{21}
The third question proposed by the bishop is:
"Is laparotomy licit when performed for extrauterine pregnancy or ectopic gestation?"
The approved answer of the Holy Office to this question is:
"In a case of necessity, laparotomy for the purpose of removing an ectopic foetus (conceptus) from the abdomen of the mother is licit, provided the lives of both the foetus and the mother, as far as is possible, are carefully and fitly guarded."
The expression, "dummodo et foetus et matris vitae, quantum fieri potest, serio et opportune provideatur," is capable of various translations and interpretations.
The words might have this meaning: "In a case of necessity you may do laparotomy and remove an ectopic gestation, provided you do not kill either the mother or the foetus." If that is the interpretation, the decree means that we may never remove an unviable ectopic foetus when we know that the foetus is alive, because removal will kill it.
The sentence can also be translated in this sense: "In a case of necessity, you may do laparotomy and remove an ectopic foetus from the mother, provided you take full care to save mother and child if that is possible."
If that is the signification, it is evidently very different from the first interpretation. It would mean: do the laparotomy, remove the foetus, and if you possibly can save both mother and foetus do so, but if you can not, take the best means you can to save one or the other.
If the decree refers only to cases in which the foetus is viable, it would appear to be unnecessary—we need no decree of the Holy Office to let us do a laparotomy to remove a viable foetus. If it does not refer to a viable foetus, it refers to an unviable foetus, but to remove an unviable foetus is to either kill it or to hasten its death.
Génicot (Institutiones Theologiae Moralis, Louvain, 1902, vol. i. p. 358) has this interpretation of the decree:
"In conceptione extra-uterina licebit sane recurrere ad laparotomiam similemve operationem, quando aliqua etiam tenuissima spes affulget salvandi infantem, simul ac mater fere certo liberabitur. … Ubi vero nulla spes hujusmodi{22}affulget, neque in hoc casu licebit abortum directe inducere, etiamsi foetus certo moriturus sit antequam in lucem edatur, et baptismum recipere nequeat. Etenim S. Inqu., dum provocat ad responsum 19 August, 1888, satis indicat abortus inductionem a se haberi tamquam operationem directe occisivam foetus ideoque semper illicitam."
There is no question of anabortionin a laparotomy for extrauterine gestation; abortion is altogether a different operation in method and nature. Secondly, the other decree of the Holy Office to which he refers speaks of a direct killing of the foetus, but there is no direct killing of the foetus in the operation for ectopic gestation, nor is the indirect hastening of the foetus's death a means to an end. The decree on abortion is so clear it leaves no room for doubt.
Cardinal Monaco, in theEpistola ad Archiepiscopum Camarcensem, August 19, 1889, says the Holy Office decreed that "In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quamcraniotomiamappellant, sicut declaratum fuit die 28 Maii, 1884, et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis."
Note the words "directeoccisivam." Craniotomy is a direct killing, and a direct killing used as a means to an end; moreover it is an altogether unnecessary killing. Artificial abortion in the case of an unviable foetus is also a direct killing as a means to save the mother's life, but the removal of an unviable ectopic foetus is neither a direct killing, nor is it a means toward any end.
Since the meaning of the decree concerning laparotomy in extrauterine pregnancy is by no means clear, we may discuss the question until the law has been fully promulgated, ready to conform to the real meaning of the decree whenever it is explained. In that spirit we may now consider the cases that occur in ectopic gestation.
Case I. A surgeon is called in to treat a woman and he finds her in a state of collapse. He makes a diagnosis of tubal pregnancy, which has gone on to rupture with hemorrhage, and the bleeding will evidently be fatal to the mother unless it is checked. Practically the only chance of saving the{23}mother's life is coeliotomy and the ligation of her open arteries. Dr. Howard Kelly (Operative Gynaecology, vol. ii. p. 437) says: "When the hemorrhage is sudden and excessive the patient falls in collapse; but, in spite of these alarming symptoms, she may survive a succession of similar attacks and the foetus and sac may continue to develop." This exception complicates the case slightly. If the surgeon were absolutely certain that the only possible chance to save the woman's life is coeliotomy and haemostasis, the case would be somewhat different from one in which there is some chance of escape by spontaneous haemostasis. That chance, however, is so slight, and so far beyond any means we have for forecasting, that it is mere luck, and it is to be neglected. The surgeon may safely consider the patient in the gravest actual danger.
(a) Before he opens the abdomen he can not tell whether the foetus is alive or not; but the stronger probability is that it is not, and the certainty is that it has no chance at all to remain alive more than a few minutes or hours, unless the surgeon is willing to trust to sheer luck in the expectation that he may happen to have one of Dr. Kelly's exceptions before him.
(b) The operation to save the mother is this: as quickly as possible he makes a vertical slit from four to six inches long through the woman's belly-wall. Then commonly the free blood begins to run out, or it may even spurt out some feet into the air. The surgeon can see nothing for the blood and the presence of the entrails. If the blood is not freshly welling up he bails it out with his hands or a ladle; if it is spurting he at once thrusts in his hand, feels for the foetal sac, lifts it up, and puts on clamps near the uterus on one side and near the pelvic brim on the other. This stops the hemorrhage, and he can then work more leisurely, but unfortunately this also stops the flow of blood to the foetus. He can not first examine the foetus and then stop the hemorrhage. He can not back out even if he finds a live foetus without letting the mother die on the table.
(c) If the placenta is already loose from the Fallopian tube the child is dead or it will die in a few seconds or minutes. If it was not loose the lifting out may tear it loose, and this{24}tearing loose will hasten the death of the foetus a few minutes (but give a chance for baptising it).
