Question Four: On Operations concerning Ectopic Fetuses

I. Ectopic or extrauterine pregnancy can occur, whose nature and causes we indicated in little work A, I, q. 1, n. VI.

It exists under various forms, of which the principal are:¹

¹ Concerning extrauterine pregnancy, cf. Antonelli, Medicina Pastoralis, I, nn. 244–248; Dr. Aussems, Buitenbaarmoederlijke zwangerschap; Dr. Pestalozza, Trattato di Ostetricia, II; Bouscaren, Ethics of Ectopic Operations, pt. III, c. V.

1. Tubal, when the fertilized ovum remains and develops in the tube or oviduct. This is called: a. truly tubal, which is more frequent, if it develops in the middle of the duct; b. tubo-abdominal, if it is near the mouth of the duct which faces the ovary and abdomen; c. tubo-uterine, if it is near the mouth of the duct which faces the uterus. In this case, after some time the fertilized ovum can pass into the uterus, and then the pregnancy which began as extrauterine becomes uterine in its second phase.

2. Ovarian, which is rare, when the fertilized ovum remains and develops in the ovary itself.

3. Abdominal, when the fertilized ovum remains in the abdominal cavity and develops there. Some doubt whether this is possible as primary, insofar as the pregnancy begins in the abdomen; for it certainly can be a secondary phase of a tubal, ovarian, or even uterine pregnancy, insofar as the fertilized ovum at a later time, for example because of some rupture, is received into the abdomen and continues to develop there.

Extrauterine pregnancy generally does not attain maturity and comes to an end before term; sometimes, however, the fetus continues to perfect development, either in the tube, which in that case does not rupture but is greatly distended, or in the abdomen, but he cannot be born. He can then be extracted by laparotomy and Caesarean section.

Ectopic pregnancies are found relatively rarely, in a proportion of 1.2–1.5 percent; absolutely, however, their number is rather great, and many cases have already been observed.

II. The false opinions of certain physicians are to be noted, who equate ectopic pregnancy with a diseased organ and a lethal tumor, or with harmful cells; several theologians also formerly taught this. Hence, just as it is always licit for the mother to remove a diseased organ or a lethal tumor, so it would always be licit to remove an ectopic fetus, who always constitutes a mortal danger to the mother.

But this is certainly false:

1. because a diseased organ is a part of the mother and is subordinated to the good of the maternal body, and likewise a lethal tumor which directly affects an organ of the mother; while an ectopic fetus is not a part of the mother, but a distinct individual who is not subordinated to the good of the mother;

2. because the fetus, from the moment of conception, is probably a man, having rights to life and integrity equally with the mother. Hence, just as it is not licit directly to injure or kill the mother in order to save the fetus, so neither is it licit directly to injure or kill the fetus in order to save the mother;

3. which is evident from the response of the Holy Office, 4 May 1898, to III: "Is laparotomy licit when there is question of an extrauterine pregnancy, or of ectopic conceptions?" Response: "In compelling necessity, laparotomy is licit for extracting ectopic fetuses from the mother's womb, provided that the life of both fetus and mother, insofar as possible, is seriously and opportunely provided for."

From this it follows at least with certainty that ectopic fetuses cannot indiscriminately be considered as a diseased organ of the mother and a lethal tumor; otherwise extraction would always be licit, no limitation would have been placed in the response of the Holy Office, and indeed it could be neglected and would have no value in practice.

But extraction cannot be performed unless:

1. there is necessity, not just any necessity but a compelling one, so that no other means is available and time is altogether urgent;

2. the life of both fetus and mother is provided for, where the fetus is placed first; and

3. this is done, insofar as possible, seriously and opportunely: opportunely according to the circumstances indicated by the very nature of the matter, namely, the time, manner, and place; insofar as possible seriously, so that there is a true probability, and the greatest that can be had in the case, of preserving the life of each.

The Holy Office itself explained this on 5 March 1902: "Whether it is ever licit to extract from the mother's womb ectopic (extrauterine) fetuses still immature, before the completion of the sixth month after conception?" Response: "In the negative, according to the decree of 4 May 1898, by force of which the life of fetus and mother is to be provided for seriously and opportunely insofar as possible; but as regards the time, according to the same decree, let the petitioner remember that no acceleration of birth is licit unless it is completed at a time and by means whereby, according to ordinary occurrences, the life of mother and fetus is provided for." This explanation is taken from the same decree of 4 May 1898, response I. But if acceleration of birth were performed at a time when the ectopic fetus is not viable, it would not be completed at a time and in a manner whereby, according to ordinary occurrences, the life of the fetus is provided for; thus if it were performed before the sixth month was completed, unless someone possessed a means of artificial incubation.

This response of the year 1902 does not appear to have been specially approved or promulgated; hence some deny its authority or call it into doubt. Yet not safely. For it concerns a declaration of the natural law, which does not require promulgation; moreover, canon 17 of the Code, which requires promulgation of an explanatory interpretation of a doubtful law, had not yet been issued; finally, as Gemelli notes, it did not require new approval or promulgation, because it was a merely literal interpretation of the text of the decree of 1898, taken from the words of that decree itself.²

² Cf. Nouvelle Revue Théologique, 1933. Note that the decree of 5 March 1902 was not denied by Fr. Vermeersch; and that he admits direct abortion to be illicit also for an ectopic fetus. Cf. Nouvelle Revue Théologique, 1933, p. 610.

