Article II: On Removal of the Oviduct Containing the Fetus

I. State of the question. The case is proposed by Fr. Vermeersch in the second edition, 1928, Theologia Moralis, II, n. 629: "In compelling necessity, it is permissible to remove the oviduct, or the part of the oviduct, which is judged to be about to rupture with great danger. This is licit even if it contains a fetus who will be removed at the same time. The reason is that the death of the fetus is then merely permitted; directly, nothing is chosen except the mutilation of the mother, which is licit in order to save the whole body."

L. Bouscaren wrote expressly on this matter in the well-known work Ethics of Ectopic Operations, Chicago, 1933. He says that it is indeed illicit directly to extract the fetus or directly to interrupt the pregnancy, but that this is licit indirectly for a proportionately grave reason; he limits this, however, to one case, excision of a dangerously diseased tube. He attempts to show that such an operation is indirectly lethal, not directly, and therefore licit for a proportionately grave reason. For since tubal pregnancy is a pathological case in which the tube is diseased, it is licit, given necessity, to excise it. The danger which threatens the tube does not arise proximately from the fertilized ovum or from the fetal sac, but from the tube itself, already diseased. And therefore, just as it is licit to extirpate an infected uterus in compelling necessity, so also the tube. Thus in the praised work,¹ part 4, c. 6.

¹ Cf. also Ecclesiastical Review, 1935; and Werner Moore, Principles of Ethics, 1935.

II. Judgment. This appears true: there is a parity between excision of a tube which causes danger and excision of a pregnant uterus infected with cancer. Hence it is probable in the same manner that each operation is licit, because the tube, like the uterus, is a part of the mother which is subordinated to the good of the mother. Nevertheless, it is licit only in necessity, and indeed compelling necessity, as the Holy Office says, 4 May 1898, so that:

1. there is no other means of saving the mother;

2. the danger proceeds from the present state or condition of the oviduct, for example, because it is already diseased; and

3. the danger is not only foreseen as probably to occur, but is morally certain and imminent.

In the case, expulsion of the fetus is not the means of saving the mother, but the excision of the tube itself. To expel the fetus would not suffice while the tube remained, because the tube itself is diseased and brings danger to the mother.

They object: The danger arises from the pregnancy and is removed by removal of the pregnancy; therefore the action directly injures the fetus and is lethal to him.

Response. Pregnancy is indeed the mediate and remote cause of the danger, but the very state of the diseased tube is the proximate and immediate cause of the danger. This arises mediately from pregnancy, but immediately affects an organ of the mother. Hence the pregnancy is not to be removed directly and immediately, but is removed mediately and merely consequently from the direct and immediate removal of the diseased organ.

III. Applications. The author of the aforementioned work applies his opinion in practice much more broadly than we have stated. He says that, outside a case of urgent necessity, excision of the tube is not indeed always to be performed immediately, but neither must one always wait. There must be a proportionately grave reason; this is a proportionate necessity of the mother. For since the probability of saving the fetus is almost nothing and very small by comparison with obtaining the safety of the mother, it is sufficient for performing the operation immediately that there be a notably greater probability of saving the mother more securely in this way. Therefore:

1. if the woman can be placed under medical observation, one must wait before operating;

2. if she cannot be subjected to observation, ordinarily the operation is to be performed immediately, because there is a notably greater probability of saving the mother in this way;

3. if, on the occasion of another operation, a tubal pregnancy is accidentally discovered, the operation is also licitly performed immediately when another later operation would be very dangerous for the woman, as often happens; in this case there is also that sufficiently greater probability;

4. in a case in which excision of the tube is licit, it is also licit to attempt the transfer of the ectopic conception from the tube into the uterus, into which it is to be inserted;

5. if, however, the fetus has already reached the fourth or fifth month of gestation and approaches more nearly the time when he is viable, it will be necessary to wait before operating, unless the probability now approaches moral certainty, or it is almost morally certain that the mother cannot otherwise be saved;

6. if the fetus is already viable, ordinarily he is to be extracted by a Caesarean operation, which of itself is also obligatory, and it cannot regularly be permitted that the fetus die in the mother's abdomen.

We think that the principle invoked does not provide a secure way, but one full of dangers and widely open to laxer solutions. First, it does not provide a firm and definitive judgment, since the lesser probability for the life of the fetus could be increased by the progress of surgical art and by the greater ability of the surgeon; and that notably greater probability for the mother could be understood more strictly or more broadly, and by almost everyone as he wishes.² Moreover, in estimating the proportionate reason:

² In the terminology of St. Alphonsus, a much or notably greater probability is equivalent, in ordinary circumstances, to moral certainty. But this is not the terminology of the author, since he distinguishes a notably greater probability from moral certainty, and indeed from a probability which approaches this certainty. Therefore this notion of a notably greater probability, according to the mind of the author, appears sufficiently extensible.

a. not only are the probability of the mother's death and the probability of the infant's life to be weighed comparatively, and the condition more favorable to the mother considered;

b. attention must also be given to whether an operation performed immediately does not render the conditions of the infant much worse, as in fact occurs, since in place of a possibility and a certain probability of life there is now a complete and radical impossibility;

c. likewise, whether the operation is strictly necessary here and now, for otherwise the safety of the mother could perhaps be obtained in another way. For we have never heard that it is licit to cause the death of another per se, although indirectly, except in urgent necessity for preserving one's own life, or a morally equivalent good. But excision of the tube per se, necessarily and always, causes the death of a nonviable infant. Therefore urgent necessity is required for performing it. Hence:

1. For the operation to be performed immediately, there seems regularly to be required that condition which the author requires only for a fetus of the fourth or fifth month, namely, that it be morally certain that the mother cannot otherwise be saved. This condition will not be present unless the necessity is proximate.

2. That the ectopic pregnancy is discovered on the occasion of another operation is an extrinsic circumstance which ordinarily does not change the case essentially. A greater opportunity to perform the operation is not yet a compelling necessity or a morally certain danger of death to be avoided, unless at the same time there were present a grave hemorrhage affecting the pregnancy.

3. We approve, however, what the author said concerning the attempt to insert the ectopic conception into the uterus. It is licit to attempt this in place of another operation, provided that there is a serious and more probable hope of saving the fetus in this way. But this probability can scarcely be present unless the operation is performed in the first weeks of conception.³

³ Cf. Ferreres, Casus conscientiae, I, on the Fifth Precept, case 10; Dr. Clément, Le Droit de l'enfant à naître, p. 71; and Bouscaren, op. cit., pt. 4, c. 6.

4. Likewise, we altogether approve what is said concerning a Caesarean section to be performed in order to extract a viable fetus. Nor can the contrary custom which prevails in a certain region be legitimated, at least insofar as it deprives the infant of Baptism. In a case of ectopic pregnancy, Caesarean section is not so dangerous and deadly: according to rather recent statistics, the danger of death for the mother is not more than 22 percent, and there are still more favorable statistics; moreover, even if the operation is not performed, not every danger is absent for the mother. The more opportune time for performing the section for the life of the fetus appears to be at eight and one-half months of gestation.

IV. Observations. In every case of excision, Baptism is to be conferred upon the infant. Nevertheless, it is not licit to excise the tube or extract the fetus so that he can be baptized, because he is not to be subjected to a directly lethal action so that he may receive Baptism and attain eternal salvation, since evils are not to be done that goods may come about, nor can an evil be chosen as the means to a good end.