Q: Is there a justification for the use of methotrexate in ectopics that are not able to be surgically removed, without either a hysterectomy or a difficult (potentially catastrophic hemorrhage) "removal" of the diseased portion of the womb, and subsequent questionable fertility thereafter? This issue raises itself often enough in the form of cornual, cervical and caesarean scar ectopics.
Does the presence or absence of a fetal heart change the indications for methotrexate? Given the fact that medical knowledge agrees most ectopics are none viable at diagnosis (a minority with a fetal heart beat, though some too early to display such) and almost all naturally (aside from the rare abdominal ectopic) will not be viable pregnancies, could methotrexate be justified along the grounds of "assault on the mother" if left, or observed, given the very real and serious threat of maternal death? Thank you for your thoughts. -- Dr L.M., Brisbane, Australia
William E. May offers the following response.
A: I will make a few comments on Dr. L.M.'s e-mail before setting forth my position. He wondered whether such use could be justified "along the grounds of 'assault on the mother' […] given the very real and serious threat of maternal death?"
"Assault on the mother" is not a good justification for this use of methotrexate because we can never consider the fetus or unborn child to be a (materially) unjust aggressor. He or she is an innocent human person whose presence in his or her mother's body in an ectopic pregnancy puts him or her as well as the mother in mortal danger. If there is "absence of a fetal heart beat," and if it is then morally certain that the fetus is dead, then there is nothing immoral in "removing" its corpse from the mother.
Now I want to present my view, noting first of all that in "Evangelium Vitae," No. 58, Pope John Paul II defined abortion as the "deliberate and intentional killing, by whatever means it is carried out, of a human being in the initial phase of his or her existence, extending from conception to birth." His way of defining abortion is most important. As scholars have pointed out, prior to this encyclical, Catholic moral theologians (e.g., D. Prummer, J. Noldin and others) defined abortion as the "removal of the fetus from its place in the mother's body." John Paul II's definition, however, allows us to distinguish between abortion as "removal," something not intrinsically immoral, and abortion as "deliberate and intentional killing," something always gravely immoral.
Dr. L.M. spoke of "removal" of the "diseased portion of the womb." During the 20th century Jesuit J. Lincoln Bouscaren made a "diseased part" of a woman's body central to an argument to justify a partial or total salpingectomy (the surgical removal of that portion of a woman's body threatened with rupturing and causing her death because of an ectopic pregnancy if such surgery could not be postponed without increasing danger to the mother). His argument was approved by the American bishops.
Thus, in the 1971 set of Ethical and Religious Directives for Catholic Health Care Facilities, directive No. 16 stipulated: "In extrauterine pregnancy the affected part of the mother (e.g., cervix, ovary, fallopian tube) may be removed, even though fetal death is foreseen, provided that (a) the affected part is presumed already to be so damaged and dangerously affected as to warrant its removal, and that (b) the operation is not just a separation of the embryo or fetus from its site within the part (which would be direct abortion from a uterine appendage) (emphasis added), and that (c) the operation cannot be postponed without notably increasing the danger to the mother."
However, in all editions of these directives, now called Ethical and Religious Directives for Catholic Health Care Services since 1994, the relevant directive simply says: "In case of extrauterine pregnancy, no intervention is morally licit which constitutes direct abortion." Hence if use of methotrexate, or a salpingostomy as distinct from a salpingectomy, or other means does not constitute direct abortion, i.e., is not the "intentional and deliberate killing of an unborn child," then use of these means could be, many Catholic moralists today maintain, morally justifiable ways of coping with extrauterine pregnancies.
Methotrexate attacks the DNA in the trophoblastic tissue that attaches the unborn child to its site within the mother's body; it thus attacks the trophoblast attaching the child to the fallopian tube or cervix or other part of an ectopic pregnancy (I prescind from unborn children implanted in the mother's abdomen insofar as this is very rare and children so implanted usually can survive until birth).
