Catholic Health World

Pregnancy complications can bring on complex ethical questions

Respect for life is at core of directives on prenatal decisions

The fourth section of the Ethical and Religious Directives for Catholic Health Care Services contains seven directives on providing care and treatment to a pregnant mother and unborn children.

Applying those directives to actual patient situations can be complex and confusing, even for providers who are well-versed in Catholic moral teaching. During a Nov. 2 CHA webinar that drew an estimated 1,500 participants, John Paul Slosar, a ministry bioethicist, explained the principles that undergird several of the beginning-of-life directives applicable to medically complex pregnancies, and he described how ethicists would apply those principles to patient situations.

The beginning-of-life directives are grounded in a concern for the "inherent worth and value of every human life due solely to the fact that we are made in the image and likeness of God and destined for eternal union with God," Slosar said during his presentation on "Ethics at the Beginning of Life: Complex Cases, Difficult Decisions." Slosar is senior director of ethics for St. Louis-based Ascension Health.

He said that this concern for human dignity leads Catholics to recognize an obligation to preserve life and a corresponding obligation never to directly kill innocent human life. Complex ethical issues may arise when there are two lives at stake — the mother's and the baby's — and the effect of a therapy would be good for one of them and bad for the other.

The principle of "double effect" is generally relevant in such cases, said Slosar. When applied to medical cases, this principle suggests that a treatment that offers a benefit but that also has a foreseen harmful effect can be justified in some cases. It can be justified when the treatment is therapeutic, the harm is an unintended side effect, a less harmful treatment is not available, the benefit is equal to or greater than the harm, and the harmful effect is not the means used to achieve the intended benefit.

Slosar said that these concepts are codified in directives 47, 48 and 49. Directive 47 says that therapies whose purpose is to cure a serious condition in a pregnant woman are justified if they cannot be safely postponed, even if they result in the death of the fetus. Directive 48 says in the case of an extrauterine pregnancy — or a pregnancy occurring outside of the uterus — no therapy is allowed that is a direct abortion. (Directive 45 provides the definition of a direct abortion — a procedure that is not permitted in a Catholic hospital.) Directive 49 says that labor may be induced after a fetus is viable if there is a proportionate reason to do so.

Slosar explained how each directive might be applied to patient situations.

He described the fictitious case of an expectant mother at 20 weeks' gestation with preterm premature rupture of membranes causing leakage of amniotic fluid, a condition that puts the life of the preterm fetus at serious risk and that puts the mother at risk for a life-threatening infection. Intravenous antibiotics are administered, but the mother develops a life-threatening infection anyway. In order to eliminate the infection source, the patient and her physician consider inducing labor. The direct intention is to evacuate the infection, an infection that in this case can only be treated through the removal of amniotic fluid. This treatment outcome can only be achieved if labor is induced, in this scenario. That course would result in the death of the baby, who has not yet reached the age of viability.

Directive 47 states: "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."

Applying directive 47 to the example of the woman's crisis pregnancy, Slosar explained that the physician could be justified in inducing labor because the intention is to eliminate an infection that is threatening the mother's life and because other treatments have not been successful. The baby's death is a foreseen, but unintended, consequence.

A second fictitious case concerned a mother at 15 weeks' gestation whose fetus is missing part of its brain. The baby will almost certainly die within days of birth. The physician recommends that the mother terminate the futile pregnancy to avoid the psychological distress of carrying a nonviable baby to term.

Slosar said that, applying directive 47, this termination would not be justified because the mother's life is not at risk — the condition only affects the health of the baby. Also, the reason for the termination — to relieve the psychological burden to the mother — is not considered proportionate to the effect of the act, that is, the death of the baby, within the Catholic moral tradition.

Slosar last considered the case of a hypothetical patient at seven weeks' gestation who has an ectopic pregnancy, or a pregnancy occurring outside of the uterus. A baby never survives this type of pregnancy. The physician says that he can remove a section of the patient's fallopian tube, detach the embryo from the tube or dissolve the bond between the embryo and the tube with chemicals. Slosar said theologians generally agree that the first treatment is permissible but differ as to whether the other two procedures are morally permissible under directive 48. He said that some interpret some of these treatments as causing a direct abortion, while some view them as an indirect abortion.

During a question and answer session at the close of the webinar, Slosar explained the type of reasoning ethicists and others should employ when assisting clinicians and their patients with such questions. He said it is essential to know the intent of therapies applied, the options that patients have and the outcomes that are expected.

He underscored that it is important for ministry providers to offer counsel and pastoral care to patients facing pregnancy complications. By offering patients compassion and patience, ministry clinicians can help these patients to navigate the difficult decisions they must make and to cope with the consequences of those decisions, Slosar said.

Copyright © 2010 by the Catholic Health Association of the United States
For reprint permission, contact Donna Troy or call (314) 253-3450.