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Moral Analysis of a Procedure at Phoenix Hospital

M. Therese Lysaught Loyola University Chicago, [email protected]

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Recommended Citation Lysaught, M. Therese. Moral Analysis of a Procedure at Phoenix Hospital. Origins, 40, 33: 537-552, 2011. Retrieved from Loyola eCommons, Institute of Pastoral Studies: Faculty Publications and Other Works,

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This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License. © Catholic News Service, 2011. cussions leadingupto thebishop’s decision to for more documentation onthecase.)In dis Catholic status. (See Origins, Vol. 40, No. 31, St. Joseph’s Hospital andMedical Center ofits direct abortion, andhesubsequentlystripped the November 2009procedure constituteda Bishop Thomas J. Olmsted determined that in amoral analysisofthesituation. Phoenix child, theologianM. Therese Lysaught said that resulted inthedeathofunborn sial procedure on anill pregnant woman moral precepts” outacontrover incarrying Catholic moral tradition anduniversally valid with theEthical andReligious Directives, A Catholic hospitalinPhoenix “acted inaccord LysaughtM. Therese Phoenix Hospital of Procedure at Moral Analysis

CNS documentary service other.” matter of choosing one life ‘or’ the mother ‘or’ the child. It was not a “It was not a case of saving the - - professor who specializes in moral theology professor whospecializes inmoral theology situation. Lysaught, aMarquette University provide anindependentmoral analysis ofthe the systemtowhichSt. Joseph’s belongs, to the hospitalandCatholic Healthcare West, rescind thehospital’s Catholic status, heasked 10-15 percent forapregnant ofmortality risk a carries hypertension cy withpulmonary pregnancy, sinceinthebestcase, pregnan her safestcourseofaction was toendthe and was then 7 1/2 weeks pregnant. her great toavoid it,shehadconceived efforts tine pregnancy testrevealed thatinspiteof symptoms ofherdisease. The results ofarou at her pulmonologist’s office for worsening a Clinical HistoryandEvents moral analysis follows. Catholic Bishops’ CommitteeonDoctrine. The Bioethics Center andtheU.S. Conference of ed onstatementsby theNational Catholic ground for herconclusionsandcomment ofthecase,history provided theoretical back could besaved.” Lysaught lookedattheclinical longer anychancethatthelifeofthischild Lysaught wrote. She added, wasno “There initsmaternal environment,”of a pathology ofitsown because of a pathology butbecause cal staff, thefetushadbecometerminal, not ofthemotherandhermedi the bestefforts Olmsted rejected her conclusions. “In spite of and bioethics, provided theanalysis; Bishop The pulmonologist counseled herthat sion was seen on Oct. 12, 2009, sion wasseenonOct. 12,2009, hyperten trolled pulmonary of moderate but well-contory 27-year-old womanwithahis continued onpage538 ------contents 552 549 537 552 Commentary onthe Moral Analysisof On File Datebook by M.ThereseLysaught Hospital Procedure atPhoenix Number 33 Volume 40 January 27,2011 Bioethics Center by theNationalCatholic Phoenix HospitalSituation continued from page 537 heart muscle to weaken and fail. Pulmonary Father John Ehrich, the woman trying to carry to term, and because of hypertension is a serious illness that becomes medical ethics director for the severity of her disease, her own prospects progressively worse; it is not curable but it can the Diocese of Phoenix, wrote the following statement in were closer to 50-50. Importantly, the woman, be treated, easing the symptoms; it is some- 1 May 2010: a Catholic with four children, decided not to times fatal. “A recent news story has terminate. The normal physiologic changes accompa- brought to our attention On Nov. 3, 2009, the woman was admit- nying pregnancy — increased blood volume the potential dangers that ted to St. Joseph’s Hospital and Medical Center (40 percent), increased cardiac output (30-50 still exist during pregnancy with worsening symptoms. At this time, the percent by 25 weeks) and slightly decreased for both mother and child. woman was 11 weeks pregnant. A cardiac cath- systemic blood pressure (10-20 percent by 28 We naturally ask, what is eterization revealed that the woman now had weeks) — exacerbate pulmonary hyperten- the right thing to do if a pregnant woman’s life is in “very severe pulmonary arterial hypertension sion, leading to the increased risk of mortality danger? Is it ever legitimate with profoundly reduced cardiac output”; in for the mother.2 to perform an abortion to another part of the record, a different physi- In the current case, the patient’s attempt save the mother’s life? As cian confirmed “severe, life-threatening pul- to continue the pregnancy in order to nurture Catholics, we have clear monary hypertension,” “right heart failure” the child’s life led to two negative physiological teaching in this area that helps us to act in accord with and “cardiogenic shock.” The chart noted that outcomes: the failure of the right side of the God’s will and in recognition she had been informed that her risk of mor- patient’s heart and cardiogenic shock. of the human dignity of every tality “approaches 100 percent,” is “near 100 Failure of the right side of the patient’s heart person. percent” and is “close to 100 percent” if she means that the heart can no longer pump were to continue the pregnancy. The chart also blood into the lungs so that the blood can be “Some Basic Principles noted that “surgery is absolutely contraindi- oxygenated. Without oxygenated blood, the “It is important to note at cated.” body’s organs and tissues quickly begin to die. the outset that these are Cardiogenic shock is “a state in which the heart very complex issues which has been damaged so much that it is unable demand careful reflection. We “The chart noted that she had been to supply enough blood to the organs of the first need to start with some body.”3 basic moral principles. informed that her risk of mortality In cardiogenic shock, cardiac output “First, no one can do evil that good may come. We com- ‘approaches 100 percent,’ is ‘near decreases and one begins to see evidence of tissue hypoxia — lack of oxygenation of the monly know this as ‘the end 100 percent’ and is ‘close to 100 does not justify the means.’ patient’s tissues and major organs. Clinical Just because we can do some- percent’ if she were to continue the criteria for cardiogenic shock are “sustained thing does not mean that we hypotension (systolic blood pressure <90 mm should. pregnancy. The chart also noted Hg for at least 30 min) and a reduced cardiac “Second, when speaking of a that ‘surgery is absolutely contra- index (<2.2 L/min/m2) in the presence of ele- woman who is pregnant, we vated pulmonary capillary occlusion pressure are always referring to two indicated.’” people: mother and child. (>15 mm Hg).” In addition, visible signs of car- Therefore, any medical inter- diogenic shock can be observed at the bedside, vention must seek the good Pulmonary hypertension is a type of high including “hypotension and clinical signs of of both mother and child. In blood pressure that affects only the arteries poor tissue oxygenation, which include oligu- short, we are dealing with in the lungs and the right side of the heart. It ria [low urine output], cyanosis [blue color- two patients, not just one. So, we never would speak of begins when the arteries and capillaries in the ation of the skin], cool extremities and altered 4 how the mother’s life is at lung become narrowed, blocked or destroyed, mentation.” risk without reference to her making it harder for blood to flow through the There is no cure for pulmonary hyperten- unborn child. Her child has lungs, raising the pressure in those arteries. sion. In this case, however, two additional as much dignity and value One consequence of this restricted flow is pathologies emerged — the pathology of right as she does. Morally speaking that the heart’s lower right chamber (the right side heart failure and cardiogenic shock. These we can never prefer one life over the other. ventricle) has to work harder to pump blood pathologies were immediately caused by the “Third, the unborn child into the lungs, which eventually causes the physiologic changes accompanying pregnan- can never be thought of as a pathology or an illness. ISSN 0093-609X, Origins, CNS Documentary Service, is published weekly (except biweekly during July, August and That is, the child is not that December's last week) by Catholic News Service, 3211 4th Street N.E., Washington, D.C. 20017-1100. Copyright © 2011 which threatens the life of by Catholic News Service/U.S. Conference of Catholic Bishops. Periodical-class postage paid at Washington, D.C. the mother, rather it is the Editor, Edmond Brosnan; Associate Editor, Mary Esslinger; Layout, Emily Thompson; Director of CNS, Tony Spence. pathology or illness (can- Editorial: (202) 541-3284. Circulation: (202) 541-3290 - www.originsonline.com. cer, premature rupture of Subscriptions: One year, $114; two years, $199; three years, $284; foreign postage additional. Single copy: $8. Back membranes, hypertension, issues: Inquire for availability and rates. Attach mailing label to change of address requests and subscription corre- pre-eclampsia, etc.) which spondence. Postmaster: Send address changes to Origins, CNS Documentary Service, 3211 4th Street, N.E., threatens the mother’s life. Washington, D.C. 20017-1100. While it is often possible that Documentation in Origins is selected on the basis of interest and usefulness in reference to current issues. Publication does not signify endorsement by Origins or its sponsoring body, the U.S. Conference of Catholic Bishops.

