The attorney general of California announced last week a lawsuit against a Catholic hospital, saying the hospital failed to perform an abortion after a pregnant woman’s water broke 15 weeks into her pregnancy.
The woman, who was pregnant with twins, was diagnosed with premature rupture of membranes.
The attorney general’s lawsuit says Providence St. Joseph Hospital in Eureka, California, determined that at least one of the babies had a detectable heartbeat, and that the mother’s life was not sufficiently at risk to warrant an abortion, per the hospital’s policies.
The woman ultimately drove 12 miles to another hospital, where she received an abortion.
The California lawsuit is the most recent accusation that the Supreme Court’s 2022 reversal of Roe v. Wade puts women’s lives at risk, when doctors and hospitals refuse to perform abortions in cases of medical emergency.
Pro-life groups maintain that respecting unborn life need not come at the cost of the mother.
But what does any of that mean practically? What exactly should a Catholic hospital do when a pregnant woman experiences a medical emergency?
Philip Cerroni, an ethicist at the National Catholic Bioethics Center, said that while the Catholic Church never permits a direct abortion, that does not mean a pregnant woman facing a medical emergency should be turned away from receiving care.
Cerroni did not comment on the California case specifically, as he said there are some facts about the situation that are not entirely clear.
But he suggested that in such situations, people often have the wrong focus — and that the best focus is on better medical intervention for patients in life-threatening situations.
In general, Cerroni told The Pillar, when a pregnant woman faces a medical emergency, the initial goal should be to medically manage the emergency condition, while also trying to protect the life and health of the baby.
“I think everybody agrees…more medical management needs to happen,” he said.
In evaluating those situations, he stressed, the starting point should be the recognition that there are two patients – the mother and the baby.
With that principle as the foundation, it becomes clear that the goal should be to give both patients the best chance of survival, he said.
“I think sometimes with these cases, a false dichotomy is set up: well, it's either great risk to the mother or terminating the pregnancy.”
Instead of viewing an abortion as the only option in an emergency, he said, hospitals should look at medical management options. These may involve blood pressure medications to manage hypertension, antibiotics to prevent infection in the case of premature rupture of membranes, or even an extended inpatient stay to wait for the baby to arrive at the point of viability outside the womb.
It’s possible that treating the mother’s condition may sometimes result in the death of the baby, Cerroni acknowledged.
That possibility is taken into account by the Ethical and Religious Directives for Catholic Health Care Services (ERDs), norms promulgated by the U.S. bishops’ conference to set ethical standards in Catholic health care facilities, based on Catholic teaching about human dignity.
The ERDs govern the policies implemented by Catholic hospitals and doctors across the United States.
They state, “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”
For example, if a woman has uterine cancer, the uterus itself has become a sick organ and needs to be removed.
“The cancer in her uterus is putting her life at risk, independent of her pregnancy,” Cerroni explained. “You can remove the cancerous organ to save her life.”
The principle of double effect
In evaluating how to treat pregnancy emergencies, Catholic moral teaching relies on the principle of double effect. This principle holds that if an action itself is morally good or neutral, a bad side effect may be tolerated – although not intended – alongside a good effect, under certain conditions.
In cases of medical emergency during pregnancy, this means that an action taken for the purpose of saving a mother’s life – a good effect – may also result in the unborn baby’s death – a bad effect. This bad effect may be accepted, and even foreseen, but cannot be intended.
However, the principle of double effect has stipulations surrounding it. One is that the good effect must be proportional to the bad effect – it is not acceptable to achieve a small or moderate good through an action that also causes a great evil.
Another stipulation is that the principle of double effect can only be applied when the action being taken is morally good or neutral, and the bad effect cannot be the means of achieving the good effect. It is not morally licit to perform an evil action in order to achieve a good result.
The principle of double effect can be used to demonstrate why the removal of the uterus is justifiable in cases of uterine cancer, even though the unborn baby will die as a result, Cerroni said.
