Ectopic Pregnancy and the Principle of Double Effect

A week ago, I posted a link on my FaceBook page to an blog post by William Briggs responding to an article by Charles Camosy on Catholic Moral Theology in which he is exploring a concept he calls “an innocent aggressor.”  A non-Catholic friend asked me in the commbox about Catholic teaching on ectopic pregnancy.  I found a nice summary at the Catholics United for the Faith website.  This satisfied my friend, but after reading the posts by Camosy, Briggs and the CUF article,  I found myself chewing over this question.  

According to traditional Catholic teaching, the only morally licit procedure  is a salpingectomy: removing the portion of the fallopian tube in which the embryo is implanted.  It is considered morally illicit to perform a salpingostomy:  a small incision is made in the side of the fallopian tube and the implanted embryo is removed.  It is also immoral to treat the ectopic pregnancy chemically by administering Methotrexate, a drug which causes the embryo to be expelled.  The latter two are considered illicit because they are “direct abortions” while the first is licit because the procedure removes a damaged fallopian tube which threatens the life of the mother (due to inevitable hemorrhaging and infection), with the unintended but foreseeable consequence of killing the embryo.

My problem is that I honestly cannot fathom the distinction being made here:  it seems to me to be a distinction without a difference.   In both cases the ultimate intention seems to be the same:  to save the life of the mother, given that the presence of the embryo presents a grave threat to her life.     In both cases the consequences are the same:  the embryo must be removed, and since not viable, it dies.

The classical argument is that these procedures are different, morally, because the salpingostomy acts directly on the embryo; this is regarded as an abortion and therefore a moral evil.  In contrast, the salpingectomy acts indirectly by removing a few millimeters of fallopian tube containing the embryo.  By the principle of the double effect, the intention is to treat a diseased fallopian tube and the death of the embryo is a side effect that is completely foreseeable but not in any way intended by the action, and is therefore morally licit.

My problem is that I do not find this argument persuasive.  Rather, it seems more like a post facto rationalization: a moral fig leaf to justify an action that intuitively seems to be the correct moral choice—saving the life of the mother, the only one who can be saved—while providing the actor moral distance from the consequences of his/her actions—the death of the embryo.  That this consequence was not the actor’s intention seems irrelevant:  it seems to me that a person must take moral responsibility for any act that follows directly from his/her actions.

This strikes me as a weakness in any argument that attempts to apply the principle of the double effect.  While I am sure that this problem has been addressed by moral theologians and ethicists, I have not seen an explanation that is satisfactory.  I will confess, however, that I am not well read in this area, and would welcome references and an summaries of these arguments.

This question in the context of ectopic pregnancy has been addressed once before on Vox Nova, from a very personal point of view.  Unfortunately from my perspective, none of the broader moral questions were addressed in the comments.    I don’t have any answers, but it seems to me that people like Camosy (and others like Charles Curran before him) are attempting to ferret out some other approach to this problem, one which brings to light more clearly the moral issues involved, simultaneously upholding Catholic teaching on abortion while trying to discern why this particular case is different.

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  • http://communitarian-perspective.blogspot.com M.Z.

    If one maintains that life is indistinguishable in moral status from conception to natural death, it is an inescapable conclusion. Among most people in our society, this belief is not maintained. The typical anti-abortion belief is that the fetus enjoys a right to life equal to that of the physical health of the mother. Therefore, once it is established that the mother’s physical health is in danger, abortion is considered a regrettable, but licit means of addressing that danger. This is not how the Catholic belief has been expressed. I am quite sympathetic to women who would claim that the Church considers their fertility and health a trivial concern in determining how a fetus will not see the light of day such as one implanted in the fallopian tube.

  • Jordan

    I share your confusion and concern David. The restriction of treatment to salpingectomy also strikes me as a scholastic distinction without many pragmatic considerations. Another question which you might also want to consider is the possibility that the ectopic fallopian tube will likely require repair after salpingectomy. Unfortunately, a poorly healed fallopian tube might cause yet another ectopic pregnancy. A deformed fallopian tube also decreases the chances of a later successful conception. Isn’t procreation a primary good of marriage?

  • http://turmarion.wordpress.com turmarion

    Frankly, I’ve long thought the whole principle of double effect itself is “a post facto rationalization: a moral fig leaf to justify an action that intuitively seems to be the correct moral choice…while providing the actor moral distance from the consequences of his/her actions….” Consider just war: G. K. Chesterton (who never went to war) and C. S. Lewis (who did, but IIRC was gassed in WW I and didn’t spend that much actual time on the front) both argued that if the cause is just, the soldiers should be cheerful and light-hearted, and that it’s wrong for us to expect them to go to war with “long faces” and forgo the pageantry and pomp of war. In short, be in a good mood when you’re killing someone in a just war.

    I wrote a post at my blog dealing with some of these issues awhile back. I noted that the Orthodox take a different view, quoting a prayer by St. John Damascene: “O Lord and Master Jesus Christ, our God, who alone hath power to forgive the sins of men, do thou, O Good One who lovest mankind, forgive all the sins that I have committed in knowledge or in ignorance, and make me worthy to receive without condemnation thy…life-giving Mysteries….” I used to think it odd to speak of sins made in ignorance since in the Western, forensic view, you have to have full knowledge and consent of the will, so it’s impossible to sin unknowingly. One might commit a material sin, but never a formal one, by accident or without knowledge.

    As I learned more about the Orthodox viewpoint, I came to understand that the Eastern view of sin is more medical than forensic. We suffer from sin as from a chronic disease, and often, given the state of the world, any choice we make is sinful. It really is a matter of choosing the lesser of two evils, not using a philosophical dodge to argue that a just war or the death of the embryo caused by the surgery, etc., is not actually a sin. We commit sins sometimes without knowing it, and sometimes knowing it but not willing it. It might be necessary, but it’s still a sin; consider what St. Basil said of soldiers in a just war:

    Our Fathers did not consider the killings committed in the course of wars to be classifiable as murders at all, on the score, it seems to me, of allowing a pardon to men fighting in defense of sobriety and piety. Perhaps, though, it might be advisable to refuse them communion for three years, on the ground that they are not clean-handed.

    The principle of double effect would argue that if the war was just and the soldiers’ conduct in accord with that (e.g. killing only enemy soldiers, not civilians), they aren’t even guilty of sin at all, and would therefore not even have to confess, let alone be barred from Communion.

    It seems to me the Eastern view is more psychologically realistic, more willing to call a spade a spade, less likely to make ex post facto rationalizations, and more humane both in recognizing our weakness and the sinfulness of the world, and at the same time not downplaying our own (sometimes necessary) sins. I think this view would really solve, not all, but a lot of problems if we adopted it.

    • David Cruz-Uribe, SFO

      “The principle of double effect would argue that if the war was just and the soldiers’ conduct in accord with that (e.g. killing only enemy soldiers, not civilians), they aren’t even guilty of sin at all, and would therefore not even have to confess, let alone be barred from Communion.”

      A quick response to this point: it is my understanding that this was not always the position in the west. I read, somewhere, that the soldiers who fought with William the Conqueror were given strict penances, even though the war was just, to atone for the sin of killing their brothers. I have never been able to find this again, though.

  • http://gaudetetheology.wordpress.com gaudetetheology

    Have you read Keenan on the principle of double effect? Theological Studies 54 (1993):294-315. He discusses various approaches to ectopic pregnancy as well as other key cases.

    He’s done some other work on virtue ethics and (if I remember right) casuistry that I also found interesting and helpful.

    I agree with you that double effect frequently seems to be used as a fig leaf of justification. The discussion on casuistry that I’m remembering (hopefully accurately) argued that its current use as an absolute test is a misapplication; and that in its original context, difficult moral decisions were made by wise people who had been well formed in the Christian virtues. Heuristics like the principle of double effect were originally developed as general guidelines and rules of thumb, not tests.

    • http://gaudetetheology.wordpress.com gaudetetheology

      oops, and now that I’ve actually re-read more of that paper I cited, I see that it contains the argument I was thinking of:

      “I use the work of Albert Jonsen and Stephen Toulmin in order to show that the simple application of a principle to a case is not the method of true casuistry. . . . I build on their evidence and add that the authority of a principle is derived from its genesis, i.e. that the principle is a shorthand expression of the taxonomic relationship among a number of paradigm cases. . . . I argue that using the principle [geometrically] vests the principle with unwarranted authority and that, used [taxonomically], the principle simply demonstrates that one case is congruent with a paradigm case and that the lightness of the solution is already internal to the case.”

    • David Cruz-Uribe, SFO

      This is an interesting distinction between guideline and test. I wonder how you would actualize it in practice?

      I will look up the reference you sent.

  • http://renegadetrad.blogspot.com A Sinner

    This question is far from decided, actually.

    Yes, un-nuanced conservative sources are likely to tell you that you have to remove part of the fallopian tube too so that you aren’t acting “directly” on the embryo, but there is a very good case that this is actually a grossly materialistic view of the notion of a “direct” object morally. It’s a weird sort of over-simplification of the problem with a strange “rabbinical technicality” of a solution.

    I believe no less a theologian than Germain Grisez (whose orthodoxy is not in question) has said that even a craniotomy (which is definitely acting very directly on the fetus!) could be licit in a case where it was going to die anyway, because the moral object chosen (and which the act facilitates) is still the removal of the child rather than its death, which is neither an ends nor a means, but simply a result of the removal and the process (something like “changing the shape of the body”) used to remove.

    Indeed, by this logic, almost every single “life of the mother” situation is rendered moot and NOT direct abortion because in almost every such case the saving of the mother relies merely on the removal of the child, not its death. The difference is quite clear: if the technology existed (and someday, almost certainly, it will) to then save the removed embryo or fetus, the doctors in such cases almost certainly would. The death is not desired as an ends, nor even as a means; it results merely as a side-effect of the removal since the technology does not exist yet for that removal to be followed by saving the child. But the mother’s health is certainly not dependent on the child dying, merely being removed, and whether you remove the embryo by itself, or with a piece of the mother’s tissue…is irrelevant to the question of whether its death is “directly” chosen. So there’s really no need to remove the fallopian tube too as some sort of moral sacrifice or collateral damage.

    If you ask me, this is almost certainly the better opinion. Just don’t try to tell people like the bishop in Phoenix that…

    • David Cruz-Uribe, SFO

      Your reasoning seems cogent, but as you point out it is not considered orthodox as the Phoenix case shows.

      • http://renegadetrad.blogspot.com A Sinner

        The politically-motivated opinion of one bishop does not constitute all of orthodoxy. Indeed, I know of no dogmatic declaration on this question.

        My own opinion was actually shifted in light of a Vox Nova article during the Phoenix case: http://www.patheos.com/blogs/voxnova/2010/12/21/no-entitlement-to-own-facts/

        I would recommend you (re-)read Ms. Lysaught’s article. Though I went in suspicious, Ms. Lysaught’s arguments actually convinced me. And as I said, some of her sources, like Grisez, are considered bastions of orthodoxy. As far as I know, Germaine Grisez never got any notice from the CDF telling him that his opinion re: what constitutes “direct” action is wrong!

        As you point out, if “direct” action is distinguished by so grossly physicalist a criterion as “moving a few millimeters to the left”…it is hardly credible. Rather I think, with Grisez and Lysaught, we must understand direct as being a MORAL question, not a physical question. It’s not about whether you “touch” the baby or merely “pull it along” while touching a structure that is technically the mother. It’s about whether the baby’s death is directly within the object chosen by the will. In the case of something like a difficult pregnancy is almost certainly is not: the intent is to save the mother, and the object chosen, the means by which that end is achieved, is the removal of the child. It’s death or survival after that is irrelevant, and indeed we might imagine the child being saved if something like an artificial womb existed (and it will soon enough).

        The conservative position (which is not the same as the “orthodox” one) is indeed incoherent, because just consider: if the technology already DID exist to simply transfer the embryo to an artificial womb…they would NOT demand that any of the surrounding tissue of the mother be removed. But, the fact that that technology does not exist yet is actually irrelevant to the liciety of the act of removal itself. If removal is okay in the case where it could be followed by the additional act of saving the embryo, then removal must be okay in itself (even in cases where it can’t be). The only consideration then becomes the question of foreseen consequences and proportionality. Obviously, in cases where you remove the embryo merely for convenience’s sake when it could otherwise survive if left in place…there is no justification (even if you claim the death was not directly desired, merely the removal) because the death is simply disproportionate to the good gained. But given that we’re talking about cases where at most one of the two will survive (and often where the baby will die either way), there is no real controversy about proportionality of consequences in life of the mother cases.

        It would be both theologically more coherent, and politically advantageous, if the Church backed away from the notion that life-of-the-mother cases ever constitute direct abortion. And there is no threat to orthodoxy in this opinion; Lysaught’s argument, I was pleasantly surprised to find, did not invoke any radically dissenting principles or paradigms (as so much “liberal” theology often does). Rather, it was grounded in orthodox sources and principles and made every effort to show how the position proposed was actually the one most compatible with traditional principles and magisterial statements (like John Paul’s Veritas Splendor).

        I’d be wary in general of considering the “conservative” position on such questions as the orthodox one. Likewise, even, the question of civil law. Though many conservative sources, even hierarchs and hierarchal offices, might try to tell you things like “you can never vote for a pro-abortion candidate” or that the only acceptable regime is one in which abortion is always criminalized…in reality, no orthodox principle demands such a legal consistency, and in many cases I think a good argument could be made for decriminalizing (different than legalizing) abortion in the first trimester or even pre-viability is a valid legal position for pragmatic reasons, even while believing that abortions in such cases are still objectively murder (but enforcement would just be invasive and impossible; how do you prove it wasn’t a miscarriage? Do you invade the privacy of a woman and her gynecologist??)

        • http://turmarion.wordpress.com turmarion

          Excellent posts, Sinner. I have nothing to add.

        • Paul Connors

          A Sinner: ” the object chosen, the means by which that end is achieved, is the removal of the child. It’s death or survival after that is irrelevant”

          I suppose if someone were to propose throwing you off a 100-foot cliff so that you could enjoy the experience of weightlessness for the first 99.9 feet, then you would be quite content with that as a morally valid proposal, on the grounds that your death or survival after that point would be irrelevant? (And after all, perhaps some means of catching you might be invented — later on.)

        • http://renegadetrad.blogspot.com A Sinner

          Paul: see my comments re: consequences and proportionality.

          Given that my death would be foreseeable in your scenario, and avoidable, being able to experience weightlessness is hardly proportionate a reason.

          On the other hand, if someone was jumping out of a building to escape the heat and smoke of a fire (as on 9/11) then that is very arguably not suicide because their moral proposal was just to “get out” and the consequences were proportionate since their death was imminent anyway.

          As I said, removing an embryo with no way to save it merely for convenience would not be justifiable, even if your moral proposal in itself was indifferent to the death. But we’re talking about a situation where at least one death, and possibly two, is ALREADY on the table either way.

          If I were on a platform in the ocean and a man was on fire burning, yes, I could push him to the sharks even if I know he’ll drown. Because my moral proposal, then, isn’t to kill him. That’s irrelevant (and indeed if I could save him too I would). The proposal is to “remove a burning object from the platform so that it doesn’t burn down and send us all into the sea.” The burning man’s death is a foregone conclusion either way, but my choice isn’t to directly kill him at all, it’s to remove him from the wooden platform. The fact that the only means of removal has the side-effect of his death is sad, but justifiable as a consequence given what is at stake. This is not directly choosing his death as either an end or a means, because his death is not instrumental at all.

          And cutting off the piece of the platform he’s standing on rather than pushing him into the sea in a less roundabout fashion has NO effect on the moral analysis here. (The analogy with ectopic pregnancies should be clear).

        • Paul Connors

          A Sinner: “Given that my death would be foreseeable in your scenario, and avoidable, being able to experience weightlessness is hardly proportionate a reason.”

          Of course! My point was rather that you had said:

          A Sinner: “the object chosen, the means by which that end is achieved, is the removal of the child. It’s death or survival after that is irrelevant”

          Whereas, as far as I can tell, what you meant was something much less general, such as: “It’s death or survival after that is irrelevant, because its death is unavoidable.” (A condition that seems wholly central to your line of argument, but not clearly expressed at that point.)

          A Sinner: If I were on a platform [e.g. a wooden raft] in the ocean and a man was on fire burning, yes, I could push him to the sharks even if I know he’ll drown. Because my moral proposal, then, isn’t to kill him. That’s irrelevant (and indeed if I could save him too I would). The proposal is to “remove a burning object from the platform so that it doesn’t burn down and send us all into the sea.” The burning man’s death is a foregone conclusion either way, but my choice isn’t to directly kill him at all, it’s to remove him from the wooden platform.

          (i) To be more accurate: to evaluate the morality of any proposed course of action, one must first take into account the actions to be performed and all the foreseeable consequences, and then with that information decide on the morality of what is proposed. It may happen that, in some cases, a decision is reached that some of the consequences are unavoidable — but that can’t be specified beforehand as some kind of moral proposal. So one can’t say beforehand: “my moral proposal isn’t to kill him”. Rather, that’s a conclusion that might be reached once everything has been evaluated.

          (ii) The example you present is very significantly different from the ectopic case. In an ectopic pregnancy there is nothing wrong with the child (thus the child is not analogous to a burning man), and the problem is that (e.g.) the weakened maternal fallopian tubes may cause internal hemorrhaging and subsequent death. So a more analogous case would be: A mother on the raft is carrying her child in her arms. The mother is on fire. She decides to throw her child into the shark-infested waters, in the expectation that the resulting splashes will put out the mother’s flames.

          A Sinner: “The burning man’s death is a foregone conclusion either way, but my choice isn’t to directly kill him at all, it’s to remove him from the wooden platform.”

          It seems that your claim amounts to following some principle like this: If a person is expected to die at some point in the future by means X, it is permissible to instead make them die at some other chosen time by means Y, if we can come up with a proportional benefit for doing so.

          Is that what you mean? I can think of examples which will make this a very unattractive principle to hold to. Perhaps you can tighten it up to avoid them.

        • http://renegadetrad.blogspot.com A Sinner

          No, I wouldn’t summarize the principle that way at all. It has nothing to do with whether the person is going to die at some point in the future anyway (everyone is), but rather about whether the death itself is instrumental to achieving the end, or whether it is only a side-effect. My principle is nothing other than traditional double-effect!

          The only apparently controversial thing is how “directly chosen” is understood (is distinguished from “side effect”) in this interpretation of double-effect.

          The “conservative” interpretation apparently thinks that removing the embryo by itself is “directly choosing its death,” but that removing it “riding along” on a small piece of the mother’s tissue is not for some reason, even though in both cases it is removing the embryo that ultimately solves your problem. Pretending that the fallopian tube is independently pathological in the latter case when its only problem is the presence of the embryo (a problem that could be solved by removing the embryo rather than removing the whole tube “around” it) is not a morally relevant distinction, and is reasoning made in bad faith. It’s not about “weakened fallopian tubes,” the fallopian tubes could be fine if the embryo weren’t in the wrong place! Removing the whole tube unnecessarily (medically speaking) is not necessary to render the death of the embryo a side-effect, morally. The embryo’s death is already a side-effect of its removal, removing the fallopian tube adds an additional unnecessary layer, renders the death “a side-effect of a side-effect.”

          The imminence of the death of the embryo also in such a case might add something to the argument regarding the proportionality of the consequences. But in itself it is not “absolutely essential” to my line of arguing at all. What I say still applies even if you were talking about a case that was “life of the child OR life of the mother” rather than “mother or BOTH,” in other words a case where letting the child continue to gestate might allow the child to live, but kill the mother, it might STILL be licit to “remove” the child to save the mother even if this removal resulted in the death of the child. But the child’s death here isn’t directly chosen at all, because the mother’s salvation does not depend on the death at all (and, indeed, doctors would save the child if they could). It is a side-effect of removing it.

