PBA203Y: Medical Dilemmas

Guiding Principles: How Many Patients?

The guiding principle, recognizing the human rights of the pre-born, is not that either the life/rights of the child or mother takes precedence over the other, but that we're dealing with two patients in any complication surrounding pregnancy and we need to do our best to attend to the well-being of both.

As this CNN article about a successful fetal surgery writes: “But for this surgery, there were two patients: Kenyatta and her baby.”

Is Abortion Ever Ethically Permissible?

  • Killing an innocent human being is never OK – even if it's to save another human being
    • example: if one 5yo needs a heart transplant, we can't kill another healthy 5yo to take that child's organ
    • But that doesn't mean we do nothing
      • Stephanie Gray analogy: we're driving and trying to get safely to our destination. One route involves driving over and killing an innocent person, so that particular route is blocked off to us – but there are other routes that get us to the same destination, may just be longer/more complicated

Is Abortion Ever Medically Necessary?

What do abortionists say?

Dublin Declaration

“As experienced practitioners and researchers in obstetrics and gynaecology, we affirm that direct abortion – the purposeful destruction of the unborn child – is not medically necessary to save the life of a woman. We uphold that there is a fundamental difference between abortion, and necessary medical treatments that are carried out to save the life of the mother, even if such treatment results in the loss of life of her unborn child. We confirm that the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women.”


Double-Effect Reasoning & Examples


Performing an act with 2 morally significant effects is justified if 1) the evil effect is not intended as a means or an end, and 2) there is a proportionately serious reason for allowing the evil effect. 1)

Or, to put it differently, 4 principles:

  1. Can't do evil (the action taken must be good or morally neutral)
  2. Can't intend evil (the evil effect must not be intended)
  3. Can't depend on evil (the evil effect must not be the means through which the good comes about – the ends doesn't justify the means, we cannot do evil so that good may come about.)
    1. Blaise: Could we add another step? E.g. with salpingectomy: if, in the future, we can care for an embryo or fetus that young, then the baby could be transferred (to an artificial womb or whatever). But with salpingostomy or methotrexate, she will always be dead b/c we killed her
  4. There needs to be a really good (proportionate) reason to tolerate evil as an unintended but foreseen side-effect


Summary of Interventions

The Ethical and Religious Directives established in the United States for Catholic Health Care Services provides thoughtful guidelines that respect both lives (not because they're Catholic, but because they're pro-life)2):

47. Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

49. For a proportionate reason, labor may be induced after the fetus is viable.”
Ectopic Pregnancy

* ectopic pregnancy

    • Methotrexate stops the growth of rapidly dividing cells, including embryonic cells, and thereby kills the embryo
      • Unethical: intentionally targeting + killing baby
  • salpingectomy vs. salpingotomy
    • Salpingectomy refers to the surgical removal of a Fallopian tube.
      • Ethical because intention is to target pathology, not baby (could hypothetically add a step to save baby, in future, e.g. with an artificial womb)
    • Salpingectomy is different from and predates both salpingostomy and salpingotomy. The latter two terms are often used interchangeably and refer to creating an opening into the tube (e.g. to remove an ectopic pregnancy), but the tube itself is not removed
      • Salpingotomy/ostomy: Unethical: directly and intentionally killing the baby
“But what's the difference?” Comparing different interventions

Imagine that you are rowing on a lake, and you see two people drowning. You want to save both, but you only have the time or the strength to rescue one person–and while you are doing that, the other person drowns. Were you responsible for the second person's death? Certainly not–you just weren't able to save them.

Now imagine that you are in the same scenario, where two people are again drowning. You pull the first person out of the water–but then you push the second person's head under water. This time, we you responsible for the second person's death? Yes, you were.

In both cases, the second person dies. But morally, we recognize that there is a difference between not being able to save someone, and intentionally killing them.

