[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.