(d) If the lifting out does not tear loose the supposedly fixed placenta, the foetus either will die anyhow if the mother dies, or it will die if the mother lives, because to save her the surgeon must put ligatures just where the flow of blood will be shut off from the foetus. Commonly there is no time to even look for the foetus until after the maternal arteries have been closed.
(e) The same conditions could exist in the rupture of a pregnancy in a rudimentary uterine horn as in a rupture in tubal gestation.
What is the surgeon to do in a case like this? Fathers Holaind (Amer. Eccl. Rev., January, 1894, in a note on p. 39), Lehmkuhl and Sabetti say: do coeliotomy, ligate the mother's arteries, remove and baptise the foetus.
The analysis of the case is this: (i) Theactionis the stopping of a fatal hemorrhage in a woman, and possibly, though not certainly, an indirect incidental hastening of a foetus's inevitable death.
(2) Theobject of the actionis the haemostasis, which is good, and the possible indirect hastening of the foetus's death, which is evil, but, as we shall see, excusable evil.
(3) Theend of the actionis to save the mother's life—a good end.
(4) Thecircumstances are: (a) that possibly, through mere luck, the woman's condition is not necessarily hopeless: a few women have escaped in this seemingly imminent peril—but that chance of escape is not soundly probable; the stronger probability by far is on the side of a fatal issue; therefore the chance for escape may be neglected, and the woman's case may be regarded as hopeless if operation is foregone.
(b) The quickest possible work on the surgeon's part is necessary, and there is no time or chance to examine the foetus's condition before tying the maternal arteries. Before he opens the mother's abdomen he can tell nothing whatever of the foetus's condition, but the probability is all in favour of the fact that the foetus is already dead or moribund.
(c) Themeansare coeliotomy, and the ligation of the{25}uterine and ovarian arteries to stop the mother's bleeding. This ligation, in the contingency that the foetus is still attached to the Fallopian tube, will also shut off the blood from the foetus, yet the uncertain shutting off of the foetal blood-supply is not intended by the surgeon as a means toward his end in any degree direct or indirect, but it is an evil circumstance associated with the action which may hasten the foetal death—even here the hastening is uncertain.
(5) Theaction has two effects,—one, the saving of the mother, is directly intended and evidently good; the other, the possible indirect hastening of the foetus's death, may or may not be evil. The moral centre of the whole case is this possible hastening of the foetus's death. If that possible hastening is licit the whole action is licit; if it is not permissible it will vitiate the entire action.
Suppose that there is no doubt that the ligation of the maternal arteries in this case really hastens the foetus's death some minutes: it would still be an indirect volition. Father Lehmkuhl also calls it indirect and licit. Father Sabetti denied that it is indirect, but he held that it is licit for another reason. Sabetti said (Aner. Eccl. Rev., August, 1894): "It is evidently false to say that a means which isdirectlyadopted for obtaining an end is onlyindirectlycontained in the intention of the agent who so adopts it." That is true, but the minor proposition in a syllogism drawn from that statement is to be emphatically denied. The cutting off of the foetal blood is a fact associated with the means, not a means direct or indirect toward the end, which is to save the mother—the means to save the mother is the stopping of her bleeding.
This is not hair-splitting in the opprobrious sense of that term. The bases of all sins are absolutely abstract principles, and because abstract principles can not be pinched or weighed, they have often little meaning for the opposition in an argument. There is only the width of a hair between Heaven and Hell at many places along the frontier, and there is only the difference between a direct or an indirect volition separating murder and a good deed. The best ethics frequently consists in delicate hair-splitting; and despite the protests of sentimentalists, one of the most valuable benefits of Moral Science is{26}to show us how to handle moral poisons for good purposes, as a physician uses the material poisons, opium and aconite.
If the foetus in this case of rupture in ectopic gestation were a materially unjust aggressor on the mother's life, the indirect hastening of its death would be justifiable according to all moralists, and the direct hastening would be licit according to Cardinal de Lugo, who was, in the opinion of St. Alphonsus, "post D. Thomam inter alios theologos facile princeps" (Th. Mor., lib. 4. n. 552).
Sabetti held that the foetus is a materially unjust aggressor. His reason for this opinion is that the extrauterine foetus is not in a position in which it has a right to be. If it were in the uterus, its natural position, it would have a right to its position. Ectopic gestation is a disease, not a physiological condition.
Father Aertnys (Amer. Eccl,Rev., July, 1893) denies that the foetus is an aggressor materially unjust. He says: "Nequaquam enim mortem intentat matri, sed actione, quam non ipse sed corpus matris producit, conatur ad lucem pervenire, et iste conatus non nisi ex naturali concursu rerum fit matri causa mortis. Infans ergo non estaggressoret multo minus estaggressor injustus. Hinc nego paritatem cum homine mente capto, qui delirans alteri mortem intentat; hic enim agit motus a sua voluntate, licet absque culpa, et ponit actiones in se injustas, utpote ad necandum directe intentas."
In the same periodical (January, 1894) while repeating this statement he says: "Sive in utero existat sive alibi reconditus sit [sc. foetus], nequaquam mortem intentat matri, siquidem non ipse actione propria conatur egredi, sed corpus matris infantem expellit et haec expulsio a matre emanans fit matri causa mortis."