(Uterine) Cancer

Pre-eclampsia/ Eclampsia

  • A disorder of pregnancy characterized by the onset of high blood pressure and often a significant amount of protein in the urine.
  • The condition begins after 20 weeks of pregnancy.
  • In severe disease there may be red blood cell breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances.
  • Pre-eclampsia increases the risk of poor outcomes for both the mother and the baby. 
  • If left untreated, it may result in seizures at which point it is known as eclampsia.
    • FIXME ex. Sybil in Downton Abbey
  • Close monitoring is needed
  • Labor induced early labor if needed
  • (Difference between inducing labor to prevent keeping baby and mom in a serious riskyy situation and inducing labor just because–> Terminal diagnosis, inducing labor)

Savita Halappanavar

  • Savita H. Didn't get an abortion when she requested one, then died. Problem: correlation isn't causation, post hoc ergo propter hoc fallacy. Example of ice cream cone, if you ask me for an ice cream and I don't give it to you, and then you die of a heart attack, no one suggests that the heart attack was because of the ice cream cone

(notes from STUCK + https://thelifeinstitute.net/info/the-tragic-death-of-savita)

  • In 2012, the debate in Ireland over legalized abortion exploded with the tragic deaths of Savita halappanavar and her pre-born daughter Prasa
  • Media outlets around the world were quick to point out that Savita was denied the abortion that could have addressed her condition - septicemia, or a bloodstream infection – and saved her life. The case is often presented as a clear example of the necessity of abortion to save a mother's life.
  • However, what many news reports failed to discuss was that an autopsy revealed that in addition to septicemia, Savita had E. coli ESBL, an antibiotic-resistant bacteria that is associated with urinary tract infections, or UTIs. The fact that e. coli ESBL was present is significant, as this type of bacteria can lead to septicemia. In fact, the Journal of antimicrobial chemotherapy records that E coli is one of the most common organisms to cause a UTI, and complicated UTIs are often associated with pregnancy. This information means that it is difficult to reach a definite answer as to how Savita actually died, and it calls into question how ending the life of baby prasa through abortion would have killed the E coli.
  • Scenario #1: It is possible that the E coli bacteria was present in Savita's uterus, as a result of ascending into her vagina and entering the other dilated cervix. In this case, in order to save her life, the infected membranes would have had to be eliminated from her uterus. The ethical course of action in this situation would have been to induce labour, which would have targeted her condition - expelling the infected membranes - rather than directly ending the life of her pre-born daughter through an abortion.
  • Scenario #2: However, it is also possible that the E coli ESBL ascended her urinary tract and caused an infection in her kidneys. This type of infection can lead to uterine contractions that, left untreated, can result in cervical change. If this was the case, neither induction of labour nor abortion would have eliminated the E coli esbl, and because this bacteria is resistant to antibiotics, this is what could have led to septicemia.
  • What many news reports did not mention regarding this case is that medical inquest revealed more than a dozen preventable human errors which resulted in the necessary medical action not being taken.
    • For example, while a blood test was taken when Savita first arrived at the hospital which showed an elevated white blood cell account, this information was not recorded on her chart.
    • Further, her vitals were not checked every 4 hours, and several clear signs of sepsis were missed.
    • All of these discoveries that I'm mentioning were found in the investigative reports by the Health Information and Quality Authority, and the Health Service Executive, as well as the Coroner's Court inquest into savita's death.
  • Ultimately, what can be learned from this tragic story is that it is possible that an ethical course of action was necessary to treat Savita's septicemia – to treat her bloodstream infection. But in neither case was abortion the answer. Abortion doesn't cure septicemia. Abortion doesn't kill E. Coli bacteria. All abortion does is kill a pre-born child. It's very much possible that it would have been necessary to end savita's pregnancy and remove her child. The question is, should they have removed her child in one piece, or in pieces?
  • When the media used this story to further the case for legalized abortion in Ireland, they forgot a fundamental moral principle: we may not kill to save.

Do maternal mortality rates increase under anti-abortion legislation?

  • Statistical response: pro-life legislation =/= high maternal mortality rate
    • E.g. see lower maternal mortality rates of Ireland, Poland, Chile
    • 2 cases
      • South Africa [208-1980, 121-1990, 155-2000, 237-2008]
        • Legalized abortion in 1997: 11 years later highest it’s been. MMR increased after becoming legal!
      • Chile [70-1980, 44-1990, 24-2000, 21-2008]
        • 1989, abortion completely prohibited
        • provides a singular research case of maternal and abortion mortality before and after abortion prohibition
        • Reduction in MMR during last 5 decades correspond with improvements in education, access to clean water, decr. illiteracy rate of pregnant women, incr. maternal health facilities e.g. delivery by skilled attendants
        • In other words, access to legal abortion not necessary to achieve low rates of maternal deaths.
A peer-reviewed study published last week examines 50 years of data and concludes that the trajectory of maternal mortality in [Chile] has consistently declined, decreasing from 293.7 in 1957 to 18.2 in 2007 (per 100,000 live births). That’s a decrease of 93.8%, which constitutes a major success story measured in women’s lives. Yet Chile outlawed abortion in 1989. Chile didn’t just place small restrictions on abortion — it outlawed abortion without exception, including in instances of rape or for the health of the mother. And since many neighbouring countries also restrict abortion, there’s no real reason to believe Chilean women are travelling outside Chile to get abortions. - Andrea Mrozek https://nationalpost.com/opinion/andrea-mrozek-if-abortion-saves-lives-whats-happening-in-chile


