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Abortion and Double Effect

Legislation to restrict abortion frequently gets shot down by the courts for failing to include an exemption protecting “the life or health of the mother.” The word health lacks a hard definition, and people freely apply it not only to matters of grave physical health but also to mental health, economic health, and even social health. The issue of the life of the mother, though, is explicit and gives lie to the misuse of this exemption in abortion law.

Cases in which a pregnancy may threaten the life of the mother are extremely rare. Former U.S. surgeon general C. Everett Koop has famously stated:

In my thirty-six years of pediatric surgery I have never known of one instance where the child had to be aborted to save the mother’s life. . . . If toward the end of the pregnancy complications arise that threaten the mother’s health, [her obstetrician] will either induce labor or perform a Caesarian section. His intention is to save the life of both the mother and the baby. . . . The baby’s life is never willfully destroyed because the mother’s life is in danger. (Moody Monthly, May 1980)

Most doctors have never encountered a “life of the mother” case. But what if the situation does arise? Is there a moral solution? Let’s begin with a hypothetical: You are a doctor. Your patient is a woman who is not pregnant. She has aggressive uterine cancer, and the only way to treat the cancer is to surgically remove her diseased uterus.

The action of removing her uterus has two effects; one is desired and the other is not. The desired effect is to save her life. The undesired effect is to render her permanently sterile. This, in and of itself, goes against the proper ordering of the woman’s reproductive functions. Are you, the doctor, morally culpable for this wrong? The answer is no. The principle of double effect means that sometimes one must perform an action that is in itself morally good but may also have an unintended ill effect for which the person is not morally culpable.

Intention, Causality, and Gravity

Three questions determine whether an action with a double effect is moral or immoral.

1. The first is the question of intention. One can never intend the evil effect (CCC 1752). One’s intention must be only for the good effect. The evil effect must be a regrettable byproduct.

2. The second is the question of causality. St. Thomas Aquinas articulated the principle that “the end does not justify the means” (CCC 1759). One may never do evil hoping that good may come of it. A bad effect may be the consequence of a morally good act, or it may occur simultaneously along with it, but the anticipated good must never be a result of evil actions. Such acts are never morally licit (CCC 1756).

3. The third question is of comparable gravity. Is the good being done proportional to the evil consequences of the action? In order to justify taking the action, it must be. When an action has both a good and an evil outcome, the gravity of the two must be weighed against each other. Although “circumstances of themselves cannot change the moral quality of acts themselves; they can make neither good nor right an action that is in itself evil.” Still, they can and do “contribute to increasing or diminishing the moral goodness or evil of human acts” (CCC 1754).

With these principles in mind, let’s revisit our hypothetical situation. (1) Your intention, as the doctor, is to save the life of your patient. Your primary goal is to protect her health. (2) You are not doing evil in order to achieve a good; on the contrary, you are doing a good—removing a diseased organ that is threatening her life. The evil of rendering her sterile occurs simultaneously with that good but does not cause it. (3) Lastly, the good of saving her life greatly outweighs the evil of her being sterilized. Thus, it is a morally good action.

A Tragic—but Moral—Choice

But what if the hypothetical patient is pregnant? Her pregnancy is only a few weeks along, but her uterine cancer is extremely progressed. She needs to be treated as soon as possible if she is to have any chance of survival.

As the doctor, you now have two patients—the mother and her unborn child. Your duty and desire is to preserve the life and health of each of them. What do you do? If you do not remove the mother’s cancer, she will die very soon. At this stage in the baby’s development, it is entirely dependent upon the mother for life. If the mother is not treated and dies, the baby will die, too. You will lose both patients. But the only way to save her life is to remove her uterus, home to a developing person who will die as a result of the operation.

This is a tragic situation to which a moral solution must be found. If the doctor believes that the mother can survive long enough to carry the baby until it is viable—that is, until it can live on its own outside the womb with medical assistance—then the mother may choose to risk her own life to save the life of her child. Even though it may mean decreasing her chances of survival, she may choose to postpone treatment of her cancer.

If the progression of the cancer will not allow for that option, and the mother needs surgery immediately if she is going to live, you, as her doctor, have only two choices: You can allow both patients to die or you can save one and lose the other. The moral choice is to save the mother.

The principle of double effect applies: (1) Your intention is to perform a good—to save the mother’s life by removing her cancerous uterus. The evil effect of causing the death of the baby is not desired. It is a very sad and unfortunate result of the good act. (2) The evil effect does not cause the good result. You are removing a diseased organ that is killing the mother, not performing an abortion. The baby will die during or shortly after the operation, but the purpose of the operation is not to kill the child. (3) Two very grave matters must be weighed against each other. Saving one person is better than allowing both to die through inaction, even though it means the death of one.

The Mother’s (Insert Here) Health

The criteria used to determine that this rare choice is morally acceptable are the same criteria that tell us that abortions for “the health of the mother” are immoral. If an abortion is performed to preserve a less-than-life-threatening.aspect of the mother’s health, it is simply wrong, by all three criteria of the moral principle of double effect.

Although the intention is ostensibly to preserve the health of the mother, all too often the mother’s mental or emotional health—even financial or social health—is invoked to justify the act. In some cases, the doctor may foresee problems arising in a pregnancy that would put the mother at risk.

But regardless of the reason cited, the action taken is the abortion of the child, and the direct intention of that act is death. When an abortion is performed to “preserve the health of the mother,” the abortion is the cause of any perceived benefit to the mother. In other words, an evil is being done to pursue a supposed good, and this is never morally licit. Finally, we must weigh the moral gravity: A grave evil is being done—the direct and intentional killing of an innocent person—to achieve a lesser good. Whether the intended benefit to the mother’s health is small or great, actual or contrived, “good health” can never equal life itself. Abortions performed “for the health of the mother” fail the test on all three counts.

Actual cases where a decision must be made between the mother’s life and the baby’s are rare, but they do occur, and there is always a moral response. Morally mature, ethical doctors are equipped to handle these difficult situations in the rare instances that they arise.

Legislation to regulate these rare occurrences has opened the door to abortion on demand. Statistics bear this out. The National Right to Life Committee reports that 93 percent of abortions are performed for “social reasons,” while the mother’s health is cited in only 3 percent of the cases. (In another 3 percent the baby’s health is cited, and 1 percent cites rape or incest.) “Saving the life of the mother” never came up in the report (

The principle is simple: The direct killing of an innocent life is a grave evil and is never allowed, but when the mother’s life is in danger, medical ethics have always recognized the principle of double effect. And so has the Catholic Church, which has long protected the life of the mother. In 1907, long before abortion on demand was legal through most of the Western world, the Catholic Encyclopedia included this statement in its article on abortion:

If medical treatment or surgical operation, necessary to save a mother’s life, is applied to her organism (though the child’s death would, or at least might, follow as a regretted but unavoidable consequence), it should not be maintained that the fetal life is thereby directly attacked.

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