What Father Aertnys says in these two passages is true of an intrauterine foetus, but it is altogether erroneous when applied to an extrauterine foetus, of which alone there is question here. In extrauterine pregnancy the uterus or any other part of the maternal body does not "try to expel" the foetus; the uterus has nothing at all to do with the case—the very name of the condition isextra-uterine pregnancy. If an ectopic gestation{27}goes on to term (a very rare happening), there will be false labour and uterine contractions, and these cease after a time without effect one way or the other; but in all cases of rupture and the like the uterus is outside the question and the mother is passive. There is no attempt by the mother in extrauterine pregnancy at expulsion either before rupture or at any other time unless the dead foetus putrefies, and the maternal tissues "try to expel" it as a foreign body by breaking down into an abscess. The foetus simply grows, and its bulk bursts the tube. If it were in the uterus, the uterus would enlarge synchronously with the foetus and there would be no rupture, but the tube will not give beyond a certain point, therefore it bursts.
In normal uterine pregnancy at term the uterus and other maternal muscles are the active factors in expelling the foetus—the foetus is passive. In ectopic gestation the foetus is active, the mother is passive, and there is no attempt at expulsion from either side. In this case the foetus in the tube through the action of its own vital principle draws nourishment from the mother and grows gradually larger till it bursts the tube (it may even move its arms and legs if advanced), and this rupture tears open arteries wherethrough the mother bleeds, commonly to death. This is evidently material aggression.
Father Aertnys says the foetus differs from the murderous lunatic in this, that the madman is moved by his will, although blamelessly, in doing unjust actions directly intended as homicidal. The fact that the lunatic uses his will has no weight whatever in permitting me to defend my life against him, it is an accidental thing outside the question; but Father Aertnys in mentioning the madman's will means solely, if I understand him, that the madman is really an active aggressor. The foetus, however, is also an active aggressor without using its will. I might fall from a height toward a man and certainly endanger his life while I was not using my will at all, not conscious of the man's presence under me, or even while I was using all the power of my will against the result. In any of these cases I should be a materially unjust aggressor; and if in trying to prevent my body from killing him the man killed me, he would be blameless.
{28}
Now, in the first place, the tubal foetus is an aggressor; and since, secondly, its position is unnatural, monstrous, a disease, a thing not intended by nature, it has no right to its position, and it is therefore a materially unjust aggressor. Since it is an aggressor on the very life of the mother in a place where it should not be, the surgeon therefore may at the least stop the fatal bleeding it causes. If the foetus dies as an unwished for, though permitted, consequence of this haemostasis, the surgeon may lament this result, but he is blameless.
The foetus was blocked in its unnatural position through a defect in the mother, nevertheless it remains a materially unjust aggressor. If I by an accidental blow had made a man insane, and later this lunatic tried to kill me, I, or my legitimate protector, might lawfully kill the lunatic in defence of my life. This is an exact parallel to the case of the mother and the extrauterine foetus.
The extrauterine foetus is not like a foetus in a craniotomy case. Where there might be question of craniotomy the foetus is not an unjust aggressor even materially, as has been said: first, because it is not an aggressor in any manner, it is altogether passive; secondly, it has a perfectly natural right to be where it is. In ectopic gestation with fatal rupture the foetus is, first, an active aggressor; secondly, it has no right to be where it is. In craniotomy the foetus is killed as a direct means toward the end that its head may be reduced and extracted and the mother saved; in extrauterine gestation with fatal rupture the foetus is incidentally killed as a consequence of the haemostasis, and not as a means in any sense of the term. In craniotomy the child is wantonly killed since there are other means of saving the mother; in extrauterine pregnancy with fatal rupture the hastening of the death of the child is unfortunately associated with the only possible means we have to save the mother.
In Case I., therefore, we have an action that has an object partly good and partly, very probably, not evil; the end intended is good; the circumstances are justifiable or indifferent; consequently in Case I. the surgeon may do coeliotomy, tie the uterine and ovarian arteries, and if the foetus{29}happens to be alive he may reluctantly and indirectly permit the hastening of its death after attempting to baptise it.
Case II. The conditions presented in Case I. are the ordinary and most common that the surgeon meets with in treating ectopic gestation, but other conditions may be found.
Suppose the surgeon, before operation, diagnoses a case of ectopic gestation, but that he can not tell whether or not the foetus is alive. The probability leans toward the side that the foetus is alive, because there is no indubitable history, as physicians say, of maternal symptoms that indicate rupture.
Medical authorities tell him to do coeliotomy at once, ligate the uterine and ovarian arteries, and remove the foetus. Would he certainly or probably be justified in following out this medical doctrine?
The mother is in actual,very probabledanger of death, but not in actual,certaindanger of death. She may possibly escape if operation is deferred; she has a negligible chance of escape if no operation is performed after the death of the foetus; coeliotomy and ligation of the uterine and ovarian arteries give her by far the surest chance of escape, so sure an opportunity for escape when performed early that it can scarcely be called a mere chance.
If operation is deferred the chances for rupture are about 22 per centum, say, one and a half in five chances, and all ruptures are not necessarily fatal. The chances of the mother's death, however, are much higher than that, because death can come in ectopic pregnancy from causes other than rupture. From 63.1 to 68.8 per centum (say, 66.3 per centum) of ectopic gestations treated by the expectant method result in death to the mother—just two-thirds of the women die. A. Martin in a series of 265 cases of ectopic gestation where the expectant treatment was employed found a maternal mortality of 63.1 per centum; Parry in 500 similar cases found a mortality of 67.2 per centum; and Schauta in 241 cases a mortality of 68.8 per centum.
In the 87 years between 1809 and 1896, 77 cases of coeliotomy for the delivery ofviableectopic foetuses were reported{30}in all medical literature with a maternal mortality of about 58.3 per centum. Between 1809 and 1888 there were 37 coeliotomies with a maternal mortality of 86.5 per centum. Between 1889 and 1896 there were 40 such operations, with a maternal mortality reduced to 32.5 per centum by modern surgical methods.