In conversation

  • Define abortion - direct and intentional killing of preborn child
  • Confirm whether person is pro-life in other cases. Do they acknowledge presence, rights of both humans? (HRA etc.)
  • Remember heart apologetics – person may have personal connxn – ask if they had a particular medical scenario in mind
  • FIXME Oriyana's testimony, based off Dr Levatino:
    • “Would you agree that the majority of life-threatening scenarios that are specifically related to pregnancy tend to arise in the 2nd or 3rd trimester?
    • “How long does an emergency C-section take?”
    • “How long does a late-term abortion take?”
    • “Even if abortion was morally neutral, which procedure would you pick?”
  • FIXME Katie's wording: “I agree that there may be times when we need to end pregnancy and remove a child. The question is, do we remove that child in one piece – or in pieces?”
  • Stephanie Gray: “What medical condition in the woman's body will be fixed by attacking the baby's body?” 3)
  • FIXME paraphrasing Devorah: “Abortion can certainly make the medical scenario simpler – because it's always easier to treat just 1 patient, rather than 2. But we acknowledge that we can't kill a human being just because her presence causes difficulty; and we acknowledge that there's no situation where a woman would have to die because she can't get an abortion. That's what we mean when we say that abortion is never medically necessary: we mean that if, tomorrow, abortion was somehow eradicated from the earth, there's not a single woman who would have to die as a result.”
Testimony: I talked to a student named Hannah. She was pro-life except when the mother’s life was in danger. We discussed medical situations, specifically preeclampsia and ectopic pregnancy, and medical procedures, C-section and Salpingectomy respectively, other than abortion that a doctor can perform to save the mother. I also mentioned to her that many doctors affirm that abortion isn’t medically necessary. Realizing that abortion is not medically necessary, Hannah agreed with me that abortion is never okay. Before we parted ways, she shared with me that she wants to become a doctor and she said, “I’m glad I talked to you because you changed my perspective.” We shook hands and Hannah left completely pro-life. - Michelle Caluag

FIXME testimony videos

Nina's testimony – Dublin Decl'n, Levatino

https://www.facebook.com/217971845050/videos/913740249023182/ – intention, drowning analogy

Misc Notes

FIXME Communication/PR and legal problems for when pro-lifers say “abortion is never medically necessary” ERI article: https://blog.equalrightsinstitute.com/abortion-and-medical-necessity-improving-the-pro-life-approach/ SPL short video summary of article: https://youtube.com/shorts/4bZqIkJ9gH4?feature=share

FIXME both an apologetics issue AND a strategy issue re: laws FIXME objection: “we need to get rid of all abortion laws because even if there are medical exemptions, providers will not intervene out of fear or confusion about the laws”

This is like saying “we need to get rid of all sexual assault laws because sometimes healthcare providers need to perform emergency pelvic exams on unconscious patients, and if there are laws prohibiting sexual assault, they will hesitate or refrain from doing emergency pelvic exams because of fear or confusion about the laws”

Or “if we have laws that generally prohibit sticking a knife in another person's head, then fearful/confused doctors will hesitate to perform emergency brain surgeries, so we need to get rid of all laws against head stabbing”

FIXME missed miscarriage case in Ohio and DC: explanation of why it seems incredibly unlikely that anti abortion laws played a role in delay of care, especially since the delayed care began in a place with no abortion restrictions (Washington DC) https://youtu.be/nRZAFw3tNiM?si=MuQ58c7beJZacO2G

Thomas Kavanaugh – see Stuck p. 147
Love Unleashes Life p. 63