          Of course, in such a case, such a course of action can only be undertaken for a sufficiently proportionate reason (and when we’re talking about death, the only proportionate reason ever is saving life). There might be more controversy about proportionality given that the consequences involve trading one life for another rather than a clear cut case of “one or both.” But as Grisez points out, in such a case simply not taking action is also equivalent to making a choice (in that case, in the baby’s favor). The fact that it is “physically” passive (ie, non-interventionist) doesn’t change the fact that the moral structure of the choice is still “Leave the baby where it is, to save its life, with the side effect of the mother dying,” and the only other choice is, “Remove the baby, to save the mother’s life, with the side effect of the baby dying.” So at that point, one of those two choices is being made either way, and one has to decide.

          So, for example, let me propose another analogy that might satisfy you. Let’s say a building is on fire. The only way out for various reasons is go across an elevated hallway 50 stories up (like the one that connects the Petronas Towers in Kuala Lumpur) into the other building and out. A really fat man, however, is stuck in the hallway blocking it, hundreds of people trapped behind him in the burning tower. There are only two options for getting him out: either breaking some of the glass wall next to him and pushing him out, or waiting for a helicopter rescue team to arrive an hour later with special equipment that could save him/get him unstuck. Remember, in the time it will take the rescue crew to arrive, the building will continue to burn and plenty of people stuck behind him in the building will burn to death. It seems that the progression of the fire is such that the fat man himself will in fact survive the hour wait, but it will mean the death of many behind him in like: the extra hour of time to exit through the hall would allow them all to escape. However, without the rescue team, the only other way to get him out of the way is to break the glass wall that he is wedge against and push him out. He will fall to his death if you do so, however it will open up that passage for everyone.

          In such a case, traditional double-effect actually means it is okay to push the guy even though if you didn’t he might survive. Because your moral proposal is not to kill him. You don’t want that either as an ends or a means, and if he were to somehow survive you’d be happy. As Grisez points out in the craniotomy case: the proposal would be the same if he were already a dead body, or if he were an inanimate object. His death in itself is not instrumental at all, has no role in the internal logic of the moral object. All that’s instrumental is removing him from the hall. His death is, sadly, a foreseeable consequence of that. Not a directly chosen object, but a side-effect. However, given that we’re talking about one death versus many more if he is not moved…pushing him is justifiable.

          Requiring the fallopian tube be removed in the case of an ectopic pregnancy is like arguing that breaking the glass and pushing the guy isn’t ok, but that totally severing the section of the hallway he is in and letting the whole section fall (with him in it) is fine, even though this latter task would be harder and would then require finding some way to bridge the gap to let everyone else cross over. Even if it were doable, it would be morally unnecessary. The moral proposal is the same whether you remove the fat man by himself or “riding along” on a section of the hallway. Your problem isn’t that he is alive, it’s that he’s blocking the hall. And to save lives, you have a right to to “unblock the hallway,” to “remove the obstruction,” even if that removal results (foreseeably, but non-instrumentally) in his death.

    • raitchi2

      The endorsement by Grisez that A Sinner mentions is here:

      “However, assuming the four conditions are met, the baby’s death need not be included in the proposal adopted in choosing to do a craniotomy.84 The proposal can be simply to alter the child’s physical dimensions and remove him or her, because, as a physical object, this body cannot remain where it is without ending in both the baby’s and the mother’s deaths. To understand this proposal, it helps to notice that the baby’s death contributes nothing to the objective sought; indeed, the procedure is exactly the same if the baby has already died. In adopting this proposal, the baby’s death need only be accepted as a side effect. Therefore, according to the analysis of action employed in this book, even craniotomy (and, a fortiori, other operations meeting the four stated conditions) need not be direct killing, and so, provided the death of the baby is not intended (which is possible but unnecessary), any operation in a situation meeting the four conditions could be morally acceptable.85”

      The Way of the Lord Jesus V2 Ch 8 Q D (http://twotlj.org/G-2-8-D.html)

    • David Cruz-Uribe, SFO

      “Yes, un-nuanced conservative sources are likely to tell you that you have to remove part of the fallopian tube too so that you aren’t acting “directly” on the embryo, but there is a very good case that this is actually a grossly materialistic view of the notion of a “direct” object morally.”

      Sorry to be responding late to this: according to Keenan (in the article reference above) the Holy Office in 1898 and again in 1902 “stated that the direct removal of the fetus before viability was unacceptable.” He gives no indication that this opinion was ever reversed or nuanced. Indeed, a quick search of the USCCB turned up a pamphlet that repeats the same view: removing the fallopian tube is licit, removing the embryo directly is no.

      Thus this seems to be pretty firmly established as the orthodox position.

      • http://renegadetrad.blogspot.com A Sinner

        Those arent dogmatic statements though. I’d follow up with the source from Grisez then, because he is a professor at Mount St Mary and, as I said, has never been forced to retract his opinion and is a vocal opponent of dissent. He apparently has reason to believe his position is allowable.

        • David Cruz-Uribe, SFO

          The only source I could find quickly that mentioned Grisez was the National Catholic Bioethics Center in Philapdelphia: their newsletter categorically rejects Grisez’ position.

          http://www.utahcatholicdiocese.org/images/family%20life/E&M%20October2010_COMMENTARY.pdf

          This is clearly an area of much debate, but I think in this case Grisez finds himself aligned with those trying to reinterpret Catholic teaching on this subject.

          In passing, I need to read more about his “New Natural Law Theory.”

        • http://renegadetrad.blogspot.com A Sinner

          I suspect that sometimes conservatives are apt to defend the most rigorist and strict position for fear of a slippery slope.

          Personally, though, an “externalistic” description of the moral object ultimately falls apart in its coherence. To me, the question of goods and evils as morally relevant has to be located within the act of the will.

          In this case, while death is certainly one of the foreseen consequences, I fail to see how it could be considered part of the moral object or intent, when it is irrelevant, in itself, to both. It enters into the moral considerations only as a consequence.

  • raitchi2

    As a heath care provider in training (physician assistant), I have thought a lot about this one too. I can’t imagine myself recommending that my patient should have an invasive procedure (with its risks: infection, permanent urinary incontinence, loss of feeling in genitals, and even death) over taking a single dose of a drug, because I’m not morally comfortable with being more active in an already doomed baby.

    • http://renegadetrad.blogspot.com A Sinner

      I’m a bit more uncomfortable with the “drug” solution just because it’s harder to imagine the doctors saving an embryo removed in that fashion if artificial wombs did exist (which there would be an obligation to do if they did).

      As I understand it, the embryo in such drug cases is either reabsorbed or flushed out. The first case (re-absorption) definitely is problematic, because then you are not talking about the removal of the embryo (which could hypothetically be followed by saving it somehow), but about an absorption process which might be directly equivalent to killing it. In such a case, one might argue that the child’s death (in the form of it’s re-absorption by the mother’s body) IS directly within the “chain of means” chosen as needed to cause the desired end.

      If it’s flushed out (alive) then I think a better argument could be made that all you’re doing is “removal,” but it still feels borderline to me given the question of how (when artificial wombs ARE invented) the doctors would get to the baby in time to rescue it. But, of course, until they are invented, doctors don’t have to go about the procedure pretending like they are already here. If “removal” is effected either way, and if there is no reason (yet) to remove in a more controlled fashion, then adding additional risks to the mother’s health for the sake of a moral technicality wouldn’t make sense. But, if the artificial womb was invented, there would be an obligation, obviously, to do things in such a way as the embryo could be safely transferred.

      • http://turmarion.wordpress.com turmarion

        I’m almost afraid, Sinner, given the “conservative-but-not-orthodox” attitudes that are prevalent, and given a lot of Catholic bioethics to date, which tend to be suspicious of anything of a reproductive nature happening outside the human boyd, that an artificial womb would be opposed for other reasons even though it could solve problems such as this. Obviously one wouldn’t want to go Brave New World; but artificial wombs might even reduce the chances of using the drugs about which you rightly raise concerns. I’m afraid that in the current climate, the bishops would (and I realize the irony of the metaphor here) throw out the baby with the bathwater.

        • http://renegadetrad.blogspot.com A Sinner

          There wouldn’t be any controversy about cases where it was used to save the child in a case where it would otherwise die, like transferring it in the case of an ectopic pregnancy.

          There would be a lot of “slippery slope” questions, though. People using the artificial wombs instead of ever being pregnant, etc

          And then there are the middling “enabling” cases that are so debated. Artificial wombs might allow the gestation of all the IVF embryos trapped in limbo, but is that enabling the whole system? Transferring a child to an artificial womb (and allowing the woman to give up all responsibilities at that point) would be preferable to an abortion that ended in death, but isn’t that cementing a culture of women having a “right” not to carry a pregnancy to term?

          However, an abuse does not negate a valid use.

  • Commoner

    I’ve always wondered if the Church would consider it morally licit and/or even laudable to refuse a salpingectomy (or any other treatment) in the case of a tubal pregnancy. After all, God could perform a miracle. You never know.

    The Church simply had to come up with something to deal with ectopic pregnancies once science demonstrated to us that mothers with tubal pregnancies are doomed to die if the fetus isn’t removed. Otherwise, She would have lost all credibility in the eyes of real people, who would regard choosing to die rather than have the fetus removed in such a case as ignorant and misguided at best. Most likely, people would consider such a choice suicidal and deranged—certainly not an act respectful of human life.

    I tend to agree with the Eastern train of thought on these kinds of choices, which resonates with pretty much every human being who has ever lived. Sometimes there is no good choice that doesn’t involve sinfulness of some sort. I think we all know that, deep down in our hearts. We pray, make the best decision we know how to, and trust God will make up for the deficiences of the fallen world we live in.

    • Istern

      I’m a bit disturbed in this thread to see an attitude something almost like “eagerness to dissent.” It’s like this case is taken as an example of “a place where the orthodox teaching is clearly absurd, so let’s use that as a foothold to deconstruct the traditional Catholic moral paradigm in general” even though posters like Sinner, raitchi, and Chris Sullivan have all demonstrated that orthodoxy does not, in fact, require the absurdity in question. But it’s almost like certain posters WANT the conservative approach to be required in order to prove an inconsistency in the orthodox fabric that would allow them to ignore or unravel it.

    • Jordan

      Istern [August 29, 2013 11:44 pm]: But it’s almost like certain posters WANT the conservative approach to be required in order to prove an inconsistency in the orthodox fabric that would allow them to ignore or unravel it.

      Faith requires doubt. If faith were only a matter of imperfect contrition, then believers would be nothing more than intellect-deficient automatons who profess “trust” in certain beliefs simply out of a fear of eternal damnation. I can’t believe that God gave us imperfect reason only to demand that we not exercise this reason.

      Although I am a man and not directly affected by the real-life application of life-issue casuistry, when the issue of fertility bioethics arises my mind immediately turns to the many women in my life and not necessarily to a copy of the CIC or to Summa volumes. What would I do or say if one of my close friends were lying on a gurney and faced with the choice of abortion and survival or death and the death of her child? I would not know what to say or do until the moment of crisis. I suspect that many “orthodox” Catholics, when confronted with this question in an abstract exercise, might say that they would let the mother die. I still doubt that most persons with a beating heart could effect a Kierkegaardian teleological suspension in a time of acute crisis. et super hanc petram aedificabo ecclesiam meam, and even Jesus’s choice candidate to lead the apostles stumbled quite a bit.

  • Paul Connors

    Cruz-Uribe: “…an action that intuitively seems to be the correct moral choice—saving the life of the mother, the only one who can be saved”

    Since you are dubious of double-effect, could you state some moral principles that you are willing to commit to? What is this “intuition”? (At least part of advantage I see for double-effect is that the alternatives quickly become horrifying.)

    • http://turmarion.wordpress.com turmarion

      I can’t speak for David, but I’d tend to go with the Eastern view that I touch on here and describe in greater detail at the blog post I linked to. That perspective would make fewer positive a priori assumptions (“in situation X, given Y, the moral thing to do is Z”); but it would be more dependent on the woman, her husband, her doctors, her confessor, and any hospital ethicists available, all working together given the concrete aspects of the specific situation, to make the best possible decision. It wouldn’t have the cookie-cutter consistency that all too many in the Church and elsewhere seem to want; but that, IMO, would be a feature, not a bug.

      • Paul Connors

        Your reply doesn’t identify any moral principles, which was what I was asking for.

        I read the linked post, but that exchanges double effect for what seems to me to be a smudging of the distinction between general sin (things that God doesn’t want) and personal sin (our own choices to enact things that God doesn’t want). If circumstances limit what I am able to personally choose, that does not defile me. “What comes out of a man is what defiles a man. (Mar 7:20 RSV)”

        • http://turmarion.wordpress.com turmarion

          The moral principles I’d espouse are pretty much generically Christian: don’t kill, don’t steal, be truthful, etc. The question here is not a matter of the principles, but how one balances them against each other in difficult circumstances. I don’t claim to have one overarching principle with which to replace double effect–rather, one has to take the broader principles and look at the individual case. That might sound insufficiently rigorous, or not generalized enough, but I think that’s a feature, not a bug.

          As to David’s “intuition”, what’s hard about it? If an ectopic pregnancy is allowed to continue, both the woman and the child will die with certainty. The only way that either can be saved is to remove the child, with or without more or less of the fallopian tube. With current technology, the child could not be saved, but the mother could be. In some future context in which the child might be placed in an artificial womb for the rest of the term, or temporarily until it can be replaced in the mother’s uterus properly, it would be imperative to do so and save both, but to repeat, in such a case it is now possible to save only one, the mother.

          It seems an obvious moral intuition that you save everyone you can; and that it would be immoral to allow both to die; so the trade-off seems fairly obvious. The question is how one justifies it–by double-effect, which, to me, seems abstract and ex post facto; or by an appeal to saving the life that can be saved; or by some more subtle application of double-effect, as A. Sinner does?

          If circumstances limit what I am able to personally choose, that does not defile me.

          That’s the typically Western (Catholic and Protestant) view; the Orthodox do not share it. The question is which view of sin accords with reality best, the forensic (Western) or medical (Eastern)? My opinion is that it is the latter.

        • Paul Connors

          turmarion: “The moral principles I’d espouse are pretty much generically Christian: don’t kill, don’t steal, be truthful, etc. The question here is not a matter of the principles, but how one balances them against each other in difficult circumstances.”

          Agreed. And that’s why I see the value in double-effect, since it is just the working out of “Don’t choose evil”.

          turmarion: “It seems an obvious moral intuition that you save everyone you can; and that it would be immoral to allow both to die;”

          There’s allowing to die, and then there’s choosing to have the goal of killing. They’re not equivalent. There’s also the principle: “Don’t kill an innocent person”. Except if you wrap it up as: “Don’t kill innocent people unless they’re dying anyway, and you can make a suitable gain by it”, and then apply it almost exclusively in situations where those innocent people are never going to speak to us, we too easily get bamboozled. (Which has been an ongoing problem since Gen 3:1-6)

          turmarion: “some more subtle application of double-effect, as A. Sinner does?”

          A. Sinner appeals to Grisez and Lysaught, who are arguably subtle, but wrong.

        • http://renegadetrad.blogspot.com A Sinner

          But they’re also arguably right. Either is arguable within the bounds of orthodoxy.

          Your killing versus “letting die” distinction may be true, but it has nothing to do with whether the choice one makes is PHYSICALLY “active” versus non-interventionist.

          “Not doing” something can be just as much an active moral choice.

          The only coherent way to make the distinction regards the inner causal logic of the choice, and whether the death is directly chosen as an ends or means (killing), or whether it is a “parallel” result, foreseeable but not at all essential or instrumental, of the means chosen to achieve some OTHER end (letting die).

          In other words, there is no distinction between “I sat there and didn’t help when I could because I wanted him to die” and “I shot him because I wanted him to die.”

          On the other hand, there IS a distinction between “I didn’t give him food because I wanted to bring about his death” and “I didn’t give him food because I was giving all the food to her, even though I knew he would then starve instead.”

  • http://twitter.com/kylecupp Kyle Cupp (@kylecupp)

    “My problem is that I honestly cannot fathom the distinction being made here: it seems to me to be a distinction without a difference.”

    This is my sense as well. Framing the removal of the fallopian tube in a way that separates it from the act of depriving the embryo of sustenance is absurdly abstract. Removing the tube means cutting off the embryo from what it needs to survive. Starving the embryo is not your intended end, of course, but you are nonetheless starving it, deliberately choosing the means that starves it. You intend the means that kills it. You are killing it, and not just letting it die.

    I’m not saying that this action cannot be justified, but I’m very skeptical that double effect does it. And, truth be told, I think double-effect is grossly overused.

    • Paul Connors

      Kyle Cupp: “Removing the tube means cutting off the embryo from what it needs to survive.”

      Removing the tube also means cutting off from the mother the faulty tube that was threatening to kill her. It’s a double-effect.

      Now the Principle of Double Effect is just a working out of the principle: “Don’t choose evil”. I’ve yet to see any alternate methodology for dealing with double-effects which didn’t amount to either vague hand waving, or else something whose consequences were horrendous. And I would rather expect any alternate set of principles that contradicted PDE to amount to choosing evil over good.

      But perhaps not. Do you have some alternate set of principles to suggest?

      • http://renegadetrad.blogspot.com A Sinner

        Removing the embryo by itself, without the tube (which apart from the embryo’s presence is NOT faulty, by the way, and can continue functioning just fine in the future once the ectopic embryo is removed)…is ALREADY double-effect, though. The embryo’s death is no where included in the proposal chosen. It is in no sense instrumental to achieving the desired end; if the baby somehow survived, the procedure would be considered JUST AS (in fact, probably more) successful. So the death is clearly not a direct object of the choosing at all; it isn’t desired and it isn’t, in itself, necessary to the inner causal logic of the choice being made. Only the “removal” is. The death results as a side-effect of the removal, but it is truly a side-effect because the removal is not chosen to achieve the embryo’s death, it’s chosen to save the mother. The death that also follows the removal is a “parallel” (ie, side-) effect of the removal, but the removal and the death are NOT equivalent or collapsable one into the other in the moral analysis. The removal and the death are logically abstractable from each other, as cause and effect, as the hypothetical of transferring the embryo to an artificial womb clearly shows. The removal and the death are two different things. The latter is a foreseen consequence of the former, but it is morally a SIDE-effect given that it is “parallel” to and unnecessary to the chain of causes set in motion by the will, which desires the removal to save the mother, NOT to kill the embryo (and indeed would save the embryo if it could).

        • Paul Connors

          A Sinner: “the tube (which apart from the embryo’s presence is NOT faulty”

          There are a variety of places that an ectopic embryo can implant. Whether these are viable depends on where the implantation occurs, not on the embryo. If the embryo can get a sufficient blood supply, and without causing maternal hemorrhages, it can be (and has been) carried to term.

          If there were some way of medically treating the point of implantation so as eliminate the various blood supply problems, then such treatment would allow the embryo to be carried to term.

          I.e. it’s the point of implantation of that is the problem.

          A Sinner: “and can continue functioning just fine in the future once the ectopic embryo is removed”

          Depending on the sequence of events, it’s easily possible that the affected part of a fallopian tube must be removed (ergo it’s certainly not functioning just fine). And it’s also the case that problems with the tube can occur later, even after removal of an embryo.

          I.e. it’s the point of implantation of that is the problem.

          While it’s certainly true that the problem with the point of implantation is being revealed because of a pregnancy, it still remains that the proximate problem is the point of implantation.

          A Sinner: “So the death is clearly not a direct object of the choosing at all”

          While it is certainly true that, in some situations, death is unavoidable, that does nothing whatsoever to prevent a choice to kill in some specific way, and at some specific time. If somebody has far-advanced stage IVB pancreatic cancer, and is morally certain to die within a couple of days, it’s still obviously murder if I blast their head with a shotgun. Likewise, aiming to kill the embryo at a specific time and in a specific way is still murder, even if its death in some other way was unavoidable.

          As for the rest of what you say, I refer to what I said in (i) of the comment here. Specifically, if a death occurs as a result of some action, the reason for the death is to be sought for in the whole history of specific events, plans, and goals. If an unviable embryo is removed from its mother, because that was exactly what your goal was, and if you knew that it was going to die because of that, then that’s murder. The fact that removal and death are separate things is irrelevant in those circumstances, as is the fact that a prior “moral proposal” did not mention such things.

        • http://renegadetrad.blogspot.com A Sinner

          You can’t just…assert that. You say even if removal and death are abstractable it’s still murder if you know the death will happen, but the whole point of double-effect is that you can foresee something bad happening but it can be allowed for proportionate reasons as long as it is not intended and is a side-effect rather than a directly chosen means.