The results as regards the children were almost the same in the two series, and perhaps a little better in the latter series. In the first series the 37 children were alive at delivery: the length of time in which three of these children lived is not given; three more were alive but they did not breathe; the others lived from a few seconds to days, weeks, months or years. One was well at six months, another at one year, another at seven and a half years, another in its fourteenth year, another in its fifteenth year. In the second series the results as regards the children were, as has been said, almost the same. The 40 cases that were reported from 1889 to 1896 are the standard for this phase of ectopic gestation, because they come under the diagnosis and treatment of the present day. They represent closely all such cases that occurred in the entire world between 1889 and 1896, because physicians report these operations to medical societies, and active physicians are almost without exception members of such societies—outside the civilised world these operations do not take place. In the seven years there were annually less than six cases of coeliotomy for ectopic gestation at term in the world, therefore operations at term may be neglected in discussing Case II., and the argument may be confined to the ordinary cases of expectant treatment. Schrenck in 1892 collected 610 cases of ectopic gestation which had been reported between 1887 and 1892; during the same time there were 23 cases (less than 4 per centum) of operations for the delivery of viable foetuses.
If the physician that has made the diagnosis in this Case II. leaves the patient, she may have a fatal hemorrhage at any moment. Dr. Howard Kelly reports (Operative Gynaecology, vol. ii. p. 438) a fatal hemorrhage in two days from rupture where the foetus was only as large as a Lima bean. The hemorrhage may be so suddenly fatal that the woman drops{31}to the floor unconscious just as if she had been shot. Dr. Harris (International Cyclop. of Surgery, vol. vi. p. 784) tells of a case where three of the best obstetricians in Philadelphia met in consultation daily for 16 days expectantly watching development, but the woman died from hemorrhage in thirty minutes before any of these physicians could be called to her aid. Death may be brought about by anaemia after repeated hemorrhages. Some hemorrhages can be mistaken for colic by the physician, and this error will defer until too late the treatment for hemorrhage.
If the woman is living in a hospital where there is a resident surgeon with instruments ready, she has a better chance than if she is in her own house. Even if she has a surgeon within call the outcome of the case for her will depend largely on his skill, his presence of mind, the preparedness of his instruments, the general condition of the patient, and many other circumstances.
The instruments, ligatures, gauzes, solutions, dressing, etc., for coeliotomy are multitudinous, and all must be sterile, or the woman will be killed by septicaemia even if the hemorrhage is stopped. It is almost impossible to keep a set of instruments and the other things used in a coeliotomy always sterile and ready for instant use.
The skin surface of the patient's abdomen must be sterilised, or pus infection will get into the peritoneum through the wound. In all ordinary coeliotomies this surface is carefully sterilised by a long process the night before the operation, a protective dressing is put on, and the sterilisation is repeated the next day just before the operation. This is so important that its voluntary omission is malpractice. In the hurried operation for tubal rupture there would be no time for sterilisation of the abdominal skin surface, and probably no time to sterilise the instruments and other things used, especially the surgeon's hands.
The surgeon to do any coeliotomy needs assistant physicians—one to anaesthetise the patient, and at the least one other to work with him in the operation. He should have three or four physicians and one or two nurses. He can not do a coeliotomy alone. Hence the patient in a ruptured{32}extrauterine pregnancy must have at the very least two physicians within call.
The woman, then, in Case II. before operation has one chance in three of life if no operation is done until the child is viable, and if she remains alive till the child is viable (when she must be operated upon) her chances for life will be no better, judging from modern statistics.
At any moment, therefore, she is in actual peril of death by two chances in three, and probably more if all special circumstances are considered. The foetus is a materially unjust aggressor in this case before rupture or other similar mishap, as it was in Case I., but not to the same extent. In Case II. it is a materially unjust aggressor as two is to three; in Case I. it is a materially unjust aggressor as three is to three.
If a lunatic is just about to fire three cartridges at me, I may know the chances are only two in three, or even only one in three, that he will hit me fatally, nevertheless I may licitly kill him to stop the firing and save my life. The mother in Case II. is in exactly similar danger of life.
The objection that the danger to my life from the action of the lunatic existshic et nuncand that the danger to the mother's life does not threatenhic et nunc, is not of any weight. She is in actual dangerhic et nunc, even while the surgeon is in the room examining her. Moreover, the matter of time here is accidental. If you give a man a poison that may kill him in ten hours, or one that may kill him in ten days, the action is essentially the same.
I am of the opinion that if this second case were proposed to moral theologians many of them would decide that the surgeon should explain the case fully to the patient or her family, and if immediate operation were insisted upon he should withdraw from the case. Nevertheless, as far as I can see, he has sound probabilism on the side that operation is justifiable.
But, it may be objected, in Case I. the surgeon ligated the uterine and ovarian arteries to stop an actual hemorrhage, and he permitted the death of the foetus; in Case II. there is no hemorrhage yet, there may possibly be none at all. I answer{33}that in Case II. if he operates he ties the two arteries to forestall an imminent hemorrhage which might begin within the next hour if it were not securely shut off, and to forestall sepsis by leisurely and proper precautions, and exactly as in the first case he permits the death of the foetus, he indirectly kills an unjust aggressor. If the lunatic is aiming at me I do not have to wait until he begins firing to licitly shoot at him. The sooner I shoot,servato moderamine inculpatae tutelae, the more prudent my action.
