Article II: On Puncture of the Amnion

I. Puncture of the amnion is the perforation, tearing, breaking, or even laceration of the covering or membranes of the fetus, including that which immediately surrounds the infant, namely, the amnion; hence of itself it brings about the flow and evacuation of the amniotic fluid, and thus the expulsion of the fetus, and death if he is not yet viable. We say: of itself, because some authors, such as Salsmans, say that the puncture, by means of a little siphon, an injection instrument, or a darning or knitting needle (stopnaald of breinaald), can sometimes be made altogether slight, so that it would not necessarily entail the total emission of the fluid, the rupture of the amnion, and the expulsion of the fetus. According to the testimony of Fr. Salsmans, certain eminent gynecological physicians think this possible; in which case some would think that there is a danger of indirect abortion, but not direct abortion.

II. State of the question. It is evident that such puncture of the amnion is of itself and generally illicit, as being direct abortion (indeed, it is the easiest and most usual manner of procuring abortion), because it is a direct action upon something of the infant, namely, the membrane which is his, not the mother's; and immediately it does nothing except injure the infant alone. Hence the good effect, if any is hoped for, is obtained only through the evil effect. But it is asked whether it is always and in every case the direct procuring of abortion and therefore illicit. The question is posed for three cases:

The first case is a descent, prolapse, retroflexion, or incarceration of a retroverted pregnant uterus which otherwise, that is, without diminution of its volume, cannot be restored within an abdomen that is too narrow. In this case many admitted this one exception and said that the puncture is licit and is not then direct abortion. The reason is that the danger is not in the pregnancy, but in the distention of the uterus; this is removed by the rupture of the amnion, so that the uterus can be restored to its place and the danger to the mother averted. But this is done before the abortion. Therefore the expulsion of the fetus itself is not chosen as the necessary means of averting the danger to the mother. And therefore, in the case, puncture of the amnion is not a direct killing, although proximately connected with it, because before the expulsion of the fetus the good effect is procured, namely, diminution of the volume of the uterus.

Thus Dr. Capellmann, who had vigorously defended the illiceity of embryotomy and direct abortion¹ (even against certain Catholic theologians), teaches in his well-known work Medicina Pastoralis;² hence many easily followed him in this matter, or themselves favor him: thus Waffelaert, De Iustitia, bk. I, pt. 2, latter section, a. 2, §2, n. 88; Antonelli, Berardi, Cornelisse, Theologisch-praktische Quartalschrift, 1905, and Génicot.

¹ De occisione foetus, 1875.

² "If, then, all the other remedies known to the physician for effecting the restoration or liberation of the uterus have been employed in vain, I judge the indirect procuring (namely, permission) of abortion, effected by puncture of the membranes and evacuation of the amniotic fluid, to be licit. For: 1. the mother is in immediate danger of life and, without restoration of the uterus, will perish together with the ovum (namely, with the fetus); 2. there is now no other remedy for saving the mother (according to the hypothesis); 3. evacuation of the fluid is immediately capable of averting the danger to the mother's life. Here, therefore, the danger to the mother does not arise from pregnancy physiologically considered, but merely mechanically from the enlargement of the uterus. Evacuation of the fluid removes this mechanical impediment and diminishes the uterus, from which diminution there immediately follows the possibility of restoration and the repelling of danger from the mother, before the abortion, which indeed will certainly occur afterward, occurs; all of which things happen in such a way that abortion, or expulsion of the embryo from the uterus, is not necessary for removing the danger." On the Fifth Precept, I.

The case, however, occurs very rarely; ordinarily other means are available: "Restoration of the uterus is now obtained in another way," says Vermeersch.³

³ Theologia Moralis, 2nd ed., II, n. 627.

The second case is similar, namely, acute hydramnios, when the volume of the fluid is excessive; in this case puncture of the amnion is also judged licit by many.

The third case is when the puncture would be necessary for conferring Baptism upon an infant who otherwise would perish in the mother's uterus, while he could not otherwise be reached and baptized there. The case rarely comes to be considered.

Now it is fitting to consider separately, first, the two prior cases, and then the third, because of the diversity of the object and end: the danger to the mother is to be averted, and Baptism is to be procured for the infant.

III. Puncture of the amnion employed to avert danger from the mother appears illicit, as being direct abortion, except in a case in which there is no probable danger of expelling the fetus, if such a case exists.