          Blasting off someone’s head with a shotgun does sound like something that would usually only be undertaken in situations where their death was intended as an ends or a means. But even then not necessarily; just look at self-defense. You might for some reason find yourself in a situation where a head-shot is your only way to incapacitate them, even knowing (but not intending) it will probably kill them. But the death is not necessarily instrumental to your desire to merely incapacitate them and hence self-defense is allowed, etc

          • Paul Connors

            A Sinner: “You say even if removal and death are abstractable it’s still murder if you know the death will happen, but the whole point of double-effect is …”

            Because it’s murder, it simply doesn’t qualify as double effect at all. The chosen act under consideration is the removal of a non-viable ectopic child. This is morally certain to be followed by its death. But the killing of an innocent is not allowed for any reason — so there is simply no need to go into any of the reasoning as to why the child was removed. It’s never going to qualify as decidable under double-effect, because the act under consideration is known to be evil, and this fails the very first step of the Principle of Double Effect.

        • http://renegadetrad.blogspot.com A Sinner

          Paul, your answer here is “begging the question.”

          That is to say, the whole question being debated here is whether “removing a non-viable embryo” is a species of act in itself that necessarily contains the death. Not just as a consequence (we all know it’s a consequence; but foreseen consequences are handled somewhat differently in Catholic morality) but as intrinsic to the moral object itself.

          I’m asserting, for a variety of very logical reasons, that removal of a non-viable-aged ectopic pregnancy cannot be called a different kind of act compared to removing a viable-aged ectopic pregnancy. They are carried out with the same intent (which is not “to kill” anyone) and would seem to be the same type of act with the same internal logic regarding the sequence of causation in why they’re chosen.

          You come here and, essentially, simply assert that they’re not the same type of act, the same moral object.

          But why? The only reason you give is because the foreseeable consequences are different in the two cases.

          That’s true, but foreseen consequences are already a separate “font of morality” in Catholic analysis which looks at an act in terms of intent, moral object, and consequences.

          So if you want to assert that we’re talking about two different kinds of moral objects here, you have to explain WHY pre-viability removal and post-viability removal are different for a reason that doesn’t just rely on referencing the consequences, because the consequences are, in catholic moral analysis, a separate category already.

          So: ASIDE FROM the foreseeable consequence, what distinguishes the removal of pre- and post-viability embryos as a type of act in itself (when done with the same intent)?

          As far as I can tell, it’s impossible to distinguish the two in a morally relevant way without referencing consequences.

          • Paul Connors

            Throwing someone into deep water who cannot swim is a different moral action than throwing someone in who can swim. And pushing someone off a 100-foot cliff is a different moral action that pushing someone off a 1-foot cliff.

            As Aquinas says(ST II.1 A9) : “a moral action [..] derives its goodness not only from its object, whence it takes its species; but also from the circumstances”.

            Alternatively, look at the logic of removing a pre-viable child:

            (i) Once the non-viable child is removed, it will certainly die.
            (ii) No one can intend the impossible.
            (iii) Therefore, it is impossible to intend that the child not die.

            And this would falsify your claim that there is no intent to for the child to die.

        • Paul Connors

          Actually, there’s a step in the argument that should be made explicit:

          (i) I intend to remove the non-viable child.
          (ii) Once the non-viable child is removed, I know it will certainly die.
          (iii) No one can intend the impossible.
          (iv) Therefore, it is impossible for me to intend that the child not die.

        • http://renegadetrad.blogspot.com A Sinner

          There doesn’t have to be a positive intent “for the child not to die.” Merely the lack of a positive intent for the child TO die! Negatives can’t really be intended anyway!

          The intent, morally, is the “end” the will is seeking. The will in this case (whether you remove the embryo on its own, or “riding along on” a piece of the fallopian tube) is not seeking the death of the child as an end (nor as a means, actually; the death has no causal role in itself). That’s not desired, merely a foreseen consequence.

          Whether or not “throwing someone into deep water who cannot swim” is a different moral action than “throwing someone in who can swim” will also depend on the inner logic of the choice. As John Paul II said in Veritas Spelndor, “In order to be able to grasp the object of an act which specifies that act morally, it is therefore necessary to place oneself in the perspective of the acting person” and “By the object of a given moral act, then, one cannot mean a process or an event of the merely physical order, to be assessed on the basis of its ability to bring about a given state of affairs in the outside world.”

          Your analysis, and that of the “conservatives” on this question, seem to consider “direct killing” to be defined by a process of the merely physical order, assessed on the basis of its bring out about a given state of affairs in the outside world. But John Paul makes it clear, this is the wrong way to look at identifying the moral object.

          But as I’ve tried to explain in this thread, the moral object is based on the INTERNAL moral logic of the choice. What is being chosen as a cause, and why? “Death” has no causal role in bringing about the salvation of the mother in this case, merely “removal.” The internal logic of the moral object is the same pre- and post-viability. The death is then morally relevant as a CONSEQUENCE, yes, but consequences not intended as an ends or means in themselves can be indirect side-effects and thus allowable by double-effect.

          William J. Murphy from the Josephinum elaborates:

          “St. Thomas himself offers the example of killing in self defense. In
          doing so, he explicitly intends to differentiate between actions which, in the physical order, may look exactly the same, but in terms of their species (good or evil) are radically different because of their different moral objects. What differentiates actions of the object “self-defense”
          (good moral object) from those of the object “homicide” (intrinsically evil moral object) is the intention or end of the agent, which is either to preserve his or her own life or to end the life of another. Importantly, in this passage in the Summa, Thomas does not attend to the physical/material component of the action. The self-defender may have used a variety of agents in a variety of ways (e.g., hitting the assailant over the head with a tire-iron; pushing the assailant over a cliff, etc.). Prima facie, an observer cannot immediately determine to which moral species this action belongs; only
          when it is understood “from the perspective of the acting person” and evaluated according to the acting person’s intention, can we know the proper object and species.”

          “To kill” may not be the object of pushing someone off a cliff at all. If the intent is merely to incapacitate, then the moral object is self-defense, even if the death is foreseen as an inevitable (but non-instrumental, in itself) consequence. Same thing with “removing” a non-viable embryo, I’d think. If the object is to save the mother in the EXACT SAME WAY that removing a viable embryo saves her, then the object is the same even though there is a foreseen consequence of (a non-instrumental) death.

          • David Cruz-Uribe, SFO

            This may be a matter of terminology, but one place where I think we part company (even though I understand your analysis) is the moral distance that “foreseen but unintended consequence” puts between the actor and the consequences of his/her actions. I think, morally, the actor must take ownership of the consequences of his/her actions, even if they are licit. Perhaps you mean this as well, but it seems hidden in the language of the formal arguments you are using.

            This may hint at the Eastern approach a couple people commented on early in this thread.

        • Paul Connors

          A Sinner: “There doesn’t have to be a positive intent ‘for the child not to die.’ Merely the lack of a positive intent for the child TO die!”

          The plan to remove the non-viable child doesn’t have as a goal that the child die, because that would certainly be wrong. It doesn’t have as a goal that the child not die, since that would be impossible. Hence the plan doesn’t take into account whether the child lives or dies!

          Really? The moral status of a living child in the womb, in this plan, is treated exactly the same as the status of (e.g.) a tumor? (That, I would say, is a clue that something strange is going on with the argument.)

          A Sinner [quoting from Veritatis Splendor]: “By the object of a given moral act, then, one cannot mean a process or an event of the merely physical order”

          Of course! That’s exactly correct! I thoroughly agree! Which means one cannot claim: “Someone’s act has killed an innocent child, therefore they have certainly committed a moral wrong.” (I.e. a claim of the kind: Such-and-such an event of the physical order has occurred, therefore a moral wrong has been committed.)

          That’s because we have to be sure that (a) the person understood what it was that the actions accomplished; and that (b) these actions took place voluntarily. And these take us straight into the perspective of the acting person, just as Veritatis Splendor requires.

          A Sinner: “Your analysis … on this question, seem to consider ‘direct killing’ to be defined by a process of the merely physical order”

          There’s no such claim! In the plan in question, one assumes that those designing and carrying out the plan understand what will happen, and are acting voluntarily — and there again comes in the perspective of the acting persons.

          A Sinner: “…If the object is to save the mother…”

          If the removal of the child, with its subsequent certain death, is an intrinsic evil, then all the arguments referring to saving the mother are completely irrelevant.

          A Sinner: ” If the object is to save the mother in the EXACT SAME WAY that removing a viable embryo saves her, then the object is the same”

          You’re referring to some specific properties of the consequences. But for intrinsic evils the consequences are irrelevant.

          A Sinner: “the death is foreseen as an inevitable (but non-instrumental, in itself)”

          For an intrinsic evil, it’s irrelevant whether the evil is instrumental or not.

          All in all, you (for the success of your argument) have to somehow demonstrate that the death is definitely not to be classified as an intrinsic evil. It is not clear to me how you will show that the death after removal is not an intrinsic evil, because you keep referring to consequences and ulterior intentions (saving the mother) that are irrelevant to deciding if some act is an intrinsic evil.

          Veritatis Splendor has some highly relevant quotes on the issue of intrinsic evil, and my reading of them certainly convinces me that the death after removal is an intrinsic evil. I shall assume that you can find them just as easily as me.

        • http://renegadetrad.blogspot.com A Sinner

          “This may be a matter of terminology, but one place where I think we part company (even though I understand your analysis) is the moral distance that ‘foreseen but unintended consequence’ puts between the actor and the consequences of his/her actions. I think, morally, the actor must take ownership of the consequences of his/her actions, even if they are licit. Perhaps you mean this as well, but it seems hidden in the language of the formal arguments you are using.”

          Well, consequences are treated differently in Catholic morality than intent or moral object. Consequences are external. This doesn’t mean that consequences have no bearing on morality or that we don’t “own” the consequences (especially the foreseeable ones) but it does mean that an evil consequence, in itself, does not necessarily morally warp the person’s will internally speaking or accrue to him in terms of internal moral culpability. It does not make one a bad or un-virtuous person, in itself, to have brought about a bad consequence, foreseen or not.

          [It might, however, accrue “ethically” and externally, ala something like strict-liability in tort law, if you understand the morals/ethics distinction I’m making here. This might open a door to turmarion’s “Eastern” notion…]

          This is not saying there is no responsibility to consider consequences or something like that! Remember, the last condition of double-effect is that the foreseen but unintended consequence has to be judged proportionate (ie, outweighed) by the good brought about by the action. The obligation to discern this is still a grave responsibility and means you definitely “own” the consequences.

          It’s just that almost any action (in reality, double-effect is not an “exotic case” principle, but is actually at play in EVERY choice we make!) has consequences that are good AND bad. EVERY choice is like this. Every choice has pros and cons. We are obligated, first of all, to make sure that the good outweighs the bad. But double effect ALSO tells us that we can never choose the evil consequences DIRECTLY, they can never be our intended end nor a step in the direct “chain of cause” leading from our choice to the intended end (ie, an intrinsic evil cannot be an ends or a means). Our intended end has to be the good effects, and the moral proposal in itself, in its own inner causal logic, cannot involve any intrinsic evils (like death, or theft, etc).

          It’s basically just saying that if something bad results, it has to be A) outweighed by the good, and B) not desired in itself nor as an instrumental means/cause to achieving that which is the desired end. This is the meaning of “side-effect.” I don’t see how that involves renouncing ownership of consequences. One is still responsible for discerning that the good will outweigh the bad effects of any given choice (at least those foreseeable) and like I said, we might even still be able to attribute a sort of ethical “strict-liability” responsibility to the bad consequences even if they are, morally, “side effects” which perhaps is addressed more in the East (and, I’ll point out, in existentialism).

          But it is saying that one does not become a bad person, internally, for merely bringing about a bad effect externally. Otherwise we couldn’t make any choices at all, because all choices have mixed consequences. The only thing that would be morally warping internally though (the Western definition of “a sin”) is if the evil entered into the INternal logic of the choice itself (as an ends or a direct means). Or if the evil effect was foreseen to NOT be outweighed by the good but one still went ahead with things.

        • http://renegadetrad.blogspot.com A Sinner

          “The plan to remove the non-viable child doesn’t have as a goal that the child die, because that would certainly be wrong. It doesn’t have as a goal that the child not die, since that would be impossible. Hence the plan doesn’t take into account whether the child lives or dies!”

          Correct. As Grisez says in his craniotomy example, the internal proposal would actually remain the same if the child were already dead…so this shows that the death itself cannot be called an intrinsic causal part of the proposal. The child dying is irrelevant to the logic of the moral proposal itself, which means that the evil of its death does not enter into the internal logic of the choice.

          “Really? The moral status of a living child in the womb, in this plan, is treated exactly the same as the status of (e.g.) a tumor? (That, I would say, is a clue that something strange is going on with the argument.)”

          It’s not treated exactly the same at all! Because the last font of morality IS still consequences. Double-effect requires (among other things) that the evil consequences be proportionate to the good achieved. So when foreseeing that the child will, in fact, die…this has to be analyzed relative to the good effect achieved. In the case of saving another life, there is a valid argument for proportionality based on the fact that the death of the child is balanced by the mother living (and this is especially persuasive in a case where doing nothing will lead to BOTH dying unnecessarily).

          But outside of cases where another life will be saved, death is never proportionate even just as a foreseen side-consequence. Merely to relieve pain or distress, for example, the embryo could not be removed, and this would remain true even if it WERE attached to a piece of the Fallopian tube! (Whereas a tumor clearly could be removed to relieve mere pain and distress).

          If the problem was really as you’re saying, Paul, it would be okay to remove the fallopian tube with an embryo in it…even in cases where what was at stake was less urgent than the mother’s life. If the embryo’s death is located in the moral consideration at the point of moral-object rather than consequences, and this was somehow solved by removing the tube with the embryo riding along rather than removing the embryo by itself…then this would remain true even in cases more minor than the mother’s life. But obviously that’s not true because it doesn’t satisfy the “proportionality” criteria where the bad consequence must be “outweighed” (or at least “matched,” as it were) by the good.

          So, again, what matters here is not whether the embryo is removed by itself or “riding along” on a piece of the mother (that’s irrelevant!) What matters is if the consequence of its death is proportionate to the good being sought. Once again, the embryo’s death is clearly relevant to the analysis at the point of consequences, NOT the point of intention or moral object.

          Even by your own logic, the potential wrongness of removing the embryo is relative to whether the consequence is proportionate, NOT about merely HOW the embryo is removed (by itself or riding along on something else). Otherwise, again by your own logic, what’s the problem with removing an embryo “riding along” on a Fallopian tube OUTSIDE a life-or-death situation for the mother? No, clearly the evil of the embryo’s death is a problem to be considered under the header of consequences, not under the header of the moral object itself.

          “That’s because we have to be sure that (a) the person understood what it was that the actions accomplished; and that (b) these actions took place voluntarily. And these take us straight into the perspective of the acting person, just as Veritatis Splendor requires.”

          No no no, Paul, you’re getting all sorts of concepts confused here. The (a) and (b) you have listed are the features of culpability that, along with grave matter, are required for the subjective imputation of mortal sin. John Paul, however, wasn’t talking about mitigating factors for culpability here at all or anything like that. Your reading an entirely different area of moral theology into it here that he wasn’t talking about at this point at all.

          He was talking about what the moral object is in itself. Your twisting his quote to basically mean “The moral object IS an event of the physical order, it’s just that not all objectively grave matter gets subjectively imputed as a personal sin on account of a lack of knowledge or freedom of consent.” But that isn’t what John Paul was talking about here.

          He was saying that even the identification of the moral proposal itself, the kind of moral act considered internally, cannot be defined just based on the external bodily/physical act or its consequences (otherwise, for example, two things that externally and physically “look the same” in terms of what you do, like murder and self-defense, or stealing versus receiving a gift, would be the same moral object). Self-defense is not distinguished from murder merely because of a lack of knowledge or consent. Self-defense may be carried out with FULL knowledge and consent. It’s still not murder.

          “There’s no such claim! In the plan in question, one assumes that those designing and carrying out the plan understand what will happen, and are acting voluntarily — and there again comes in the perspective of the acting persons.”

          Yes, the understand what will happen. That is why the consequence is “foreseen.” But being foreseen doesn’t make a consequence inadmissable. Indeed, that’s what the whole principle of double-effect deals with: foreseen but unintended consequences.

          The way you’re speaking, it’s as if you don’t believe a side effect can ever be foreseen AND unintended. But if that were the case it would condemn removing the embryo WITH a Fallopian tube just as much as removing it on its own without the tube around it.

          “If the removal of the child, with its subsequent certain death, is an intrinsic evil, then all the arguments referring to saving the mother are completely irrelevant.”

          Here’s your problem, you’re defining “removal of the child, with its subsequent certain death” as one object, one concept. It’s not. There are at least two things there abstractable from each other: A) there’s the removal, B) there’s the subsequent certain death. Morally speaking, they are not bootstrapped to each other as if the moral status of one somehow “seeps” into both.

          B) is clearly an intrinsic evil; death always is, considered in itself. But A)…A) seems neutral. Removing an embryo from the womb, in itself, is not problematic. Sometimes babies are removed and put in an incubator. Sometimes they are just…born! Sometimes even a pre-viability baby will be removed temporarily for prenatal surgery and then put back. In the future, transfers to an artificial womb or to another woman might be possible, etc etc. “Taking an embryo out of the womb” is not in itself morally problematic (And if it were, it would remain so even if it were “riding along” on a piece of fallopian tube!)

          Yet it is only A) which is directly chosen in the case of an ectopic pregnancy. Yes, B) results inevitably, as a foreseen but unintended consequence. But foreseen but unintended side-effects can be tolerated if their evil is proportionate to the good intended. And B) most certainly is a side-effect rather than directly chosen, because it isn’t desired, and nor does the death have any direct causal/instrumental bearing on bringing about the good in question.

          The problem the mother has is not that the embryo is alive, it’s merely that the embryo “is present in the wrong place.” This problem is successfully solved by “moving the embryo,” NOT by “killing it.” If the moving results in its death, that’s just as much a SIDE-effect whether or NOT it is is “riding along” on a piece of fallopian tube.

          “You’re referring to some specific properties of the consequences. But for intrinsic evils the consequences are irrelevant.”

          But your problem is in identifying a consequence (death) of the act (the moving) as part-and-parcel-inseparable-and-unabstractable from the act itself. But it’s not. The ACT is “moving” (which is morally neutral.) The death that results is a CONSEQUENCE, yes, but only a consequence, and morally relevant only as such.

          You say “for intrinsic evils the consequences are irrelevant” and yet you have defined “moving an embryo [out of the womb]” as an intrinsic evil BASED ON a consequence that act has. So which is it? Are consequences “irrelevant for” intrinsic evils? Or are some things categorized as intrinsic evils exactly because of their consequences? Because right now you are claiming both things. I think you’re all tangled up.

          “All in all, you (for the success of your argument) have to somehow demonstrate that the death is definitely not to be classified as an intrinsic evil. It is not clear to me how you will show that the death after removal is not an intrinsic evil, because you keep referring to consequences and ulterior intentions (saving the mother) that are irrelevant to deciding if some act is an intrinsic evil.”

          No, Paul. I don’t have to demonstrate that the death is not an intrinsic evil. The death IS an intrinsic evil and I’ve never claimed otherwise. It is an intrinsic evil in your fallopian-tube-removal case also! What I have to demonstrate (and have) is that the intrinsic evil of the death is not directly chosen, but is rather a side-effect, when you move the embryo out from where its presence is causing a problem, and that it’s irrelevant whether this removal occurs by removing the embryo by itself, or “riding along” on a piece of fallopian tube.

          You seem to indicate further confusion when in the last sentence you speak about an “act” being an intrinsic evil. The death of the embryo is not an act, obviously. The death of the embryo is a result. It is an intrinsic evil, yes, but it would only make a human moral ACT intrinsically morally evil IF the death itself entered directly into the inner moral logic of that act as either an ends or means. As JPII said in VS, intrinsic evils (such as death) can never be chosen as an ENDS or a MEANS. This is what is meant by “directly choosing.” Well, what is the death of the embryo in this case? Is it chosen as an end in itself? Obviously not. Is it chosen as a means? No, because the death itself is totally irrelevant. The means is the moving, not the death, the death is just a side-effect of the means, but the death itself is not part of the causal chain at all (which would, indeed, be unaffected if the embryo somehow survived being moved).