538 origins cy that exacerbated the underlying pathol- exists in a vacuum. The human body is a com- ogy of pulmonary hypertension. The physi- plex and carefully balanced network. the pregnancy will aggra- vate an existing condition, ologic changes accompanying pregnancy at 10 In this case, the normal functioning of an we should never accuse the weeks initiated the emergency situation. These organ (the placenta) within a diseased net- child of being a threat to the changes not only put the mother’s life at risk. work (of pulmonary arteries) created a lethal mother. Rather, they put the mother’s life in peril. situation. Importantly, although in one respect “In difficult situations when Moreover, the life of the fetus was equally in the placenta was functioning “normally,” it was the mother’s life is threatened peril due to the pathologies of right heart fail- also functioning pathologically in two ways. by an underlying condition, ure and cardiogenic shock. Oxygen delivered to First, once the placenta initiated its normal the solution can never be the placenta and fetus is dependent on mater- function at week 10, a crisis was created. to directly kill her unborn child. To do so is an abortion. nal arterial oxygen content and uterine blood Second, once the patient entered cardiogenic A dilation and curettage or flow. Decrease in maternal cardiac output and shock, the placenta also became hypoxic. In dilation and extraction pro- decrease in blood oxygenation can adversely these two ways, then, the placenta not only cedure in this context is the affect fetal oxygenation; the uterus and pla- initiated a threat to the mother’s life; it also same thing as an abortion centa number among the organs becoming became the immediate/presenting cause of since it is the direct killing of hypoxic during this crisis. Further, maternal the inevitably fatal threat to the fetus. an unborn child. The reason for such a procedure never hypotension may constrict the uterine artery, matters. It is also important 5 decreasing blood flow to the fetus. to note that the secondary Therefore, on Nov. 5, 2009, mother and “The child’s life, because of natu- intention or goal does not fetus were both in the process of dying. Due change the moral evil of this ral causes, was in the process of to the age of the fetus, there was no possibility act. As John Paul II taught infallibly in his encyclical that it could survive outside the womb. Nor, ending.” ‘The Gospel of Life’: due to the mother’s heart failure and cardio- “‘I declare that direct abor- genic shock, was there any possibility that the tion, that is, abortion willed fetus could survive inside the womb. In short, These facts are important to establish as an end or as a means, in spite of the best efforts of the mother and of because the claim has been made that the always constitutes a grave her medical staff, the fetus had become termi- hospital sought primarily to end the life of the moral disorder, since it is nal, not because of a pathology of its own but fetus as the means to saving the mother’s life. the deliberate killing of an because of a pathology in its maternal environ- This, however, is physiologically inaccurate. It innocent human being. This doctrine is based upon ment. There was no longer any chance that is likely that in this case as in many cases of the natural law and upon the life of this child could be saved. This is natural fetal demise, the death of the fetus in the written word of God, is crucial to note insofar as it establishes that at se would have had no physiologic effect on the transmitted by the church’s the point of decision, it was not a case of saving mother. tradition, and taught by the the mother or the child. It was not a matter of In many cases of fetal demise, the preg- ordinary and universal mag- choosing one life or the other. The child’s life, nancy itself continues; fetal death is often not isterium’ (No. 62). because of natural causes, was in the process detected for weeks or months, although the of ending. pregnancy itself continues to proceed and “What Can Be Done? There was, however, a chance that the life of develop because the hormones required for “So what can be done in such the mother could be saved. There was one pos- sustaining and advancing the pregnancy come a situation? That depends upon the actual pathology or sibility for treating and reversing the pathol- not from the fetus but from the placenta. illness. The pathology should ogy of the emergent conditions of right heart Based on these facts, the ethics committee always be treated, to the failure and cardiogenic shock. The interven- at St. Joseph’s Hospital and Medical Center was extent possible, all the while tion for treating this pathology was to elimi- asked for a determination of whether or not remembering that there are nate the cause of the increased blood volume the intervention to address the placental issue two patients who are at risk. and increased demand for cardiac output. The via a dilation and curettage would be morally When treating the illness, physicians should always try cause of this increased blood flow and cardiac appropriate according to Catholic teaching. to protect the life of the child, demand was not the fetus but rather the pla- Per their reading of the “Ethical and Religious who has just as much a right centa — an organ in its own right. This requires Directives for Catholic Health Care Services” to life as the mother. clarification. (4th edition) and their understanding of the “In the best of circumstances Until about nine weeks into a pregnancy, Catholic moral tradition, the ethics committee a physician will treat the the ovaries are responsible for the production determined that the intervention would not be mother’s pathology and of progesterone, which maintains the preg- considered a direct abortion. They therefore hold off on more aggressive treatment until the child is nancy in the uterus and causes the increase in approved the intervention, which was carried past the point of viability, blood volume cited above. At about 10 weeks, out on Nov. 5, 2009. at which time labor can be the placenta is the organ that takes over this induced. Sometimes, how- work, becoming a shared organ between the Moral Analysis ever, the actual pathology mother and the child. In this case, having The primary question in this case is whether must be treated prior to the reached week 11, the placenta was producing the ethics committee at St. Joseph’s Hospital viability of the child and may indirectly cause the death of the physiological changes that imperiled the and Medical Center was correct in their deter- the child. mother’s and child’s lives. No organ, however, mination that the intervention did not consti-

origins 539 tute a direct abortion and was therefore justifi- in the least denying the influence on morality “This situation is altogether able according to the Catholic moral tradition. exercised by circumstances and especially by different from a dilation and “Direct” is a technical term in the Catholic intentions, the church teaches that ‘there exist curettage, since a dilation and curettage is the dismem- moral tradition, as is “abortion.” Therefore, an acts which per se and in themselves, indepen- bering and removing of the extended presentation of the tradition in this dently of circumstances, are always seriously body of the child. A dilation regard is required to evaluate the committee’s wrong by reason of their object.’”9 and curettage or dilation decision. These teachings were reiterated by John and extraction in this cir- Paul II in Evangelium Vitae: cumstance is the same as an Magisterial Teaching “Procured abortion is the deliberate and abortion, since it is the direct killing of the child. Catholic Healthcare West strives to embody direct killing, by whatever means it is carried the fundamental commitment of the Catholic out, of a human being in the initial phase of his “There is a significant dif- ference, morally speaking, faith “to promote and defend human dignity or her existence, extending from conception between directly killing ... the foundation of [our tradition’s] concern to birth. ... It is true that the decision to have versus allowing a child to die to respect the sacredness of every human life an abortion is often tragic and painful for the as an unintended side effect from the moment of conception until death.”6 mother, insofar as the decision to rid herself of of life-saving treatment. A They understand this commitment to the fruit of conception is not made for purely similar, although not com- pletely analogous, distinction embody a preferential option for those who are selfish reasons or out of convenience, but out is made between murder and the most vulnerable, including and especially of a desire to protect certain important values self-defense. The end result those persons who are not yet born.7 such as her own health. ... I declare that direct is the same, but the action Consequently, direct abortions are forbid- abortion, that is, abortion willed as an end or taken and the circumstances den in all Catholic Healthcare West hospitals. as a means, always constitutes a grave moral change the way we evaluate Catholic Healthcare West bases this deci- disorder, since it is the deliberate killing of an the end result. Once again, 10 the end does not justify the sion on magisterial teaching on abortion and innocent human being.” means. intrinsically evil acts. Important magisterial While never wavering from this position, documents here include: The “Declaration on magisterial teaching has also affirmed an

“The Catholic Position Procured Abortion” (1974), Veritatis Splendor important nuance in the Catholic tradition, (1993) and Evangelium Vitae (1995). Key namely, that not all interventions that result “Today we often hear people say, ‘I’m against abortion passages from these documents are provid- in the death of the fetus qualify as abortions. unless in cases of rape, incest ed below. As the “Declaration on Procured Pius XII’s “Address to the Associations of Large or situations that threaten Abortion” states: Families” (Nov. 26, 1951) states this position the life of the mother.’ The “Divine law and natural reason, therefore, most clearly. He provides the foundation for Catholic position is much exclude all right to the direct killing of an inno- the magisterial teaching outlined above, not- simpler; ‘we are always against abortion.’ Every abor- cent man. However, if the reasons given to ing: “The direct attack on an innocent life, as a tion is murder since it con- justify an abortion were always manifestly evil means to an end — in the present case to the stitutes the unjust killing of and valueless the problem would not be so dra- end of saving another life — is illicit.”11 Yet he an innocent life. Thus, it can matic. The gravity of the problem comes from also goes on to explicitly clarify an important never be justified under any the fact that in certain cases, perhaps in quite a dimension of this position, namely, the quali- circumstance. considerable number of cases, by denying abor- fier “direct”: “The question might arise, tion one endangers important values to which it “It has been our intention here to use ‘Isn’t it better to save one life is normal to attach great value, and which may always the expressions ‘direct attempt on the as opposed to allowing two people to die?’ One thing we sometimes even seem to have priority. We do life of the innocent person,’ ‘direct killing.’ The must always remember is not deny these very great difficulties. It may be reason is that if, for example, the safety of the that no physician can predict a serious question of health, sometimes of life future mother, independently of her state of what will happen with 100 or death, for the mother. ... We proclaim only pregnancy, might call for an urgent surgical percent accuracy. We will that none of these reasons can ever objectively operation, or any other therapeutic applica- never be able to eliminate confer the right to dispose of another’s life.”8 tion, which would have as an accessory con- all risks associated with pregnancy. What we should Veritatis Splendor includes abortion among sequence, in no way desired or intended, but not do, however, is lower risks its long list of intrinsically evil acts, which it inevitable, the death of the fetus, such an act associated with pregnancy describes as follows: could not be called a direct attempt on the by aborting children. It is not “Reason attests that there are objects of the innocent life. In these conditions the opera- better for a woman to have to human act which are by their nature ‘inca- tions can be lawful, as can other similar medi- live the rest of her existence knowing that she had her pable of being ordered’ to God, because they cal interventions, provided that it be a matter child killed because her preg- radically contradict the good of the person of great importance, such as life, and that it is nancy was high risk. made in his image. These are the acts which, in not possible to postpone it till the birth of the “When we try to control every the church’s moral tradition, have been termed child, or to have recourse to any other effica- possible situation in life, ‘intrinsically evil’ (intrinsece malum): They are cious remedy.”12 we end up playing the role such always and per se, in other words, on This passage clarifies three essential of God. As people of faith account of their very object, and quite apart points.13 we know that our lives are from the ulterior intentions of the one acting First, “direct” is characterized as having the always in God’s hands. In and the circumstances. Consequently, without desire, intention or will to kill. Actions in which

