6. On Craniotomy

133. Notion. Craniotomy (cephalotripsy, embryotomy, perforation, decollation, exenteration, embryothlasia) is a surgical operation by which an infant in the maternal womb is cut up and, once cut up, extracted in parts. In present times physicians sometimes perform this operation if a mature infant, on account of the narrowness of the mother or other reasons, cannot be brought forth into the light, and therefore if this operation were omitted the mother with the infant would perish.

134. Principle. Craniotomy and other surgical operations directly causing the death of the fetus are altogether illicit.

This is plain from the responses of the Holy Office on May 24, 1884, and Aug. 19, 1889. Here are the words of the prior response: "Whether it can safely be taught in Catholic schools that the surgical operation which they call craniotomy is licit, namely when if it is omitted the mother and son would perish; but if it is admitted, the mother is to be saved, with the infant perishing? - After all things had been weighed for a long time and maturely, and consideration also had been had of those things which have been written on this matter by expert Catholic men ... they [the General Inquisitors] judged that the response should be made: It cannot safely be taught." Leo XIII confirmed this response. But craniotomy not only cannot safely be taught; it is also altogether illicit, as is plain from the response of the Holy Office on July 24, 1895. - Now the reason is that craniotomy and other similar surgical operations are the direct killing of innocent offspring. But never and for no one is it lawful directly to kill the innocent, as was said above, n. 131.

Before the responses of the Holy Office it seemed to certain theologians (Ballerini, Avanzini, Constantini) that craniotomy was licit on account of the following reasons: a) Of two evils the lesser must be chosen. But it is a lesser evil to kill the child alone than the child together with the mother. Now if craniotomy is omitted, mother and infant will die. - b) From that operation only the death of the infant is hastened, who otherwise also after a brief interval will certainly die. But it is lawful to hasten death a little for the sake of preserving the safety of the mother. - c) The infant is a cause of death for the mother. Therefore he is an unjust aggressor. But it is lawful to kill an unjust aggressor if this is necessary for saving life. - d) Ordinarily a man can yield his right of living for another, as, for example, he who falls into the sea can yield his air belt to another, even if he himself is then certainly about to perish. But in the case in which, without craniotomy, the mother with the son is about to perish, it is deservedly permissible to presume that the son yields his right to life for the preservation of the mother's safety. - Although those reasons are not altogether to be spurned, nevertheless they are by no means convincing. For the first reason indeed avails ordinarily speaking, namely if the avoidance of the greater evil can be had without an intrinsically evil act. But it is never lawful to do evils that goods may come, just as it is not lawful to lie in order to save the whole world. But the direct killing of an infant through craniotomy is intrinsically evil. - The second reason avails if it is a question of indirect hastening of death, but not of direct killing. Thus, for example, it is not lawful to kill a wounded man, certainly about to die, that he may be freed from pains more quickly. - The third reason is false; for the infant is not an unjust aggressor, but dwells without any fault at all in a place proper to himself. With better right the mother could be called the unjust aggressor of the infant. For through the action of the mother the infant was conceived and placed in the womb, and now he wishes to go out, but is impeded by the bad disposition or infirmity of the mother. Therefore rather the mother ought to sustain danger of life than the infant. - Finally, the last reason avails for indirect killing, or for the free undergoing of the extreme danger of death, but not for direct killing. Hence no one can permit that he himself be directly killed in order to save another.

135. Licit ways for saving both mother and offspring. In the case in which the infant truly cannot be born in the natural way, the physician can licitly do two other surgical operations by which the life both of the mother and of the offspring is preserved, namely either Caesarean section or symphyseotomy (hebosteotomy, pubiotomy). Certainly those two operations are sometimes more difficult than craniotomy, and also more dangerous for the mother, but on account of the difficulty or the danger arising it is not yet lawful to kill the infant. As is plain from the statistics brought forward by Bergmann,¹⁶⁸ only 2-3% of mothers die after Caesarean section has been done, provided nevertheless that the physician knows well the surgical art.

Both Caesarean section and symphyseotomy are a cutting open of the abdomen. Certainly the first is deeper, but the other, in which the bones of the pubis must be divided, is harsher. There were ancient authors, e.g., Cangiamilla, who taught that even a priest, when a physician and another fit person are lacking, ought in a case of necessity to perform this operation in order to baptize the infant. But this in our times and in our regions cannot be brought into practice for many reasons, e.g., a) because the priest lacks both the necessary instruments and sufficient skill to perform those very difficult operations, b) because he would be most gravely punished by the civil laws, c) because sinister criticisms could easily arise, greatly wounding his reputation, and finally d) because a great doubt exists whether by those surgical operations a priest could extract that fetus alive and baptize him. In places of foreign missions, when missionaries have special faculties and know somewhat the medical art, they themselves can licitly perform those surgical operations in great necessity. But when special faculties are lacking, the decree of the Holy Office on Dec. 13, 1899, must be observed: "The extraction of a fetus from the womb of a pregnant and deceased mother, although it is to be disclosed and persuaded, nevertheless His Holiness expressly guards and prohibits lest missionaries in particular cases involve themselves in ordering the section, much less in performing it."

¹⁶⁸ Medicina pastoralis 1st ed., p. 48.

136. The manner of acting with physicians in this matter. Modern physicians, even Catholic ones, are not rarely in good faith concerning the liceity of craniotomy in the case in which the life of the mother cannot otherwise be saved. For the reasons brought forward above for the liceity of craniotomy have some appearance of truth. Hence even the Sacred Penitentiary itself at first did not wish to resolve the controversy; for when it had been asked about this matter: "Whether at any time there is licit the operation which is called craniotomy, or a similar operation, which of itself directly tends to the killing of an infant placed in the womb?" on Nov. 28, 1872, after the things set forth had been maturely weighed, it had responded: "Let him consult approved authors, whether old or recent, and act prudently." - To this is added that physicians expose themselves to an urgent danger both of punishment inflicted by penal laws¹⁶⁹ and of sinister criticisms, if in extreme necessity they omit craniotomy for saving the mother. Therefore it belongs to a prudent confessor to judge whether it is better to leave the physician in good faith, provided nevertheless that baptism be conferred upon the offspring about to die. For thus the eternal salvation of the infant is procured and the life of the mother is saved. For sometimes material sins must be permitted so that formal sins may be avoided. Thus also teach Lehmkuhl,¹⁷⁰ Noldin,¹⁷¹ and others.

If in a difficult birth the fetus is already certainly dead in the womb of the mother, then indeed it can be cut up, so that it may be more easily extracted. But if the fetus is not certainly, but more probably, dead, then several authors also rightly teach that craniotomy is licit for saving the mother, because the living mother ought not to give her life for a fetus more probably already dead. - But when the mother giving birth refuses Caesarean section or symphyseotomy, the physician can now do nothing, and must permit the death both of the mother and of the offspring. For it is impossible for him by licit means to impede the death of both.

¹⁶⁹ Cf. German Penal Code § 222.

¹⁷⁰ Theol. mor. I, n. 1002.

¹⁷¹ De praeceptis n. 340.