          “the death after removal is an intrinsic evil. I shall assume that you can find them just as easily as me.”

          Yes, death is an intrinsic evil. It is an intrinsic evil when the embryo dies after being removed inside a piece of fallopian tube too! The question in this thread is all about whether that intrinsic evil is “directly” chosen when an embryo is removed to save the mother’s life, or whether it is a side effect.

          For you to make your argument successfully, you’d have to demonstrate some morally relevant difference that would somehow make moving the embryo by itself a direct choice of its death, but removing it inside a piece of fallopian tube a side-effect, even though in both cases the problem is the presence of the embryo in the wrong place, and in both cases the solution is, ultimately, removing the embryo.

          Of course, you might claim that in your case the solution to the embryo being in the wrong place is not removing the embryo from that place (though it’s unclear why, apart from consequences which are a separate moral category, removing would be controversial)…but rather removing the place itself entirely! But to me that sounds like saying that if you can’t remove Winnie the Pooh from the Honey Tree without decapitating him, then the better solution is just to blow up the whole Honey Tree (killing Pooh in the process). Which is clearly absurd.

          • Paul Connors

            While there are a few things I might justifiably respond to, I would like to concentrate specifically on the question as to whether or not the death of the child is intended (i.e. in the case where we remove a non-viable living fetal child from within its mother, in order to save the mother from potentially fatal pregnancy-related problems).

            To show that the death is definitely intended requires only two principles (which are related, but slightly different):

            (A) That if some effect A is intended, and effect B will certainly go with A, then B is also intended.
            (B) That if some kind of thing is divided into two parts, P1 and P2, and if part P1 is intended, then part P2 is also intended.

            Some examples of (A):

            If someone jumps off a plain 100-foot cliff (i.e. just a plain drop with nothing around that is going to impede gravity in any way) and intends to drop the first 50 feet, then they intend to drop the second 50-feet as well. (If they don’t intend the second drop then something is drastically irrational with their thinking!)

            If someone acts in self-defense against a murderous attacker, then they intend to stay alive, and they intend to stay breathing after the fight.

            If someone removes a cancerous womb to save a pregnant mother, then they intend that cancerous womb not to subsequently affect the health of the mother (but they don’t intend any contained fetus to be removed, so the death of the child can be unintended).

            A simple example of (B):

            If I have $5, and I intentionally give $3 to charity, then I must intend to have $2 left over. (One can’t intend that the ordinary laws of arithmetic not apply!).

            Then use principles (A) and (B) in the following ways:

            – principle (A) shows that if we know that a child will certainly die if it is removed, and we intend the removal, then we also intend the death.

            – principle (B) shows that if we intend to separate the mother from the child (so as to benefit the mother), then we also intend to separate the child from the mother (so the removal in question is intended).

            Hence the death of the child is definitely intended.

            (Principle (A) is defended by Aquinas in the following way: “For what is always or frequently joined to the effect falls under the intention itself. For it is stupid to say that someone intends something but does not will that which is always or frequently joined to it.”)

          • David Cruz-Uribe, SFO

            Paul, a query of logic:

            “(A) That if some effect A is intended, and effect B will certainly go with A, then B is also intended.”

            “If someone removes a cancerous womb to save a pregnant mother, then they intend that cancerous womb not to subsequently affect the health of the mother (but they don’t intend any contained fetus to be removed, so the death of the child can be unintended).”

            A = “remove cancerous womb”

            B= “remove fetus from mother”

            In your language, B will certainly go with A. Therefore, how you can you say that the removal of the child is unintended? I guess you could parse between “removal” and “death” but this is where you and I (and A Sinner) part company.

          • Paul Connors

            David Cruz-Aribe: “A = ‘remove cancerous womb’ B= ‘remove fetus from mother’. In your language, B will certainly go with A. Therefore, how you can you say that the removal of the child is unintended?”

            ‘Remove cancerous womb’ is intended.

            ‘Remove cancerous womb plus contained fetus’ is not intended — though circumstantially unavoidable, against my will. The cancerous womb and the contained fetus are distinguishable objects.

            Hence A does not go with B: the intention of A does not certainly go with the intention of B.

        • http://renegadetrad.blogspot.com A Sinner

          Not just him versus us, David, but him versus the whole tradition of double-effect, as you point out.

          If itunintended (as he seems to be arguing) then there can be no double-effect is impossible for a consequence to be both foreseen AND side-effects, and as you say…at that point there’s no reason to justify removing a uterus or fallopian tube with a child “riding along” who will die either.

          I assume you’d admit that removing a cancerous pregnant uterus is allowed, Paul. But the same logic applies there! The intent is to remove it to save the mother, but the child’s removal and subsequent death will always go along with that too! And yet, double-effect concludes they are foreseen-but-not-intended. There is absolutely NO difference.

          • Paul Connors

            A Sinner “I assume you’d admit that removing a cancerous pregnant uterus is allowed, Paul. But the same logic applies there! The intent is to remove it to save the mother, but the child’s removal and subsequent death will always go along with that too!”

            Hmmm. I’m guessing that you did not see my reply to David before making your comment, and that you somehow also missed my comment previous to that one, where I specifically mentioned the case of a cancerous uterus under double effect.

            Consistent with exactly how double effect has always been worded, the intention is to remove just the cancerous womb, but not the contained fetus. Removal of the fetus from its only life-support is unintentional, but inescapable because of (e.g.) the limitations of modern medicine.

            I’m hardly ignoring “the whole tradition of double-effect”! Rather I’m representing it accurately. (You do seem to regularly misconstrue parts of what I write.)

      • http://renegadetrad.blogspot.com A Sinner

        Right, Paul, where the seeming dissonance in your position comes in is that you condemn one thing but allow another by the exact same logic!

        You say: “Consistent with exactly how double effect has always been worded, the intention is to remove just the cancerous womb, but not the contained fetus. Removal of the fetus from its only life-support is unintentional, but inescapable because of (e.g.) the limitations of modern medicine.”

        But we can formulate the other way with just the same format: “the intention is to just remove the ill-located embryo, but not to kill it. The death of the embryo is unintentional, but inescapable because of (e.g.) the limitations of modern medicine.” Namely that we can’t yet transfer it to an artificial womb after removing it, incubators aren’t good enough yet.

        You’ve indicated that the difference is that for some reason you are unwilling to abstract the “death” from the “removal” (even though someday technology will let us)…and yet you’re willing to abstract the removal of the fetus from the removal of a uterus even though there is no logical way ever that both of those won’t always happen together! (ie, when the technology does arrive to save the fetus removed in a cancerous uterus, it will involve removing the fetus from said uterus to put it somewhere else!)

        All you’ve done is add an extra step, which makes the death “a side-effect of a side-effect.” But double-effect doesn’t require two layers of indirectness like that.

        • Paul Connors

          A Sinner: “But we can formulate the other way with just the same format: ‘the intention is to just remove the ill-located embryo …”

          As I have pointed out in a previous comment, the removal is certainly an intentional killing and thus not permitted. So your proposed symmetry doesn’t work.

          A Sinner: “You’ve indicated that the difference is that for some reason you are unwilling to abstract the ‘death’ from the ‘removal’ …”

          Correct — with ‘for some reason’ actually being the specific lines of reasoning I gave in a previous comment, showing that removing a non-viable child with no alternate life-support available is intentional killing.

        • http://renegadetrad.blogspot.com A Sinner

          Grr, but Paul, the reason we’re going in circles is because you haven’t explained why the removal is an intentional killing in one case but not in another just because in the other it is being removed with something else in addition. You haven’t laid out the moral relevance of that.

          It is especially odd to claim that “removal of embryo” and “death” cannot be abstracted and always go together (and thus must both be “intended”) when we can, in fact, imagine the former occurring without the latter (given a good enough incubator) but then are willing to abstract “removal of the fetus” from the “removal of a cancerous-but-pregnant uterus” and admit the former is not intended even though there is no logical way the latter could ever happen without the former.

          So I’m asking very specifically: what trait allows the logically-inseperable removal of a fetus in a cancerous-but-pregnant uterus to be unintentional and its death a mere “side-effect” which does not allow the same distinction of intention between the logically (and someday practically) seperable removal of an embryo and its death?

          • Paul Connors

            A Sinner: “So I’m asking very specifically: what trait allows the logically-inseperable removal of a fetus in a cancerous-but-pregnant uterus to be unintentional and its death a mere ‘side-effect’ which does not allow the same distinction of intention between the logically (and someday practically) seperable removal of an embryo and its death?”

            The two cases are different. In fact, I think I’ve already answered this question, but it’s always worth repeating in different words, since the variation may help get the point over.

            Case A: Removal of a cancerous womb in a mother pregnant with a non-viable child.

            The goal (i.e. the intention) of the operation is to remove the cancerous womb. It is definitely not the goal (i.e. it is unintentional, against the will) to remove the child within the womb. However, because of the limitations of modern medicine, there is no practical way to both remove the cancerous womb, and keep the child alive in place (or even attached to any alternate form of life-support). The fatal removal of the child is an unintended side-effect of the goal of removing the cancerous womb.

            So, the goal is what we are trying to achieve, and a side-effect is something that we are definitely trying not to achieve, but find inescapable in some particular set of circumstances. This is all classic double effect.

            Case B: Removal of an non-viable child from a pregnant mother suffering from health problems due to the pregnancy.

            Here, the stated goal is to save the mother’s precarious health with an operation that removes the non-viable child. The question then is: Is the subsequent death of the child a side-effect of this goal, or is it also intended?

            Firstly, we can view the operation in two ways: as the removal of the child from the mother (which is the stated goal), or as the removal of the mother from the child. But these are identically the same event — just described in different words. (If the mother is separated from the child at 2pm, then the child is separated from the mother at 2pm. If the mother is separated from the child in Such-and-such Hospital, then the child is separated from the mother in Such-and-such Hospital. Etc.

            So, if the stated goal of the operation (i.e. its intention) is to remove the child from the mother, then it is identically a goal — i.e. it is just as intentional — to separate the mother from the child. This suffices to show that the removal of the child is intentional, and not a side-effect.

            Secondly, because the removal has been shown to be a goal of the operation, if we are morally certain that the removal of the non-viable child is going to lead to its death, then the death is also a goal of the operation. It might not be desired or wished for, but it is a goal: it is intentional.

            That’s because if some event is intended (a goal), then everything that is known to follow the event is also intended. (Someone jumping off a plain 100-foot cliff cannot have a realistic goal of falling only 50 feet. We know that’s not what’s going to happen!) (And also note carefully that this applies to goals, because they are intended, and not to side-effects, because they are not intended.) Since the death of the child is certainly going to happen after the intentional removal, then the death is also intentional.

            Summing up, the death of the child in Case B is intended, and is not any kind of side-effect.

            So cases A and B are different. There is a side-effect in case A, but not in Case B.

        • http://renegadetrad.blogspot.com A Sinner

          “The goal (i.e. the intention) of the operation is to remove the cancerous womb. It is definitely not the goal (i.e. it is unintentional, against the will) to remove the child within the womb.”

          Paul, again, THIS is what you’re not answering and what the dissonance seems to me to be.

          You’ve stated that the reason that “removal of embryo” and “death” must always be considered BOTH “intentional” (even if the death itself is undesired and adds nothing to the process of saving the mother)…is because the two are inseparable, because “what is always or frequently joined to the effect falls under the intention itself.”

          Yet, you for some reason ARE able to say that the “removal of the child within the womb” can be unintentional when the womb itself is removed! Even though the removal of a child WITHIN a cancerous-but-pregnant uterus is an effect that is ALWAYS joined to the removal of said uterus. Not just practically, but by logical necessity!

          To use your own phrasing: they are an identical event. If you remove the uterus at 2PM, then you remove the child at 2PM. The removal of the child is joined inseparably to the removal of the uterus, so it must be part of the intent too! Under your logic at least. There’s no way that a child could remain “in place” inside the mother, if the very “place” the child IS within the mother is being removed. It’s not just a question of technology even, but of logic.

          So I guess to be even clearer my question is this: why is the death that follows the removal of a non-viable embryo by itself something that is “always or frequently joined to the effect” and so “falls under the intention itself”…but the removal of a child that follows the removal of the cancerous-but-pregnant womb which it is in…apparently NOT being classed by you as something that is “always or frequently joined to the effect”…even though in the latter case, the logical bootstrapping of the two actually seems STRONGER (and even though in BOTH cases the removal wouldn’t necessarily lead to death IF an artificial womb or better incubator existed)?

          You’re not explaining why or how the removal (and then death) of the child that “always follows” the removal of a pregnant uterus can be unintentional, but that the death of the child that “always follows” a removal of a non-viable embryo…is allegedly always intentional. If it were merely a question of what “always follows”…that’s really not enough to explain the difference here.

          • Paul Connors

            A Sinner: “why is the death that follows the removal of a non-viable embryo by itself something that is ‘always or frequently joined to the effect’ and so ‘falls under the intention itself’ … but the removal of a child that follows the removal of the cancerous-but-pregnant womb which it is in … apparently NOT being classed by you as something that is ‘always or frequently joined to the effect’ … even though in the latter case, the logical bootstrapping of the two actually seems STRONGER …”

            What will follow a goal is part of the goal.

            The word ‘goal’ there refers to something quite precise, and it is easy to overlook that.

            Take the case of cancerous womb. The goal (intention) is to remove the cancer. Because of limited medical options we choose the act of removing the womb and its contents. However, note that:

            Removing the cancer is the goal.
            Removing the rest of the womb is not the goal.
            Removing the contents of the womb is not the goal.

            So, I agree that the contents of the womb will be removed (and thus the child will die) as a result of the act. But the chosen act was not the goal. Not everything that follows from the chosen act is intended. It’s just everything that follows from the goal that must also be included as intentional.

            [I think you and A Sinner have reached an impasse here. I will keep approving comments, but I am going to suggest you wrap it up. — DCU]

        • Paul Connors

          DCU: “[I think you and A Sinner have reached an impasse here. I will keep approving comments, but I am going to suggest you wrap it up. — DCU]”

          I strongly disagree that any impasse has been reached. A Sinner has engaged the discussion quite directly, and though I am convinced (even more so than at the beginning) that his line of argument is mistaken, we have not merely been circling around, or failing to respond, or failing to make progress.

          His response is considerably better than other comments, which rely on bald assertions of fact picked out of the air, scientifically incorrect statements, and the rawest of appeals to pure emotion. All of which might normal for blogs, except that the topic deals with whether we should kill innocent people. I’m astonished.

          However: as you wish.

          P.S. If you add to a comment belonging to someone else, WordPress will not notify anyone that you have done this. (I only noticed your addition by accident.) If you make your own comment, people following the post will be notified in the usual way.

        • David Cruz-Uribe, SFO

          Sorry about that: I try to use editorial “boxes” for comments such as that but I see the problem.

          Feel free to continue if you want: but like I said, I think you guys are not making any progress. If you disagree and A Sinner wants to continue, go ahead.

        • http://renegadetrad.blogspot.com A Sinner

          Eh. I don’t really know if we’re making progress, though we’re certainly not just repeating the same points or circling either. I’m understanding Paul’s position better, actually, but I’m not sure it’s going to get us anywhere. I’ll try, though.

          Paul, let me try to lay out what I currently see as your position.

          Your position seems to be that since “removing the cancer” is the goal (is goal the same as intent?), and since removing the uterus is “not the goal,” merely the MEANS chosen to achieve it, that anything following from this means that isn’t intrinsically related to “removing the cancer” can be called a “side-effect” and fall under Double Effect.

          The way that you think simply removing an obstructing embryo by itself (rather than a “pathological fallopian tube,” even though it’s only pathology is the presence of the embryo…) is different from this, is because then you see the “goal” truly as “removing the embryo” and the death is intrinsically linked to that goal and so is part of it and a direct effect chosen with the goal.

          I understand the distinction you are making, I think? However, the reason I think this is invalid is because there is no particular reason to identify “removing the embryo” as the goal/intent rather than as simply a MEANS like “removing the uterus.”

          By which I mean, you’ve formulated the cancer case like this:
          Goal – Remove the cancer
          Means – Remove the Uterus
          Side-effects of the Means – Remove the fetus, and it’s death

          And you’ve formulated the ectopic case like this:
          Goal – Remove the embryo
          Means – Remove the embryo (it’s both goal and means?!?)
          Direct Inseparable Effect of the Goal – Death of the embryo

          Apparently you’d prefer it to be formulated like this:
          Goal – Remove the threat of a hemorrhage
          Means – Remove the tube that will be the site of said hemorrhage
          Side-effects of the Means – Also remove the embryo, and it’s death

          However, I wonder if the second formatting is really fair at all, especially with that identification of the goal and means. The way I think of it is more like this:

          Goal – Unblock the Tube
          Means – Remove the embryo
          Side-effect of the Means – the embryo dies

          That is to say, it’s unclear why you’re parsing the removal of the embryo as a “goal,” as an end in itself (which is what “intent” means; it refers to the desired end of the action). The removal of the embryo isn’t anymore the goal than removing the uterus is the goal in the cancer case. They’re not removing the embryo for removal’s owns sake as if that’s their desired END, they’re removing it only as a means towards the goal of “removing the threat of a hemorrhage,” which is the exact same “goal” as in your preferred solution!

          However, beyond all this even, I’d argue that “removing the threat of a hemorrhage” or “removing the cancer” aren’t even really validly called the goal or intent either. Those too are a means. They’re not an end in themselves. They’re simply another step in the chain of means to the ultimately goal of saving the mother’s life. THAT is the proximate end of ALL the procedures.

          The way I think traditional moral theology parses things is this: you have an intent, an end, a reason for which you’re doing something, a good which is the proximate end of your choice which requires, in itself, no further justification. The preservation of life is certainly one such “basic good” which serves as the proximate end of our choices. In both cases it is to save the live of the mother. In both cases, then, a “chain of causes” or means is set into motion by the will through the act it chooses.

          In the cancer case it looks like:

          Save the mother<–remove the cancer<–remove the uterus

          In the ectopic case it would look like:

          Save the mother<–unblock the tube<–remove the embryo

          In the first case, there would be a "side chain" off of "remove the uterus" with the parallel effects of "remove the fetus," and "fetus dies." In the second case, there would also be a "side chain" off of "remove the embryo" that would say "embryo dies" but it is no less a SIDE effect, and no more connected to it's corresponding "link" in the DIRECT chain of action than the fetus's death in the case of "remove the uterus."

          You seem to be saying that EACH link in the causal chain constitutes a separate proximate end or intent or "goal" and that EACH causal "step" in the chain has to be analyzed according to the standards applied to the final Intent (in which, in your system, an inevitable consequence is inseparable from the intent). But in that case I'd ask why "remove the uterus" is any less subject to this analysis in terms of its effects than "remove the embryo"…both are merely means to another intent, neither is an end or goal in itself.

          • Paul Connors

            A Sinner: “Your position seems to be that since ‘removing the cancer’ is the goal (is goal the same as intent?)” …

            Yes, I sometimes use ‘goal’ instead of ‘intention’. For the purposes of this discussion, I treat them as identical. I think ‘goal’ can be a better word to use, since ‘intention’ can easily be ambiguous in very unhelpful ways. (Using the word ‘goal’ helps to focus what some plan is actually aimed at achieving — when the goal isn’t achieved, a planned action would be regarded as a failure.)

            A Sinner: “By which I mean, you’ve formulated the cancer case like this: Goal – Remove the cancer,
            Means – Remove the Uterus, Side-effects of the Means – Remove the fetus, and its death

            Yes, that’s the way I see double-effect being correctly applied in that situation.

            A Sinner: “And you’ve formulated the ectopic case like this: Goal – Remove the embryo, Means – Remove the embryo (it’s both goal and means?!?), Direct Inseparable Effect of the Goal – Death of the embryo

            I presume you mean that this is a formulation I see being an incorrect application of double-effect. And I would change it slightly to “Goal: Save mother’s life; Means: Remove the embryo; Direct effect (not side-effect), death of the embryo.”

