Methotrexate Direct Killing and Mutilation of the Unborn Child Essay

Methotrexate is one of these drugs. This drug is an antimetabolite drug that controls the building of new cells and therefore used in the treatment of cancer, autoimmune diseases, and ectopic pregnancies. Unfortunately, it is also used to induce abortions. The same properties of the drug which are meant to stop cancer also prevent the growth of cells for fetuses, thereby leading to abortions. This paper shall discuss the thesis that: utilizing the cytotoxic drug Methotrexate to resolve an ectopic pregnancy is not a morally permissible option.Methotrexate Direct Killing and Mutilation of the Unborn Child Essay.  Moreover, killing the killing of the unborn child is a direct and intrinsic effect of the drug, and for which reason, its use in resolving ectopic pregnancies must be prevented. This essay shall explore this debate, particularly focusing on the argument that the use of methotrexate for ectopic pregnancies is immoral and against the Catholic teachings and against ethical norms.

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Ectopic pregnancies are serious health concerns. In these pregnancies, the embryo does not implant in the uterus, instead, it implants in other areas that cannot safely and successfully sustain it. In these instances, it may implant in the fallopian tube, cervix, ovaries, and in some extremely rare cases, in the abdomen1. These pregnancies are life-threatening for both the mother and the fetus2. In the United States, ectopic pregnancies are considered one of the leading causes of maternal morbidity and deaths3. Moreover, most ectopic pregnancies occur in the fallopian tube, however, these pregnancies have a very low survival rate for the unborn child. Since fallopian tube ectopic pregnancies are the most common, they shall be the main focus of this essay. The primary remedies for ectopic pregnancies include salpingectomy, salpingostomy, and the use of the drug methotrexate4. The first two remedies are invasive surgeries that either remove or cut open the fallopian tube. The third intervention is drug intervention5.

Ethicists have continued to debate about two means of treating ectopic
pregnancy, namely, the removal of the embryo from the tube (salpingostomy)
and the use of methotrexate. This article examines the major arguments
in favor of considering salpingostomy intentional killing. The
article goes on to evaluate the major arguments in favor of the conclusion
that methotrexate is intentional killing or intentional mutilation.
The tentative conclusion reached is that both salpingostomy and the use
of methotrexate should be considered morally permissible.
Extrauterine or ectopic pregnancies occur outside the uterus; the vast
majority of these are found in the fallopian tube. As the pregnancy continues, Methotrexate Direct Killing and Mutilation of the Unborn Child Essay.
the fallopian tube may burst and lead to hemorrhaging which can cause
maternal death. It is estimated that in the United States alone ectopic pregnancy
is the number one cause of maternal fatality in the first trimester of
pregnancy and results in the death of some forty to fifty women each year.
2
In some cases of ectopic pregnancy, the embryo has already died but
the trophoblast, the forerunner to the placenta, continues to bore into the
fallopian tube. In cases in which the embryo has died but the placenta continues
to be built—so-called “persistent ectopic pregnancy”—any medically
indicated treatment is permissible, since abortion is no longer possible. If
we define the term as Pope John Paul II reaffirmed, direct abortion (abortion
The Linacre Quarterly 76(3) (August 2009): 265–282.
© 2009 by the Catholic Medical Association. All rights reserved.
0024-3639/2009/7603-0004 $.30/page.
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willed as an end or as a means) is always wrong because it is the deliberate
(i.e., intentional) killing of an innocent human being.3
Of course, once the
human embryo or fetus has died, abortion is no longer possible; and any safe
means of removing the embryonic remains and other products of conception
from the formerly expectant mother is morally acceptable.
How should cases in which the human embryo is still alive be treated?
How should health-care providers—and health-care institutions and hospitals—committed
to the basic equal dignity of all human beings respond to
this medical emergency?
In current medical practice, the following treatments are used to treat
tubal pregnancy:
1) expectant management,
2) removal of the tube with the embryo inside it (salpingectomy),
3) removal of the embryo alone leaving the tube intact
(salpingostomy),
4) administration of methotrexate.
In this paper, I will discuss these procedures in order to determine which of
these treatments may licitly be practiced by those affirming that every single
human being should be protected by law and welcomed in life.