To put it in another form—in Case II. the surgeon is standing before a dam (the stretched Fallopian tube) that is threatening to break at any moment and cause death to a woman below it, because there is a lunatic (the foetus) behind it tearing away the masonry. If the surgeon shunts off the water just above the dam (the ligation of the arteries), he will suddenly let the lunatic who is tearing away the masonry fall down to the rocks at the bottom of the dam and be killed. May he let the lunatic fall? Certainly he may. But perhaps the lunatic will not succeed in tearing away the masonry. He is well provided with tools to do so; the chances are even two in three that he will succeed. Is he or the woman to be given the benefit of the doubt? The woman, by all means; she has a doubt worth in juridic value at the least twice as much as that which the lunatic has.
In any case of ectopic gestation the foetus has a very faint chance indeed of even living long enough for baptism if the expectant treatment is employed. We have seen that between November 1809 and November 1896 there were reported 77 cases of operation for the delivery of viable foetuses. Eleven of these children survived, 67 died within a few months, and many of these died just after delivery. Still, probably all might have been baptised. Judging, however, from the geographical distribution of the cases (see Kelly'sOperative Gynaecology, vol. ii. p. 458) and the names of the operators, only about 14 of these children received baptism.
Now, since Schrenck found 610 ectopic gestations reported in five years, this indicates that the average number of cases of ectopic gestation which occur in the civilised world is at the least 122 a year, for many more (twice as many, at the lowest{34}estimate) are not diagnosed or not reported when diagnosed. In the 80 years, then, between 1809 and 1896 there were at the least 9760 cases of ectopic gestation in the civilised world; in the uncivilised countries there were certainly as many more with not a child saved, or even brought out of the pelvic cavity. To be sure, by rejecting perhaps a third of the cases through bad diagnoses and neglect of reports, there were 20,000 cases; and in all these hardly 20 children baptised—one in a thousand.
Modern surgical methods and improved diagnosis will do little to better the condition, from the nature of the disease. Between 1893 and 1896 there were 21 cases of operation for the delivery of viable foetuses reported, and this list is approximately correct, because the surgeons that operate on such material are men that as a rule report their work even when it is to their discredit. In these 21 cases, 6 mothers, 28 per centum died, 72 per centum recovered. Even if modern surgery should save all the mothers who had escaped until the foetus was viable, and should bring all the children to baptism, there would not be more than about 7 such cases in the world annually. Increased skill in diagnosis would raise the number of children brought to baptism, but it would more than proportionately raise the whole number of ectopic gestations discovered. If 10 foetuses were brought from the pelvic cavity alive in the 130 cases of ectopic gestation of the year, the chances for an extrauterine foetus to only reach baptism at a viable age (not to live after baptism) are only 7 in 100 at a most liberal estimate. Statistics are unreliable, of course, but I am giving odds of two to one. The foetus has a much better chance for baptism if the coeliotomy is done as early in the pregnancy as possible, but it has a negligible chance of life in any case. Since the creation of man there have been less than 15 extrauterine children saved, and of these 15 four were less than a year old when reported, and three under five years of age: the oldest was fifteen years of age, and all were weaklings.
The practical rule, then, is that the ectopic foetus will die anyhow, and operation onlyindirectly(mark the word) accelerates the inevitable death of a materially unjust aggressor,{35}while it gives the mother the best chance for her life, which is in very grave peril.
Case III. The surgeon before operation diagnoses with the help of consultors extrauterine pregnancy, but he or they can not tell whether the foetus is alive or not. What should he do?
In my opinion he may operate with much more solid probability than that which exists in Case II. If the argument is more for the death of the foetus than for its life, this, of course, strengthens the permissibility of the operation.
(1) The danger to the mother is exactly the same,caeteris paribus, as in Case II.; (2) the foetus is only probably alive. An actual danger to life is opposed to the probable life of a materially unjust aggressor; therefore the surgeon may probably operate at once. Probable here is used in the technical sense of the term.
Case IV. The following case is given because a similar one was proposed in the articles in theAmerican Ecclesiastical Review, but it is not a practical case.
The surgeon, after consultation, does not know whether the growth in a woman's pelvis is a malignant tumour or a sac containing an extrauterine foetus. If the growth is a malignant tumour, the woman is in actual and certain danger of life, her death is a mere matter of time if a malignant tumour is not removed, and the sooner the tumour is removed the better. If operation is deferred, metastases of the tumour will have occurred, and operation will be too late. The indication when we find a malignant tumour is, if it is not already too late to operate, to take it out at once.
If the surgeon thinks that the growth may possibly be a foetus, and he puts off the operation until a time when certain signs of pregnancy should be present to establish a diagnosis of gestation, or their lack to establish a diagnosis of tumour, it would almost surely be too late to operate in the event the growth turned out to be a malignant tumour.
As has been said, the case is not practical, because malignant tumours of the tube are so very rare that they are not to be looked for,—only one or two have been observed.{36}Malignant tumours about the tube should be diagnosed. Supposing, however, the case to stand, it offers in favour of operation a probabilism stronger than that in any case except Case I., because the mother's danger is graver, and the argument concerning the foetus is the same as that in Case III.
Case V. Suppose a doubtful case like Case III. or Case IV., but after the surgeon has opened the abdomen he finds a foetus evidently alive. This is an improbable but a possible case. Case V. then becomes like Case II. with the addition of another grave danger to the lives of both the mother and the foetus, which is the coeliotomy already performed. The suggestion that the surgeon can leave the woman, back out of the case, is absurd. If he closes the abdomen, the coeliotomy may cause tubal abortion, the wound might have to be opened again in a few hours or a few days, and the mother would be left in much greater peril than she was in Case II. For the reasons already given, he should go on with the operation.
Case VI. Suppose a case like Case V. in every particular except that when the surgeon finds the foetus he can not tell whether it is alive or not. He should,a fortiori, finish the operation.
