When Pregnancy Goes Awry: The Moral Ending to an Ectopic Pregnancy

“It is not permissible, however, to initiate or recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with implantation of a fertilized ovum.”

It was an angry woman who raised the issue in the combox on my blog: What is the right way to treat an ectopic pregnancy? The Catholic Church, she implied, is more concerned about its “stupid doctrine” than about a woman in a life-threatening situation. She wrote:

“...in some cases in the very early stages, this can be treated with a medication that essentially disintegrates the embryo. Poof, gone! This treatment is not allowable under Catholic doctrine. They will instead remove a section of the fallopian tube, or perhaps the entire thing.”

Poof, gone?! The commenter—who, I would note, was not a physician or an ethicist—insisted that the only “safe” way to treat ectopic pregnancy was by use of the drug Methotryxate, which dissolves the embryo without requiring surgery for the mother.

But is she right?

First, I agree that an ectopic pregnancy is a dangerous, even life-threatening complication. For some reason—possibly a recurrent infection and resultant blockage of the fallopian tube—the fertilized ovum fails to travel its expected course through the fallopian tube to implant safely in the uterus. Instead, it implants somewhere else, most likely the tube itself, where there is no room for the embryo to develop and where the growing embryo may cause the tube to burst. The result is internal bleeding and potential infection.

But is it true that Catholic theology allows no recourse to end the pregnancy, even when the embryo cannot live and the mother's life is in danger? For an answer to that question, I sought the expertise of Fr. Tad Pacholczyk, director of education at the National Catholic Bioethics Center. I'm pleased to share his very helpful explanation.

What is an ectopic pregnancy?

An ectopic pregnancy is one in which the fertilized ovum implants in the fallopian tube or in some other location that poses a danger to the life of both the mother and child.

Is it morally acceptable to use the drug Methotrexate to end an ectopic pregnancy?

Methotrexate is sometimes used to address the problem of a fallopian tube ectopic pregnancy. The Magisterium has not taken a position on the use of methotrexate by name for the condition of the fallopian tube ectopic pregnancy. It has only affirmed that direct abortion is never permissible, while the indirect taking of a life may be tolerated when all the requirements of the principle of double effect are satisfied. The matter of methotrexate therefore remains a question for individual conscience to resolve, until such time that there is an authoritative teaching on the question.

A person in these circumstances should learn about the differing views on this issue held by theologians and ethicists whose work is in accord with the Magisterium, and should then make a decision in good conscience.

How does Methotrexate work?

Methotrexate is an anti-cancer drug, which interferes with DNA synthesis and attacks rapidly dividing tissue. The trophoblast cells that surround the embryo (and which will later become the placenta), are rapidly dividing. The intent and effect of administering the drug is the release of the improperly attached surrounding cells from the fallopian tube wall. In the process, the embryo also is impacted and expelled. This results in the death of the embryo.

Differing Viewpoints Regarding Use of Methotrexate

Some respected Catholic moralists justify the use of methotrexate in an ectopic pregnancy under the principle of double effect:

1. The Object of the Act Must be Good or at Least Morally Neutral: The object is to stop the destructive action of the embryo's surrounding tissues, which have attached to the fallopian tube and will lead to the rupture of the tube and the loss of the embryo, as well as creating a potentially fatal, or at least very critical, condition for the mother.

2. The Good Effect Must Be Intended and the Bad Effect Merely Foreseen: The intent here is to prevent the rupture of the fallopian tube and its results; the foreseen, but unintended, bad effect is the demise of the embryo.

3. The Bad Effect Cannot Be the Cause of the Good Effect: The bad effect (death of the embryo) is not the cause of the maternal cure; rather, stopping the invasive cells is the cause.

4. The Good Effect Must Be Proportionate to the Bad Effect: Preventing the death of the mother and therefore the deaths of both mother and child together has a moral value not any less significant than the indirect and unintended loss of the embryo.

There are other ethicists who disagree. They deny that methotrexate is morally permissible because they view the surrounding tissue, and the ensuing placenta, as a vital organ of the fetus, essential to providing nourishment and protection. They would hold that stopping the development of such tissue is intending to stop the development of a vital organ of the embryo, which is to intend the death of the embryo.

Are there alternative treatments available?

There are alternatives to methotrexate.

One would be salpingectomy (cutting and removal of the tube, with the embryo still attached inside, with the embryo's demise foreseen). This also is almost universally viewed as justifiable under the principle of double effect. However, it does damage at least one fallopian tube and therefore may reduce the ability to conceive a child later.

Another procedure, salpingostomy, in which the fallopian tube is slit and the embryo removed, is also debated by ethicists. Salpingostomy can preserve the tube's function. Most ethicists view this procedure as a direct attack on human life.

In summary, then, there are two opinions on Methotrexate: one is that it is licit to use, as it releases the trophoblast (the layer of cells over the blastocyst, where the newly fertilized egg will implant) and secondarily impacts the embryo. The other is that it attacks a vital organ of the embryo: the trophoblast, which will become the placenta (thus, not licit). The Magisterium has not spoken on this matter specifically, so individuals must make a conscientious and informed decision.

Father Tad, since there are faithful Catholic ethicists who hold each viewpoint in this important matter, could you share what you personally believe?

I personally believe the use of methotrexate in ectopic pregnancy is never morally defensible and represents an action directed against the body-person of the growing human being.

In my discussions with physicians, they acknowledge that methotrexate affects not only the trophoblast, but also the bodily tissues of the embryo itself that are rapidly dividing, and for this reason there is the danger of birth defects associated with its use. Hence I believe administration of the drug constitutes a direct attack on the embryo and is never morally permissible if the embryo is alive.

Salpingectomy, on the other hand, represents a therapeutically indicated action on the body person of the mother, with the secondary effect that the life of the child will be lost, a foreseen but unintended effect.

So in summary, Father Tad explains that when the fetus/embryo is still living, but when expectant management of the tubal pregnancy is no longer possible without serious and imminent danger of harm or death, then:

  • Salpingectomy (cutting the tube on both sides around the embryo) can be licit with a proportionate reason since it targets the damaged tube for removal with the foreseen death of the fetus/embryo.
  • Salpingostomy (the scooping out of the embryo) would not be licit, since it constitutes a direct targeting for removal and destruction of the embryo/fetus by the nature of the medical procedure.
  • Methotrexate (MTX) is still debated but highly questionable (i.e., not morally safe).

The Church does not have an explicit position on any of these three procedures; the debates center on whether or not each constitutes a direct abortion or a legitimate application of the principle of double effect.

Father Tad referred me to yet another resource, the U.S. Conference of Catholic Bishops' Ethical Directives for Catholic Health Care Services. In number 36, that document explains:

“It is not permissible, however, to initiate or recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with implantation of a fertilized ovum.”

The point about “removal,” Father Tad explains, confirms that the other two treatment methods, salpingostomy and methotryxate, are not licit when the fetus/embryo is alive. Salpingostomy is clearly intended to remove the fetus/embryo. And methotryxte (MTX) would seem also to be wrong, because it targets the embryo for removal by attacking the trophoblastic cells at the site of implantation.

But of course, if it is medically determined that the fetus/embryo is no longer living, then there are no moral concerns with either salpingostomy or MTX aside from the ways they might harm the mother.

For more information, refer to Fr. Tad Pacholczyk's longer article on ectopic pregnancy.