I. Expectant Management
In expectant management, nature is allowed to take its course in hope
that the situation will resolve itself. In about 40 to 64 percent of the cases, a
tubal pregnancy spontaneously aborts, and the threat to the mother’s life is
removed without having to resort to surgery or chemical intervention.4
With
expectant management, the pregnant woman is carefully monitored in terms
of serial hormone levels and by means of ultrasound. Methotrexate Direct Killing and Mutilation of the Unborn Child Essay. If the human embryo
grows and the hormone levels continue to rise, then some intervention is
medically indicated. Expectant management is a morally permissible way to
treat tubal pregnancy when it is medically indicated. Where expectant management
is no longer medically indicated, other treatment options should be
used.
II. Removal of the Tube with the Embryo Inside It
(Salpingectomy)
This proposal is widely accepted as an application of the principle of
double effect. This double-effect reasoning can be presented as follows:
1) Considered by itself and independently of its effects, the action
of removing the damaged fallopian tube is not evil. As in the
August 2009 267
case of removing a cancerous uterus, the fallopian tube has
become pathological and a threat to the health of the woman.
It is a good action to alleviate a pathology, even if it means
excising once-healthy organs.
2) The evil of the embryo’s death is not a means to the good but
rather a side effect of the morally legitimate goal of stopping
or preventing maternal bleeding.
3) The evil of embryonic death is not intended as an end. The
removal of the tube is not a pretext sought for bringing about
the death of the embryo.
4) Finally, there is a proportionate reason for allowing the evil effect,
because without the surgical intervention the mother may
die, and the embryo will die even without the intervention.
These two procedures—expectant management and removal of the
tube (or section of the tube) with the embryo inside it—have found nearly
universal acceptance by those committed to the basic equality of all human
beings from conception to natural death. Unfortunately, removal of the tube
diminishes the potential fertility of the woman, and in cases where problems
already exist with the other tube, may render her sterile.
III. Removal of the Embryo Leaving the Tube Intact
(Salpingostomy) Methotrexate Direct Killing and Mutilation of the Unborn Child Essay.
The medical advantage of removing the embryo from the tube is that
the fallopian tube remains intact, facilitating future pregnancies. Since the
life of the embryo is almost certain to be lost, many ethicists reason that it
makes sense to preserve what can still be preserved—namely, the woman’s
capacity for fertility. This can be done by salpingostomy.
Ethicists are divided about whether this procedure constitutes direct
abortion.5
I can think of three hypothetical arguments that support the view
that removal of the embryo alone is intrinsically evil, yet I believe each of
those three arguments fails to withstand critical scrutiny.
A first objection to salpingostomies is that removing the embryo alone,
rather than the pathological tube with the embryo within it, is direct abortion
because it is certainly fatal for the embryo. These procedures bring about
death with certainty, so they must be intentional or direct killing. However,
most ethicists also agree that if a woman discovers that she has uterine cancer
that she may have the uterus removed even if she is pregnant with a baby
that is not yet viable.6
In other words, she may have the cancerous uterus
removed even if it is certain that the pre-viable unborn child will die. This
removal is not intentionally killing the unborn despite the certain side effect
268 Linacre Quarterly
of fetal death. So the fact that some medical procedure brings about fetal
death with certainty does not mean that it is intentional or direct abortion.
Similarly, the removal of the pathological tube along with the human embryo
(salpingectomy) also causes certain embryonic death, so the certainty
of death by no means indicates that the procedure is intentional abortion.
Secondly, it is sometimes argued that removal of the human embryo
from the tube simply is the very same thing as killing the embryo, just as cutting
off someone’s head simply is killing the person. But what if the human
embryo could be successfully removed and implanted in the uterus? Some
claim that this has already taken place. Methotrexate Direct Killing and Mutilation of the Unborn Child Essay. Writing in the American Journal of
Obstetrics and Gynecology, L. Shuttles reports:
In Gifford Memorial Hospital, Randolph, Vermont, in 1980, a 27-yearold
patient with unaccountable infertility and regular 28-day cycles had
intercourse around the middle of the month. Approximately four weeks
later severe pain developed in the region of the left fallopian tube.…
Exploration while the patient was under regional anesthesia revealed a
single corpus luteum in the left ovary, some uterine congestion, and on
the direct palpation on the left tube a small 4 to 5 mm mass. With careful
incision into the tubal lumen an intact embryonic sac was enucleated,
still completely covered with chorionic villi…. It was immediately
placed in an oxygenated saline solution warmed to body temperature. A
segment of infusion tubing was cut, one end slanting and the other attachable
to a glass Preto syringe with a large rubber bulb enabling one to
aspirate or express as desired. With gentle suction the slanted end of the
tubing was passed into the myometrium in the upper, anterior aspect of
the uterus until discernible decidual tissue was observed. With the tubing
in situ, the embryonic sac was taken up into the glass syringe, which
was then attached to the tubing and expressed in utero. Tamponade of
the puncture side with a very wam [sic] pad controlled any bleeding.
