On Wednesday, January 19, 2011, the Washington Post published an article titled "Religious Hospitals' Restrictions Sparking Conflicts, Scrutiny." In the article, the author lists several examples of "limitations on care [for women] available at Catholic hospitals." Among these is how Catholic hospitals deal with ectopic pregnancies. "Standard of care for ectopic pregnancies, which are life-threatening, is to inject the drug methotrexate or to remove the embryo surgically while leaving the fallopian tube intact, both procedures that are intended to preserve fertility. But some Catholic hospitals refuse to perform either and will extract the embryo only by taking out the fallopian tube."

In saying this, the author echoes a 19-page report (Below the Radar: Ibis Study Shows that Health Care Providers' Religious Refusals Can Endanger Pregnant Women's Lives and Health) published by the National Women's Law Center on Thursday, January 20, 2011. The press release announcing the report states that "certain religiously affiliated hospitals put women's health and lives at risk by restricting doctor's ability to provide the best medical care to pregnant women experiencing miscarriages and ectopic pregnancies." The hospitals do this, supposedly, because of their interpretation and application of the ERDs.

What do the ERDs say about ectopic pregnancies? Directive 48 speaks to this issue: "In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion." What are the possible interventions? There are actually four approaches to addressing these situations. The first consists in expectant management, i.e., simply monitoring the situation to see if the tubal pregnancy resolves on its own. The second consists in the partial or complete removal of the fallopian tube, which also contains an embryo (salpingectomy). The third involves slitting the fallopian tube and "stopping the destructive activity of the trophoblast by removing the invasive trophoblastic cells along with the damaged tubal tissue."¹ The embryo is also necessarily removed in the process (salpingostomy). And the fourth consists in administration of the drug methotrexate which prevents the trophoblastic cells from continuing to divide and doing damage to the tube that could result in severe hemorrhaging. The embryo also eventually dies. Its demise is foreseen, but not intended.² The physician's action is directed at the pathological and harmful tissue, and not at the embryo. Medically, the use of methotrexate tends to be the preferred treatment because it does not involve surgery and leaves the woman's fertility intact. In light of Directive 48, the question is whether any of these procedures constitutes a direct abortion.

While the first approach results in the death of the embryo, nothing is done to bring about that death. There is no direct abortion here; the embryo is simply permitted to die. Virtually all theologians agree that the second approach constitutes an indirect abortion (the procedure is aimed at removing a pathological organ and is necessary to save the life of the mother) and so is morally licit. The demise of the embryo is foreseen, but not intended. Among Catholic theologians and ethicists, there is disagreement regarding the third and fourth procedures. Some see them as a direct attack on the embryo and, so, a direct abortion,³ while others see them as aimed at removing pathological tissue — the trophoblast — and, unavoidably and concomitantly the removal of the embryo. They judge this to be an indirect abortion.⁴ The magisterium has not resolved this controversy. Hence, neither Church teaching nor the ERDs forbid the third or fourth approaches (so long as these approaches can legitimately be argued as not constituting direct abortions). Currently, both opinions are in play.

Hence, if some Catholic hospitals have policies that prohibit salpingostomy and the use of methotrexate, this is not because these procedures are forbidden by Church teaching or by the ERDs. Rather, it is because an individual or individuals decided either to take the safer course or personally believed that salpingostomy and the use of methotrexate constitute direct abortions and are, therefore, in conflict with Directives 48 and 45. However, given the on-going debate, it is permissible for Catholic hospitals to employ both the third and fourth approaches. As the editors of the National Catholic Bioethics Center's Catholic Health Care Ethics note: "Resolution of this debate will depend on further specification of the exact nature of these medical procedures and further refinement of the arguments about the moral object of each act. Generally, if there are two competing but contrary bodies of theological opinion about a moral issue, each held by experts whose work is in accordance with the magisterium of the Church, and if there is no specific magisterial teaching on the issue that would resolve the matter, then the decision makers may licitly act on either opinion until such time that the magisterium has resolved the question."⁵

R.H.

Notes

1. Albert S. Moraczewski, "Ectopic Pregnancy: B. Arguments in Favor of Salpingostomy and Methotrexate," in Edward J. Furton, et al., eds., Catholic Health Care Ethics: A Manual for Practitioners, Philadelphia, PA: The National Catholic Bioethics Center, 2009, p. 122.
2. Ibid., p. 123.
3. See, for example, William E. May, "Ectopic Pregnancy: A. Arguments against Salpingostomy and Methotrexate," in Edward J. Furton, et al., eds. Catholic Health Care Ethics: A Manual for Practitioners, Philadelphia, PA: The National Catholic Bioethics Center, 2009, pp. 119-121; Edward Furton, "The Direct Killing of the Innocent," Ethics and Medics 35, no. 10 (October 2010): 1-2.
4. In addition to the article by Moraczewski cited above, see Germaine Grisez, The Way of the Lord Jesus, vol. 2, Living A Christian Life (Quincy, IL: Franciscan Press, 1993), pp. 499-503; Kevin O'Rourke, "Applying the Directives: The Ethical and Religious Directives Concerning Three Medical Situation Require Some Elucidation," Health Progress 79, no. 4 (July-August 1998): 64-66; Martin Rhonheimer, Vital Conflicts in Medical Ethics: A Virtue Approach to Craniotomy and Tubal Pregnancies, edited by William F. Murphy, Washington, D.C.: Catholic University of America Press, 2009, especially pp. 83-121.
5. Edward J. Furton, et al., eds., Catholic Health Care Ethics: A Manual for Practitioners, Philadelphia, PA: The National Catholic Bioethics Center, 2009, p. 123.

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