540 origins the death of the fetus is not desired, intended its moral object? Was it, in other words, a direct or willed cannot “be called a direct attempt on killing, a “deliberate or intentional” action in these situations the reality of our dependence upon him the innocent life.” Second, it suggests that the which the death of the fetus was “willed as an becomes ever more clear and opposite of “direct” is “nondirect” rather than end or a means”? pronounced.” “indirect.” The term “indirect” suggests that 2. If not, ought the intervention be prop- an agent could “indirectly will” an end, which erly understood as an action that had a differ- is not descriptively accurate, per Pius. Rather, ent moral object but also had a nondirect (not Father Ehrich’s statement, the agent is not willing, desiring or intending desired, intended or willed) accessory conse- along with many other docu- the “accessory consequence”; therefore, “non- quence of the inevitable death of the fetus (a ments, can be found on a direct” (or “nonwilled”) seems more accurate. category allowed by the tradition as morally website set up by the Diocese Third, Pius makes clear that the term “direct” acceptable in certain cases)? of Phoenix, is a description of a moral act, not a physical 3. Or, is it the case that given the inevitable www.arizonacatholic.org. act; in other words, whether the operation/ and immediate demise of the fetus (due to therapeutic application causes the inevitable lack of viability and lack of oxygenation), it The Jan. 13, 2011, edition death of the fetus in a physically direct or indi- is not accurate to even speak of the death of of Origins, Vol. 40, No. 31, includes a statement by rect manner does not enter into his argument. the fetus as an accessory consequence of the Phoenix Bishop Thomas J. intervention? Olmsted and a document To address these questions requires a from St. Joseph’s Hospital and “Due to the age of the fetus, there brief overview of the Thomistic notion of the Medical Center. The margin “moral object.” I will then outline the reason- notes section of that edition was no possibility that it could ing and conclusions of two leading scholars also includes more informa- tion. survive outside the womb. Nor, due of the Catholic moral tradition who specifi- cally address cases analogous to the one that to the mother’s heart failure and occurred at St. Joseph’s. cardiogenic shock, was there any The Moral Object possibility that the fetus could sur- Determining the object of an act is one vive inside the womb.” of the most critical steps in moral analysis. Understanding how the moral object is con- stituted in an act, however, remains one of These clarifications are noteworthy because the most difficult and complex components the classical tradition at times refers to certain of Catholic moral theology. The notion of the interventions (such as those described by Pius moral object was articulated by St. Thomas XII above) as “indirect abortions.” This lan- Aquinas in the Summa Theologica (I-II, Q guage of “indirect” has carried over into the 18-21), which formed the basis of the develop- contemporary literature and is still, at times, ment of the subsequent Catholic moral tradi- used within the Catholic literature. tion. Such a description, however, is predicated Many leading contemporary Thomistic upon a confusion of the Thomistic notion of scholars hold, however, that with Thomas’ the moral object of an action, has led to a mis- neo-Scholastic interpreters and much of the application of the principle of double effect classical tradition, important nuances in the and suggests that there could be exceptions understanding of the moral object — and, to the absolute moral norm prohibiting the indeed, of the morality of human actions intrinsically evil act of abortion. — were lost. This resulted in methodologi- Moreover, it is notable that none of the cal problems in 20th-century Catholic moral magisterial documents cited above — nor, as theology, problems to which revisionism and we shall see, the June 23, 2010, statement enti- proportionalism attempted to respond, unfor- tled “The Distinction Between Direct Abortion tunately creating a whole host of new method- and Legitimate Medical Procedures” issued by ological problems. the USCCB Committee on Doctrine — use the One of the most valuable contributions of phrase “indirect abortion.” Veritatis Splendor has been the renewed atten- Therefore, these documents, in addition tion it has brought to the notion of the moral to the Catholic moral tradition at large, make object. William J. Murphy Jr., associate profes- clear that direct, deliberately willed abortion is sor of moral theology at the Pontifical College intrinsically evil and, as such, never justifiable. Josephinum in Columbus, Ohio, and editor of The questions central to our particular case, the Josephinum Journal of Theology, highlights therefore, are: six specific affirmations about the moral object 1. Was the procedure that occurred at St. offered by John Paul II in §78. Echoing Pius XII, Joseph’s Hospital on Nov. 5, 2009, in this case John Paul II reiterates that the moral object properly described as an “abortion,” in terms of of an action is determined by the proximate

origins 541 end deliberately chosen by the will (in tal punishment or shooting someone to over a cliff, etc.). Prima facie, an observer conformity with reason). In John Paul II’s bring about their death; not taking an cannot immediately determine to which words:14 anovulant pill, but taking an anovulant moral species this action belongs; only “The morality of the human act pill to prevent the procreative conse- when it is understood “from the perspec- depends primarily and fundamentally on quences of the marital act or taking an tive of the acting person”18 and evaluated the ‘object’ rationally chosen by the delib- anovulant pill to treat endometriosis.”17 according to the acting person’s inten- erate will” (emphasis in original). A proper description of the moral tion can we know the proper object and “In order to be able to grasp the object object, then, certainly includes the “exte- species.19 of an act which specifies that act morally, rior act” — since it is a necessary part Third, a woman could be faced with a it is therefore necessary to place oneself of the moral action as a whole — but it threat to her life due to pregnancy. That in the perspective of the acting person” derives its properly moral content first woman could, via what would look phys- (emphasis in original). and foremost from the proximate end ically/externally like one and the same “The object of the act of willing is a deliberately chosen by the will. Thus, action to an external observer, pursue freely chosen kind of behavior.” “It is in the object is named as greeting a friend, two very different moral ends and there- conformity with the order of reason.” repelling aggression, capital punish- fore two very different species of moral “By the object of a given moral act, ment, murder, contraception or healing. action, good or evil. She could deliber- then, one cannot mean a process or an It is absolutely necessary to empha- ately will to sacrifice her life for her child, event of the merely physical order, to size, then, that in the Catholic tradition, based on a call to martyrdom. To do so, be assessed on the basis of its ability to the moral object of an act is not equiva- she would reject certain kinds of medi- bring about a given state of affairs in the lent or reducible to its physical/material cal interventions. However, she might outside world.” component. Three examples might help also have a history of depression, feel “Rather, that object is the proximate to clarify this point. oppressed by the demands of raising her end of a deliberate decision which deter- First, as mentioned by Murphy, the other children, perhaps have a history mines the act of willing on the part of the object of the action of taking an anovu- of attempting to take her own life. She acting person.” lant pill cannot be construed only in could, via the same action above (reject- Moreover, as Murphy notes, “in insist- terms of the physical act of taking the pill. ing certain kinds of medical interven- ing that this moral object must not be The object of the act — as either “contra- tions), intend to end her own life. In so understood as ‘a process or an event of ception” or “therapy” — is determined doing, the moral object of her act would the merely physical order,’ John Paul’s by the end or intention chosen rationally be “suicide” (intrinsically evil), not mar- primary target was revisionist theory, by the deliberate will. Therefore, if the tyrdom, which would make her act evil which inherited what might be called intention of taking such a pill is to pre- in species. ‘a physical understanding of the moral vent conception the moral object of the More examples could be offered, but I object’ from the post-Tridentine casuist action is contraception, which is by its hope these three are sufficient to demon- tradition. The pope’s approach, however, species intrinsically evil. If the intention strate that within Catholic moral theory, also challenges many more traditional of taking the same pill, in the same man- there is a complex interplay between the Thomists, who sometimes treat the ner, is to treat endometriosis, the moral physical/exterior act (that which can object that determines the morality of object of the action is healing, which by be observed by a third party) and the the human act as something of the mere- its species is good. actual moral act, which is comprised of ly physical order, or as what is caused Second, St. Thomas himself offers both the interior act of the will and the physically.”15 the example of killing in self-defense. exterior act, but whose object/species is Nonetheless, the “exterior act” is not In doing so, he explicitly intends to dif- determined by the formal component, irrelevant — together the “interior act of ferentiate between actions which, in the interior act of the will. The physical/ the will” and the “exterior act” comprise the physical order, may look exactly the material action is not irrelevant to the one act. However, it is clear from Thomas same, but in terms of their species (good determination of the object, but it is also that moral actions get their object — or evil) are radically different because of not sufficient. their “form” — from the interior act of their different moral objects. What dif- More specifically, it is clear that within the will.16 ferentiates actions of the object “self- the Catholic tradition not all surgical or Murphy describes this complex bal- defense” (good moral object) from those pharmacological interventions which ance as follows: of the object “homicide” (intrinsically prima facie physically directly end the “A proper description of the moral evil moral object) is the intention or end life of a fetus fall into the species of acts object would not be my arm, which is a of the agent, which is either to preserve named “abortion.” As Pius XII noted, thing of the physical order, and not sim- his or her own life or to end the life of the Catholic tradition holds that certain ply raising my arm, which lacks reference another. medical interventions aimed at healing to an end — but raising my arm in order Importantly, in this passage in the a mother or saving her life that simulta- to greet someone; not removing Tom’s Summa, Thomas does not attend to the neously cause fetal death (at the level of watch, but removing Tom’s watch to play physical/material component of the physical causality) may be justified and a trick or removing Tom’s watch to appro- action. The self-defender may have used in fact are not categorized as “abortions.” priate it; not shooting someone, but a variety of agents in a variety of ways Justified via the principle of double shooting someone to repel his aggression (e.g., hitting the assailant over the head effect, the three primary types of such or shooting someone to carry out capi- with a tire iron; pushing the assailant interventions include:

542 origins —Surgical removal of a fallopian tube University of America Press, Washington, mother.”26 containing a fetus. D.C., 2009).23 Here he offers analyses With respect to the life or death of the —Surgical removal of a cancerous informed by the Summa Theologica and embryo, the question “to kill or let live” uterus containing a fetus. Veritatis Splendor with regard to extra- can no longer be decided about or cho- —Administration of chemotherapy or uterine pregnancy, particularly tubal or sen. The only practical and moral ques- other pharmaceuticals required to treat ectopic pregnancies, and craniotomy for tion that remains regards the mother: “To maternal diseases or conditions which obstructed delivery. 24 let die or save?” He also states clearly that may result in fetal death. He considers craniotomy not because “the decision to allow both mother and In these cases, precision of descrip- it is a current procedure; contempo- child to die — at least when the mother tion and terminology is critically impor- rary advances in cesarean section have can be saved and the child will die in any tant. Such cases are not referred to — rendered this question mostly moot. case — is simply irrational”; this is not an and are not generally considered — to However, he recognizes that: (a) crani- ad hominem comment but rather a very be abortions, even though in the first two otomy was a key case of debate for 19th- specific Thomistic critique, based on the cases, a living fetus is surgically removed and early 20th-century moral theolo- critical role of reason in moral discern- from the mother’s body and in the third, gians and magisterial authors; (b) schol- ment and action.27 the pharmaceuticals may effectively be ars on both sides of the debate relied While the justification for the classic abortifacient. on problematic methodologies that cases of maternal-fetal conflict in the Significantly, the recent statement misconstrued Thomas; and (c) the ques- tradition (cancerous uterus, etc.) have from the Committee on Doctrine dis- tion embodies key elements that con- relied on the principle of double effect, cusses these interventions but does not tinue to trouble contemporary debates Rhonheimer argues that in cases where refer to them as “abortions.” The object over potentially analogous interventions there is no chance for the child to sur- of the act in these cases is deemed to (i.e., craniotomy, by definition, consists vive, the principle of double effect is not be properly described as “benefitting the in a physically direct intervention on the applicable because there are not in fact health of the mother” or, in some cases, fetus and therefore looks, from an exter- two effects. as “saving the life of the mother” (if, for nal observer perspective, like an appar- Given that no action can save the life example, the fallopian tube has rup- ent morally direct attack on a child to of the child, its death effectively falls out- tured). These actions are not exceptions save the life of a mother). side the scope of the moral description of to the norm prohibiting direct abortion. Rhonheimer also focuses on these the action. Moreover, since there are not These actions are properly described as two cases because in these cases medi- two effects, one cannot argue that the a different category of action because of cal personnel are faced with a situation death of the child is a means to the end their different moral object, which is, in in which it is certain that without medi- of saving the life of the mother: the words of Veritatis Splendor, “capable cal intervention, both mother and child “In this case [of ectopic pregnancy of being ordered to God.”20 will die. or craniotomy], the killing of the fetus Rhonheimer agrees that direct abor- would not consist in a choice of the death The Moral Object of the Intervention tion is intrinsically evil and can never be of a human being as a means to save the at St. Joseph’s Hospital justified. He specifically rejects any moral life of the mother. … Only if the fetus Two leading scholars of the Catholic methodology (i.e., proportionalism) that would otherwise survive could its death moral tradition bring the perspective of involves the “weighing of goods”: “It is be said to be chosen as a means — and Veritatis Splendor and a nuanced under- morally impermissible,” he notes, “to thus caused ‘directly’ in a morally rel- standing of the Thomistic concept of weigh two lives against each other and evant way. But in our case, the death of “moral object” to bear on cases analo- to make a preferential choice.”25 Such a the fetus is not willed in order to save gous to the one at St. Joseph’s. I will here method, he argues, entertains the pos- the mother; as far as the life of the fetus draw on the analyses and arguments of sibility of choosing against the life of the is concerned, it is beyond any kind of Father Martin Rhonheimer and Germain child, a possibility that is never permitted willing.”28 Grisez to assess that case.21 in the Catholic moral tradition. Here Rhonheimer follows St. Thomas While many cases of obstetric conflict in his account of the moral object of the Martin Rhonheimer do present such a possibility — the pos- act. He notes, as discussed above, that for Father Martin Rhonheimer is a Catholic sibility of choosing against the life of the many analysts the “physical directness” priest, incardinated in the Prelature of the mother or the life of the child — in cer- of the act seems highly significant, but he Holy Cross and Opus Dei. He is currently tain instances the child’s chance of sur- argues that it is not morally determina- professor of ethics and political philoso- vival is negligibly small or, in fact, non- tive. He maintains that the object of the phy at the School of Philosophy of the existent. These cases, he argues, have a act in these cases is properly described as Pontifical University of the Holy Cross in distinguishing, morally relevant feature, “the saving of the mother’s life”: Rome. His writings have focused specifi- namely, that: “The killing of the fetus [in salpin- cally on the work of Thomas Aquinas as “Only the life of the mother is at the gectomy or craniotomy] falls here under well as abortion and contraception.22 disposal of another human being — the the pure and simple genus naturae of The following analysis relies on his fetus is no longer even subject to a deci- the moral (intentional) act of ‘saving recent work Vital Conflicts in Medical sion between ‘killing or allowing to live’; the mother’s life.’ (Stated in Thomistic Ethics: A Virtue Approach to Craniotomy the only morally good thing that can terms: The fatal medical intervention by and Tubal Pregnancies (Catholic be chosen here is to save the life of the which the fetus or embryo is removed is