The tube was then repaired and the abdomen closed. The pregnancy test
remained positive. After normal postoperative and prenatal course, a
normal infant was delivered at term.7
If this report and a much older one like it are accurate,8
it would not be true
to say that salpingostomy necessarily involves the death of the embryo. In
other words, removing the embryo from the fallopian tube in itself is not
simply the same thing as intentionally killing. Although there is not yet an
established procedure for this transfer, one can hope that advances in microsurgery
and early detection of tubal pregnancy would make possible both a
preservation of the embryonic human being and the reproductive capability
of the fallopian tube.
I believe that the removal of the embryo from its pathological site of
implantation by surgical removal of the embryo alone (salpingostomy) is
August 2009 269
implicitly recognized as a morally good or indifferent action, considered
by itself and independently of its effects (condition 1 of the principle of
double effect), even by those who condemn these procedures. A number of
respected ethicists vigorously oppose removing the embryo alone, including
William E. May, Eugene F. Diamond, and Kelly Bowring, but they nevertheless
endorse efforts at embryo transplantation from the fallopian tube to the
uterus.9
But such transplantation necessarily involves detaching the embryo
from its location in the fallopian tube—which if it were truly evil in itself
and not merely from its effects—would be an act that is intrinsically evil
and therefore never to be performed regardless of the consequences. So at
least implicitly, these authors do not hold that detaching the embryo from
its pathological location in itself is intrinsically evil (or they should—to be
consistent—condemn as intrinsically evil any effort to transplant a tubal
pregnancy into the uterus).
It might be responded that it is immoral to remove the embryo from
its pathological implantation site if one has no safe haven for the embryo,
such as the uterus. Methotrexate Direct Killing and Mutilation of the Unborn Child Essay. To use a different example, it would not be wrong to take
someone off a life raft in order to put that person in a larger safer boat, but
it would be wrong to knock someone off a life raft if there were no place to
put him, even if the person is certain to die on the life raft. Since there is no
feasible transplantation technique for ectopic pregnancy, the removal of the
embryo is morally wrong. If there were such a technique, it would not be
wrong to remove the embryo leaving the tube intact.
However, if there is some further condition that can be added that renders
an act accurately and morally described as no longer evil, then we are
no longer talking about an intrinsically evil act. Again, if something is intrinsically
evil—as opposed to circumstantially evil—then no further circumstance
can render that act good, including the further circumstance that
they can be removed to another place of safety. In other words, the response
itself implicitly indicates that removing a human embryo from its point of
pathological location is not intrinsically evil, just as removing someone from
a lifeboat is not intrinsically evil. Both may be circumstantially evil; but then
one must take into account the additional circumstances; and so the act in
itself is not intrinsically evil.
In addition, some argue that removal of the embryo without the tube
is illicit because it involves physically doing something to the body of the
embryo that is not of benefit to the embryo, unlike removal of the tube along
with the embryo in which the maternal fallopian tube is the object of the
intervention. In the words of William E. May,
[in] the hysterectomy (and, similarly, the salpingectomy in handling a
tubal pregnancy), the medical intervention is performed on the mother,
270 Linacre Quarterly
whereas in the “removals” of the unborn child by …. salpingostomy…
the interventions are performed on the unborn child.
10
However, the removal of the embryo from the fallopian tube does
not constitute an “attack” on the body of the human embryo, for it can be
performed—although it is usually not—in such as way that the embryo’s
physical integrity is not undermined. Removal of the embryo from the pathological
location of implantation could be done such that the tubal maternal
tissue that has been damaged is removed—leaving the embryo’s bodily integrity

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intact.11 Indeed, if transplantation is facilitated, the removal would
constitute a therapeutic intervention for both the mother as well as the human embryo.Methotrexate Direct Killing and Mutilation of the Unborn Child Essay.