Therefore, according to the decree, it is certainly illicit at least to act directly toward the expulsion of a nonviable ectopic fetus, for example, to open the fetal sac and expel its contents, to dilate the tube and press the ovum out of the tube, to open the tube and cut the ovum out of it, or in any other way whatever to procure his direct abortion. This follows already from the responses of 19 August 1889 and 24 July 1895, which by the responses of 4 May 1898 and 5 May 1902 [printed here as May; above, 5 March 1902] are explicitly applied to ectopic fetuses.

The decrees do not expressly speak of indirect abortion; but the common mind of theologians is that it does not fall under the decrees.

III. The following conclusions can be deduced from this:

1. Therefore the same principles hold concerning an ectopic fetus as concerning a uterine fetus, and thus it must altogether be held that every action directly lethal to an ectopic fetus is illicit. Such would be to act upon the cyst by electrical force or morphine injection, because by these means "the fetus would be exposed directly and per se to certain death, and no relief would be afforded to the mother if it were a mere tumor; but if it were a fetus in the cyst, the safety of the mother would proceed from the direct killing of the fetus."³

³ Antonelli, op. cit., II, n. 111.

There is also the fact that the fetus could not then be baptized.

2. The ectopic fetus is not an unjust aggressor. He is not an aggressor, not even a material one, after the manner of a man who in madness attacks another; for the latter places an act which nevertheless cannot be imputed to him because of the defect of liberty, while the fetus properly does not act, but rather is acted upon by the mother and by natural forces. Hence the mother could rather be said to aggress against him, since because of a defect of the mother and the natural concurrence of circumstances he is prevented from being in the normal and natural place. Through his coverings he indeed produces villi which strive to insert themselves into the maternal body and to take nourishment from it, but this is because the natural place, namely, the uterus, is not offered to him and is necessary for him to develop and preserve life; but this is a merely instinctive striving of vegetative life. Adherence to the mother, namely, belongs to natural development; therefore it is not a materially unjust action. And the intrinsic exercise of his own life and its preservation is itself a right, and cannot be called aggression, since it is not an action which has the mother alone as its immediate terminus. He is not unjust, because he does not pass beyond the paths of right, nor is he bound to renounce the things necessary for life.⁴

⁴ Cf. Creusen, Le foetus injuste agresseur?, in Miscellanea Vermeersch, I, where he expressly poses the question of aggression concerning an ectopic fetus and resolves it negatively.

Hence he is no more an aggressor than a uterine fetus who cannot be brought forth into the light.

3. Excision of an immature ectopic fetus is prohibited not only apart from a present necessity of the mother, as some would wish to insinuate, or when his direct killing is manifestly sought; but always, even in compelling necessity, unless the life of fetus and mother is provided for seriously and opportunely, as the Holy Office says. Otherwise it would be precisely equivalent to direct killing.

4. Neither is it to be called licit for saving the mother provided that there is the slightest hope of saving the fetus, as Antonelli has it.⁵ For this cannot be reconciled with the decree affirming that no extraction is licit "unless it is completed at that time and by those means whereby, according to ordinary occurrences, the life of mother and fetus is provided for." For when the life of the fetus is ordinarily provided for, the life of the fetus itself is likely; and therefore there is already a hope which is not the slightest, but well founded and truly probable.

⁵ Op. cit., II, n. 112.

5. The same rules which hold for a fetus certainly living are equally to be applied to a fetus probably living.⁶ Some have said: if there is no means of resolving the doubt, the principle can be held that the certain right of the mother prevails over the probable right of the infant. Thus Génicot in the first editions of Theologia Moralis, I, n. 376; Antonelli, loc. cit.; and to some extent Noldin, Theologia Moralis, II, n. 341. But this is false, for it is illicit to expose oneself even to a probable danger of killing, as Vermeersch rightly notes, Theologia Moralis, II, n. 628; just as a hunter who doubts whether an animal is a wild beast or a man, and wounds or kills it, is guilty of homicide.

⁶ The decree of the Holy Office, however, does not speak expressly of a fetus doubtfully living, but supposes conception.

Hence this was deleted in the new edition of Noldin's work; similarly, Fr. Salsmans amended it in the latest editions of Génicot's work, adding: "The question is not of a merely probable right of the fetus, but of the certain right of a probable fetus." Certainly, one who, while doubting the presence of a living fetus, performs extraction or excision, directly wills to extract or excise and kill him if he is present. In the case, namely, there is a doubt of fact, in which the principle of probabilism cannot be applied, but in which that which is safer must be done.

As we already wrote in little work A, I, q. 7, n. II, note 1, the invoked principle, that the certain right of the mother prevails over the probable right of the infant, is rightly applied when the certain preservation of life in the mother and a probable danger to the life of the infant arise equally immediately, as a twofold effect, from the same action or the placing of the same cause. It does not hold in the present case, because the danger introduced to the life of the probable infant would be the means of preserving the life of the mother, that through which provision would be made for the mother.

IV. Disputes still remain concerning certain operations, namely, whether they are direct expulsion and killing, or, on the contrary, indirect, whereby the good effect is immediately produced and not through the evil effect. Three in particular are subjected to dispute:

1. removal of the fetal sac;

2. removal of the tube or oviduct in which the fetus is contained or to which he adheres;

3. ligation or severing of the arteries, whereby the flow of blood is prevented from being brought to the fetus.

These must now be discussed.