With other moral theologians I thus judge that use of methotrexate can be used to "remove" the unborn child implanted outside the womb; the death of the child is the foreseen but not intended side-effect of an action morally specified as the necessary removal of the unborn child from the mother's body as the means, not morally evil in itself, chosen to protect the mother's life.
I hope that this answer will be helpful to Dr. L.M. and others.
 Among scholars who have pointed this out, one of the most prominent is Angel Rodriquez Lu¬no, "La valutazione teologico-morale dell' aborto," Commento Interdisciplinare alla "Evangelium Vitae" (Vatican City: Libreria Editrice Vaticana, 1997), p. 419.
 Salpingectomy is the surgical removal of a woman's entire fallopian tube. Once the tube has been removed the woman can no longer conceive in this tube, but only in her other fallopian tube. In other words, a salpingectomy negatively affects her fertility.
 A salpingostomy is a surgical incision into the fallopian tube, "slitting it," as it were, and then removing the fetus attached to the tube and then suturing the place where the tube has been slit. Thus the woman will still be able to conceive a baby when an ovum from her ovary passes through the tube and is fertilized by sperm. In other words, a salpingostomy does not seriously affect her fertility whereas a salpingectomy does.
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Follow-up: Condoms and Natural Family Planning
The March 31 column "AIDS and the Spousal Use of Condoms" elicited this question from a reader:
Q: We have the following situation: A married couple is told by the doctor that a pregnancy will be life threatening to the woman. To protect her life, the couple decided to avoid future pregnancies (they already have 2 kids) and to do this using the accepted methods of natural family planning.
However, since natural family planning is not 100% (no method is) and since here the question is one of putting in danger the wife and mother's life, why would it not be licit to back-up the natural family planning with the use of a condom as an additional measure?
The couple will still abstain from sexual relations during the woman's fertile periods and in all aspects observe natural family planning. Thanks for your answer. -- P.J., Krakow, Poland
E. Christian Brugger offers the following response.
A: This difficult and heartrending scenario is the type that can strongly tempt good people to use proportionalist reasoning.
Proportionlists say that there are no actions that are in themselves ("intrinsically") wrong; but that to achieve a proportionately great good, any type of act may be committed.
In this case, the great good is to protect the life of the woman; therefore using condoms with the intention to render sexual intercourse sterile in the case that natural family planning should fail, is morally legitimate. As apparently plausible as this sounds, the conclusion is erroneous. In this scenario, even though natural family planning (which for a good reason (iusta causa) is perfectly legitimate to use to avoid pregnancy) is the primary method used, the couple is also using condoms to avoid pregnancy. They are using two methods. The one is legitimate, the other is morally wrong. If the condom is chosen with the intention to render intercourse sterile should it unwittingly be fertile, then the condom is used contraceptively.
Pope Paul VI taught in "Humanae Vitae" that "any action which either before, at the moment of, or after sexual intercourse, is specifically intended to prevent procreation -- whether as an end or as a means" is intrinsically evil ("Humanae Vitae," No. 14). A proportionalist would respond by saying this negative judgment is unreasonably legalistic; that in this case, there is clearly a proportionate reason to override the ordinary presumption against using contraception; and that a Catholic (or any person) is free to dissent from the Catholic teaching.
But this reply is shortsighted and superficial. Not only are we responsible to make reasonable choices with our physical health, we must also make choices that are good. A bad choice, such as the choice to contracept, renders our will and ourselves morally evil. John Paul II taught in "Veritatis Splendor," that if an act is intrinsically evil, no circumstance can render it good. Such acts "remain 'irremediably' evil acts; per se and in themselves they are not capable of being ordered to God and to the good of the person" ("Veritatis Splendor," No. 81).
Why is this the case? The Pope explains saying that an act is good "when it has as its aim the true good of the person in view of his ultimate end." But intrinsically evil acts, such as choices to contracept, "are always and in every case in conflict with that good" ("Veritatis Splendor," No. 82). Because the couple's intercourse may bring a new life into the world, although in the case of this couple such a possibility is remote, the choice to contracept implies that they have envisaged a potentially new life (however remote) and have willed against its coming-to-be. Their choice is contra-life and therefore wrong.