origins 543 the material part of the act, whereas the of the mother’s life.”33 Germain Grisez basic intention or the finis proximus of Rhonheimer’s analysis is directly Germain Grisez is a Catholic moral theo- the life-saving act is the formal part of the applicable to the case at St. Joseph’s inso- logian and author of the magnum opus moral object of the act).”29 far as: (a) it is a case where both mother three-volume treatment of Christian In these cases, where the fetus is and child are in immediate danger of morality entitled The Way of the Lord not dying at the time of the interven- dying and (b) there is no chance that the Jesus (1983). Grisez spent his career tion but will not be able to survive due child can be saved. Even more clearly articulating a new form of natural law to the imperiled state of the mother, than in cases of extrauterine gravidity thinking, deeply grounded in the work Rhonheimer argues that the death of the or the cancerous uterus, the child at St. of Thomas Aquinas and his interpreters, fetus is “to be considered a purely physi- Joseph’s had already begun to die and his and his work is thoroughly consonant cal evil caused praeter intentionem [out- or her death was, at the point of interven- with the teachings of the magisterium. side of the moral intention].”30 tion, inevitable. In addition to works on natural law, he This is shown, he argues, “by the fact has consistently written on questions of that one would not feel justified in per- contraception and abortion. He is cur- forming the intervention if the child had “A pathology threatened the rently emeritus professor of Christian a real chance of survival. But in our case, ethics at Mount St. Mary’s University in lives of both the pregnant it is not only that the death of the embryo Emmitsburg, Md. is regretted ... but that it is decided to woman and her child, it was In Volume 2 of The Way of the Lord perform the operation solely because it Jesus, subtitled Living a Christian Life, not safe to wait or waiting is known — and regretted for this reason Grisez takes up the question, “Is abortion — that the child will not survive. This is a surely would have resulted in always the wrongful killing of a person?”35 significant difference.”31 As with Rhonheimer, Grisez’s argument the death of both, there was He bases this analysis on Aquinas’ again centers on the concept of the example of self-defense. Rejecting the no way to save the child and moral object with specific attention to argument that obstetrical cases ought intention. As he notes, “Intentional kill- an operation that could save to be understood under the rubric of ing is synonymous with another expres- self-defense, he demonstrates that for the mother’s life would, at sion sometimes found in the church’s Aquinas, the object of the act of legiti- teaching: direct killing,”36 but yet “one least prima facie, result in the mate self-defense is “good” — even if it can knowingly cause something without involves a physically direct act of killing child’s death.” intending it.”37 — because the act of self-defense, on In other words, Grisez argues, follow- the basis of its moral object, is an act of ing Pius XII, one can knowingly cause “self-preservation,” which is a good. In Therefore, Rhonheimer would claim a death without it being a direct killing. Rhonheimer’s words: that (a) one cannot properly in that By this logic, not all intentional abor- “What is effectively done here [in case speak of the intervention as hav- tion involves intentional killing; in other Thomas’ case of self-defense] is nothing ing two effects; and (b) that even if one words, “someone might choose to abort other than an act of killing; but the inten- could establish that the “matter” of the without choosing to kill.”38 tio is the preservation of one’s life and, action of the dilation and curettage was Grisez posits two scenarios where one because the act of killing occurs praeter or appeared to be a physically direct act might choose to abort without choosing intentionem, the object of the action is of killing, morally, the death of the child to kill, those situations in which: determined formally by the intention of would have been praeter intentionem, “A woman suffering from kidney self-preservation. ... The parallel [to the outside the scope of the intention and disease becomes pregnant and wants obstetrical case] consists only in this: therefore outside of the proper moral to avoid the health problems that will that an act can be an act of killing mate- description of the action. result from carrying the child, or a rialiter but something else entirely for- He holds the latter position both on woman becomes pregnant as a result of maliter, e.g., self-preservation, the saving formal grounds (the intention of the rape and wants to be freed of her ongo- of a life, medical therapy. The object of an intervention was not to kill the child ing suffering. In either case, and perhaps action is determined on the basis of the but to save the mother) and on mate- in a few others, in seeking abortion the formal aspect, not the material.”32 rial grounds (that the child’s death was precise object of the pregnant woman’s Consequently, he argues, certainly inevitable and so therefore could not be choice might be, not the baby’s death or interventions on extrauterine pregnancy chosen). any consequence of it. On this assump- but also craniotomy are not properly Consequently, Rhonheimer would tion, the proposal adopted is, not to kill understood, per their object, as “abor- likely argue that the object of the act of the unborn baby, but to have him or her tion”: intervention at St. Joseph’s was “saving removed from the womb, with death “With respect to the moral object of the life of the mother” or “legitimate as a foreseen and accepted side effect. the action, this intervention has nothing medical therapy,” not “abortion.”34 He An abortion carrying out such a choice to do with an abortion; it is rather a ther- would also argue that there was no other would not be an intentional killing.”39 apeutic measure in favor of the woman, reasonable (in the Thomistic sense) or He continues on to argue that even with the only intentional content of the morally good course of action that could though these cases would count as “abor- action being the healing and the saving have been chosen or pursued. tion” but would not count as intentional

544 origins killing, it would still be wrong to abort the (and, a fortiori, other operations meeting Importantly, however, in the section child or accept the baby’s death.40 Simply the four stated conditions) need not be where Grisez outlines the above argu- because it is not an intentional killing, for direct killing, and so, provided the death ment, he does not use the term “abor- Grisez, does not make it justifiable. of the baby is not intended (which is pos- tion.” In the preceding sections, he clear- The only circumstance in which sible but unnecessary), any operation in ly uses the term (Ch. 8, D3b: “Sometimes Grisez holds that it would be licit to a situation meeting the four conditions intentional abortion does not involve accept the baby’s death would be to save could be morally acceptable.”44 intentional killing”; Ch. 8, D3c: “Abortion, the mother’s life, and then only when even if not intentional killing, usually is certain conditions are met.41 He argues wrong”). as follows: “The purpose of a dila- Yet when he moves to discuss cases “Sometimes the baby’s death may be meeting these four criteria, the word tion and curettage in and of accepted to save the mother. Sometimes “abortion” disappears: the heading for four conditions are simultaneously ful- itself is not, as the National the section is “Ch. 8, D3d: Sometimes the filled: (i) some pathology threatens the baby’s death may be accepted to save the Catholic Bioethics Center lives of both a pregnant woman and her mother”; and the word “abortion” only child, (ii) it is not safe to wait or waiting states repeatedly, ‘the dis- appears once in this discussion, and not will surely result in the death of both, (iii) in relation to interventions which result memberment of a fetus.’” there is no way to save the child, and (iv) in or accept the death of the child. an operation that can save the mother’s It appears that Grisez wants to sug- life will result in the child’s death. In the subsequent section, he makes gest that not only are cases meeting these “If the operation was one of those clear that “sometimes the baby’s life four criteria properly identified as “indi- which the classical moralists considered should be given priority”45 and that “if rect,” but that their object is not “abor- not to be a ‘direct’ abortion, they held the mother’s life is not at stake, it is unfair tion” but rather “saving the mother’s life.” that it could be performed. For example, to accept the baby’s death.”46 But he also in cases in which the baby could not emphasizes that “in a situation in which Analogies to Cases be saved regardless of what was done the lives of both a pregnant woman and Therefore, should any ethics committee (and perhaps in some others as well), her child are at stake and both cannot be at a Catholic hospital research the litera- they accepted the removal of a cancerous saved, if an operation can be performed ture on this question, they would obtain gravid uterus or of a fallopian tube con- with a prospect of saving one or the a consensus opinion from two leading taining an ectopic pregnancy. This moral other, fairness can require the procedure conservative scholars of the Catholic norm plainly is sound, since the opera- more likely to save at least one.”47 moral tradition, both of whom have writ- tion does not carry out a proposal to kill Again, the application to the case at ten in defense of Humanae Vitae, who the child, serves a good purpose and vio- St. Joseph’s Hospital is clear. The case are expert scholars of Thomas Aquinas, lates neither fairness nor mercy.”42 clearly meets Grisez’s four criteria: (i) a are dedicated to Veritatis Splendor and He recognizes that some moral- pathology threatened the lives of both Evangelium Vitae, and who have made ists, both classical and contemporary, the pregnant woman and her child, (ii) clear their dedication to magisterial would classify certain other procedures it was not safe to wait or waiting surely teaching.48 as “‘direct killing,’ since the procedure would have resulted in the death of both, That opinion would have supported in question would lead to the baby’s (iii) there was no way to save the child, the conclusion reached by the ethics death.”43 Like Rhonheimer, he cites the and (iv) an operation that could save the committee at St. Joseph’s Hospital and question of craniotomy for obstructed mother’s life would, at least prima facie, Medical Center. delivery. He wishes to challenge this result in the child’s death. The ethics committee’s delibera- position and does so as follows: Grisez would therefore likely hold that tions were also no doubt influenced by “However, assuming the four condi- the intervention enacted at St. Joseph’s the general knowledge within Catholic tions are met, the baby’s death need not ought not be categorized as a direct kill- health care of the obstetrical cases men- be included in the proposal adopted in ing, for the baby’s death was not what tioned above that are understood to choosing to do a craniotomy. The pro- was intended. be justified according to Directive 48. posal can be simply to alter the child’s As mentioned earlier, Rhonheimer Reasoning analogously from these cases physical dimensions and remove him or explicitly argues that in such cases, the would lead the committee to: her because, as a physical object, this moral object is not “abortion” properly a. Attempt to rely on the principle of body cannot remain where it is without speaking but rather “saving the life of the double effect, although both Rhonheimer ending in both the baby’s and the moth- mother.” Grisez includes the foregoing and Grisez suggest that in these particu- er’s deaths. To understand this proposal, discussion under a general heading “Ch. lar cases, there are no longer two effects. it helps to notice that the baby’s death 8, Question D: Is Abortion Always the b. Reason that in the cases of a can- contributes nothing to the objective Wrongful Killing of a Person?,” suggest- cerous uterus, ectopic pregnancy or che- sought; indeed, the procedure is exactly ing that even these interventions ought motherapy, the intervention does in fact the same if the baby has already died. to be named “abortion” but ought also to physically directly kill the child although “In adopting this proposal, the baby’s be considered “indirect” since the death it is understood to be “indirect” on the death need only be accepted as a side of the child is outside of the intention of moral level; therefore, the committee effect. Therefore … even craniotomy the agent/act. would likely have viewed the interven-