“Removing an organ that's presenting a life-threatening risk is a morally good act. With the treatment, you want only the good effect to remove this cancerous organ, not the bad effect, ending the life of the child. The child's death is not the means of achieving the good effect. It is a side effect of removing this cancerous organ. And there's proportionality.”
Another example is that of an ectopic pregnancy, in which an embryo implants in a woman’s fallopian tube rather than her uterus. Left untreated, the fallopian tube will rupture, creating a life-threatening emergency for the mother and resulting in the death of the unborn baby.
There are several possible treatments for an ectopic pregnancy, all of which result in the embryo’s death.
But Catholic bioethicists, guided by the principle of double effect, overwhelmingly argue that the morally licit option is a salpingectomy, in which a portion of the mother’s fallopian tube is removed, with the implanted embryo in it.
“The argument is that this is a maternal organ that will rupture and will put her at great risk, as a pathological organ of the mother. So you can intervene directly on that [pathologically affected] maternal organ, knowing that as a side effect, the embryo that's inside won't be able to survive.”
By taking a medical management approach to a pregnant woman’s health condition and using the principle of double effect to evaluate treatment options, many medical emergencies can be stabilized in a way that avoids a tragic outcome and respects both mother and baby, Cerroni said.
The debate over inducing labor
But what if medical management alone is not enough to stabilize a crisis situation?
If a medical emergency takes place after the point of fetal viability – the point at which the baby is capable of surviving outside the mother’s womb, around 24 weeks into pregnancy – the answer is straightforward, Cerroni said: induction of labor.
Directive 49 of the ERDs states, “For a proportionate reason, labor may be induced after the fetus is viable.”
“The Church is very clear that it is not an abortion if you induce labor after viability if you're trying to save the mother's life,” Cerroni said. “And the big reason for that is although it's putting the child at some risk, it's also the best chance that the child's going to survive - getting that kid delivered rather than having that child and the mother [both] expire.”
But if the medical emergency takes place before the baby is old enough to live outside the womb, and medical management of the mother’s condition is not sufficient to stabilize the situation, then things become more complicated, Cerroni said.
A direct physical attack on the fetus – such as a D&E or D&C – is never permissible under Catholic teaching. However some Catholic bioethicists say it is acceptable to induce labor in some crisis situations.
But not everyone agrees.
The question of pre-viability induction of labor is being debated among Catholic ethicists, Cerroni said. There are essentially two camps: One that considers pre-viability induction of labor to be permissible under the principle of double effect, and another which considers it to be a form of direct abortion and therefore impermissible.
The first group of ethicists views emergency induction of labor before viability as an intervention that directly treats a pathology in the mother’s body, in order to save her life.
This group holds that the action being taken – induction of labor – is itself morally acceptable, and therefore the principle of double effect applies. The baby’s death is a tragic and undesired side effect, but the action to save the mother is morally licit.
Cerroni said it is also important to note that group still sees a stark difference between early induction resulting in a baby’s death and an abortion procedure such as a D&E or D&C, which is never permissible.
The idea is that inducing labor is separating mother and baby, because they are in a situation where both are going to die if they are not separated, he said. There is no harming the child or violating his or her bodily integrity.
According to Cerroni, ethicists in that camp argue that the act of inducing labor is categorically different than the act of cutting a baby’s body apart, injecting poison into a baby’s heart, or cutting off nutrients while the baby starves to death – all common methods used in abortion procedures.
Sometimes hospitals recommend these abortion techniques because they are quicker and more convenient than going through the process of induced labor.
However, Cerroni said, the Catholic teaching that all human beings have intrinsic dignity beginning at conception makes it clear that the unborn baby should be treated as a person to be respected and not simply medical tissue to be removed and disposed of.
“Even if this child is going to die shortly after induction, we need to deliver this child and take care of his or her well-being as much as we can in the only way that we can at this point…not violating that child's physical integrity, not cutting him or her up.”
“That is the only and greatest thing that we as the community are ever going to be able to do to protect their human rights, since they won’t grow up, and have other opportunities for us to do that,” he noted.