Case VII. A case of ectopic gestation is diagnosed, the conditions are explained to the woman, and she refuses to be operated upon. Is she justified? The probability is one to two that she will escape death if she waits, and much less than one to two if she finally refuses operation. The moralists would tell her she may refuse operation.
Case VIII. Let us suppose a case where a Fallopian tube either has its lumen so narrowed by a gonorrhoeal inflammation that although the spermatozoa may pass through and fecundate the ovum this fecundated ovum can not get out to the uterus; or, secondly, that the gonorrhoeal infection has completely shut the tube, yet migratory fecundation has occurred through the route of the other tube and the passage along the fundus of the uterus to the ovary of the infected side. In either case an ectopic gestation begins.
The first case is improbable from a medical point of view,{37}and the second is barely possible. Gonorrhoeal infection of the tubes is common enough, but when it occurs it usually shuts the tube up permanently. In chronic salpingitis at times the ovarian end of the tube is not wholly closed at once, and since the body of the ovary is very rarely affected by gonorrhoea, there is a possibility worth considering of a tubal pregnancy through migration to occur.
In such a condition the woman might have been infected with gonorrhoea, first, before her marriage through fornication or accident; second, after her marriage through adultery or accident; third, after the marriage by her husband.
If she had been infected through fornication or adultery, she is accountable for the foreseen consequences of her sin, and she has put an impediment for which she is responsible before the embryo. Suppose the physician knows these facts. Then the excuse for indirectly hastening the death of the foetus does not, at first sight, seem to exist, because the foetus is apparently not a materially unjust aggressor. It could easily happen that a surgeon's refusal to operate in a case like this would cause the death of the mother and foetus. Should he let both perish? Is he to let the mother die for the sake of staving off for a half-hour the certain death of a useless embryo the size of a pigeon's egg? It is not a useless embryo the size of a pigeon's egg, but a human being, the most important thing on earth, and a human being shut off from life and baptism as a direct consequence of that woman's brutal sensuality. But the woman may be the mother of other helpless children. What is to be done? Let us recur to the example of the homicidal maniac.
If I accidently by a blow make a man insane and that insane man afterward tries to kill me, I or my protector may permit his death to save my life. If I maliciously make a man insane and he afterward tries to kill me, may I or my protector kill him in my defence? Some may say that I may not because I have lost all juridic superiority over the madman as a consequence of my sin against him. That position, however, does not seem to be correct.
If it is correct, parity makes the assertion true that the foetus in the case supposed above may not be indirectly{38}killed to save the mother. If it is not true, the foetus may be indirectly destroyed. Does my sin against the insane man give him a right to kill me? By no means. Nothing but defence of life or its equivalent gives any private individual the right to kill another. The man might kill me before this aggression of mine, in defence of his sanity, but after the fact such a killing would be mere revenge, or anactus hominis, not a right.
The woman, we suppose, has maliciously put the foetus in its position of material aggressor, but has the foetus the right to kill her? No; the foetus is an individual not acting in self-defence, it is merely growing. Has the woman or the surgeon, her protector, the right to permit the death of the foetus to defend the woman's life? I think they have, because the foetus here also is, from its unnatural position, a materially unjust aggressor.
But, you say, this is a vicious circle. You justify the permitted death of the foetus in Case I. because it is a materially unjust aggressor, and it is a materially unjust aggressor because it is in an unnatural position where it has no right to be; but in the present case the mother put it in the unnatural position, and it therefore has a right to be where it is. No: the consequence does not follow. The fact that the mother put the foetus in its unnatural position does not give the foetus arightto be in that position, although it constitutes a ground for her punishment by proper authority. You object again, if this woman has a right to permit the death of the foetus to save her own life, how may she be punished for that death? She will not be punished for the actual coeliotomy which indirectly caused the death of the foetus, but she will be punished for the sin of putting that child in a position in which it had to be killed. This seems to be a distinction without a difference. As far as the mother is concerned,transeat; but it is a real distinction as far as the surgeon is concerned.
If the woman's condition is a result of accidental infection before or after marriage, the case goes into the class of those discussed above, and operation is justifiable.
If her infection comes after her marriage adulterously, her{39}sin is the greater, but the operation is justifiable for the reasons which were given in the case of culpable infection before marriage.
If she had been infected by her husband, the operation is justifiable—the father is accountable for the foetus's death.
Fortunately the entire case is so nearly hypothetical that it is little more than mere words.
AUSTIN ÓMALLEY.
{40}
Tumours of the uterus and its adnexa at times, though rarely, complicate pregnancy, and they may involve certain moral questions that have been little discussed. The tumours that cause difficulty are ovarian and uterine.
Cystic ovarian tumours commonly do not prevent impregnation, if there has been an absence of inflammation. When these cysts are small they may not disturb pregnancy or delivery; large cysts can, however, become a source of danger. They may sink into the pelvis and block the channel of delivery needed by the child at term; they may have their pedicles twisted, and thus become gangrenous and septic. Big cysts of the ovary may during the growth of the pregnant uterus press upon the portal vein, or the diaphragm, or they may burst or cause sepsis. Litzman, in 56 cases of ovarian tumours complicating pregnancy, had only 10 normal deliveries; and Remy held that 23 per centum of these cases, when left untouched, result in death to the mothers. Stratz says the mortality is 32 per centum, and it has gone as high as 40 per centum. Some physicians teach that any ovarian cyst found complicating pregnancy should be removed surgically. Other authorities hold that they should all be treated expectantly: if they threaten the life of the mother, they should be tapped by a trocar through the belly-wall or the vagina, and removed only after labour. This second operation is safe, and I think it should prevail.