            A Sinner: “Apparently you’d prefer it to be formulated like this: Goal – Remove the threat of a hemorrhage in a pathological tube, Means – Remove the tube that will be the site of said hemorrhage, Side-effects of the Means – Also remove the embryo, and its death

            And I prefer it, because it’s a rational description of what is being done, and a correct application of double-effect, and scientifically accurate. So why would I not “prefer” it?

            A Sinner: “The way I think of it is more like this: Goal – Unblock the Tube Means – Remove the embryo Side-effect of the Means – the embryo dies”

            In the case of my preferred formulation, the answer to the question: “Why are you performing an operation to remove the tube?” would be “Because that tube is, or is very likely expected to be, the source of a fatal hemorrhage in the mother”.

            But I don’t see a similarly medically-serious answer to the question, “Why are you unblocking the tube?”

            A Sinner: “they’re removing it only as a means towards the goal of ‘removing the threat of a hemorrhage,’ which is the exact same ‘goal’ as in your preferred solution!”

            The hemorrhage occurs in the tube, not in the embryo. One thing you said in the past was: “It’s not about ‘weakened fallopian tubes,’ the fallopian tubes could be fine if the embryo weren’t in the wrong place!” Identifying the embryo as the problem that has to be fixed is just wrong. There can be pregnancy-related problems in the tube even after the embryo is taken out — even years after the pregnancy. The problems don’t even have to be in the tube — they could potentially be anywhere in the body. (I’m wondering how much you’ve looked at exactly what medical problems occur with ectopic pregnancies. Some of what you say does not seem like a reasoned response to what actually occurs.)

            A Sinner: “They’re simply another step in the chain of means to the ultimately goal of saving the mother’s life. THAT is the proximate end of ALL the procedures.”

            Yes, actions generally occur in chains (e.g. I do this, so that I can do that, so that then I can do that, etc.).

            A Sinner: “But in that case I’d ask why ‘remove the uterus’ is any less subject to this analysis in terms of its effects than ‘remove the embryo’ … both are merely means to another intent, neither is an end or goal in itself.”

            Each and every step in the chain can have its own goal, means and effects; and each and every step has to be morally justifiable. Because evil can never be intended, even as a single step in the middle of a chain of actions.

        • http://renegadetrad.blogspot.com A Sinner

          “And I would change it slightly to ‘Goal: Save mother’s life; Means: Remove the embryo; Direct effect (not side-effect), death of the embryo.'”

          Ok, then I don’t understand again. Why is “death of the embryo” a direct effect of the Means in this case, but NOT a direct effect of the Means in the uterus-removal case? In both cases it is inevitably adjunct to the means, but in neither case is the means itself the goal. It stands in the exact same causal relation, and the exact same “structural” position in terms of the analogy we’ve laid out here between them.

          “In the case of my preferred formulation, the answer to the question: ‘Why are you performing an operation to remove the tube?’ would be ‘Because that tube is, or is very likely expected to be, the source of a fatal hemorrhage in the mother’ But I don’t see a similarly medically-serious answer to the question, ‘Why are you unblocking the tube?'”

          Don’t you though? The answer is pretty much exactly the same as far as I can tell. You’re unblocking the tube “Because if you don’t, the tube will burst causing a fatal hemorrhage.”

          “The hemorrhage occurs in the tube, not in the embryo. One thing you said in the past was: ‘It’s not about “weakened fallopian tubes,” the fallopian tubes could be fine if the embryo weren’t in the wrong place!’ Identifying the embryo as the problem that has to be fixed is just wrong.”

          This is an odd way to spin it. For some reason you’re acting as if in cases where the doctors choose to remove the embryo alone instead of the whole tube, the embryo itself is being labelled “a problem” that needs to be “fixed” (in which case its death would be the direct corollary of “fixing it”). But I think that’s a bizarre way to look at it; the embryo isn’t being identified as the problem, rather the problem lies in “the wrong place.” The embryo in itself is not problematic, it’s being attached to the fallopian tube is. There’s a difference.

          However, your point here brings up a MUCH deeper flaw in your position, one which I have been anticipating.

          Basically, the way you speak here, it’s as if you think we’re talking about two different problems with two different solutions (one acceptable, one not). The way you speak it’s as if some women are suffering from “a pathological fallopian tube,” which problem can be solved by removing the tube, and that others are suffering from “an embryo,” which problem can’t be solved because it means a direct choice to solve that “problem” which practically means killing the embryo.

          However, this is absurd, because we aren’t talking about two different problems! There is only one problem! The “problems” are equivalent and absolutely identical! They are the self-same problem!

          The way you’re speaking, it’s as if you think how we choose to verbally describe the problem actually changes the nature of the problematic situation itself! And that morality comes down to choosing a “strategic” verbal formulation of the problem and then acting in accordance with the logic implied by that formula.

          But that’s ridiculous. Whether we speak of a “pathological fallopian tube” or “an embryo being in the wrong place,” we’re talking about the SAME situation. These are both describing the SAME problem, in the same woman. How we choose to “identify” the problem in terms of verbal description is not going to somehow retroactively alter the situation.

          You’re speaking as if by removing the whole tube, we’re making the problem the tube, but if we remove the embryo than we’re saying the embryo itself was problematic. But that’s silly: the nature of a problem is NOT retroactively determined by how we choose to respond to it, or what verbal construct we attach to describing it.

          In both cases it’s the same situation: an embryo has attached to the fallopian tube, and if it keeps growing it will be too big for it, will burst it, the embryo will die anyway at that point, the mother might hemorrhage out, etc. There is NO moral relevance to choosing to merely DESCRIBE, verbally, the problem as “about the fallopian tube” or “about the embryo.” Where we verbally choose to stick the label “problem” doesn’t change the practical facts ONE BIT. The WHOLE SITUATION is the problem. But in no case is the embryo itself being called a problem to be solved, merely its location.

          Any system which thinks that the morality is determined by how we choose to construct the problem verbally…is a system that is up in the clouds.

          “Each and every step in the chain can have its own goal, means and effects; and each and every step has to be morally justifiable. Because evil can never be intended, even as a single step in the middle of a chain of actions.”

          Ok, so “remove the uterus” is a goal at one step (we remove that uterus SO THAT the cancer is removed with it). It has “removing the fetus, and the fetus dying” as an effect inevitably joined to it. So why is that consequence indirect, when you insist that “get the embryo away from the wrong place” (we remove the embryo SO THAT the fallopian tube won’t burst) has the embryo’s death as a direct effect, even though the death itself has nothing to do with the logic of “getting it away from the wrong place,” albeit it later follows since we don’t currently have the technology to put it back into the right place.

          If each step in the causal chain has to be treated as a proximate end and analyzed as such, then why isn’t the step “remove the uterus” being analyzed by you as such, as a proximate goal directly attached to the fetus being removed and dying?

          • Paul Connors

            A Sinner: “Why is ‘death of the embryo’ a direct effect of the Means in this case, but NOT a direct effect of the Means in the uterus-removal case? In both cases it is inevitably adjunct to the means, but in neither case is the means itself the goal. It stands in the exact same causal relation, and the exact same ‘structural’ position in terms of the analogy we’ve laid out here between them.”

            In the case of uterine cancer, the mother is saved by removing the womb — and that removal has two effects — firstly, it removes the cancer (intended); secondly, it removes the child (unintended, but inescapable). In the ectopic case (specifically, the case where the embryo is simply being taken out of the tube), there aren’t two effects, just one — the child is removed to where it will die.

            In summary form:

            Save mother BY removing womb WHICH removes cancer and removes child WHICH kills child.
            Save mother BY removing child WHICH kills child.

            I don’t see what “structural” problem you see. The first case looks exactly the way double-effect typically looks like. And the second case is direct, and has no double-effect.

            Paul Connors: “But I don’t see a similarly medically-serious answer to the question, ‘Why are you unblocking the tube?'”

            A Sinner: “You’re unblocking the tube ‘Because if you don’t, the tube will burst causing a fatal hemorrhage.'”

            Right, it’s the tube that is the problem.

            A Sinner: “we aren’t talking about two different problems! There is only one problem!”

            Agreed: one problem. But there are two solutions — one with no direct killing, and one with a direct killing. Hence the two solutions are different.

            A Sinner: “it’s as if you think how we choose to verbally describe the problem”

            No, because the actions that take place in the two different solutions are visibly quite different. In one case (e.g. salpingectomy), the tube is cut out (which currently unavoidably contains the fetus). And in the other case (e.g.) a slit is made in the tube and the fetus is removed through it. Those are not different verbal descriptions — they’re different operations!

            A Sinner: “an embryo has attached to the fallopian tube, and if it keeps growing it will be too big for it, will burst it”

            No, that’s NOT actually what the underlying problem is. You need to look up what the trophoblastic cells are doing to the tube. The tube is being pathologically weakened, and this starts happening right from the time the fetus becomes attached to the tube. Because the trophoblastic cells affect the blood supply around the point of implantation, it becomes easy for hemorrhages to occur. For example, it’s easy for a hematoma in or near the tube to build up sufficiently for it to rupture the tube. To quote Bouscaren (who was the one who first showed that removing the tube was a permitted double-effect) “it is absolutely false that in tubal pregnancy the tube remains sound until the moment of its external rupture“.

            Reading back on previous comments, I’m wondering how much this misapprehension has affected your analysis of the problem. It certainly could lead to entirely the wrong moral conclusion about what is going on. I note that the comments from other people also make me wonder what they think the medical facts are. I strongly suspect that anyone who seemed to deny that there was a pathological problem with the tube had a radically incorrect medical picture of what was happening (e.g. Keenan), and thereby didn’t get the moral picture correct either.

        • http://renegadetrad.blogspot.com A Sinner

          “In the case of uterine cancer, the mother is saved by removing the womb — and that removal has two effects — firstly, it removes the cancer (intended); secondly, it removes the child (unintended, but inescapable). In the ectopic case (specifically, the case where the embryo is simply being taken out of the tube), there aren’t two effects, just one — the child is removed to where it will die.”

          Paul, I think we ARE going in circles now because even though I’ve approached this from a variety of angles, you won’t provide an answer for why this is so other than assertion.

          Obviously, as I’ve said many times, I think there are clearly two effects to removing the embryo; the intended effect is that it lessens the stress on the Fallopian tube to the point where, often, it will then not rupture, the mother will survive, and the tube can even function in the future for other conceptions (the second effect is the death, of course). You have never sufficiently answered why you consider this operation to have “only one effect” without recognizing that it also, in fact, effectively saves the mother tube-intact.

          You claim that these cases would be formulated, “Save mother BY removing womb WHICH removes cancer AND removes child WHICH kills child. Save mother BY removing child WHICH kills child.”

          But why not formulate the second case, “Save mother BY moving embryo WHICH takes the stress off the fallopian tube AND leads to child not being implanted anywhere WHICH leads to child’s death”?

          “I don’t see what ‘structural’ problem you see. The first case looks exactly the way double-effect typically looks like. And the second case is direct, and has no double-effect.”

          You keep insisting it has no double-effect but there are clearly two effects! The salvation of the mother tube-intact, and the child no longer being implanted and so dying. This is, however, not intended or desired because they would re-implant the child somewhere else if they knew how.

          “Right, it’s the tube that is the problem.”

          Right, but that doesn’t mean the whole tube has to simply be removed. There’s no reason you can’t also try to fix the tube while leaving it in place, by addressing the major stressor which is that an embryo has attached to the wall, in the wrong place.

          “No, because the actions that take place in the two different solutions are visibly quite different. In one case (e.g. salpingectomy), the tube is cut out (which currently unavoidably contains the fetus). And in the other case (e.g.) a slit is made in the tube and the fetus is removed through it. Those are not different verbal descriptions — they’re different operations!”

          Yes, they’re different operations, Paul. I’m not denying that they’re different solutions. What I’m saying is that two different solutions do not change the nature of the problem. The problem is the SAME in either case. Choosing this or that solution does not change what the problem is, as if one “makes” the problem the tube but the other “makes” the problem the embryo. The solution chosen has no ability to “make” the problem anything, because the problem is not determined by the solution!

          “No, that’s NOT actually what the underlying problem is. You need to look up what the trophoblastic cells are doing to the tube. The tube is being pathologically weakened, and this starts happening right from the time the fetus becomes attached to the tube. Because the trophoblastic cells affect the blood supply around the point of implantation, it becomes easy for hemorrhages to occur. For example, it’s easy for a hematoma in or near the tube to build up sufficiently for it to rupture the tube.”

          Okay, great. That still obviously doesn’t necessitate the removal of the whole tube. Doctors obviously prefer removing the embryo alone rather than the whole tube for a reason. Because they know that can lead to the same results to the same problem while leaving more of the mother intact (and, indeed, however much the Fallopian tube may have been damaged, removing the embryo takes away the major stressor and allows the tube, often, to go on functioning.)

          Indeed, Paul, if it’s a question of simply looking to identify a locus of “problem” and “solution” that is not “the embryo” because you’re afraid of touching it “directly”…then we might choose a middle-ground position and say that the problem is (instead of the whole tube, or the embryo) simply the connection-point between tube and embryo. The section of the wall where the “placental” matrix has embedded itself or something like that. This is a pathology in the tube, no?

          But would it be morally objectionable to you, if medically possible, to simply “shave out” this section of the tube’s wall rather than removing the whole tube? The side effect would still be, of course, that the embryo inevitably “rides along on” this piece of the tube’s wall…but does formulating the whole thing so that it’s “a section of the lining of the tube’s wall” that is acted on rather than “the embryo itself” satisfy you?

          If so, I think your distinctions really are purely verbal, because when the doctors remove the embryo the do, in fact, take a little of the tube’s wall with them anyway, so the procedure, I think, probably COULD be formulated as “operating on a piece of the tube, with the embryo just riding along” even when the whole tube isn’t removed. But given that the practical operation is the same, does it really matter whether you verbally describe this as “removing the embryo with a piece of the tube coming with” or “removing a piece of the tube with the embryo coming with”?? Does morality really rise or fall on the correct verbal description??

          • Paul Connors

            A Sinner: “I think there are clearly two effects to removing the embryo; the intended effect is that it lessens the stress on the Fallopian tube to the point where, often, it will then not rupture, the mother will survive, and the tube can even function in the future for other conceptions (the second effect is the death, of course). You have never sufficiently answered why you consider this operation to have ‘only one effect’ without recognizing that it also, in fact, effectively saves the mother tube-intact.”

            Somehow, somewhere, you are in disagreement with some part of my argument, but we have not been able to make it clear exactly what that disagreement is. So now let me lay out my argument for why an operation that has the goal of removing an embryo is not permitted. I will number the steps, and perhaps you could point out (as precisely as possible) the steps you are in disagreement with. As far as I’m aware, I’ve laid out in previous comments all the reasons for the steps of the argument.

            (1) IF the goal of an operation is the removal of a pre-viable child

            (2) THEN, given the current state of medicine, it follows that the child must die.

            (3) THEREFORE the death of the child must be included as part of the goal.

            (4) BUT having the death of an innocent human as a goal is always forbidden.

            (5) THEREFORE the operation is forbidden.

            (6) AND it is irrelevant what other thinking motivated the operation, no matter how good those motives.

            Note that (6) means that even if there were other goals or effects of the operation, these are all to be included in ‘other thinking’.

            I should point if the goal is instead (e.g) the removal of a cancerous womb, or the removal of a pathologic fallopian tube, then the steps of the argument don’t apply, because double-effect can legitimately be applied.

            A Sinner: “Doctors obviously prefer removing the embryo alone rather than the whole tube for a reason”

            To be precise, doctors who have no moral issue in removing the embryo may, depending on circumstances, choose to do that.

            A Sinner: “that can lead to the same results to the same problem while leaving more of the mother intact “

            Again, provided one sees no problem in removing the embryo. That two solutions have the same results doesn’t mean each solution must be equally good — because Catholics aren’t consequentialists.

            A Sinner: ” because you’re afraid of touching it ‘directly’ “

            The direct removal of an embryo doesn’t refer to some kind of physical touching. It refers to direct intention — i.e. where something is a goal, and not an unintentional side-effect.

            A Sinner: “then we might choose a middle-ground position and say that the problem is (instead of the whole tube, or the embryo) simply the connection-point between tube and embryo. The section of the wall where the ‘placental’ matrix has embedded itself or something like that. This is a pathology in the tube, no? “

            Since, usually, not the whole tube has been affected, only the damaged portion of the tube is removed, and the rest of the tube is reconnected. This has never made any difference at all to the moral argument, so I’m in the dark as to why you are bringing this up.

            A Sinner: “when the doctors remove the embryo the do, in fact, take a little of the tube’s wall with them anyway”

            It may sometimes happen, but that’s not their goal, though. In (e.g.) a salpingostomy, the goal is to remove the embryo.

        • http://renegadetrad.blogspot.com A Sinner

          “I should point if the goal is instead (e.g) the removal of a cancerous womb, or the removal of a pathologic fallopian tube, then the steps of the argument don’t apply, because double-effect can legitimately be applied.”

          THIS, I think, is where we disagree. You keep identifying the removal of the embryo as “the goal of the operation,” and say that since the death is inevitably linked, it must be considered intended with the goal.

          But then for some reason “removal of a cancerous womb” is not a goal, or if it is a goal for some reason it’s inevitable effect of removing (and killing) a fetus is not treated as part of that goal in the same way.

          But the problem is not the embryo’s existence and no one is saying it is. The problem is merely how the embryo is connected to the mother. This is as much a problem with the mother as with the embryo. Whether you unnecessarily remove the whole tube, or simply “disconnect” the embryo from the wall (it’s really the connection that’s the problem)…does not effect the nature of the choice.

          That is like saying, to go to the “electricity” example I posited at the end of the thread, that somehow it would be okay to disconnect the entire ROOM the ventilator-man was in from the hospital’s circuits, but not to disconnect the ventilator machine directly, even though, in the end, you’re only disconnecting the whole room on account of the one machine. It seems a distinction without difference, as if cutting a few millimeters further to the left, cutting a “bigger circle” around the embryo…somehow provides a monumental moral difference relative to the consequences.

          • Paul Connors

            A Sinner: “You keep identifying the removal of the embryo as ‘the goal of the operation’ “

            Because, you could ask a surgeon just before the impermissible ectopic operation, “What are you going to actually do?” And he would reply, “I’m going to remove the embryo through a slit in the fallopian tube.” And if that were not sufficient to identify what a goal of the operation was, you could also double-check and say something like, “And the removal of the embryo is actually what all those motions of your hands are designed and planned to achieve?”. And he would say, “Yes”. And we might also ask, “If you found out just before the operation that the embryo was no longer in the fallopian tube, would you still go ahead with the operation?”, and the surgeon would say, “No, there would be no point in the operation.” And we might also ask, “If there were some adjustment to the operation that would end up leaving the embryo untouched, would that be acceptable?”, and the surgeon would say, “Huh? What? That makes no sense. The point of the operation is to remove the embryo.”

            Whereas just before a permissible ectopic operation, a second surgeon would answer to the first question, “I’m going to remove a damaged fallopian tube”. And if you were to say, “I notice that removing the damaged fallopian tube will mean removing the embryo inside. Is that what the operation is also designed to achieve?” and he would say, “No, I certainly don’t want that, but I don’t know of any way to avoid it. I just have no control over that part of what happens.” And we might also ask, “If you found out before the operation that the embryo was no longer in the tube, would you still go ahead with removing any damaged part of the tube?”, and the surgeon would say, “Of course, that’s the purpose of the operation.” And we might also ask, “If there were some adjustment to the operation that would remove the damaged part of the tube, but leave the embryo completely unharmed, would that be acceptable?”, and the second surgeon would say, “Wow, that would be very surprising, but wonderful! Tell me how to do it.”

            I think considerations like that make it blatantly obvious that the goals of the two operations are radically different.

            But you should feel free to present some counter-arguments if you don’t think that’s right. As far as I can tell, your counter-arguments would seem all to be variations either of: “It’s going to happen, so it must be intended” (which would mean a total disagreement with the whole idea of double-effect), or else perhaps: “But the consequences end up the same, so it must all be the same thing”, (which would be a consequentialist argument, contra Veritatis Splendor). Aside from those, I’m unable to guess what your counter-arguments might be.