The second group of ethicists, however, believes that emergency induction of labor before viability is actually a lethal intervention on the body and integrity of the unborn child: severing the connection between the placenta and the uterus - cutting off oxygen and nutrient supplies - to induce labor as a means of addressing a maternal pathology.
To this group, the principle of double effect cannot be used, because the act itself is evil - in essence, an abortion. Or, at least, the bad effect is the means of achieving the good effect.
This group still believes that emergency conditions can be treated, Cerroni noted – even in ways that may result in the baby’s undesired death.
For example, if a woman is experiencing a uterine hemorrhage, this group of ethicists historically has held that it is permissible to give drugs that cause the uterus to tighten, cutting off the hemorrhage – even though this also causes contractions, resulting in the delivery and death of the baby.
In this case, these ethicists would argue that the induction of labor is a secondary effect of the drug and therefore permissible. But they would not accept the reverse scenario – administering drugs to start labor, with the secondary effect of these drugs being the tightening of the uterus.
In the case of premature rupture of membranes, infections can sometimes occur. In this situation, ethicists from both camps tend to agree that induction of labor might be permitted under the principle of double effect.
The action in this case is ejecting infected placental tissue from the mother’s body, because the infected tissue poses a risk to the mother, Cerroni explained. This action itself is a morally acceptable act, and is directed at treating the pathological tissue in the mother’s body. The child’s death is an undesired side effect.
A need for clear policies
There is no clear guidance on the question of inducing labor before viability in the ERDs, because the subject is still being actively debated, with respected Catholic ethicists on both sides. The NCBC does not have an official stance on the matter.
And Cerroni doesn’t anticipate the matter being resolved soon. People on both sides are convinced their argument is a matter of life and death – either for the mother or baby – and so they are unwilling to compromise on their position, he said.
Still, he acknowledged, there is a need for clear policies at Catholic hospitals. Catholic hospitals largely tend to side with those who accept preterm induction in cases of emergency. But the guidelines and protocols need to be clear for staff members, so patients are not turned away.
Without clear guidance available from the ERDs, Cerroni said policies regarding these situations will need to be made by individual hospitals. The ERDs do make it clear, he said, that Catholic hospitals should have an ethics committee or framework for evaluating challenging issues. They also state that if a particularly big ethical question arises, the bishop should be involved in settling it.
“I know everybody wants a simple protocol that says you can do this here, you can't do that here, etc. But we do have a framework for when we have a really difficult situation like this that has lots of medical nuances, lots of moral nuances.”
Ultimately, Cerroni sees a need for continued debate and discussion among Catholic bioethicists on the subject of pre-viability induction of labor, with the goal of arriving at a clear answer.
“That's really how these moral decisions in the Catholic setting happen. You talk it out till one of the arguments or explanations becomes evidently the most likely to be true.”
He noted that until around the mid-1990s, “it was pretty universally agreed that induction of labor before viability was a direct abortion. And that's based partly on interpretations of the historical Church teaching on abortion, as well as some rulings made by the Holy Office [now the Dicastery for the Doctrine of the Faith] in the late 19th century.”
But then in the 1990s, new scholarship came out making the case that inducing labor falls under the principle of double effect, because the death of the infant is not the means or end of the act.
That opened up new debate on the subject, which continues today.
Cerroni added that the Holy Office also previously held that a salpingectomy for an ectopic pregnancy was a direct abortion and therefore prohibited. But some 30 years later, with a reanalysis of what was going on medically in care protocols for ectopic pregnancy, that opinion was reversed.
It’s clear that more discussion is needed, he said. But while that discussion continues to take place, Catholic hospitals should be evaluating their guidelines and educating their staff so they know what policies to follow if they encounter a pregnant woman in a crisis situation.
“We should never abandon or dump patients,” Cerroni said. “[But] there's a difference…between washing one's hands of an issue and working to find a solution. And I think that working to find the solution, that's the form of accompaniment that I think needs to occur in a lot of these cases.”