Moreover, their martial intercourse is meant to be an act of genuine self-giving. The choice to use a condom to render their sex infertile in the unlikely event that the wife is fertile, means they intentionally hold back from one another their procreativity. John Paul II says this "falsifies" the act by inserting into it a de-facto withholding of the self. This is bad for the marriage and bad for any offspring that might be conceived in the case of contraceptive failure.
The Catholic Church's judgment that contraception is always wrong to choose, is therefore not arbitrary. It derives from the Church's divine mandate to teach only what is consistent with and conducive of the integral flourishing of the human person.
"One must therefore reject the thesis," John Paul II insists, "characteristic of teleological and proportionalist theories, which holds that it is impossible to qualify as morally evil according to its species -- its 'object' -- the deliberate choice of certain kinds of behavior or specific acts, apart from a consideration of the intention for which the choice is made or the totality of the foreseeable consequences of that act for all persons concerned."
In other words, the use of proportionalist reasoning to justify an act the object of which is intrinsically wrong, is illicit.
Finally, the couple should consider that natural family planning practiced tightly is as reliable as any contraceptive method available, perhaps even more reliable. The British Medical Journal published a study of natural family planning in 1993 using 19,843 women in India. When practiced correctly in order to avoid pregnancy, the study found a 99.8% success rate (i.e., 0.2 pregnancies per 100 women). I recommend the couple educate themselves on a reliable method of natural family planning, such as the sympto-thermal method using all three indicators, or the Creighton Method, and then practice that method with the greatest care.
The husband needs to be particularly sensitive not to pressure his wife to have intercourse at borderline periods. Under the circumstances, for him to do so, in my opinion, would be a grave injustice against his wife. In the end, having done our part with intelligence and diligence, we entrust to Jesus the consequences knowing that he is more interested in the welfare of our health, marriage and immortal souls than we could ever be.
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Follow-up: Oxygen and the Dying
The March 31 column "Providing Oxygen to a Dying Patient" elicited this question from a reader:
Q: I was wondering if your analysis extends to someone on a ventilator? Under what conditions is a ventilator considered to be an extraordinary measure? I know Dr. Paul Byrne and the American Life League have a very conservative view on this question. Is seems that your analysis of the COPD patient would put you on the same side of the ventilator question as Dr. Byrne and ALL. Can you comment? -- J.P. of Saddle Brook, New Jersey
William E. May offers the following response.
A: There is a great difference between withholding or withdrawing someone from a ventilator and withholding or withdrawing oxygen from a person suffering from COPD. Persons suffering from COPD are not dying or in immediate danger of death. Receiving oxygen delivered by portable canisters allows them to move about as they please (visit friends and family, drive cars, travel, etc) and is neither futile nor burdensome (e.g., the cost is not prohibitive). Thus the care given them is "ordinary" or morally obligatory; deprived of it they will be deprived of the good of life itself.
Ventilators are "ordinary" care for persons who are not dying -- e.g. temporarily on a ventilator while recovering from some emergency or from a procedure such as a tracheostomy; in such instances ventilators are neither futile nor unduly burdensome.
But ventilators are "extraordinary," i.e., not morally required and can (and sometimes should) be removed, if the person is in the process of dying. Continuing their use prolongs the person's dying, is futile, and may impose grave burdens.
I hope that this suffices to answer your question and shows the great differences between withholding/withdrawing oxygen from COPD patients and withholding/withdrawing a ventilator.
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E. Christian Brugger is a Senior Fellow of Ethics at the Culture of Life Foundation and is an associate professor of moral theology at St. John Vianney Theological Seminary in Denver, Colorado. He received his Doctorate in Philosophy from Oxford in 2000.
William E. May, is a Senior Fellow at the Culture of Life Foundation and retired Michael J. McGivney Professor of Moral Theology at the John Paul II Institute for Studies on Marriage and Family at The Catholic University of America in Washington, D.C.
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