origins 545 tion proposed in this case (dilation and Bioethics Center rejects Catholic It is most commonly used to treat curettage to detach the placenta) to be Healthcare West’s use of the phrase “ter- disorders resulting in abnormal bleed- analogous, and perhaps less grave, given mination of pregnancy” and suggests, ing, polyps and incomplete miscarriages, that here the child was already in the without charity, that it is best understood and management of placental issues. It is process of dying. as “misleading terminology which hides only rarely used as a method of abortion c. Understand that given the terminal the truth.” Precision in terminology is, (2.4 percent of the cases of abortion in condition of the baby, the moral object of however, critical to the work of moral the U.S.49). Therefore, the purpose of a the intervention was properly described analysis, as the foregoing account has dilation and curettage in and of itself is as “saving the life of the mother.” demonstrated. not, as the National Catholic Bioethics Center states repeatedly, “the dismem- Evaluation of Analyses and Statements berment of a fetus.” As part of this analysis, an evaluation “The material intervention Furthermore, as Rhonheimer notes: of the opinion offered by the National “One could add ... that neither is the prin- here was equally or potential- Catholic Bioethics Center was requested. ciple of double effect suited to determin- A comment on the applicability of the ly less of a direct attack on the ing the ‘species’ of an action according statement by the Committee on Doctrine to its object. Indeed, every application of child than other obstetrical of the USCCB was also requested. These the principle of double effect presuppos- follow below. interventions justified within es (in accordance with the first condition ...) that the act performed is already seen the Catholic tradition.” The National Catholic Bioethics Center as good or at least indifferent according Analysis — June 11, 2010 to its object. But the controversial and The National Catholic Bioethics Center Given the clinical facts of the situa- most delicate cases are precisely those offers a number of objections to the tion, the phrase “termination of preg- in which it is not clear what the object intervention at St. Joseph’s Hospital. nancy” is an accurate medical descrip- of the chosen and performed act actu- First, they claim: “The pregnancy was tion of what the intervention was trying ally is.”50 seen as a pathology. However, there was to achieve (to terminate the burden of 2. Similarly, regarding the second cri- no evidence of any pathology of the the pregnancy, not to kill the child); “save terion, the National Catholic Bioethics reproductive organs, nor of the fetus, its the life of the mother” is an accurate Center seems unduly focused on the placenta or its membranes.” moral description of the intervention. notion of the “dismemberment of the Here the National Catholic Bioethics Third, while I agree with Rhonheimer fetus.” To claim that what was “intended Center draws too stark a distinction that this case does not fall under the in the procedure was the dismember- between particular organs and the entire principle of double effect, I believe the ing of the fetus in order to remove it” physiological system of which they are a National Catholic Bioethics Center anal- can only be made by disregarding all that part. I do not mean here to invoke the ysis of the principle of double effect in Catholic Healthcare West has said about principle of totality; rather, this is simply this case is inadequate on a number of this case. a biological fact. While some pathologies counts: This also stands in direct contradic- can be localized to a particular organ or 1. The first criterion for the principle tion to John Paul II’s clear position that site, most pathologies, particularly those of double effect requires that the action “in order to be able to grasp the object of that are life-threatening, cannot be be good or morally neutral in and of an act which specifies that act morally, restricted in this manner. itself. The National Catholic Bioethics it is therefore necessary to place oneself Pulmonary hypertension is, on one Center response to this criterion begs in the perspective of the acting person.”51 level, “located” in the lungs; but inso- the question. “Action” here has tradition- As demonstrated with Rhonheimer far as the lungs are critical for the oxy- ally been understood as the most basic above, the formal intention of the act- genation of the blood, which is critically description of the action itself. For exam- ing person (or in this case persons), not important for the entire physiologi- ple, when the principle of double effect is the material action, defines the moral cal organism, and insofar as immedi- used to justify the use of narcotic agents object. On no basis can it be argued that ate effects of this pathology are cardiac that might hasten death, the response to what was intended in this case was the impairment, and so forth, it is difficult to the first criterion is usually framed as fol- dismemberment of the fetus insofar as: accept an argument which attempts to lows: “The use of narcotics to treat pain a. The mother and medical staff had, simply localize pathology. is a morally acceptable and even good to this point, done all in their power to As noted in Part I above, it can be medical action.” promote the life of the child. legitimately, medically argued that the Following this model, one would b. Ending the life of the child per se pregnancy resulted in physiological begin an analysis of the intervention at would have no effect on the medical changes that exacerbated an underlying St. Joseph’s using the principle of double condition of the mother. Therefore, the pathology, resulting in two new critical effect by noting that the procedure of death of the child could not be intended pathologies (right heart failure and car- dilation and curettage is, in and of itself, as a means to the end of saving the life of diogenic shock), all of which created a a morally neutral and most often a good the mother. An act cannot be intended pathological and ultimately fatal context medical intervention. A dilation and as a means to an end if it will not accom- for the fetus. curettage is used in a variety of gyneco- plish that end. The intentional object of Second, the National Catholic logical situations as a legitimate therapy. the procedure centered on the placenta,

546 origins which was medically and physiologically that in doing so they reduce the object of life of the unborn child. The death of the the cause of the crisis. the act to the physical action of the dila- child is an unintended and unavoidable c. The “attack” on the placenta does tion and curettage and in doing so fail to side effect and not the aim of the sur- not differ, from the perspective of the offer an accurate, Thomistic account of gery.”53 fetus, from the “attack” on the cancer- the moral object of the action in keeping The Committee on Doctrine does ous uterus — in both cases, the organ is with the Catholic moral tradition. not draw any conclusions about the St. a maternal/fetal organ upon which the Joseph case in this brief. However, per fetus is vitally dependent. Statement of the USCCB Committee on the foregoing analysis, John Paul II, d. In the current situation, however, Doctrine — June 23, 2010 Rhonheimer and even Grisez would like- because of the mother’s loss of heart The Committee on Doctrine also offered a ly argue that their analysis conflates the function, the placenta was no longer ful- brief clarification on some questions that notion of direct/indirect with medical/ filling its life-sustaining function vis à vis can arise in obstetrical situations in their physical directness. As we have seen, the the child but was imperiling the life of June 23, 2010, statement entitled “The notion of direct/indirect applies to the both the mother and the child. Distinction Between Direct Abortion and will and intention of the agent vis à vis e. The National Catholic Bioethics Legitimate Medical Procedures.” the moral object of the act as a whole, not Center claims that in discussions with to the directness of the medical interven- physicians, no physicians believe it is tion vis à vis either a pathological organ practically possible to perform a dilation “The Committee on Doctrine or the fetus. and curettage without dismemberment. The Committee on Doctrine state- statement does not address However, this fact is clinically disputed. ment does not address the situation f. Catholic Healthcare West states the situation faced by St. faced by St. Joseph’s Hospital where two clearly that the physicians took every lives were in peril and it was clear that Joseph’s Hospital where two effort to avoid harming the child, though the child was in the process of dying and it is, of course, difficult to do so. A simi- lives were in peril and it was would die shortly. As we have seen, in lar risk to the fetus holds, however, in that situation, an intervention cannot clear that the child was in the cases of extracting a cancerous uterus effectively directly or indirectly result in or removing an ectopic pregnancy. In process of dying and would the death of the child. the case of the chemotherapeutic agents Had the mother followed her physi- die shortly.” ingested by a cancer-ridden mother, the cian’s advice at 7 1/2 weeks, then clearly, chemotherapy poisons the child. The the mother would have found herself in material intervention here was equally They offer two scenarios. The first the committee’s first scenario, undergo- or potentially less of a direct attack on scenario they offer is the case of a direct ing a direct abortion. As we have noted, the child than other obstetrical interven- abortion, one in which “a pregnant however, she steadfastly refused to have tions justified within the Catholic tradi- woman is experiencing problems with a direct abortion because of her Catholic tion. one or more of her organs, apparently as faith. 3. The fetal death was in no way the a result of the added burden of pregnan- It is my understanding that St. Joseph’s cause of or necessary to bringing about cy,” and a surgical intervention “directly Hospital understood its intervention to the good effect (the alleviation of the car- targets the life of the unborn child. ... most closely resemble the second scenar- diac overload). Fetal dying had already The surgery does not directly address io offered by the Committee on Doctrine. initiated with the medical crisis of the the health problem of the woman, for I would suggest that it is notable, per our mother, and the medical crisis of the example, by repairing the organ that is discussion of Rhonheimer above, that the mother would have continued to exacer- malfunctioning. The surgery is likely to committee does not use the term “abor- bate even if the fetus had died before the improve the functioning of the organ or tion” in that scenario and instead refers mother underwent any external inter- organs, but only in an indirect way, i.e., to it under the auspice of a different (and vention. This was established in Part I by lessening the overall demands placed accurate) object: “legitimate medical above. upon the organ or organs, since the intervention.” Following the Committee Fetal demise happens frequently with burden posed by the pregnancy will be on Doctrine, St. Joseph’s Hospital would no effect on pregnancy; in this instance, removed. The abortion is the means by be justified in understanding the inter- it was the pregnancy that was imperil- which a reduced strain upon the organ vention they authorized as a “legitimate ing the mother, a pregnancy that could or organs is achieved.”52 medical intervention.” no longer sustain the fetus. It was not The second scenario they offer is the child that was imperiling the mother. that of the cancerous uterus discussed Summary The death of the child, therefore, could above and they correctly note that such In summation, the ethics committee at not medically be the means toward the procedures “indirectly and unintention- St. Joseph’s Hospital and Medical Center, good end of saving the mother’s life. ally (although foreseeably) result[s] in the fully aware of the magisterial teaching As mentioned above, the National death of the unborn child. In this case on direct abortion, was faced with a Catholic Bioethics Center analysis focus- the surgery directly addresses the health scenario in which they needed to dis- es quite intently on the image of the dis- problem of the woman. ... The woman’s cern whether the proposed intervention memberment of the fetus. In light of John health benefits directly from the surgery. would: (a) properly be described as an Paul II and Rhonheimer, I would argue The surgery does not directly target the abortion in the moral sense; or (b) if it

