Saturday, November 28, 2009

The moral problem with "early inductions" at St. Joseph's Catholic Hospital

Following an earlier post of mine on the scandalous "early inductions" at St. Joseph's Catholic Hospital, a very interesting discussion ensued in the comments section. This post is a synthesis of why I believe that the procedures at St. Joseph's are not morally acceptable.

What is happening at St. Joseph's

Before starting my explanation, I'll just repeat what exactly is happening at St. Joseph's: 
  1. A prenatal diagnosis test reveals a baby has serious birth defects.
  2. The doctors conclude that the mother is in some physical, psychological or psychiatric danger because of the baby's defect.
  3. Doctors wait until the baby reaches 21 weeks of gestation, the point at which it is considered "viable", in other words that it could theoretically survive outside the womb if it were given highly specialized intensive care treatment.
  4. The doctors then artificially induce labour so that the baby is born prematurely.
  5. They intentionally let the baby die.  They only provide palliative care to the dying baby. 

Why this is morally unacceptable

In this section I'll explain why this practice is so horrible.  Not only are St. Joseph's official guidelines - as written on paper - morally unacceptable, but their application is even worse because they're terminating babies when the mother's health isn't even in danger.

In the 5-point description above of what happens at St. Joseph's, you'll notice that the baby does not die of its deformity.  It dies due to prematurity.  Heck, even a perfectly healthy baby delivered at 21 weeks would not survive without a lot of specialized treatment in an incubator. So the cause of death for these babies at St. Joseph's is not their deformity.  Death is inflicted by the medical personnel that delivered the child. That's a huge distinction.

If a baby suffers from a severe birth defect such as anencephaly, it will surely die at some point, maybe before birth. However, to hasten is death is not the Catholic way. Just because the baby is disabled doesn't mean that it's expendable. Most Catholics agree on this point.

Now if the mother's life is in grave danger, then certainly the principle of double effect allows for a treatment to save the mother, even if the baby dies as an unwanted side-effect.  The Catholic teaching of the principle of double-effect state that you can legitimately carry out an act that is morally good, but which has unintended side effects that are morally evil. A correct application of the principle of double-effect requires that the following conditions be met:
  • The act must be morally good in itself and may not be morally evil. 
  • The good effect of the act must be that which is directly intended by the one who carries out the act. The bad effect that results may be predictable, but it must not be intended.  It is an unfortunate side-effect of the good act.
  • The good effect must not be brought about by using morally evil means. This is important:  the ends do not justify the means in Catholic morality.  You cannot commit an evil act in order that a good may result from it.
  • The good effect must be of equal or greater proportion to any evil effect that would result. 
  • Acts that have morally evil effects are permissible only when truly necessary, i.e. when there are no other means by which the good may be obtained.  If there is another way to achieve the good effect, that you must use it.

So how can this principle be applied to the "early inductions" at St. Joseph's?  The issue of ectopic pregnancy can be insightful on this matter. An ectopic pregnancy occurs when the fetus attaches to the wall of the fallopian tube rather than in the uterus.  In such conditions, the baby would eventually grow too large for the tube, causing a serious hemorrage and leading to the death of both mother and child.  

A few years ago, I contact Priests For Life and Human Life International (separately) to learn about the proper Catholic treatment for ectopic pregnancy. They both told me the same thing. The only valid application of the principle of double-effect in an ectopic pregnancy is to remove the fallopian tube (salpingectomy). Termination of the pregnancy is not a morally licit option in their opinion. What's the distinction? The removal of a fallopian tube, in itself, is a morally neutral act. The procedure is no different than if there were a tumour in the tube.  The unintended side effect is the death of the baby inside the tube. That's a valid application of double-effect. Contrast this with a termination of pregnancy, such as the "early inductions" at St. Joseph's (or abortions which are done in other places) where a direct action is taken on the baby alone. That's not a valid application of double-effect.

Does this example apply to other instances where the mother's life is in danger? I believe it does, not because of my own opinion, but because of what the United States Conference of Catholic Bishops (USCCB) has said. Let me quote from an important document they issued in 1996 called Moral Principles Concerning Infants with Anencephaly, which deals with the issue of whether or not it is licit to terminate pregnancies of expectant mothers whose child is diagnosed with anencephaly (severe abnormality):

"In other words, it is permitted to treat directly a pathology of the mother even when this has the unintended side-effect of causing the death of her child, if this pathology left untreated would have life-threatening effects on both mother and child, but it is not permitted to terminate or gravely risk the child's life as a means of treating or protecting the mother. [Comment by SG:  This is a good summary of the principle of double effect]

Hence, it is clear that before "viability" it is never permitted to terminate the gestation of an anencephalic child as the means of avoiding psychological or physical risks to the mother. Nor is such termination permitted after "viability" if early delivery endangers the child's life due to complications of prematurity. In such cases, it cannot reasonably be maintained that such a termination is simply a side-effect of the treatment of a pathology of the mother (as described in Directive 47). Anencephaly is not a pathology of the mother, but of the child, and terminating her pregnancy cannot be a treatment of a pathology she does not have. Only if the complications of the pregnancy result in a life-threatening pathology of the mother, may the treatment of this pathology be permitted even at a risk to the child, and then only if the child's death is not a means to treating the mother.