Such cysts have often been removed during pregnancy. Orgler reported 146 ovariotomies (removal of the ovaries) performed during gestation with only four maternal deaths—2.7 per centum. If the operation had not been performed{41}about 32 per centum of these women would have died. The chance against saving the child in such an operation is the crux. If there is no operation 17 per centum of the cases result in abortion and the loss of the child, as Remy found from a consideration of 321 cases. In Orgler's series of 146 ovariotomies, where he lost only 2.7 per centum of the mothers, and saved about 30 per centum that would have died (97 per centum in all); he lost 32 children through abortion caused by the ovariotomies, or 22.5 per centum; whereas by the expectant method (without tapping) only 17 per centum of the children were lost.
Bovee of Washington, however, reported 38 cases of removal of the ovaries during pregnancy with one maternal death and only four abortions, or 12.6 per centum. That is considerably less than the loss by the expectant method without tapping. As Bovee succeeded, other men now do, but it would be far better to attempt tapping first. The earlier in the pregnancy either tapping or removal is done the better.
Fibroid tumours of the uterus, complicating pregnancy, occur in about 0.6 per centum of pregnancies, and they usually go on without causing trouble; but again these tumours may block the pelvic outlet, they may dangerously press upon abdominal viscera and the diaphragm; some writers hold they may become inflamed and degenerate with sloughing and gangrene, and thus bring about sepsis and death to the mother and child. That they become gangrenous must very rarely happen; the increased blood supply should prevent gangrene, but cause an increase in the size of the fibroma.
A group of gynaecologists maintain that when fibromata cause dangerous symptoms in pregnancy the uterus should be taken out in part or wholly if the tumour is so deeply involved in the uterine wall that it can not be separated. This operation, of course, kills the foetus. At times the child is viable, and a precedent caesarean section will save it. Surgeons do not remove fibromata merely as a precaution, as they sometimes do in the case of ovarian cysts. Other surgeons say it is safe to wait. If the channel of delivery is blocked, these men wait till term and then do caesarean{42}section; in other cases the tumour will often be lifted up out of the way during the later stages of gestation or labour.
In those very rare cases where it is necessary to remove the uterus wholly or in part before the child is viable, and thereby also to kill the foetus, the operation at first glance seems in no wise to differ in nature from a craniotomy upon a living child. The condition, however, is commonly worse than one in which a craniotomy is indicated, because in the latter condition we have a viable child, and the caesarean section to solve the difficulty, but in the former we have a child not viable, and therefore the caesarean section would be useless, except for the opportunity it might give for baptism of the child. In such a case must the surgeon let the mother die lest he hasten the death of a non-viable child?
The action reduces to this, that the surgeon by operating would permit a hastening of the inevitable death of the foetus while saving the mother's life, but the child is not an unjust aggressor, not even a materially unjust aggressor. It has a right to be where it is. The only excuse for hastening its death is to save the mother's life,—there is no question of self-defence; but deliberately to hasten the death of a human being a second of time, except it be done by an individual in self-defence against an unjust aggressor, or by the state for legitimate cause, is murder. It seems probable, however, that there is something to be said in favour of the unavoidable hysterectomy (removal of the womb) in a pregnancy complicated with uterine fibromata that undoubtedly endanger life.
Such cases differ from craniotomy, or the direct killing of a foetus (which were formally forbidden by the Holy Office on May 28, 1884, and August 19, 1888, and always forbidden by the natural law) in several factors: first, in craniotomy the child isdirectlykilled, although it is not an aggressor, in the hysterectomy it is permitted to die, it isindirectlykilled; secondly, in craniotomy there is a viable child, in the hysterectomy, an unviable child; thirdly, in craniotomy there is a killing that is a means toward the end of saving the mother's life, in the hysterectomy there is a permitted hastening of the foetus's death, and this is only a circumstance inseparably joined to the act; fourthly, in craniotomy the killing is utterly{43}uncalled for, because the caesarean section, or symphyseotomy (a temporary dividing of the pubic joint to get more room) will do instead, in the hysterectomy, because the child is not viable, there is no alternate way out of the difficulty; fifthly, formal judgment has been pronounced by the Holy Office in craniotomy, no formal judgment has been made as regards this hysterectomy.
Suppose A and B are on a boat hoisting a weighty object to a ship; the tackle breaks, the falling weight mortally hurts B, and wedges him fast to the wrecked boat. The boat is about to sink and drown both men, but if A tips off the weight, and with it unavoidably the entangled B, A can float to safety. A will indirectly hasten the inevitable death of B by throwing off the weight which will drag him down. May A do so? Very probably he may.
Two swimmers, A and B, are trying to save C, who dies in the water, and as he dies he grips A and B so tightly they can not shake the corpse off. A is weak, and he will soon sink and drown owing to the weight of the corpse; B also will later go down with A and C. A, however, cuts his clothing loose from the grip of the corpse (or some one in a boat does so who can do no more) and A is saved; but thus immediately B is drowned, owing to the fact that the full weight of the corpse is upon him. Is A, or the man in the boat, justified? Probably they are. A is the mother, B the foetus, C the diseased uterus, the man in the boat is the surgeon. The mother has herself cut away from the uterus and the foetus's death is hastened.
Again, take an example used by Father Ricaby in hisMoral Philosophy, p. 205 (London, 1901). He supposes a visitor to a quarry to be standing on a ledge of rock which a quarryman had occasion to blast, and the quarry man saw that "unless that piece of rock where the visitor stood were blown up instantly, a catastrophe would happen elsewhere, which would be the death of many men, and if there were no time to warn the visitor to clear off who could blame him if he applied the explosive? The means of averting the catastrophe would be, not that visitor's death, but the blowing up of the rock. The presence or absence of the visitor, his death{44}or escape, is all one to the end intended: it has no bearing thereon at all."