Even if the surgery were performed on the body of the human embryo
with damage being done to the human embryo’s body, that would not of
itself mean that the surgery was a direct or intentional abortion/killing. In
reasoning about self-defense, St. Thomas Aquinas famously argued that the
act of self-defense is morally permissible even though performed against
the body of the attacker and even though death results from the defensive
force used.12 Obviously, the human embryo is not an “attacker” in the formal
sense, but Thomas’s point remains that the use of lethal force against
another’s body does not of itself necessarily constitute intentional killing.
My point here is not to argue that the human embryo can be killed
because the killing is justified as an act of self-defense. My point is that acting
directly on someone’s body, does not, in itself, mean that all the effects
which follow from acting directly on someone’s body are intended. In a just
war, a strategic bomber may drop a bomb which both destroys a legitimate
military target as well as kills by impinging upon the bodies of innocent
civilians, but such a bombing may be justified for a proportionate reason.13
Conversely there are some intentional killings in which no action is taken
upon the body of the victim. For example, if a lifeguard intentionally omits
saving a drowning swimmer (so as to enact revenge perhaps), the lifeguard
intentionally kills the swimmer. He has deliberately omitted an action, that
he could have and should have performed, so as to secure the death of an
innocent person. Similarly, parents who intentionally omit feeding a baby
in order to kill the infant intentionally kill but do not act upon the body of
the baby. In such cases, there is “direct” killing, i.e., an intentional killing,
although the body of the victim is in no way physically impinged upon. Acting
directly against the body of another is therefore not decisive in terms of
defining intentional killing, and therefore not decisive in defining abortion.
Finally, one could appeal to authority in arguing that removal of the
embryo alone from the fallopian tube is intentional abortion. Directive 45
of the Ethical and Religious Directives for Catholic Health Care Services
August 2009 271
adopted by the U.S. bishops states: “every procedure whose sole immediate
effect is the termination of pregnancy before viability is an abortion.”14 Directive
36 states: “It is not permissible, however, to initiate or to recommend
treatments that have as their purpose or direct effect the removal, destruction,
or interference with the implantation of a fertilized ovum” (emphasis
added).
I argue that these directives do not settle the case, since, unlike earlier
editions of health care directives issued in 1954 and 1971, the current directives
do not indicate which procedures constitute a “sole immediate effect of
terminating a pregnancy.” Does removal of the embryo from its pathological
site of implantation fall under the norm prohibiting termination of pregnancy
prior to viability?Methotrexate Direct Killing and Mutilation of the Unborn Child Essay.  As Pope John Paul II indicated in Evangelium vitae, the
intrinsic wrongfulness of abortion consists in its being the intentional killing
of an innocent human being as a means or as an end. Indeed, “termination
of pregnancy” in the morally prohibited sense should be understood in this
light—for some licit actions “terminate a pregnancy” in a morally unproblematic
sense, including removing a gravid cancerous uterus and removal of
the tube alone with the fetus, but these actions are not direct or intentional
abortions. Direct abortion, “termination of pregnancy” in the morally illicit
sense, is properly understood as intentionally taking of human life—as a
means or an end—prior to birth.
Perhaps soon a technique will be found that facilitates transfer of an
ectopic pregnancy from the fallopian tube into the uterus. Imagine that the
procedure is safe both for women and their developing children. If directives
45 or 36 were to be interpreted as condemning all removals in all
situations, then these ectopic transplants would have to be forbidden in all
Catholic hospitals. The embryo, who could be easily saved, would have
to be allowed to die, for the life-saving transplantation would involve removing
the embryo from its initial site of implantation. Since directives
45 and 36 were given to serve human life, not undermine it, interpreting
either directive in the strict sense to exclude all embryo transplantation in
all circumstances is not in accord with the values/goods that the directives
are intended to serve.
Indeed, one could argue that the action, considered by itself and independently
of its effects, is a benefit for the embryo itself. The human embryo
cannot properly develop in the fallopian tube, so removing the embryo from
its current lethal location is of benefit to the embryo, even if the later stages
of what could be a rescue attempt are virtually doomed to fail in producing
a live birth. In removing the embryo from the fallopian tube, a pathological
condition is alleviated for the mother and the embryo, despite the bad side effect of virtually certain embryonic death. Methotrexate Direct Killing and Mutilation of the Unborn Child Essay.