origins 547 rather entailed a different moral object. to save the life of the mother. The death Aquinas in Support of Veritatis Splendor on the Moral Object,” Logos: A Journal of Catholic Thought and Given the medical facts of the case, it of the fetus was, at maximum, nondirect Culture 11.1 (2008): 100-126. The six affirmations here was germane to their deliberation that in and praeter intentionem. are direct quotes from Veritatis Splendor §78. 15 Murphy, 102, emphasis in original. this instance it was not a matter of weigh- More likely, the fetus was already 16 Aquinas, Summa Theologica I-II q. 19, a. 2 and q. 20, ing one life against another or choosing dying due to the pathological situation a. 1. Also Summa Theologica I-II, q. 1, a. 3, ad. 1. In Summa Theologica I-II, q. 18, a. 6, Aquinas notes: “Acts one life over another; they were faced prior to the intervention; as such, it is are called human insofar as they are voluntary, as with a scenario in which without action inaccurate to understand the death of we have said. Now there is a twofold act in voluntary action: the interior act of the will and the external both mother and child would die and the fetus as an accessory consequence to act; and each of these has its object. Hence just as that regardless of the course of action, the intervention. the exterior act receives its species from the object it is concerned with, so the interior act of the will the child was now terminal. I conclude that St. Joseph’s Hospital receives its species from the end, which is its proper Their decision to proceed with the and Medical Center acted in accord with object. ... Now that which is on the part of the will is related as form to that which is on the part of the dilation and curettage to relieve the the Ethical and Religious Directives, exterior act, for the will uses members as instruments pressure placed by the placenta on the Catholic moral tradition and univer- for action. ... The species of a human act, therefore is considered formally in terms of the end, but materially mother’s cardiovascular system in order sally valid moral precepts in working to in terms of the object of the external act” (Excerpts to address the immediate pathologies of respect the sanctity and dignity of life, from the Summa Theologica are taken from Treatise on Happiness, translated by John A. Oesterle (Notre right-side heart failure and cardiogenic first doing what they could to foster the Dame, IN: University of Notre Dame Press, 1964). shock and thereby save the mother’s life lives of both the mother and the child Thus, the finis of the internal act of the will is the crucial moral element for Aquinas, because exterior would find full support from the care- and then, when it was clear the child had actions, which flow from the internal act, are only ful, rigorous arguments provided by two begun the dying process, to do what they moral and truly human insofar as they proceed from a person’s operations of intellect and will. Aquinas of the Catholic moral tradition’s leading could to save the mother. explicitly says the moral object as finis or end is related figures, Father Martin Rhonheimer and to action in the manner of a form, because it gives the action its species [Ad secundum dicendum quod obi- Germain Grisez. Notes 1 ectum non est materia ex qua, sed materia circa quam, Analysis of the works of both of these The Mayo Clinic, “Pulmonary Hypertension,” www. et habet quodammodo rationem formae, inquantum mayoclinic.com/health/pulmonary-hypertension/ dat speciem. Ibid.]. In short, the object provides the authors also suggests that the action DS00430. moral act with its intelligibility-giving telos. This is why 2 taken at St. Joseph’s is fully in keeping Tarun Madappa, MD, MPH, and Sat Sharma, MD, in question 20, a. 3, Aquinas says that “the interior act FRCPC, “Pulmonary Disease and Pregnancy,” eMedi- of the will and the external act are one act considered with the position of Veritatis Splendor. cine, http://emedicine.medscape.com/article/303852- morally.” Following the opinions of these overview. Thomas continues in Summa Theologica q. 18, a. 7, to 3 authors, I would argue that the inter- “Cardiogenic Shock,” National Library of Medicine, distinguish between moral acts in which the exterior www.nlm.nih.gov/medlineplus/ency/article/000185. act is per se ordered to the end and those that are not: vention that occurred at St. Joseph’s htm. “The object of an exterior act can be related in two 4 Hospital on Nov. 5, 2009, cannot properly Sat Sharma, MD, FRCPC, and Michael E Zevitz, MD, ways to the end willed. In one way, it can be ordered “Cardiogenic Shock,” eMedicine, http://emedicine. per se to it, as fighting well is ordered per se to victory; be described as an “abortion,” in terms medscape.com/article/152191-overview. in another way, accidentally, as taking what belongs to of its moral object. At most, the effect 5 Madappa and Sharma, ibid. another is ordered accidentally to giving alms.” In the 6 U.S. Conference of Catholic Bishops, “Ethical and former case, or “if the object is ordered per se to the on the child can only be categorized as Religious Directives for Catholic Health Care Services,” end, [then] one of the differences determines the other “indirect,” which is morally permitted by 4th edition (2001), Part I. per se. In this way, one of the species will be contained under the other.” More specifically, “the specific dif- 7 Ibid., Directive 3. the Catholic tradition. ference derived from the end is more general, while 8 Congregation for the Doctrine of the Faith, Most important, the death of the child the difference derived from an object ordered per se to “Declaration on Procured Abortion,” §14, emphasis that end is specific in relation to it. For the will, whose was not willed, either by the mother or added. proper object is the end, is the universal mover with 9 the medical staff; the child was a deeply Pope John Paul II, Veritatis Splendor, §80, emphasis in respect to all powers of the soul, whose proper objects original. are the objects of their particular acts.” In other words, wanted child. Effecting the death of the 10 Pope John Paul II, Evangelium Vitae, §§58 and 62, in acts where the exterior act is ordered to the interior child would not achieve any medical or emphasis added. act, the species of the interior act (via the will) deter- 11 From Pope Pius XII, “Address of Pope Pius XII to the mines the species of the act as a whole. This is further ancillary end. Therefore the death of the Associations of Large Families, Nov. 26, 1951,” in Love explicated and confirmed by Aquinas in Summa and Sexuality, ed. Odile M. Liebard (Wilmington, Theologica q. 20, a. 3. child was not the means to any end in 17 N.C.: McGrath Publishing Company, Consortium Murphy, 113. this case. Books, 1978), 125. Quoted in Martin Rhonheimer, 18 Veritatis Splendor, §78. It is difficult to see how any Catholic Vital Conflicts in Medical Ethics: A Virtue Approach to 19 In Aquinas’ account of self-defense (Summa hospital or member of their staff could Craniotomy and Tubal Pregnancies (Washington, D.C.: Theologica II q. 64, a. 7), no mention is made of Catholic University of America Press, 2009), 34. It is whether the aggressor is innocent, unjust, or ir/ratio- have reached a conclusion different from worth noting that while the question of the “life and nal. Aquinas speaks only of “an aggressor.” One does the one taken by St. Joseph’s Hospital death of the mother” is mentioned here by Pius XII not have to describe the fetus or child as an aggressor, and in the “Declaration on Procured Abortion,” none however, in order to use the case of self-defense analo- given: (a) the opinions of two highly of the documents speak to the situation faced at St. gously to analyze cases in which there is threat to life. Joseph’s where both the mother’s and the child’s lives 20 Veritatis Splendor, §80. reputable conservative scholars in the are in peril. 21 It is worth noting that a position consonant with those Catholic moral tradition; (b) the medi- 12 Liebard, 126-7; Rhonheimer, 35, emphases in of Rhonheimer and Grisez was offered almost 40 years Rhonheimer. It should be noted that one difference cal facts of the case; (c) the hospital’s ago by Bernard Haring: “The malice of abortion is an between the case Pius XII describes and the case at St. attack on the right of the fetus to live. Since the doctor familiarity with justified cases of indirect Joseph’s is that in the former, the mother’s condition in this situation can determine with great moral cer- is independent of the fact that she is pregnant. Pius’ fetal termination in the literature; and tainty that there is no chance for both the mother and example remains important, however, insofar as it the fetus to survive with his ‘direct’ intervention, he (d) their familiarity with the principle of demonstrates that the moral object of the action, even accepts the only chance to protect and serve life which in cases that involve physically direct killing, derives double effect. Divine Providence has left to him. He saves the life of from what is intended, not from what is not intended the mother while he does not truly deprive the fetus of It is my opinion that the intervention (St. Thomas Aquinas, Summa Theologica, II-II, q. 64, a. its right to live since it could not possibly survive in the 7: “(Moral) acts do not take their species from what is performed at St. Joseph’s Hospital and event of the doctor’s failure to save the mother’s life” not intended.”). (Medical Ethics (Fides Publishers, 1973), 109). Medical Center on Nov. 5, 2009, cannot 13 Here I follow Rhonheimer, 35ff. 22 Martin Rhonheimer, Natural Law and Practical 14 properly be described as an abortion. Here I follow William F. Murphy’s helpful analysis of Reason: A Thomist View of Moral Autonomy (Fordham Veritatis Splendor and his careful exposition of the University Press, 2000); Martin Rhonheimer, The The moral object of the intervention was Thomistic notion of the moral object in “A Reading of