If these examples of indirect killing are allowable, why may not the surgeon in the rare example presented here remove the uterus and indirectly permit the hastening of the foetus's death? That hastening of death is not an end, nor a means toward an end, but a circumstance only reluctantly and indirectly willed. The end is to save the mother's life, and the means is the removal of a septic or impacted uterus.
It may be objected that an artificial abortion wherein the womb is emptied of an unviable foetus to save the mother's life is only an indirect hastening of this foetus's death, but there is a difference: in abortion the removal of the foetus is the means whereby the end is attained, in the hysterectomy the removal of thetumouris the means whereby the end is attained. This argument is advanced only tentatively and with diffidence, that the matter may be discussed and settled by authority.
Sometimes carcinoma (a cancer) complicates pregnancy—once in 2000 cases is above the average. A carcinoma is a malignant tumour, and the malignancy is made much worse by the stimulus of pregnancy with its increased blood supply. The maternal deaths from carcinoma of the uterus during pregnancy is, according to the latest and most favourable statistics, 30 per centum. The mortality of the children is from 50 to 63 per centum.
Now, first, if an artificial abortion is induced while the foetus is unviable, the foetus is lost and the mother's condition is not materially improved.
Secondly, if curettement (a scraping away with a sharp spoonlike instrument), cauterization, or amputation of the uterine cervix are performed, the mother is helped very little, if at all, and consequent abortion is frequent.
Thirdly, if caesarean section is done at term the child has a good chance (Sanger saved 16 of 18 children thus in one series: over 88 per centum), but this operation nearly always kills the mother when cancer is present, unless the entire uterus can be removed, and often it can not be removed; that{45}is, the case is inoperable and removal is useless owing to extension of the cancer into the surrounding tissues.
Fourthly, if the mother's condition is hopeless, a caesarean section gives the child a chance for life, but the operation will hasten the mother's death in nearly every case.
The first and second cases here are not practical. If the surgeon can remove the uterus at term after a caesarean section, that is the most reasonable operation for the mother and child, and it offers no moral difficulty.
If the mother's condition is so bad that the uterus may not be removed, the chances are that her death will be hastened by caesarean section, but if caesarean section is not done, from 50 to 63 per centum is the ratio against the saving of the child. I do not think a general rule can be given as regards the certainty of hastening the maternal death: the reckoning is to be made to meet the particular condition. It seems, however, probable that in every case of inoperable carcinoma of the uterus complicating pregnancy a caesarean section would hasten the maternal death. She will die anyhow from the cancer, but in certain cases she may live longer if the section is not done.
If, again, a carcinoma of the uterus is inoperable at term, the delivery of the child may be impossible without caesarean section, from uterine inertia, or the opposition of the dense inflamed tissues, or the friability of these tissues. In such a case without the section she would die, and die probably sooner than with it. The operation would possibly slightly prolong her life, by, say, a few hours or days, and it certainly would give the child a very good chance for its life. She may, of course, die upon the operating table, but she would die in childbed without the section.
The case is different from the ordinary caesarean section done because of a narrow pelvic bony girdle. In the latter condition the chances that the mother will live are very high if the surgeon is competent, but in the carcinoma case she will die no matter who the surgeon may be, and very probably, or almost certainly, her death will be hastened by the operation in the majority of cases.
If the condition is such that the woman can not be delivered{46}without the section, I see no difficulty against operation, because the surgeon can not, as far as I know, say positively whether he will hasten the maternal death or not, and in the circumstances he may take advantage of the doubt.
If the woman with an inoperable carcinoma uteri may be deliveredwithoutsection, should such a delivery be chosen although it raises the chances of mortality as regards the child from about 12 per centum to at the least 50 per centum? It is a matter of a very probable hastening of the mother's death as weighed against the safety of the child—the child has about one chance in two of life without the section, and, say, seven chances in eight with the section. The operation is far preferable as regards the child alone, but not preferable as regards the mother alone. Is it then allowable?
In the hysterectomy for fibroma already considered, the mother is saved and the child's inevitable death is certainly hastened; in the caesarean section the child is most probably saved, and the mother's inevitable death is most probably hastened; we might say, in some cases, that her death is undoubtedly hastened. If in the carcinoma case here the child had no chance whatever for delivery except by the caesarean section, while the mother's death would be probably or certainly hastened, she might legitimately consent to the operation or she might legitimately refuse the operation.
The child, however, has, as we said, one chance of delivery in two without the section, while the mother's death will very probably be hastened. If the mother's death would certainly be hastened by the section, her death, although it would be a circumstance and indirect, not an end nor a means, would not have counterbalanced against it necessarily the saving of the child's life, because the child has one chance in two in any event. In such an hypothesis the operation seems to be unjustifiable.
If, however, the hastening of the mother's death is only probable and not certain, may we oppose that probability to the advantage that must accrue to the child through the section? If the doubt that her death will be hastened is soundly probable, the woman may consent to the operation. She risks through charity the hastening of her own death for a great{47}advantage to the child, but she may risk legitimately immediate death in major surgical operations for an advantage less than the saving of life itself. She may have her skull opened for the removal of a depressed bone that is causing paralysis, she may have her knee-joint opened for the wiring of a patella to prevent lameness, but both these operations always immediately endanger life. She may go into a burning house, jump into a river, and so on, to save her child from possible injury.
AUSTIN ÓMALLEY.