prevent an atheistic ethicist from accepting that reasoning.
You may have posted that question, but I'm quoting you directly here:
"In doing research on this issue, I was not able to find any examples of babies being saved from ectopic pregnancies using Caesarean section."
You asserted that I made this claim, but I did not.
Regarding your question, I gave a source. Check footnote number eight. There has been at least one recorded case of an ectopic pregnancy being resolved through surgery. Also, if a woman has a cancerous uterus and she can't wait until the child is viable, that may also be a cause for life-saving surgery resulting in the death of the fetus. But in this case, it wouldn't be a literal abortion, it would be a hysterectomy, with the foreseen but unintended result of the death of the embryo/fetus.
"You asserted that I made this claim, but I did not."
"Regarding your question, I gave a source. Check footnote number eight."
Footnote eight concerns an embryo, not a Caesarean section. By the way, exactly how did you access a copy of an edition of the "American Journal of Obstetrics and Gynecology"? Do you have a subscription?
"…[I]f a woman has a cancerous uterus and she can't wait until the child is viable, that may also be a cause for life-saving surgery resulting in the death of the fetus."
But that would probably not be considered Caesarean section and defeats the purpose of the question that started this line of discussion ("156, would you rather kill the child outright, or deliver [him or her] prematurely with possible health problems?").
"…[I]t wouldn't be a literal abortion, it would be a hysterectomy…"
Hysterectomies are usually considered abortions. Whatever terminology you use, they kill the fetus.
"I never said you should accept them because they come from a Catholic or otherwise religious authority."
That was the only basis you gave for them.
"You are dismissing them simply because the reasoning was proposed by a Catholic…"
I am not dismissing them, I am questioning them. And I would do that if they were proposed by a Zoroastrian or an atheist — or anyone else, for that matter.
"There is nothing in the reasoning that would prevent an atheistic ethicist from accepting that reasoning."
I cannot speak for atheistic ethicists, but can think of one obstacle that would prevent any critical thinker from accepting that reasoning — the complete lack of evidence for it.
"It's not irrelevant."
Yes, it is.
"Can you show me any examples of life-threatening pregnancies being saved by Caesarean section?"
I believe caesarean section is the typical "treatment" of pre-eclampsia/eclampsia, which can be life-threatening. So says wikipedia.
Quite possibly the most succinct and current info I came across about this subject. Sure pleased that I discovered that site by accident. I’ll probably be subscribing for your feed so that I will get the most current updates. Like the information here.
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