For the action directly and immediately injures the fetus, and only mediately and subsequently is capable of procuring the good of the mother. For:

1. It is exercised upon elements which belong to the fetus: the amniotic fluid is contained by a membrane which pertains to the fetus and therefore belongs to the fetus; hence incision of the amnion has the character of a lethal wound inflicted upon the fetus. Thus Vermeersch, Theologia Moralis, II, n. 627.

2. The act of cutting or puncturing is assumed as a means precisely insofar as it is lethal, that is, insofar as it expels the fluid without which the fetus cannot live, and indeed expels the fetus himself. Thus Wouters, Theologia Moralis, I, p. 511.

3. The distention of the uterus is removed and diminution of its volume is brought about through removal of the fluid necessary to the life of the fetus; therefore the evil effect itself seems causally to precede the good effect, and the latter is procured only through the evil effect.

Hence theologians began to speak more doubtfully on this matter, and many even to deny the liceity of the operation, such as De Smet, De Sacramentis, n. 316; Vermeersch, loc. cit.; Nouvelle Revue Théologique, 1913; Prümmer, Theologia Moralis, II, n. 141; Wouters, loc. cit. Indeed, in the more recent edition of Capellmann's work, prepared by the physician Bergmann under the supervision of Fr. Hürth, S.J., everything that had been said concerning the liceity of this operation was removed. Salsmans also speaks more cautiously on this matter, for the reason presented in Casus Conscientiae, c. 157, and Génicot, Theologia Moralis, I, n. 377, IV, namely, "the diminution of the uterus is obtained immediately, and therefore the physician is given the ability to restore the uterus to its natural seat; but the abortion occurs only after this good effect," was abandoned in the most recent, twelfth edition of Génicot's work. Nevertheless, "a slight puncture of the membrane necessary for the life of the mother, which does not induce morally certain further tearing of the membrane and abortion," is admitted; but from this it can rather be concluded that the abortion is direct, since indirect abortion can be licit even if morally certain.

We said, however, except in a case in which there is no probable danger of expelling the fetus, because if abortion then follows, it will be per accidens. But we add, if such a case exists, a possibility which some affirm. It can indeed be admitted that this exists theoretically; but in practice we doubt it, for in practice is there not always a grave danger of enlarging the puncture and inducing rupture? In that case the operation would be illicit, because it is illicit to expose oneself even to a probable danger of injuring or killing one's neighbor. Nor is it required for illiceity that abortion follow with moral certainty, as Salsmans says, loc. cit.; it suffices that it probably follow, in order that one must abstain from the operation. Nevertheless, others assert that, even in practice, it is sometimes possible to perform the puncture without danger, especially in a case of acute hydramnios. Concerning this we are unable to judge, but the judgment belongs to those skilled in obstetrical art.

They object:

1. The danger to the mother does not arise from pregnancy considered physiologically, but from the enlargement of the uterus; hence this can be removed directly without the pregnancy first being removed.

Response. The distention of the uterus arises from the pregnancy and is removed only through the removal of an element necessary to the life of the fetus.

2. From the diminution of the uterus there immediately follows the possibility of restoring it, but not the abortion or expulsion of the fetus, which is subsequent.

Response. The danger of death to the fetus arises from the very tearing of the membrane and the effusion of the fluid, from which the diminution of the uterus and the possibility of restoration then further follow.

3. The danger is repelled from the mother before the abortion, and therefore the expulsion of the fetus itself is not chosen as the necessary means of averting the danger to the mother.

Response. The necessary means chosen is the perforation of the membrane and the effusion of the fluid, from which the death of the fetus necessarily follows. Hence, although this death does not precede chronologically in the order of time, it nevertheless necessarily precedes virtually according to the order of causality. It is caused immediately, namely, according to the order of causality, and not through the good effect.

4. It is not established that the amniotic fluid is a vital element of the fetus and therefore that the puncture as such is to be regarded as a lethal wound.

Response. It is not established that it is a nutritive element of the fetus; but it is established that the fetus cannot live except within a closed membrane retaining the fluid, so that, when it has been poured out, he necessarily dies. Hence violently and directly to take this sole means of life away from the fetus is the same as to wound him lethally.

5. The effusion of the fluid is not intended as causing the fetus to abort, as in direct abortion, but solely as a means of reducing the volume of the uterus. Once this has been done, the mother is saved, even if the fetus were to remain.