            A Sinner: “… and [you] say that since the death is inevitably linked, it must be considered intended with the goal. “

            As I’ve already pointed out, Aquinas says (which also seems obvious to me): “For what is always or frequently joined to the effect falls under the intention itself. For it is stupid to say that someone intends something but does not will that which is always or frequently joined to it.”

            If you want to disagree with Aquinas’ conclusion, present some actual counter-argument.

        • http://renegadetrad.blogspot.com A Sinner

          “And we might also ask, ‘If you found out before the operation that the embryo was no longer in the tube, would you still go ahead with removing any damaged part of the tube?’, and the surgeon would say, ‘Of course, that’s the purpose of the operation.'”

          Here is exactly where I think your position is in bad faith. The truth in real life is that, in most cases, if the doctor found out that there was in fact no embryo in the tube any longer, he would likely NOT go ahead with removing the tube anyway, as much as your “theory” suggests that he should.

          The idea that “We’re removing a pathological tube, independent of any notion of the embryo being in there” seems to be usually a “winking” formulation created to “get around” the fact that the problem is the situation of the embryo.

          It is revealed to be “winking” however by the fact that I am certain your prediction here is actually wrong; if the embryo were gone, that would totally affect the doctor’s decision and approach in most cases, because the “independence” of the “pathological tube” from the embryo issue is, practically speaking, often just a winking verbal construct.

          “I think considerations like that make it blatantly obvious that the goals of the two operations are radically different.”

          Only as a verbal construct, though. As I said, in real life the very pathology of the pathological fallopian tube IS the presence of the embryo (or directly related to it) and so whether you remove the whole tube or just embryo…the embryo is still being treated, in some ways, as analogous to a cancer of the tube.

          Doctor’s trying to maintain some technicality can wink and say “Oh, no, we’re removing the tube because it’s weakened at this point regardless of the embryo.” And yet, most doctors seem to think removing the embryo itself is enough, and that the whole tube is not particularly in need of removal once it is gone.

          If the whole tube really needed to be removed, then there would never be a question of just removing the embryo; it would simply be always the medical course of action to remove the whole tube. But why isn’t it? Obviously, because most doctors judge that the situation is sufficiently remedied by just removing the embryo.

          The doctors who remove the whole tube, then, and invoke double-effect…basically seem to be exaggerating the situation (and providing an unnecessarily invasive solution) merely in order to provide themselves a moral/ethical fig-leaf that lets them “work around” the embryo’s presence by “cloaking it” in the “whole tube section.”

          I might understand the distinction you were making if, in practice, it were a sincere distinction. But in practice it’s quite clear that it’s not. Rather, it seems that, in practice, the doctors who remove the whole tube are trying to pretend that the problem they are addressing is totally independent of the embryo’s presence and so make it analogous to the cancerous uterus case, when really the problem still is the embryo’s presence and merely constructing it differently verbally doesn’t change that fact.

          • Paul Connors

            A Sinner: “The truth in real life is that, in most cases, if the doctor found out that there was in fact no embryo in the tube any longer, he would likely NOT go ahead with removing the tube anyway, as much as your ‘theory’ suggests that he should.”

            Could you please refer us to a medical paper that documents the estimated likelihood of such a course of events? Or some such equivalent documentation? You somehow confidently say “most cases” and “likely”. Where is your evidence from?

            It would be a reckless doctor who did not consider what the level of tube damage was (based on all the diagnostic information available), and thus decide on the need for an operation, even though the embryo was no longer there. And this by itself distinguishes the operation from the embryo-removal operation (which is completely ruled out, since it would be utterly nonsensical). So you still haven’t demonstrated what you wanted to.

            A Sinner: “It is revealed to be ‘winking’ “

            What exactly is this “winking”? Are patients glad that there is a morally permissible operation that saves the mother? Of course! How is that “winking”?

            A Sinner: “most doctors judge that the situation is sufficiently remedied by just removing the embryo”

            Therefore — what??? Are you proposing to decide moral issues by letting doctors vote?

            A Sinner: “The doctors who remove the whole tube, then, and invoke double-effect … basically seem to be exaggerating the situation”

            Huh? Exaggerating??? You seem to be saying that nothing medically dangerous is going to happen to the tube — apart from a grave risk to the mother of dying when it hemorrhages!

        • http://renegadetrad.blogspot.com A Sinner

          If the removal of the whole tube apart from the embryo were truly necessary, all doctors would remove the whole tube and why would there ever be any question of removing just the embryo??

          It seems to me that you WANT the removal of the whole tube to be medically necessary (even though many doctors apparently think removing the embryo alone is sufficient) just so that you can fulfill your version of double-effect.

          • Paul Connors

            A Sinner: “If the removal of the whole tube apart from the embryo were truly necessary, all doctors would remove the whole tube and why would there ever be any question of removing just the embryo??”

            If doctors decided to help assist in suicides, would that make it good? If doctors decided to euthanize, would that make it good? So why refer to removal of the embryo as though merely the fact that some doctors do it (for whatever reason) means it’s morally legitimate to consider it?

        • http://renegadetrad.blogspot.com A Sinner

          Huh? I’m not saying that doctors’ willingness to do it means that it is morally legitimate or not.

          I’m saying that the fact that most doctors treat an ectopic pregnancy simply by removing the embryo…is pretty strong evidence against the idea that removing the whole tube is a “medical necessity.”

          And if removing the whole tube is not a medical necessity, then arguments whereby one is treating “the pathological tube that must be removed” rather than simply the presence of the embryo…well, they start to seem rather “winking,” and like the means was chosen simply to invoke a moral loophole rather than because anyone really believed the whole tube “needed” to be taken out.

  • Liam

    I’ve suspected the development (reverse engineering, perhaps?) of guidance in this area has been ruddered by the consideration that the fetus has not been baptized but the mother has had the opportunity for baptism, hence the greater care given to considerations of the fetus’s life….

  • Chris Sullivan

    IMHO, it is morally licit to surgically remove a fetus where necessary to preserve the life of the child and/or mother. We do this all the time in caesarean sections – so such an operation cannot be per se wrong. It ought to be done in such away that the operation itself does not kill or injure the child and every effort made to keep the child alive outside the womb, although sometimes current technology limits our ability to do this; therefore any death of the child is an unfortunate consequence of our limited ability to keep the child alive outside the womb and not a direct or intended consequence of the life saving operation itself.

    The moral object of such operations are to save life and not to procure abortion. They were taught as licit by Pope Pius XII.

    God Bless

    • Jordan

      At least one conservative school actually considers the direct removal of a live but inviable fetus by caesarean to be abortion even in cases where the removal of the fetus is absolutely necessary to save the life of the mother. The most moral approach in the view of this school is a full hysterectomy. Now, I don’t know the specifics of the Phoenix case, but I suspect that a full hysterectomy when the mother in labor is in significant medical distress would be highly unadvisable and perhaps almost certainly fatal. Also, even a successful “routine” hysterectomy, as with any major surgery, carries a great many possibilities for complications. The “hysterectomy or nothing” school of jurisprudence strikes me as completely academic and almost wilfully blind to practical realities. The former intellectual deficits are common to those afflicted with the XY chromosomal pair. 😉

      Some might say that an avoidance of any semblance of direct abortion is more important than the risk of death to the mother from a dangerous emergency hysterectomy. That’s a judgment that will inevitably appear to many as callous at best.

      • http://emmasrandomthoughts.wordpress.com emmasrandomthoughts

        “The “hysterectomy or nothing” school of jurisprudence strikes me as completely academic and almost wilfully blind to practical realities.”

        It’s these kinds of thought patterns that make me sympathetic to feminists who talk about the difference between the Church’s teachings on killing and the Church’s teachings on sexual matters.

    • http://renegadetrad.blogspot.com A Sinner

      Right. And whether the child is removed on his own, or rather “riding along” attached to a piece of the mother…doesn’t matter.

      There’s a lot of criticism of double-effect in this thread, but double-effect isn’t the problem with the over-simplistic “conservative” position at all. The problem with the conservative position is actually that it MISunderstands the requirements of double-effect regarding what constitutes a side effect versus a directly chosen object.

      If the death is not necessary (as Grisez explains) for the intended end of saving the mother, then it is a foreseen but unintended side effect of the means (“removal”) chosen to accomplish the intent of saving the mother.

      There is no need, however, to add an additional step of removing the Fallopian tube. In that case, you’re actually making the death “a side-effect of a side-effect” (ie, the removal of the embryo is a side-effect of removing the tube, and the death is a side effect of removing the embryo since no means to save it is yet available). However, double-effect does not require TWO “layers” of indirectness like this, merely one. So removing the tube with the embryo is unnecessary.

      The error among conservatives seems to be in viewing removing the embryo and directly choosing its death as equivalent. But they aren’t; the death is a subsequent RESULT of the removal, but only because artificial wombs aren’t invented yet.

  • http://emmasrandomthoughts.wordpress.com emmasrandomthoughts

    The whole idea that removing the fallopian tube does not make the doctor responsible for the death of the embryo is a strange idea.

    Let’s say, for the sake of the argument, that I am on a spaceship with an door that opens to the vacuum of space. I am in another room in the spaceship and I give a command to open the door, allowing a man in the room to be sucked into the vacuum of space where he dies. (Of course.) Am I not responsible for his death of this man, because all I did was open the door and remove him to the vacuum of space? Am I less responsible for his death than if I simply shoot him?

    • http://renegadetrad.blogspot.com A Sinner

      Well, shooting isn’t necessarily a very good example. The issue isn’t so much that he dies, as why he needs to do so. If there is some OTHER reason the door needs to be opened (to save other lives, let’s assume) and his death is simply the result of that…then that’s, morally, a “side effect.”

      Whereas shooting him, in that case, makes it sound like you’re choosing his death as an end in itself. The only case I can think of where shooting is not necessarily directly choosing death is in a self-defense case where you shoot someone “to incapacitate” rather than to kill (even if you know the incapacitation will lead to their death).

      There are also thought-experiments about people trapped in a cave with limited oxygen and a long time before the rescuers reach them, where everyone will die if everyone keeps breathing, but where half could survive if half were dead. Such a case is very hard, of course, in terms of prioritizing who deserves the air (which amounts to: who deserves to live). But, assuming some people heroically volunteered or there was a clear priority (like if some are infirm and won’t survive anyway), it would not necessarily be directly choosing death to “reserve air consumption for the chosen half” even if this means, practically speaking, suffocating the others. This may seem an absurd distinction, but consider the same thing when the resource is food rather than air: choosing to feed those who can survive in an analogous situation is not morally the same as choosing to starve the others, even though that’s the side-effect. It’s not that you actively want to withhold food from them and have them die, it’s that there is only so much food and it is being used for another purpose.

      But certainly, the idea that there is a moral distinction between opening the door and letting him get sucked out, and pushing him out actively, is silly.

      • http://emmasrandomthoughts.wordpress.com emmasrandomthoughts

        You’re right, pushing him out is a better way of phrasing it than shooting. I was mainly thinking of an episode of Doctor Who where Rose kills a villain by shooting out a window in a spaceship so that the villain can get sucked out into space. The writers speaking on the commentary for the episode said that they cannot have the Doctor or his companions actually shoot someone. They have to invent more complicated ways for them to destroy the bad guys. That always stuck with me because they seemed to be saying that the Doctor and his companions can’t directly kill someone. But Rose did kill the man. Of course, that probably has more to do with squeamishness about gun violence, but I don’t think that a person can argue “Hey, Rose didn’t kill the guy, she just opened a door or shot out a window.”

        I was thinking about this again when I was watching Argo. I was thinking about how most Catholic moral theologians throughout history would have found the central action of the plot to be immoral. The main character and the supporting characters save lives of hostages by staging an elaborate lie. If moral theologians were in charge of the CIA, the hostages would have been killed.
        At times like that, I favor the Eastern view of sin, as medicinal, rather than forensic Western approach. It seems to spend less time straining gnats and swallowing camels.

  • http://gaudetetheology.wordpress.com gaudetetheology

    @Paul Connors:

    There are a variety of places that an ectopic embryo can implant. Whether these are viable depends on where the implantation occurs, not on the embryo. If the embryo can get a sufficient blood supply, and without causing maternal hemorrhages, it can be (and has been) carried to term.

    If there were some way of medically treating the point of implantation so as eliminate the various blood supply problems, then such treatment would allow the embryo to be carried to term.

    I.e. it’s the point of implantation of that is the problem.

    This description is so embryo-focused that it thoroughly depersonalizes the woman whose body is being affected by all this: it renders her invisible as a person.

    Not to pick on Paul specifically, because the vast majority of discourse on this topic has the same problem: I happened to particularly notice it here, because I wondered about those cases in which ectopic pregnancies had been carried to term. What were the women’s experiences during pregnancy, compared to a uterine pregnancy? How were the babies delivered? What were the short and long term effects on the women’s health and medical condition?

    We have uteri for a reason. I find it difficult to believe that a woman can carry an ectopic pregnancy to term without severe and potentially disabling consequences.

    • Paul Connors

      gaudetetheology: “This description is so embryo-focused that it thoroughly depersonalizes the woman whose body is being affected by all this: it renders her invisible as a person.”

      Most of the medical industry is set up to kill ectopic pregnancies as quickly as possible, without affecting a woman’s subsequent fertility. There’s very little impetus from anyone to aim at doing things differently.

      gaudetetheology: “I find it difficult to believe that a woman can carry an ectopic pregnancy to term without severe and potentially disabling consequences.”

      If you google it, you will find that it is not unknown for there to be full-term ectopic pregnancies, with both mother and child healthy.

      • David Cruz-Uribe, SFO

        It is not unknown for women to have ectopic pregnancies continue to the point of delivering a (premature) baby, usually after surgical intervention. It appears to be rare to the point of miraculous for a woman to carry a baby to term, and even then it requires a caesarean to deliver it. I have found exactly one well documented case. I am not saying there are others, but they are vanishingly rare.

        The usual outcome of an ecotopic pregnancy, when left untreated, is internal hemorrhaging followed by a painful death for the mother and the misimplanted child. This needs to be kept firmly in mind as we discuss the ethics of treating this problem. The “medical industry” has been worried about this problem for far longer than abortion has been normalized: this is is why it has been a subject of debate by ethicists for more than 100 years.

        • Paul Connors

          David Cruz-Uribe: “It is not unknown for women to have ectopic pregnancies continue to the point of delivering a (premature) baby, usually after surgical intervention. It appears to be rare to the point of miraculous for a woman to carry a baby to term, and even then it requires a caesarean to deliver it. I have found exactly one well documented case.”

          Some more can be found here.

          And an interesting case where an ectopic pregnancy started in the fallopian tubes, and later moved to the outside of the uterus:

          The last case is particularly significant, since it evidently shows that moving a pregnancy from one place to another is certainly possible (and thus very far from “miraculous”) — but there is very little research being done on how this is achieved. (Because the child has no voice, and no insurance?)

          • David Cruz-Uribe, SFO

            Paul, I have to ask: what point are you trying to make by focusing on these exceptional cases?

      • http://gaudetetheology.wordpress.com gaudetetheology

        gaudetetheology: “This description is so embryo-focused that it thoroughly depersonalizes the woman whose body is being affected by all this: it renders her invisible as a person.”

        Most of the medical industry is set up to kill ectopic pregnancies as quickly as possible, without affecting a woman’s subsequent fertility. There’s very little impetus from anyone to aim at doing things differently.

        I don’t see how this statement is responsive to the portion of my comment that you quoted.

        Indeed, it further exemplifies the problem by talking about the woman only in terms of her fertility, and about a pregnancy as something that can be “killed.” Pregnancy is a state whose subject is a woman. You can kill a woman, you can arguably kill an embryo, but you cannot kill a pregnancy.

        • Paul Connors

          “Most of the medical industry is set up to kill ectopic pregnancies as quickly as possible, without affecting a woman’s subsequent fertility. There’s very little impetus from anyone to aim at doing things differently.”

          gaudetetheology: “it further exemplifies the problem by talking about the woman only in terms of her fertility, and about a pregnancy as something that can be “killed.” Pregnancy is a state whose subject is a woman. You can kill a woman, you can arguably kill an embryo, but you cannot kill a pregnancy.”

          I thoroughly agree. How can I not? It was my point too.

  • David Cruz-Uribe, SFO

    I want to thank everyone for their very thoughtful comments above. I want to begin by echoing gaudetetheology’s point above: while valuable, I agree that in many places this discussion depersonalizes the woman involved to such an extent that I want to remind folks of the trope used in much pro-life literature: when treating a pregnant woman, there are TWO patients involved. It bears saying repeatedly during any discussion of an ectopic pregnancy: the goal is to save the life of a woman whose unborn child is sure to die. Discussions about artificial wombs, transplanting embryos, etc. are interesting in the abstract but are too hypothetical to have much bearing on the real case before us. In this regard I find A Sinner’s attempts to rescue the principle of double effect in this case heroic, but ultimately unsatisfying. They seem to rely far too much on abstract distinctions that I am frankly having a hard time following. (However, see my next comment.)

    What I do want to call attention to is the fact that many people are drawing parallels with other cases, some fanciful and others quite real. Keenan, in the article cited above (which I found very illuminating and I recommend to everyone) makes the point that causuistry is not the application of abstract principles (what he calls the geometric method–I would have called it the deductive or a priori method) but rather reasoning from cases which have both internal and external certitude regarding their moral rightness: internal meaning that on close examination the answer seemed compelling, external meaning that recognized theologians also judged it correct and used it as a model for other decisions. (Internal certitude is a ramped up version of what I referred to above as my intuition about this case.)

    In his argument, the principle of double effect is a heuristic for comparing cases and discerning if they are sufficiently alike to use the conclusion in one to draw conclusions about the other. He argues that it is incorrect to apply the principle of double effect as a justifying principle: any solution that satisfies the four conditions of the principle is therefore to be regarded as morally licit, without reference to other, established precedents. Here is how he puts it:

    “The frequent contemporary urge to invoke the principle for certain problems and to offer solutions that are convoluted simply to conform to the principle’s conditions is disturbing. The paradigm for this method is [the solution of removing the fallopian tube to end an ectopic pregnancy] but there are related cases, e.g. using perforated condoms for fertility testing or for artificial insemination by a husband. Faced with an obstacle, e.g. no direct abortion, no self-stimulation, etc. a moral theologian tries to find a compassionate solution but the solution itself lacks right reasoning and therefore, moral certitude. When we hear proposed solutions in these cases, a doubt arises, a suspicion about “who’s fooling whom,” a realization that the compelling insights of the paradigm cases are lacking in these newfangled methods.”

    In his conclusion, Keenan argues that in the end, the case of the ectopic pregnancy the option of removing the embryo is so compelling that it has the desired internal certitude, and, given the theologians who accept it, has external certitude as well. He cites John T. Noonan: “the principle that can be discerned in them is, whenever the embryo is a danger to the life of the mother, an abortion is permissible. At the level of reason nothing more can be asked of the mother.”

  • David Cruz-Uribe, SFO

    Keenan, in analyzing the application of the principle of double effect to ectopic pregnancy, proceeds by using the principle to compare it to a well established principle: it is licit to remove a cancerous uterus even if it results in the death of the fetus. He points out that there is a substantial difference between the two cases, one which he feels means that the case of uterine cancer cannot be used as a guidepost for resolving the case of ectopic pregnancy (the edits below are to remove references to another case he is also analyzing which I want to omit):

    “Turning to…the ectopic pregnancy, we may still think that if the removal of the cancerous uterus during pregnancy is legitimate, so is the removal of the defective [fallopian] tube…Is ot the presence of the embryo just as “accidental” in the excision of the fallopian tube as it is in these other cases? No, and we should see why not.

    “Admittedly, one can cut a fallopian tubes at times other than pregnancy. Certainly, just as we can…remove uteruses at times when no innocent life is endangered, so we can cut fallopian tubes. But, in the case of the ectopic pregnancy, we are cutting the tube only because the embryo is there…We do not…remove the cancerous uterus only because it contains a fetus. Yet, one’s reason for cutting the fallopian tube includes the removal of the embryo. The object of the activity cannot exclude as “accidental” the effect of the embryo’s removal, precisely because the embryo’s removal is not an effect. Rather, the embryo’s removal is intrinsic to the object of the activity: the only part of the tube to be removed is that in which the embryo adheres.”