548 origins Perspective of the Acting Person: Essays in the Renewal conceived of as a rational basis for action, nor can resulted in the death of the unborn child. of Thomistic Moral Philosophy (Catholic University of the action be criticized as an injustice against the life America Press, 2008); and Martin Rhonheimer, The of the child. Consequently, the death of the embryo Bishop Thomas J. Olmsted of Phoenix Ethics of Procreation and the Defense of Human Life: is not chosen; rather, it is similar to an unintentional determined that the November 2009 Contraception, Artificial Fertilization, and Abortion, side effect, which is to say it is not a ‘direct killing.’ In edited by William F. Murphy Jr. (Catholic University of no way is it chosen as a means, and for this reason procedure at St. Joseph’s Hospital and America Press, 2010). neither is it willed in any way; that the operation is Medical Center in Phoenix constituted a 23 William Murphy mentions that this study was written possibly aimed directly at the embryo in a physically and published by Martin Rhonheimer at the request causal way is thus of little importance” (129, emphasis direct abortion, and he has since stripped of the Congregation for the Doctrine of the Faith. See in original). the hospital of its Catholic status. The Murphy, 126, fn. 35. Rhonheimer notes in his preface: 35 Germain Grisez, The Way of the Lord Jesus, Vol. 2, “This wide-ranging study was drafted for the Roman Living a Christian Life (Quincy, Ill.: Franciscan Press, hospital maintains that if it believed it Congregation for the Doctrine of the Faith and com- 1993), Nihil Obstat, Rev. Kevin T. McMahon, and could have saved the lives of both the pleted and submitted to the congregation in 2000. Imprimatur, Cardinal James Hickey. After it was carefully studied in the congregation and 36 Ibid., 470. mother and the unborn baby, it would by its then prefect, Cardinal Joseph Ratzinger, the 37 As he states: “In making a choice, one intends as one’s have done so. (See Origins, Vol. 40, No. congregation in turn asked that it be published so the end the satisfaction or benefit desired for oneself and/ 31, for more documentation on the theses it contains could be discussed by specialists” or others in and/or through carrying out the choice. (xiii). One chooses as a means something in one’s power — case.) The Philadelphia-based National 24 Importantly, reputable Catholic moral theologians some performance or omission — thought more or Catholic Bioethics Center said in its Dec. have recently argued that the drug methotrexate, a less likely to bring about the intended end. But it also commonly used abortifacient agent, is licit for the is more or less clearly foreseen that, either possibly or 24 commentary that in such cases, the treatment of ectopic pregnancies. See William E. surely, the performance or omission will have various church teaches that a good action may May, Catholic Bioethics and the Gift of Human Life good or bad consequences distinct from its intended (Our Sunday Visitor, 2008), 201-202, Nihil Obstat, Rev. end, and in making the choice these good or bad con- be performed even if a bad effect will Michael Heintz; Imprimatur, John M. D’Arcy. See also sequences are accepted, gladly or reluctantly as the arise only if four conditions are met: the Benedict M. Ashley, Jean K. de Blois, and Kevin D. case may be, as side effects” (471). O’Rourke, Healthcare Ethics: A Theological Analysis, 38 Ibid., 500. act itself must be good; only the good 5th ed. (Washington, D.C.: Georgetown University 39 Ibid., 501. Press, 2007), 82, Nihil Obstat, Rev. Patrick J. Boyle; act can be intended, not the foreseen but 40 Imprimatur, Rev. George J. Rassas. Unlike surgical Ibid. unintended bad effect; the good effect 41 Ibid., 502-3. excision of the fallopian tube (salpingectomy), the use cannot arise from the bad effect; and the of methotrexate works by addressing the unfortunately 42 Ibid., 502. pathological interface between the embryo and the 43 Ibid. unintended but foreseen bad effect can- fallopian tube. In May’s words, “Methotrexate attacks 44 Ibid., 502-3. the DNA in the trophoblastic tissue that attaches the not be disproportionate to the good being 45 unborn child to its site within the mother’s body; it Ibid., 503. 46 performed. The center noted that remov- thus attacks the trophoblast attaching the child to the Ibid. fallopian tube or cervix or other part of an ectopic 47 Ibid. ing an advanced cancerous uterus from pregnancy. ... With other moral theologians I thus 48 This number increases to five leading scholars of the a pregnant woman would meet these judge that use of methotrexate can be used to ‘remove’ Catholic moral tradition if we include May, Ashley/de conditions, but that causing the death the unborn child implanted outside the womb; the Blois/O’Rourke and Haring. death of the child is the foreseen but not intended side 49 “Dilation and Curettage,” www.emedicinehealth. of an unborn child in order to allevi- effect of an action morally specified as the necessary com/dilation_and_curettage_dandc/article_em.htm. removal of the unborn child from the mothers body as ate a mother’s hypertension would not Also, U.S. Centers for Disease Control, “Abortion the means, not morally evil in itself, chosen to protect Surveillance — United States, 2002,” www.cdc.gov/ meet these conditions. The mother in the the mother’s life,” www.zenit.org/rssenglish-29448. mmwr/preview/mmwrhtml/ss5407a1.htm. Phoenix case suffered from pulmonary Ashley, et al., similarly argue that the pathology 50 Rhonheimer, 3. here lies not in the fallopian tube but in the way the 51 hypertension. The center’s commentary embryo is attached to the fallopian tube. Therefore, Veritatis Splendor, §78. 52 follows. the intervention (methotrexate) addresses the patho- USCCB, Committee on Doctrine, “The Distinction logical interface. As such, it is a close analog to the Between Direct Abortion and Legitimate Medical use of the procedure dilation and curettage to address Procedures,” 2-3, emphasis in original. The National Catholic Bioethics the pathological interface between the placenta and 53 Ibid., 3, emphasis in original. ■ the mother’s cardiovascular system. In both cases, the Center has refrained from any public pregnancy — not the child — presents the threat to comment on the procedure that took the mother’s life; in both cases, the child will inevitably die; in both cases, without intervention, both mother place at St. Joseph’s Hospital, Phoenix, and child will die; and in both cases, the intervention in November 2009 and the disagree- targets the pathological interface between mother and pregnancy. Commentary ment which arose between the hospital 25 Rhonheimer, 122. and the local bishop, the Most Reverend 26 Ibid., 123, emphasis in original. Thomas Olmsted, as to whether the pro- 27 Ibid., emphasis in original. on the Phoenix 28 Ibid., 124, emphasis in original. cedure constituted a direct abortion. 29 Ibid. Hospital Situation Since the National Catholic Bioethics 30 Ibid., 125. Center has provided counsel to both 31 Ibid., emphasis in original. Catholic Healthcare West, the system of 32 Ibid., fn. 44. National Catholic 33 Ibid., 129. He continues: “(The so-called ‘therapeutic which St. Joseph’s Hospital is a member, abortion,’ on the other hand, is in fact a euphemism; it Bioethics Center and to the bishop of Phoenix, it previ- is not ‘therapeutic’ because it is performed at the cost of the life of an innocent person and, furthermore, ously made no public statement. because the disease for which the child is aborted is “As a Catholic health care institution However, the time has come that not healed at all by the abortion; on medical grounds alone it is illegitimate to call such an intervention a treats and cares for both the mother the center should provide some com- ‘therapy.’)” (129) and the unborn child it must commit mentary, particularly since portions 34 As he concludes: “The death of the child can be claimed to be praeter intentionem, not because the itself never to crossing a clear, bright of its confidential analysis have been intention is related solely to the removal of the preg- line: It may never directly take the life circulated by Catholic Healthcare West. nancy (with the end of saving the mother’s life), but because the intention in the action here in question of an innocent human being as it cares It should be noted the following com- can be directed only at saving the mother’s life, i.e., for both patients,” the National Catholic ments deal only with information that because the removal of the pregnancy in this case cannot include any decision against the life of the Bioethics Center said in a commentary is public and not with any confidential child, since the child has no known chance of survival. on the controversy surrounding a pro- information that may have been gained No other outcome is even in question for the child, nor can any other outcome (i.e., saving the child) be cedure on an ill pregnant woman that through the consultation services pro-

origins 549 vided by the National Catholic Bioethics institutions on what may or may not be the baby either as a means or an end. Center. done in order to protect and advance Nonetheless, one sees that the unborn human dignity in the context of Catholic child will die as a result of the removal of The Heroism of Mothers health care. the diseased organ. 3) The good action, The tragic situation that occurred at The bishops are the authoritative the healing of the woman, arises from St. Joseph’s Hospital in Phoenix in interpreters of this document. One the removal of the diseased uterus, not November 2009 should be a reminder of the directives makes provision for from the regrettable death of the baby of the extraordinary courage and self- addressing conflict situations where it which is foreseen and unintended. 4) sacrifice that mothers take upon them- would appear that one person must die The unintended and indirect death of selves in the service of new life. Although in order to save another in the course of the child is not disproportionate to the modern medical science has thankfully a difficult pregnancy. good which is done which is saving the reduced the life-threatening risks that Directive 47 reads: “Operations, life of the mother. women may assume in becoming moth- treatments and medications that have The principle, however, cannot be ers to almost nil, there still can arise as their direct purpose the cure of a pro- applied to the following case in order to extraordinarily dangerous situations for portionately serious pathological condi- justify an action that would result in the the mother and the child she is carrying. tion of a pregnant woman are permitted death of the child. A mother is suffering Even if it does not come to situations when they cannot be safely postponed from hypertension which is not caused threatening death, women must still until the unborn child is viable, even by any pathology of the reproductive bear many burdens and health risks in if they will result in the death of the system but aggravated by the pregnan- bringing a child to term. As a society, unborn child.” cy. Almost always these pregnancies and as family members, our gratitude can be carefully managed and the child to mothers can surely know no bounds. The Principle of Double Effect brought to the point of viability. Directive 47 applies what is known as The hypertension, if unchecked, Difficult Pregnancies the moral principle of double effect however, may become a danger to the On occasion, life-threatening risks can which asks whether one may perform health or even the life of the woman. indeed still arise, even though rarely. As a good action when it is foreseen that The child is removed from the uterus to a Catholic health care institution treats there might also be a bad effect resulting eliminate the conditions contributing to and cares for both the mother and the from that action (the “double effect”). hypertension. unborn child it must commit itself never The principle of double effect in the This action would generally not to crossing a clear, bright line: It may church’s moral tradition teaches that be justified by the principle of dou- never directly take the life of an inno- one may perform a good action even if ble effect: 1) The first and immediate cent human being as it cares for both it is foreseen that a bad effect will arise action performed by the physician is the patients. Those admitted to Catholic only if four conditions are met: 1) The destruction of the child by crushing or institutions know one indisputable fact act itself must be good. 2) The only thing dismembering it and removing it from about the care they receive: They and that one can intend is the good act not the uterus. Such a procedure would their children are safe from a direct the foreseen but unintended bad effect. violate the first condition of the prin- assault upon their lives. 3) The good effect cannot arise from the ciple of double effect, that is, the action This humane practice of medicine bad effect; otherwise one would do evil itself must be good. 2) In a direct abor- follows on the tradition of the great to achieve good. 4) The unintended but tion the physician intends the death of Greek physician Hippocrates whose foreseen bad effect cannot be dispro- the child as a means toward the good oath states unequivocally: “I will never portionate to the good being performed. end of enhancing the woman’s health. give a woman a medication to cause This principle has been applied Therefore, the second condition is also an abortion; I will give no one a deadly to many cases in health care, always violated. 3) Evil is done, the killing of the medicine even if asked, nor counsel any respecting the most fundamental moral child, so that the good of the woman’s such thing.” Such a commitment never principle of medical ethics, primum non health might be enhanced, protected or to violate a human life has always been nocere, “first, do no harm.” restored. In this case, evil is done that a hallmark of Christian health care as The classic case of a difficult preg- good might come of it. 4) One might well. nancy to which this principle can be argue that there is a proportionate rea- As much as physician-assisted sui- applied is the pregnant woman who has son to take the life of the child because cide or euthanasia or direct abortion advanced uterine cancer. The removal the mother’s life is at risk. However, this may appear to be the best way out of of the cancerous uterus will result in the condition is not applicable because pro- a difficult medical situation, Catholic death of the baby but it would be per- portionality applies only to a foreseen health care institutions assure everyone missible under the principle of double and unintended evil, not one that a phy- coming to them for help that there are effect. sician has chosen to bring about. other options. One can see how the conditions Of course, there are many complica- The “Ethical and Religious Directives would be satisfied in this case: 1) The tions that can arise with a pregnancy for Catholic Health Care Services” have act itself is good; it is the removal of which would morally permit an inter- been written and approved by the U.S. the diseased organ. 2) All that one vention that would result in the death Conference of Catholic Bishops to pro- intends is the removal of the diseased of the child. They are too numerous to vide guidance to Catholic health care organ. One does not want the death of consider here. Also, one must weigh all