Response. Reduction of the uterus cannot be obtained except through an injurious cutting of those things which pertain to the fetus, namely, by perforation and effusion which induce abortion; this therefore is necessarily intended as such, at least implicitly. It can be shown schematically:

IV. Puncture of the amnion in order to baptize the infant. For a case in which the infant cannot otherwise be baptized, at first sight it seems that the same must be said as in the preceding case, because if puncture of the amnion is direct abortion and direct killing, neither will it be licit for ministering Baptism, since evils are not to be done that goods may come about. Even in order to baptize, it is illicit to kill. The extrinsic end of ministering Baptism does not change the nature of the work, nor convert direct abortion into indirect, nor render a lethal action nonlethal.

Certainly; but the question is whether, in the case, only an evil effect is immediately produced, or whether, on the contrary, a good effect is already produced immediately and the abortion becomes indirect.

Now it appears to us that this can probably be maintained. And indeed in this way: the very perforation of the membranes, in this case, is an action which removes an element necessary for temporal life, namely, the amniotic fluid whose effusion it causes, but equally immediately furnishes an element necessary for spiritual life, namely, the possibility of reaching the infant and conferring Baptism. In other words, it removes the extreme spiritual necessity, namely, by perforating the membrane which is an obstacle to Baptism, but it carries with it and at the same time places the infant in extreme temporal necessity from the consequent loss of the fluid. Hence in the case, the good effect, the possibility of conferring Baptism, is not obtained through the evil effect, the effusion of the fluid, but would equally be obtained if the fluid were not poured out.

There is no parity with procuring the safety of the mother, because the possibility of this safety is obtained only through injury to the infant, namely, the very effusion of the fluid. This may be presented schematically as follows:

In the first case, the action is of itself injurious to the infant and afterward beneficial to the mother; in the other case, the action is at once injurious to the infant and beneficial to the infant.⁴

⁴ Cf. little work A, II, q. 3, n. IV, p. 63, note 1.

Thus Capellmann, op. cit., De Baptismo; Antonelli, op. cit., III, n. 386; Theologisch-praktische Quartalschrift, 1905; Cornelisse, Theologia Moralis, II, 491; Génicot-Salsmans, Theologia Moralis, II, n. 148, note.

V. Observations. It must nevertheless be noted:

1. The tearing of the membranes by means of an instrument can easily be performed in the last periods of gestation, when the fetus is at least probably viable and danger of death is imminent before complete birth; in the earlier periods, however, it can be performed only very rarely, because of the great danger which, from the destruction of the membranes, is brought upon the birth, the infant, and the mother. Hence it is not to be attempted unless it is certainly established both that the fetus is living and that his life is failing; for then the soul appears to be saved before all else and Baptism is to be conferred.⁵

⁵ Thus Capellmann, loc. cit.: "Premature destruction of the afterbirth, and the premature effusion of the fluid which follows from it, cannot occur without bringing a great impediment upon the birth itself, increasing the danger to the infant, and perhaps bringing the mother into the greatest danger.... Before the completion of the fifth month of pregnancy, we can only very rarely know with certainty whether or not the fetus lives. If abortion were imminent before this time, I would certainly abstain from every attempt to baptize by a siphon. Only then would I undertake that course..., when I was certainly persuaded both that the fetus was living and that his life was failing; and I would do this although I foresaw that, by the premature effusion of the fluid, some impediment to the birth itself would be removed. The injury to the mother to be feared from this and the accelerated death of the infant are not to be reckoned when his eternal salvation must necessarily be procured." Antonelli, op. cit., III, n. 385, adds: "Since at this time it can only very rarely be known whether the fetus certainly lives..., the tearing of the membranes and the flow of the amniotic fluid would increase the difficulty of birth and expose the fetus and the mother to grave dangers to health; and since, in this case, it cannot be known whether some part has been washed with the water, it does not appear expedient, for a doubtful spiritual effect, that bodily dangers be accelerated. Finally, if, even before the aforesaid time, it can be certainly established both that the fetus is living and that his life is failing, the membranes would have to be cut in order to confer Baptism...."

2. Baptism on the umbilical cord would not suffice, since the infant himself could be reached.

3. Let the physician judge concerning the puncture and laceration to be performed.