    This seems to have a great deal in common with A Sinners arguments above. However, rather than trying to continue to work with the principle of double effect to reach the solution that removing the embryo directly is legitimate, he simply rejects the principle in this case precisely because it does not provide a map from an established precedent. He instead chooses to argue using different principles entirely.

    • http://renegadetrad.blogspot.com A Sinner

      It certainly seems to be the same argument as mine for why there is no distinction between removing the tube and just removing the embryo.

      It departs, I suppose, in viewing the removal as still a direct abortion rather than recognizing the ability to abstract the removal from the death and to consider one as instrumental but the other not.

      Some may find that ability to abstract the two (but not yet in practice) too “hypothetical.” I understand the objection, but am personally not unsatisfied nonetheless as it boils down to something very concrete indeed: the doctors don’t want the baby to die, they’d save it if they could, the death itself is not necessary in the abstract, and it’s hard to call something you don’t want a direct choice. The rest is just fitting that intuition into established frameworks.

      • David Cruz-Uribe, SFO

        I see your point. However, I think Keenan (and I really recommend his article) makes the objection that “fitting the intuition into established frameworks” doesn’t work. I tend to agree since I find it hard to think of removing the embryo, whatever your motivations for doing it, as anything other than a direct choice. You are choosing to end one life to save another, given the fact that otherwise both will die. But again, maybe these finer distinctions are necessary.

        • http://renegadetrad.blogspot.com A Sinner

          Removing the embryo IS a direct choice in my analysis. What is not directly chosen is the death that results subsequently from the removal. That’s the nature of a “foreseen side-effect” in double-effect. It’s a result we know will ALSO be caused by an act we take, but not in itself our intended reason for doing so.

          The doctors directly choose to remove the embryo, yes. But they don’t choose to remove the embryo in order to kill it! They choose to remove it so that it won’t rupture the mother and kill them both. But their “why” for removing the embryo is NOT “to kill it,” nor is its death instrumental to their procedure at all (if it somehow survived, the procedure would still be a success); the death is not a cause at all. To be “directly chosen,” morally speaking, the death would have to be either the intent (the desired end), or at least a means (something in the direct “chain of causes” proposed for effecting that intent.)

          Sometimes when the ectopic pregnancy is removed it dies. Other times (to use the medical examples you cite above) they are able to place the premature baby in an incubator and save it! So “removal” is clearly not equivalent to “killing” because sometimes (in later-term ectopic pregnancies) the removal DOESN’T even result in the baby’s death.

          Yet the nature of the intent and moral object of the removal does not suddenly change with pre-viability babies. It’s not as if the doctors are suddenly doing a different procedure or have a different motive when they remove an ectopic pregnancy at 24-weeks and put it in an incubator and it survives versus when they do it at 12-weeks and they are (foreseeably) unable to save it after the removal. Indeed, where would you draw the line? At the age when there is a 75% chance of survival? 50%? 20%? Crossing the viability line doesn’t change the internal logic of the removal procedure, only the foreseen consequences, and even then we’re not talking about some absolute line but rather a gradient of probabilities.

          Although certainly doctors should try to wait as long as possible to give the baby the best chance of survival post-removal, ultimately the age of the baby changes nothing about the internal moral structure of the act, the only consideration that changes is that of foreseen consequences.

          But this should be sufficient to show that choosing “removal” is not equivalent to directly choosing “death,” which is a foreseen effect of the removal in some cases, yes, but a SIDE-effect given that the embryo’s subsequent death is not at all the intended reason for the removal which is, rather, stopping the mother’s tube from bursting.

          A doctor removing an ectopic pregnancy at 24-weeks is not doing a radically different TYPE of act compared to a doctor doing it at 12-weeks. Indeed, in kind, the acts are the same and with the same intent. The only difference is in the probable consequences given current incubatorial technology.

    • Paul Connors

      David Cruz-Uribe: “Keenan, in analyzing the application of the principle of double effect to ectopic pregnancy…”

      As you point out, Keenan (found here) is against the principle of double effect, claiming that it gives the wrong answer in the case of ectopic pregnancy. Unfortunately his lines of reasoning are either medically wrong, logically wrong, or very strange. For example:

      Keenan: “T. Lincoln Bouscaren refined [the double-effect argument] and claimed that in an ectopic pregnancy the tube itself was pathological.”

      It is strange to present what has been, for a long time, common medical knowledge (that the fallopian tube in an ectopic pregnancy is a source of potentially fatal bleeding) as merely the claim of a moral theologian. (Phrasing things that way makes it unclear if Keenan actually believes the tube is pathological.)

      Keenan: “Yet, one’s reason for cutting the fallopian tube includes the removal of the embryo.”

      He says that as though it were necessarily true. Surely, someone might (erroneously) have that as their reason — but it is certainly not necessary.

      Keenan: “the only part of the tube to be removed is that in which the embryo adheres.”

      Because it’s the part of the tube which is pathological! And the embryo can’t be detached from the pathology!

      Keenan tries to make the case that the whole point of removing the tube is also to remove the embryo. His line of argument fails. In which case, he has done nothing to delegitimize double-effect.

      • David Cruz-Uribe, SFO

        Keenen’s point is that referring to an otherwise healthy fallopian tube as “pathological” to justify its removoal while ignoring the cause of the pathology (the embryo misimplanted into it) is straining out gnats and swallowing camels. As I replied elsewhere to A Sinner, and I think this is Keenen’s point: to deny that you are removing the fallopian tube precisely because you are removing the embryo is to engage in moral obfuscation. There is no other reason to remove the fallopian tube.

        • Paul Connors

          David Cruz-Uribe: “Keenen’s point is that referring to an otherwise healthy fallopian tube as ‘pathological’ to justify its removoal while ignoring the cause of the pathology (the embryo misimplanted into it) is straining out gnats and swallowing camels. As I replied elsewhere to A Sinner, and I think this is Keenen’s point: to deny that you are removing the fallopian tube precisely because you are removing the embryo is to engage in moral obfuscation. There is no other reason to remove the fallopian tube.”

          Pregnancy can bring on quite a few medical problems. If the mother has high blood pressure, we treat that. If the mother has preeclampsia, we treat that. If the mother has anemia, we treat that. If that mother has gestational diabetes, we treat that. Wherever the problem is, that’s what gets treated. And the problem can progress as the pregnancy progresses.

          In an ectopic fallopian pregnancy the fallopian tube really is, or will become, pathological (there simply isn’t any scientific doubt about this). It’s thoroughly rational to treat it by removing it. This would be exactly the same as the cases above, except that the embryo and the fallopian tube are inextricably co-located. It’s that circumstance that makes it so difficult.

          So, Keenan’s point is simply not valid.

          • David Cruz-Uribe, SFO

            Gnats, camels. At this point I don’t see any grounds to continue.

          • Paul Connors

            As you wish.

        • http://emmasrandomthoughts.wordpress.com emmasrandomthoughts

          FWIW, the treatment for preeclampsia is a Casesarian section, the removal of the baby.

  • http://turmarion.wordpress.com turmarion

    FWIW, the <a href="http://en.wikipedia.org/wiki/Ectopic_pregnancy"Wikipedia article on ectopic pregnancy is really informative and fascinating. I actually learned quite a bit I didn’t know by reading it.

  • Ronald King

    What is the empathic response to this crisis?

    • David Cruz-Uribe, SFO

      A very good question? Can we find a response that is both just and sympathetic? The arguments based on the principle of double effect were intended to accomplish this, but as I have indicated seemed to depend on mental gymnastics to no good end. The accusation being raised is that to move away from this solution is to indulge mercy while betraying justice. I don’t buy it, but I see that this is an area where careful thought is required.

      • http://renegadetrad.blogspot.com A Sinner

        Well, to be fair, you might find MY double effect argument to be “mental gymnastics,” but at least practically speaking it winds up with the “intuitive” course of action intact (save the mother, but without unnecessarily sacrificing the integrity of her fallopian tube just for a moral loophole).

        If the point is just to get what is right done, then the most efficient response, it seems to me, is not to try to dismantle orthodox frameworks entirely (you will meet way too much resistance) but rather to try to make the most effective argument you can WITHIN orthodoxy, best the conservatives with their own logic, as it were.

        • David Cruz-Uribe, SFO

          I see your point. The problem is, as Keenan points out, that this is not the only place in which the principle of double effect is abused or used to produce such tortuous “solutions” that they leaving people scratching their heads and wondering what why the Church insists on such convolutions for no good reason.

          And, since the principle of double effect is not that old (in the grander scheme of Church history) I think it is worth exploring what else our tradition has to offer on this question.

        • http://renegadetrad.blogspot.com A Sinner

          But an abuse shouldn’t make us discard a use. In reality, as I think I’ve shown, there’s a good argument that the result implied by double-effect is NOT the “tortuous” one at all, and that this comes (as Lysaught argues) from a 20th century confusion (and reduction to physicalist criteria) about the nature of the moral object and what constitutes “direct action.”

          Just because ideologues have made a muddle of good principles doesn’t mean we should discard the principles just because they are now “tainted” by the muddle created by the ideologues. We should just strive to correct the muddle.

    • Jordan

      Ronald King [September 4, 2013 2:43 pm]: What is the empathic response to this crisis?

      There isn’t an empathetic response, really. Double-effect equivocation only enters into the issue of the life or death of a mother because Catholicism’s teaching on life issues, and moral theology writ large, is fundamentally gynophobic. Astute Catholics know this, and try to humanize potential medical emergencies which would necessarily kill the mother unless there were some way to fudge moral theology and kill the unborn child directly, indirectly, or through a mental serpentine Candy Land path. No man (vir) of good will wants his wife, daughter, or friend to die simply because the Catholic moral theological domino rally, if played in a calculating fashion, would almost necessarily result in the death of the mother.

      Notice I didn’t type “misogynist”. There’s a difference between “gynophobic” and “misogynist”. Christianity is one of the few religions which offered a scriptural framework for social egalitariarism. However, even the Pauline “body metaphor” was in many respects compromised by paterfamilialism. Indeed, even in the Gospels and the later elaboration of the Christian faith, Mary’s role is ultimately intercessory and wholly dependent on God the Son. This is not unlike a Roman or hellenistic household, where the necessarily male clan leader (paterfamilias/οἰκονόμος) held life-or-death control over all other women, younger men, and slaves in his household. In this respect, Christian moral theology is to some degree gynophobic as women are necessarily subordinate to men in Christianity despite its radical advances in scriptural gender equalization. Christianity could not, and still to some degree cannot, break the fetters of cultural expectation.

      Double-effect debates on life are rather like the world’s most complex Swindon roundabout so long as only persons with penises participate. This is why I tend not to get involved. I would greatly encourage this very same discussion, but instead restricted to the thoughts, concerns, and insights of women only.

      • Ronald King

        Jordan Your last line seems to me very empathetic. It is the woman who faces the crisis of life and death in this situation and it is she who grieves no matter what decision is made.

      • http://emmasrandomthoughts.wordpress.com emmasrandomthoughts

        I’m curious about your distinction between gynophobic and misogynistic. Obviously, one can fear something without hating it. Do you imply that the Catholic moral teaching fears women, or simply their bodies? I wouldn’t necessarily argue against this assertion, just trying to parse out your exact meaning.

      • Jordan

        emmasrandomthoughts [September 7, 2013 9:59 am]: Thank you Emma for the good points. I chose “gynophobic” over “misogynist” because, as you write, it is possible to fear something without hating it. Perhaps Christianity has an ambivalence about women which stems from the Incarnation: women (as an archtype) are the new Eve and also the locus of the entry of God into his creation. Certainly, other world religious traditions potray incarnation differently: Athena was born from the forehead of Zeus, and the Vedic epics have almost innumerable instances of non-human conceptions of avatars.

        Because Christian salvation history chose a uterus for its single incarnation, it has to struggle with the exaltation of Mary versus the peril of childbirth. Who to save, the God-Man or the woman who bore him? Mary is not divine. Because Christ came to us in the form of a child, it is the child who receives the priority. This is difficult for postmodernity/postchristianity to sometimes fathom, but we must consider this reality soberly.

        • http://gaudetetheology.wordpress.com gaudetetheology

          Because Christian salvation history chose a uterus for its single incarnation, it has to struggle with the exaltation of Mary versus the peril of childbirth. Who to save, the God-Man or the woman who bore him?

          It would be clearer to render Deus-Homo as God-Human, which more correctly conveys the intent of the Latin, especially when you are discussing Christianity’s perspective on women and men.

          You seem to be mapping every pregnancy onto Mary’s pregnancy, for purposes of moral reasoning. I don’t follow your reasoning here – can you explain?

          Mary explicitly consented to bear this child. This makes her pregnancy fundamentally different from pregnancies that result from sexual intercourse, which may or may not result in pregnancy. Does this affect your reasoning?

  • Ronald King

    Is there true justice without empathy?

  • http://www.personhoodinitiative.com Bill Fortenberry

    I have discovered more than 400 cases of live birth from ectopic pregnancies which have been reported in medical journals, and by my calculations, there is a 25% chance that an ectopic pregnancy which is permitted to continue to term will result in a live birth. I have further discovered that there is a greater than 96% likelihood that the mother will also survive.

    You can find my research on my website at: http://www.personhoodinitiative.com/ectopic-personhood.html

    • http://renegadetrad.blogspot.com A Sinner

      That’s fascinating.

      However, it really has little bearing on the question of whether removal of the non-viable embryo constitutes a different (and evil) moral object compared to removing a viable one.

      This data has a bearing on how we analyze the foreseen consequences and the various probabilities involved in terms of proportionality. It might lead us to the conclusion that removal of the embryo (whether attached to a section of Fallopian tube or not) is not justified in many cases because the risk to the mother is actually rather low and that combined with the chance of the baby surviving if left in place a while longer does not outweigh the certainty of its death if removed.

      However, in itself that is not an argument one way or the other for the intrinsic illiciety of such removals as a species of act. It effects our analysis of the consequences in a way that might suggest much fewer removals (of embryo or tube) are needed than currently take place, that proper proportionality is not being observed. But it says nothing about the intrinsic moral status of the type of act in the abstract.

  • http://gaudetetheology.wordpress.com gaudetetheology

    Paul wrote:

    the killing of an innocent is not allowed for any reason

    For this to be an argument in support of the absolute prohibition of removing an embryo or fetus that is endangering the life of a woman, one must construe “killing” strictly to mean “deliberately taking an action that will result in a death”, and strictly omit the meaning “deliberately refraining from action that would prevent a death.”

    Only such a construal leads to this statement, which I frankly find morally loathesome:
    all the arguments referring to saving the mother are completely irrelevant.

    If you do not love the woman whom you have seen, who is standing right in front of you, how can you claim to love the embryo or fetus whom you have not seen?

    • http://renegadetrad.blogspot.com A Sinner

      And, of course, choosing to NOT remove the embryo is a choice too, one that may result in two deaths. So why isn’t that being condemned by Paul Connor as intrinsically evil too? Only according to an “active/passive” distinction that exists only in the physical order, but which is nothing in the internal moral order. A choice “not to do” something is still an active choice on that plane. So once again, a definition of the moral object “murder” which defines something as such based on the CONSEQUENCE of death resulting from the proposed action…is insufficient for distinguishing, for example, self-defense, etc etc.

    • Paul Connors

      gaudetetheology: “… and strictly omit the meaning ‘deliberately refraining from action that would prevent a death.’ “

      Omit that? Certainly not. In effect, there are two rules.

      (a) Never intentionally take the life of an innocent by action.
      (b) Never intentionally take the life of an innocent by inaction.

      And never break either one.

      gaudetetheology: “If you do not love the woman whom you have seen, who is standing right in front of you, how can you claim to love the embryo or fetus whom you have not seen?”

      You shall not be partial in judgment; you shall hear the small and the great alike (Deu 1:17 RSV)

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  • Jordan

    re: gaudetetheology [September 8, 2013 9:09 am] [transferred for space]. Thanks for the questions. You are entirely right that Deus-Homo should be “God-Human” by virtue of Latin alone.

    You seem to be mapping every pregnancy onto Mary’s pregnancy, for purposes of moral reasoning. I don’t follow your reasoning here – can you explain?

    Marian veneration has enshrined the fiat of the Annunciation as a woman’s ideal response to the discovery of conception. In fact, Mary’s “let it be” has been amplified into a meta-metaphor for every Christian’s ideal response to the will of God and the weight of a personal Cross. The incarnation, maternity, and nativity have become the archtype for pregnancies because the Church, through Marian veneration, has subsumed even non-gestational human life events and travails under Mary’s fully human assent to the divine will. The manner of conception does not strike me as important. This is more important: the magnification of the Annunciation into the ideal Christian response to the divine suggests that all of the Christian life is couched in a gestational metaphor.

    Mary explicitly consented to bear this child. This makes her pregnancy fundamentally different from pregnancies that result from sexual intercourse, which may or may not result in pregnancy.

    I find it disturbing that you consider human sexuality overall to be intrinsically less capable of consent than Mary’s (very human) consent just because conception through sex cannot be predetermined in time. Is the opposite of Mary’s foresight of conception little or no consent in human sexuality? It is certainly true that an intrinsic part of the Christian mission is to care and pray for those who have been harmed through non-consensual sexuality. Particularly, Christians must avoid the exploitation of the victimized through shame and self-righteousness (certainly the shaming and ostracization of women who have had abortions is misogyny!). However, women and men both can give full consent to sex and the responsibility for possible conception. The humanity of this consent and responsibility is just as human as Mary’s consent to accept the incarnation of Christ. The responsibility for both divine incarnation and human reproduction resides in response, not circumstance.

    • http://gaudetetheology.wordpress.com gaudetetheology

      Jordan, thanks for your replies. We’re veering pretty far from the topic of the post, so I will respond only briefly:
      Marian veneration has enshrined the fiat of the Annunciation as a woman’s ideal response to the discovery of conception.
      I have never encountered this specific notion, only that Mary’s “yes” is the ideal human response to God in general.
      I don’t think moral reasoning is sound if based on archetypes without attention to specific circumstances.

      I find it disturbing that you consider human sexuality overall to be intrinsically less capable of consent than Mary’s (very human) consent just because conception through sex cannot be predetermined in time.
      I do not; rather, I observe that the consent is given to different things. Surely, whether a predicted outcome is certain, probable, or unlikely is relevant to moral reasoning.

  • http://stuartotwaysmith.wordpress.com Stuart Otway-Smith

    Reblogged this on Smile if you're sexy! and commented:
    by David Cruz-Uribe, SFO
    A week ago, I posted a link on my FaceBook page to an blog post by William Briggs responding to an article by Charles Camosy on Catholic Moral Theology in which he is exploring a concept he calls “an innocent aggressor.” A non-Catholic friend asked me in the commbox about Catholic teaching on ectopic pregnancy. I found a nice summary at the Catholics United for the Faith website. This satisfied my friend, but after reading the posts by Camosy, Briggs and the CUF article, I found myself chewing over this question.

  • http://gaudetetheology.wordpress.com gaudetetheology

    @A Sinner, I thought this comment above was very helpful (although hard to see at this level of indentation). I too had been thinking about goal vs intention, and leaning towards goal (telos) as the relevant concept here.

  • http://renegadetrad.blogspot.com A Sinner

    Paul (I hope you can see this), let me propose a potential analogy that might elucidate things.

    I’d like your opinion on this situation:

    There is a hospital. In the hospital is a man on a ventilator he requires to live. However, the hospital starts having problems with the electricity and they realize that the problem is with the man on the ventilator. Or, rather, the problem is with how his machine is located in the circuitry of the whole building. Basically, they realize, that if they don’t unplug him pretty soon, there’s going to be a short, and the whole building (including him!) will have a power-outage and lots of people will die. But of course, unplugging him means that he will die. They’d try, of course, to simply unplug him and quickly replug him into a separate battery or generator until they can fix the circuitry as a whole, but for some reason that isn’t possible in this specific case.