The fact that the life of a child suffering from anencephaly will probably be brief cannot excuse directly causing death before "viability" or gravely endangering the child's life after "viability" as a result of the complications of prematurity" (Source)

Even though they are talking about anencephaly, the principles can be generalized to other fetal abnormalities. The excerpt above is very explicit and clear, but I'd like to highlight a few points:
  • Notice the sentence I underlined in red: the bishops condemn any termination of pregnancy after viability if it endangers the life of the baby.  In the case of St. Joseph's, the interventions definitely endanger the life of the baby.  
  • In the sentence I underlined in green, they explain that the child's death cannot be used as a means of treating the mother.  That's exactly what they're doing at St. Joseph's.
  • In the blue sentence, they are contradicting another aspect of St. Joseph's policy, whereby the hospital says that the baby is already dying of its deformity, apparently implying that it doesn't matter if they just help it along.
In that excerpt from the USCCB document, they state that termination of pregnancy is "never permitted" if the life of the child is in danger, even if to avoid physical risks to the mother. "Never" is a very strong word. It admits of no exceptions. I'm sure they thought long and hard before choosing that word because it is very definitive. Why such absolutism? They explain themselves in the next sentence: because "it cannot reasonably be maintained that such a termination is simply a side-effect of the treatment of a pathology of the mother." They appear to be invoking the principle of double effect and saying that this wouldn't be an appropriate application. Later in the paragraph, they state that treatment may be administered to save the mother, even if the child dies. Notice how they say treatment may be permitted, not termination may be permitted. Words are important in theology and I'm sure they picked their words very carefully. The morally licit treatment must therefore be something other than termination, otherwise they would have used the word termination.

For greater certainty, the USCCB sums it up in another passage: 

"In other words, it is permitted to treat directly a pathology of the mother even when this has the unintended side-effect of causing the death of her child, if this pathology left untreated would have life-threatening effects on both mother and child, but it is not permitted to terminate or gravely risk the child's life as a means of treating or protecting the mother."

This is another great summary of the principle of double effect.  And notice, again, how they distinguish between treatment and termination:  they say "it is permitted to treat" but "it is not permitted to terminate".

In the comments section of an earlier post of mine, a good priest was sharing his thoughts about the St. Joseph's situation.  He does ministry with couples who lose their baby very early.  He related the tragic case of a baby named Sophia who had a serious defect that was not diagnosed. So she was carried to term and died shortly after birth. This is not rare:  many babies with severe deformities will actually survive until birth and beyond, before eventually dying.  If the deformity had been diagnosed, what would have happened under St. Joseph's guidelines? They would have induced Sophia at 21 weeks and left her to die. Because of their policy, she would have died at 21 weeks instead of full term. This is a perfect example of the horror I'm talking about. Despite her deformity, Sophia was able to live until term in her mom's tummy. But under St. Joseph's rules, they would have brought about her death at 21 weeks. That is not sound Catholic morality. The cause of death would have been inflicted by the medical personnel who caused the premature delivery, not by her deformity since clearly she was able to live until term.

Some doctors are understandably confused by the policy at St. Joseph's since fetal abnormalities do not generally cause the mother's life to be in danger.  Even more worrying is that St. Joseph's allows early termination in the cases of "psychological or psychiatric" dangers.  I understand that some people suffer from mental disorders and I greatly sympathize with their situation.  My Dad was a psychologist for 25 years so I know a thing or two about mental disorders. Such disorders can be exacerbated when the mother learns the bad news that her child is deformed.  Yet, I still can't see how this is a proportionate cause for early termination of the pregnancy.  Mental disorders rarely kill people, but "early inductions" without intensive care will definitely kill the baby 100% of the time.  The most serious mental disorder that comes to mind would be strong suicidal impulses.  But that can be treated with medication, therapy, and in extreme cases, with medical supervision and a suicide watch.  Even if the medication were to cause detrimental effects on the baby, this would probably be a valid application of the principle of double-effect if the lives of mother and child were at serious risk due to suicide.