550 origins the factors that are part of a given situ- procedures were? Some might have ate in his jurisdiction and is ultimately ation, some of which may never arise conformed to the moral law as indirect accountable for their fidelity to Catholic again. abortions, others may not have. It is faith and practice which guarantees But as another example of what impossible to know without the facts. humane and compassionate practices. would be morally licit under the prin- What is quite remarkable is that such ciple of double effect, one can mention procedures were apparently never sub- Humane and Compassionate Care a case in which there is an early rup- jected to ethical review by ecclesiastical Individuals approaching Catholic social ture of the membrane and the placenta authority. service and health care institutions becomes infected. In such a case, the should be able to have the assurance uterus may indeed be evacuated, that Catholic Owned “Community that what takes place in such facili- is, the infected material threatening Hospitals” ties will be consistent with Catholic the life of the mother may be removed, There was another disputed issue moral beliefs and teachings. The day even though it is foreseen that the child between Catholic Healthcare West and the bishop of Phoenix removed the will die. the bishop of Phoenix. Chandler Medical Catholic status of the hospital, a hos- Center in the Diocese of Phoenix is a pital spokesman wanted to assure the The Case at St. Joseph’s Hospital “community hospital” which is part public that pregnant women were safe It must be said that the National Catholic of the Catholic Healthcare West sys- in St. Joseph’s Hospital. Bioethics Center does not know the clin- tem. The bishop insisted that Chandler But what of their unborn children? ical facts of the case; rather it was asked Medical Center also abide by the Ethical And what of mothers who desperately to comment on the analysis initially and Religious Directives since it was a want to be able to bring their children to submitted to the bishop by Catholic member of a Catholic health care sys- term? Do they have the assurance that Healthcare West. The center was not tem which was clear from its literature, physicians will not encourage, urge or given access to the clinicians involved, website and promotional material. even pressure them into aborting their and it can only be presumed that it was children when a difficulty arises? a very difficult situation in which the We are not suggesting that the physi- physicians had to act with dispatch and “One factor which certainly cians practicing at St. Joseph’s Hospital undoubtedly with regret. would do any such thing. But the appears to have contributed Consequently, without the clini- value of solemn promises, such as the cal facts the center can only articulate to the difficulties in Phoenix Hippocratic oath or commitment to the again the moral teachings of the church Ethical and Religious Directives, is that is that the hospital was not and their proper application rather than the assurance that such pressures would speaking directly to the case. in consultation and com- never be brought to bear, even in dif- Portions of a moral analysis of the ficult situations. munication with the bishop case have been circulated by Catholic Women in the United States have Healthcare West. However, they really regarding the appropriate known since 1973 that they can go into have to do with debates over moral most hospitals in the country and have interpretation and appli- theory rather than the specifics of the an abortion if they desire. Yet expect- St. Joseph’s case, the precise details cation of the Ethical and ant mothers have still chosen Catholic of which remain unknown. However, hospitals. Why? Certainly one reason Religious Directives.” one factor which certainly appears to is that Catholic hospitals have publicly have contributed to the difficulties in committed themselves to the Ethical Phoenix is that the hospital was not in The U.S. Conference of Catholic and Religious Directives which prom- consultation and communication with Bishops agreed with the judgment of ise compassionate and sound medical the bishop regarding the appropriate Bishop Olmsted, that is, “community care and a commitment never to violate interpretation and application of the hospitals” owned, operated, financed human dignity through surgically muti- Ethical and Religious Directives. or managed by a Catholic health care lating procedures or through the direct One of the most dismaying facts to system were to be considered Catholic killing of the unborn or the elderly. come to light as a result of the bishop hospitals and subject to the Ethical and The public is free to choose the kind withdrawing the Catholic status of the Religious Directives. of health care they want. In the United hospital is the hospital’s involvement in The refusal of Catholic Healthcare States they have the options. and profit from the Mercy Health Plan West to have Chandler Medical Center Since 1973 religious health care which provides contraceptive drugs and comply with the directives would have institutions and personnel have been devices (some of which have abortifa- been sufficient grounds for the bishop protected from having to perform cient properties) and also provides for of Phoenix to deny Catholic Healthcare abortions through various legal pro- abortion under certain circumstances. West the privilege of operating in his tections such as the Church and Hyde Also, by its own admission, the hos- diocese as a Catholic system even with- amendments. The majority of Catholic pital has performed other abortions in out the tragic incident that occurred at hospitals are thoroughly committed to the past and will not promise to refrain St. Joseph’s Hospital. state-of-the-art health care which is from performing abortions in the future. The bishop has final responsibility also uncompromisingly respectful of Who knows what the nature of those for all the Catholic ministries that oper- human dignity. ■

origins 551 Periodicals datebook U.S.Postage CNS documentary service PAID Washington DC Feb. 2-5 3211 Fourth Street NE - Washington DC 20017 Annual Southwest Liturgical Conference Study Week. Sponsors: Twenty-seven dioceses in seven southwestern states. Theme: “Ever Ancient, Ever New: Preparing for the Revised Roman Missal.” Radisson Hotel Salt Lake City Downtown. Salt Lake City, Utah. www.swlc.org Feb. 13-16 On File Catholic Social Ministry Gathering. Sponsors: U.S. Conference of Catholic Pope Benedict XVI approved a mir- with two other former Anglican bish- Bishops and 14 other national Catholic acle attributed to Pope John Paul II’s ops. Father Newton, who is a 58-year- organizations. Theme: “Protecting old married man and former Anglican Human Life and Dignity: Promoting a intercession, clearing the way for the Just Economy.” Omni Shoreham Hotel. late pope’s beatification on May 1, bishop of Richborough, was ordained Washington, D.C. Divine Mercy Sunday. Pope Benedict’s to the Catholic priesthood earlier Jan. www.catholicsocialministrygathering.org action followed more than five years 15 by Archbishop Vincent Nichols of Feb. 13-18 of investigation into the life and writ- Westminster. Also ordained Catholic Institute for Diocesan Vocation ings of the Polish pontiff, who died in priests during the Mass in Westminster Personnel. Sponsor: National Conference April 2005 after more than 26 years as Cathedral were former Anglican Bishop of Diocesan Vocation Directors. Sacred pope. The Vatican said it took special John Broadhurst of Fulham and for- Heart School of Theology. Hales Corner, Wis. www.ncdvd.org care with verification of the miracle, mer Anglican Bishop Andrew Burnham the spontaneous cure of a French of Ebbsfleet. The world’s first personal Feb. 28-March 3 nun from Parkinson’s disease — the ordinariate for former Anglicans is dedi- National Organization for the same illness that afflicted Pope John cated to Mary, Our Lady of Walsingham, Continuing Education of Roman Catholic Clergy Annual Convention. Theme: “To Paul in his final years. “There were who is venerated by both Catholics and Shepherd With Wisdom and Prudence: no concessions given here in proce- Anglicans in England. The Ministry of Governance and the dural severity and thoroughness,” said Ongoing Formation of Priests.” Loews New Orleans Hotel. New Orleans, La. Cardinal Angelo Amato, head of the A Vatican official downplayed a 1997 www.nocercc.org Congregation for Saints’ Causes. On Vatican letter to Irish bishops about the contrary, he said, Pope John Paul’s handling cases of clerical sex abuse, March 1 cause was subject to “particularly care- saying the letter did not tell bishops to Symposium: “Religion in American keep the cases secret from the police. Politics and Society: A Model for Other ful scrutiny, to remove any doubt.” The Countries?” Sponsor: Berkley Center Vatican said it would begin looking at Jesuit Father Federico Lombardi, the for Religion, Peace and World Affairs logistical arrangements for the massive Vatican spokesman, said the letter and Walsh School of Foreign Service. aimed at ensuring the bishops fully Georgetown University. Washington, crowds expected for the beatification D.C. http://berkleycenter. georgetown. liturgy, which will be celebrated by followed church law for dealing with edu/events Pope Benedict at the Vatican. accusations in order to avoid a situa- tion in which an abusive priest could *March 11-12 return to ministry on the technicality Catholic Studies Conference: “In The Vatican announced Jan. 15 that Search of God in the World: Scholarly the Congregation for the Doctrine of of his bishop mishandling the process. Perspectives in Conversation.” St. the Faith had erected a personal ordi- The letter, brought to public atten- Thomas More College. Saskatoon, tion Jan. 17 by Ireland’s RTE television Saskatchewan. nariate for England and Wales “for those [email protected] groups of Anglican clergy and faith- and published by the Associated Press,

*signifies new entry ful who have expressed their desire was written by Archbishop Luciano to enter into full visible communion Storero, then-nuncio to Ireland. The with the Catholic Church.” Father Keith letter summarized the concerns of the Newton was named head of the new Congregation for Clergy regarding pro- ordinariate almost immediately after posed Irish norms for dealing with the he was ordained a Catholic priest along sex abuse crisis.

552 origins