    Is “disconnecting” or “unplugging” the man the same as directly killing him in this case? Even though the issue is not the man, but his connection to the electrical grid, and it is the “connection” that is being acted upon, not the man directly?

    • Paul Connors

      You’ve described a reformulation of the classic trolley problem. Under double-effect the man may be unplugged. The action is to adjust the electricity supply, with the intended effect that many people are saved, and the unintended effect that the loss of electricity will kill the one man.

      It’s instructive to see why it’s not the same as the impermissible ectopic problem (i.e. where the embryo is directly removed) — because in that ectopic case, there is no intermediate object (i.e. the electricity supply, or the trolley lever). There is just the child and the mother: and removing the child from the mother is identically the same as removing the mother from the child.

      • http://renegadetrad.blogspot.com A Sinner

        There is no concrete intermediate object, but isn’t there essentially an abstract one? By remaining connected to the fallopian tube, the embryo is in some sense “sucking health” from the mother. By disconnecting it, you are making sure that the mother’s health does not continue to be threatened by the embryo, even though the embryo will no longer be getting health and will die.

        I know that “health” is not like electricity, it’s not a literal “thing” flowing around the mother. Perhaps you could identify “health” more concretely as “blood flow” or something like that. That seems to usually be the ultimate problem in pregnancy and conjoined-twin cases.

        But I don’t even think that’s entirely necessarily…as the point, I’d think, is that it is the connection of embryo to mother that is the problem, not the embryo in itself. Severing the connection because that connection threatens the “biological circuitry” of the whole system is like pulling the plug on the man.

        What if we constructed things such that you’re “diverting the blood flow” (by disconnecting the placental matrix) so that the network of vessels is no longer threatening the tubal wall, even though this means blood is shut off to the embryo? That’s essentially what “removing the embryo” means.

        (But, I’d argue, even if it were a question of spatial confinement, it could be parsed as “redistributing the allocation of space” or something like that…)

        • Paul Connors

          A Sinner: “There is no concrete intermediate object, but isn’t there essentially an abstract one? “

          There is no concrete operation to remove an abstract object!

          A Sinner: “the connection of embryo to mother that is the problem, not the embryo in itself.”

          There’s a mother. There’s a child. There is no such thing as a connection that isn’t a part of the mother or part of the child.

          A Sinner: “What if we constructed things such that you’re ‘diverting the blood flow’ “

          There’s the mother’s blood flow. There’s the child’s blood flow. There’s no other blood flow.

          Separating the child from the mother IS separating the mother from the child. There simply is no intermediate object. Verbal rearrangement can’t change that. 2=1+1, no matter how inconvenient that is. It’s intentional killing.

        • http://renegadetrad.blogspot.com A Sinner

          It’s unclear to me how “electricity supply” can be an intermediate object but “blood flow” not. Yes it’s the mother’s blood. The electricity is the hospital’s electricity.

          Also Paul, to go back to an earlier example, Id put this proposition to your proposal: if doing something to someone else truly constitutes direct killing, then doing it to yourself must constitute suicide.

          But consider that case of a bunch of people on a raft in shark infested waters with one really heavy guy who is sinking the whole thing (who, indeed, would sink it even if he were the only one on the raft).

          If I understand your position, pushing him off wouldn’t be allowed. Sure, you’re pushing him off merely to remove his weight, not to drown him or throw him to the sharks. But since those are inevitably joined to pushing him off, it would be direct killing?

          And yet I think few moralists would condemn it as a suicide if the man himself willingly jumped off the raft as an act of heroism and self-sacrifice. But if it’s not suicide if he does it to himself, it’s unclear how it could be direct killing if someone else does it to him.

          I’m going to look into your Aquinas quote but I think you may be overstating the “always or often joined” idea of intent. Lets remember that Aquinas’s paradigmatic case was that of self-defense, and I wonder what you’d call the “intermediate object” in the case of stabbing someone in the heart or shooting them in the head in self-defense!

          • Paul Connors

            A Sinner: “And yet I think few moralists would condemn it as a suicide if the man himself willingly jumped off the raft as an act of heroism and self-sacrifice. But if it’s not suicide if he does it to himself, it’s unclear how it could be direct killing if someone else does it to him.”

            Suicide and murder are differently wrong, but your way of looking at the scenario treats them as too essentially identical. There are a few ways of showing this. Perhaps the simplest is to consider murder as involving theft — it impermissibly takes away the life that is owned by someone else. Whereas in suicide, though it may be wrong for other reasons, the life that is taken away is at the disposal of the suicider. Hence there is room for someone to permissibly decide (via double-effect) that though their own life will foreseeably be lost, the intended effect is good enough to permit this. But this is intrinsically not so in murder, because of the theft.

  • http://renegadetrad.blogspot.com A Sinner

    Okay, Paul. I have researched your Aquinas quote and I think I’ve untangled things here. So, I guess there is still new progress being made in this conversation!

    First, I would refer you to check out the following sources:
    http://tinyurl.com/mhqrmv7
    http://tinyurl.com/ka7se9x
    http://tinyurl.com/k8z56s3

    The first thing I’d point out to notice is that: how exactly “intent” is to be interpreted, especially as regards other effects following from the action, especially relative to double-effect…is a much debated and much discussed issue, and the Church has not officially declared any one school of theological thought here definitively correct.

    Therefore, I’d say, in something like the Phoenix case…the excommunication under the accusation of “direct abortion” was rash. If the hospital administrator approved the act with the understanding that it WOULDN’T count as a “direct abortion” according to the logic of Grisez and Lysaught…the implication is that Grisez and Lysaught’s opinion is heresy! And yet neither have ever been forced to renounce their opinion or censured for dissent or heresy, and so punishing someone who is convinced by their opinion and acts on…well, at the very least it seems like putting the cart before the horse! If the Church wants to come down definitively on one side, then they should definitively endorse one position theoretically first before starting to punish people for acting according to theological opinions that, in themselves, still apparently tolerated!

    Even if you consider the Grisez/Lysaught position in the minority currently, Catholic probabilism allows us to follow a “less safe” theological opinion as long as there are truly some good reasons or theologians behind it, as long as it is solidly probable, even if other opinions are considered more probable. Now, of course, the question of probabilism itself (versus probabiliorism, aequiprobabilism, compensationism, etc) has never been definitively resolved…but in some ways that itself is an argument in favor of probabilism! So, even if Bishop Olmstead’s opinion on the liciety of the act were objectively correct, the disciplinary decision, I think, would still have been wrong based on the principles of probabilism, because the hospital (objectively right or wrong) was still acting on a probable and tolerated opinion, which Catholic probabilism implies we have the moral liberty to do in cases of moral uncertainty or debated questions.

    However, to get back to our discussion about ectopic pregnancy specifically, Paul, I think I’ve figured out what “the problem” is.

    You are taking Aquinas’s quote that “For what is always or frequently joined to the effect falls under the intention itself. For it is stupid to say that someone intends something but does not will that which is always or frequently joined to it” to mean that an inevitable effect, what would be called a “concomitant effect” is part of the intention for the purposes of double-effect analysis.

    However, if you read those pages from Google Books I linked to, you will see that theologians apparently distinguish (and believe Aquinas distinguished) between the intent “per se” and other things included under the intention in a broader sense “per accidens.” Concomitant effects that are aside from the reason the action is chosen, which have no instrumental causal role, are part of the intention only per accidens.

    But a good argument can be made, at least, according to these sources, that the intent referred to (that must be good) in double-effect…is the “intent per se.” A concomitant effect, an inevitable and foreseen consequence…is not included in this, though it is not entirely separate from the intent in the broader sense either. It is not part of the intent, but it “falls under” it, and is still willed in some sense (one of the articles suggests it might be more precise to call these foreseen inevitable concomitant effects “voluntary” rather than “intentional.”)

    Your argument rests on an opinion that concomitant effects are part of the intent per se and so if they are evil, then the act itself is evil, and they can’t be called a “side effect” and double effect can’t apply. (I’ve found this confusing, because something like the removal of the child inside a cancerous uterus is just as concomitant an effect.) However, the disconnect here seems to be that Aquinas’s formulation of double-effect didn’t necessarily include these concomitant effects as part of the intent per se, only per accidens, and that doesn’t make the intent evil in-itself for the purposes of double effect.

    What it does mean is something I’ve already admitted in this thread: just because an evil effect is not part of the intent per se, does not mean that all responsibility for it is abnegated. This is what I meant when speaking of “strict liability,” or perhaps something like turmarion says about not liking a “loophole” that forsakes responsibility for foreseen evils that one brings about knowingly (but not per se intentionally). These effects DO still fall under the purview of the will/intention, just not in itself, not per se. However, one is still responsible for them which is why there is ALSO a condition of proportionality. It’s not as if ones hands are simply washed of these consequences. One has the responsibility for them; it’s not necessarily “a sin” in the personal culpable legalistic sense but there is still an evil brought about by the will and thus the responsibility to ensure that the consequences are proportionate, that the good outweighs the evil.

    But look into those sources. I think your confusion results from taking Aquinas to mean that a concomitant effect is part of the intent “per se,” even though his opinion on self-defense makes it quite clear that he did not mean this. He is traditionally interpreted as allowing actions (even something as immediate as a shot to the head!) that have death as a concomitant effect (with no additional factor, as far as I can tell, no “intermediate object”) but does not consider these concomitant effects to render the intent itself evil. They still fall under the intention, the will, but AS effects, and as such they do not render the intent evil per se, but they do impute a responsibility to make sure they are proportionate to the good achieved.

    • Paul Connors

      A Sinner: ” If the hospital administrator approved the act with the understanding that it WOULDN’T count as a ‘direct abortion’ according to the logic of Grisez and Lysaught …”

      … then the question would arise as to why a Catholic ethicist would decide to follow the arguments of two minor Catholic theologians rather than the exceptionally clear teaching of the Catholic Church.

      A Sinner: “Catholic probabilism allows us to follow a ‘less safe’ theological opinion “

      However, the statement of the Holy Office in 1889 said: “it cannot be safely taught in Catholic schools that the surgical operation known as craniotomy is lawful, and the same is to be said of whatever surgical operation aims directly at the killing of the foetus or of the pregnant mother.”

      And thus probabilism simply cannot apply to these issues after that time.

      And, to anticipate a possible followup, it also doesn’t matter what two minor theologians think “directly” ought to mean — what counts is what the Catholic Church means, and that has been quite clear for at least a century.

      A Sinner: “according to these sources, that the intent referred to (that must be good) in double-effect … is the ‘intent per se.’ “

      You (presumably under the influence of some of those links you cited) have now introduced the idea of “intention per se“. Note carefully that (as used in Aquinas) “intention per se” and “intention” as a whole, are different things. If someone has the goal of making effect A happen, then producing effect A is the intention per se. If effect B always follows effect A, then effect B falls under the intention (as Aquinas says), and then producing both A and B is the intention.

      Here’s a quote from Aquinas’ De Malo: “it should be said that sometimes an accidental effect is joined to [some effect] in few cases and rarely; and then the agent need not intend in any way the accidental effect while he intends the effect per se. But sometimes an accident of this type is attached either always or for the most part to the effect which is principally intended; and then the accident cannot be separated from the intention of the agent. If, therefore, something evil is joined only infrequently to the good which is intended, it is possible to be excused from sin; for example if someone cutting down a tree in a forest where people rarely pass, kills a person by cutting down the tree. But if the evil is joined either always or for the most part to the good which is intended per se, one is not excused from sin although he does not per se intend this evil.”

      Note that Aquinas clearly has two parts for the intention: a per se part (“principally intended”), and another part corresponding to the effect that always follows. And this second part cannot be separated from the intention as a whole, and is also culpable for sin. Yet exactly such a separation is precisely what is relied on in the version of double-effect that you propose! And hence your version is not at all consistent with Aquinas.

      A Sinner: “Your argument rests on an opinion that concomitant effects are part of the intent per se “

      No. No. No. Concomitant effects are those that follow from the per se intended effect, and thus form that second part of the intention as a whole.

      A Sinner: “I’ve found this confusing, because something like the removal of the child inside a cancerous uterus is just as concomitant an effect”

      Still, no. There are two things that are true. (1) Everything that follows from the goal is necessarily part of the intention. (2) But not everything that follows from a chosen means to achieve a goal is necessarily part of the intention. I think you are misinterpreting what I mean by (1), by not recognizing that I hold (2) as well.

      A Sinner: “[Aquinas] is traditionally interpreted as allowing actions (even something as immediate as a shot to the head!) that have death as a concomitant effect “

      In self-defense the goal is saving oneself, and the means chosen is force. Not everything that follows from the means chosen is necessarily part of the intention. I wouldn’t call the death of the assailant a concomitant effect — and hence not part of the intention as a whole.

      Let me say as an aside that the fact that “everything that follows from the goal is part of the intention” is sometimes significant, and sometimes not significant at all. If one’s goal is jumping 50 feet down a 100-foot cliff, then the concomitant effect is highly significant! But if one’s goal is removing the cancer in a womb, then the concomitant effects are quite limited (perhaps: the mother may weigh slightly less).

      • http://renegadetrad.blogspot.com A Sinner

        “And, to anticipate a possible followup, it also doesn’t matter what two minor theologians think ‘directly’ ought to mean — what counts is what the Catholic Church means, and that has been quite clear for at least a century.”

        Well, yes, that is the objection I would make. You anticipated well. I’d just disagree with the notion that what “direct” means has been “clear” at all, given that the articles I linked to are all, essentially, discussing what exactly “direct” means (vis a vis double-effect and intention) and that there seems to be significant disagreement and discussion and debate about just that question!

        “If someone has the goal of making effect A happen, then producing effect A is the intention per se. If effect B always follows effect A, then effect B falls under the intention (as Aquinas says), and then producing both A and B is the intention.”

        Not necessarily. That’s what those articles are debating/discussing. B certainly “falls under” the intention inasmuch as a foreseen inevitable side-effect is still voluntary and so is within the purview of the will or personal responsibility in some sense.

        But it is NOT clear (indeed, that’s what those theologians are discussing) that falling under the intention in this broader sense makes it identifiable with the intent spoken of in “condition 1” of double-effect (ie, in certain formulations, that the intent not be evil in itself; “in itself” implying that only intent per se is being referred to).

        “Note that Aquinas clearly has two parts for the intention: a per se part (‘principally intended’), and another part corresponding to the effect that always follows. And this second part cannot be separated from the intention as a whole, and is also culpable for sin.”

        Not quite. This is exactly what the theologians in those articles are debating. Yes, a concomitant effect, a foreseen inevitable effect (something “always or often joined”) is part of the intention in the broader sense. But it’s NOT clear if “double effect” requires that the whole intention in this broader sense be all good, or merely the intent per se.

        You’re using Aquinas’s “not excused from sin” to argue that he means the entire “broader” intention. But this is not actually clear. As the articles point out, this would make it hard to read Aquinas’s notion of self-defense intelligibly.

        You are leaping from “not excused from sin” to “culpable” in the sense of a personal sin. I, however, think the articles make a good case that “not excused from” refers to the responsibility for proportionality that accrues to a foreseen bad effect. That is to say, we are “not excused” from the evil because our hands are not simply washed of it just because it is not part of the intent per se. It still falls under the purview of the will in the broader sense, and so we still have to “own” it and answer for it (by providing a countervailing reason or justification; hence the requirement of proportionality). Being indirectly chosen does not take away our responsibility, they are still “chosen,” but it does affect the moral analysis inasmuch as our obligation for indirectly chosen evils becomes to make sure that they are proportionate, rather than to avoid them entirely as with directly chosen ones.

        “Yet exactly such a separation is precisely what is relied on in the version of double-effect that you propose! And hence your version is not at all consistent with Aquinas.”

        Well, again, this seems debatable. Not just by Grisez and Lysaught but by Boyle and possibly even Cajetan as described in the articles, would require only the intent per se to be all good, and would describe our responsibility for concomitant effects as a responsibility to ensure proportionality (we are not simply excused of them).

        Indeed, as I’ve said, Aquinas’s notion of self-defense seems unintelligible unless you read it this way.

        But more to the point, ALL double-effect becomes rather unintelligible if you read it this way. For example, removing a pregnant uterus with a pre-viable fetus inside always results in the removal of the child and its death. These are concomitant effects just the same, and so part of the broader intention inherent in the means chosen to remove the cancer.

        One is not “excused” from the fetus’s death in this case either, inasmuch as one still has an obligation to ensure that that effect is proportionate to the outcome (saving the mother’s life). If it was done merely because the uterus was causing the mother discomfort, one would be culpable for the fetus’s death (even though the same structure of “indirectness” is in place) because the fetus’s life is worth more than the mother’s comfort (and so the decision would be: wait until it’s born). But the fact that the death of the fetus in this situation still accrues responsibility, is still voluntary (inasmuch as it is a foreseen result of our own choice)…means that it is not totally “praeter intentionem” either! So how are you distinguishing it? Would you truly claim that the fetus’s death is entirely praeter intentionem in the uterine-cancer case? If so, why? And if so, how do you explain the continued obligation of ensuring proportionality of the effect (as, usually, no such obligation accrues to things entirely praeter intentionem, which are outside moral agency entirely).

        “Concomitant effects are those that follow from the per se intended effect, and thus form that second part of the intention as a whole.”

        Okay, but a good argument can be made (not just by me, but by the theologians in those articles) that the “per accidens” part of intention is not the thing being referred to in “condition 1” of double effect, but rather become relevant at the point of proportionality.

        “Still, no. There are two things that are true. (1) Everything that follows from the goal is necessarily part of the intention. (2) But not everything that follows from a chosen means to achieve a goal is necessarily part of the intention.”

        So the “goal” is the intent per se? And it’s only things which are intrinsically connected to that intent per se, not necessarily the means, which are concomitantly part of the “intention” and thus must be all-good…in your formulation?

        However, I thought we’ve already established that the means chosen, each step along the way, are to be analyzed as proximate intentions in themselves??

        Again, if you identify the intent per se, the “goal,” as “removing the cancer” in the uterine case, then we can also say the intent per se, the “goal” in the ectopic case is “ending stress with hemorrhage potential on the Fallopian tube.” Then the removal of the embryo becomes the MEANS to that just like the removal of the uterus, and so the death is an “effect of the means” not the intent per se, not of the goal.

        It’s still unclear why you think “removing the embryo” is an intent in itself and not merely a means, why the removal of the uterus is a means and not an intention itself requiring analysis as such, and why you think verbally winking and removing the whole tube somehow radically changes the logic of the intentionality.

        “In self-defense the goal is saving oneself, and the means chosen is force. Not everything that follows from the means chosen is necessarily part of the intention. I wouldn’t call the death of the assailant a concomitant effect — and hence not part of the intention as a whole.”

        It can be depending on the type of force chosen! If the only way to save myself is to shoot a guy in the head…yeah, I can claim that my intent per se is only “incapacitation” but I know that death is inevitably following, and thus I still have a responsibility for the death in terms of ensuring that it is proportionate to the good achieved.

        But going back to our case, it’s unclear why you think that “saving my life” can be parsed as the intent per se, the goal, and “force” (even something like shooting in the head!) merely as “the means” (whose effects thus apparently don’t have to fall under the intention)…but then think that “saving the mother’s life” can’t be parsed as the goal in the ectopic case, with the removal merely as the means (the effects of which wouldn’t fall under the intention).

        If “force” (like, shooting in the head) can be called merely a “means” to “saving my life” and not analyzed as an intention as regards all its effects, why do you insist that “removing the embryo” be treated as an intention in itself and merely as “means” to “saving the mother”?

        I’m not saying we say the embryo should be called an “involuntary aggressor” or that we should apply self-defense to this case. But structurally what do you see as the difference?

        • http://renegadetrad.blogspot.com A Sinner

          *correction: “why do you insist that ‘removing the embryo’ be treated as an intention in itself and NOT merely as ‘means’ to ‘saving the mother’?”

        • Paul Connors

          A Sinner: “… given that the articles I linked to …”

          I think there is an increasing amount of repetition occurring in this discussion. So I will end by pointing out an extremely good set of articles (partly aimed directly at countering opinions such as those you are pitching) that are available on the National Catholic Bioethics Quarterly site, in the Spring 2013 issue (currently available for free reading). These go into much better and more helpful detail about some of the things discussed here.