But that's such an extreme case.  In the overwhelming majority of cases of mental disorders, I can't see the mental anguish of the mother being proportionate to the death of the child. And there's no guarantee that the mental disorder will subside after the pregnancy is terminated.  Women who lose their baby often suffer depression.

In fact, there are at least 3 documented cases of mother's being advised or even pressured to have an early induction even though the mother wasn't at risk:

I find it difficult to accept some claims that these mothers simply misunderstood what the hospital staff was telling them.  This is not like jotting down a phone number where you can accidentally write a 6 instead of an 8.  We're talking about the life and death of these women's babies. They asked several times and spoke to different people who repeated the message several times.  In the case of Nikki Cooke, she has five letters from doctors at St. Joseph's to her family doctor recommending termination.  It's in writing. A misunderstanding is not a logical or plausible explanation.  

Possible exceptions

There exist some rare conditions where it may be necessary to remove the membranes that surround the unborn baby because these membranes have become diseased and could result in the death of the mother (and, of course, of the baby).  For example: 
  • Chorioamnionitis is an inflammation of the amnion and chorion membranes that surround the baby due to a bacterial infection.  The amniotic fluid typically gets infected too. If left untreated, both the mother and baby could die.  Apparently, antibiotics are not sufficient to fix the problem.  As a result, it is necessary to take out those membranes and the amniotic fluid from the mother.  Of course, since the baby is inside those fluids, the baby is delivered at the same time.
  • Pre-eclampsia is a dangerous condition that  leads to high blood pressure, high protein levels in the blood and seizures in the most severe cases (this is not an exhaustive list of symptoms).  This condition is potentially fatal for the mother and baby.  While the cause is not known, some theorize that it may be due to problems with the placenta.  Medication can be used to treat the moderate cases, but the most severe cases appear to be resolved only by removal of the placenta, which takes the baby out.
I've chosen my words carefully because I'm making a direct reference to the principle of double-effect. In these two cases, you will notice that it's not the baby that is killing the mother. It's the "stuff" that surrounds the baby (amnion, chorion, amniotic fluid, placenta, etc.) that is causing harm. Removing a diseased part of the body is an acceptable thing to do. For example, you may have your tonsils or your appendix removed if they become sick. In the case of the "stuff" surrounding the baby, the unintended side-effect is the removal of the baby from the womb.

Because of this distinction, I think it would be ill-advised to call these particular procedures "early inductions" because that term gives the impression that the baby is the problem and that direct action is taken against the baby to solve the problem. If you look at it from the perspective of taking out the "stuff", then you understand the morally licit nature of the intervention. Is this just a question of semantics? I don't think so. The principle of double-effect REQUIRES the physicians to approach the treatment as a removal of diseased "stuff" and not a removal of a baby. Just like the treatment of an ectopic pregnancy is the removal of a diseased fallopian tube, not the removal of a baby.

So is St. Joseph's off the hook? I don't think so. First, we have real evidence of women being asked or pressured to have an "early induction" in the absence of health risks to the mother. Second, and more importantly, even if the mother's health is really in danger AND removing the "stuff" would solve the problem, the only morally acceptable approach would be for the physicians to take every necessary means to save the baby by giving it specialized care in an incubator.

By someone could argue: all that specialized care is simply "extraordinary" and "burdensome" treatment, which a patient has the right to refuse in order to allow nature to take its course and for death to ensue.  Catholic teaching does contain provisions for refusing extraordinary treatments.  BUT in the case where a baby is delivered as a result of the removal of diseased "stuff", remember that the life-threatening condition of the baby was inflicted by the physicians through premature delivery. That's not a death by natural causes. You can't put the baby in critical condition and then wash your hands of the situation by invoking "extraordinary means" of treatment. If you inflicted the condition, you're responsible to do everything you can to fix it. That's not the practice at St. Joseph's. They just let the baby die.


To sum up, not only are St. Joseph's policies - as written on paper - morally unacceptable, but their application is even worse because they're terminating babies when the mother's life isn't even in danger.  Based on the assessment of the USCCB, I think that the practice at St. Joseph's is too direct an attack on the baby to be a valid application of the principle of double effect, and it is applied in circumstances where the mother's life is not likely to be at serious risk anyways.  

It is scandalous that the Canadian bishops, in particular the bishop of London, Ronald Fabbro, have done nothing to stop this.  Bishop Fabbro launched an investigation in March, eight months ago, but nothing has happened.  The fact that he launched this investigation after pro-lifers started raising a stink tells me two things:  1) there is likely something wrong about these practices (if they accusations were ludicrous, there would be no investigation);  2) pro-lifers can make a difference when they take action against injustice.