The recent controversy on the use of methotrexate to treat an ectopic pregnancy has raised again the dilemmas we often face in medical practice, this time vis-à-vis the Principle or Double Effect (or Doctrine of Double Effect – DDE) where the killing of an embryo when removing a tubal pregnancy is allowed morally because it is foreseen but indirect and unintended. The four conditions of double effect are:

1.      The action must not be intrinsically wrong

2.      The agent must intend only the good

3.      The bad effect must not be the means of bringing about the good effect

4.      The good must outweigh the bad (proportionality)

Advances in medical and surgical practice however have improved the outcomes of ectopic pregnancy by the possibility of saving the tube. Surgically one can now use laparoscopic procedures and medically methotrexate, which kills the placenta. Both these methods however make the killing of the embryo a direct one, which hence caused the controversy around the doctrine of double effect, as these are seen not to satisfy the third condition. However, the question is whether one should demand the proverbial “pound of flesh” in order to satisfy the philosophical conditions of a moral principle when the outcome is the same (and perhaps better, both in saving the tube and in recovery time and risks of surgery). It is also a moral principle not to put people in danger unnecessarily. The recent dilemma on having methotrexate delayed was challenged by the Department of Health as it usually takes only a few hours to resolve. But why should a committee be involved in ectopic pregnancies?

Before going into this, one needs to mention the problem with applying the DDE. It is a useful tool bioethically when doing theory. It is not useful to try to use clinically as what is direct or indirect and what is proportional may not really be clear. Perhaps the landmark example of the application of the DDE came in 1985 when the Belgian Episcopal Conference proclaimed that if a pregnant woman has cancer, she can get treatment even if it causes harm or kills the baby. Before 1985 many women died because they could not (morally) receive treatment. Ectopic pregnancies had been accepted as the tube/baby complex were considered as pathological tissues. No attempt was made to save the tube as the technology did not yet exist.

The controversies arise in countries where abortion is illegal. Although, for example, in the UK abortion is legalized for health reasons, with two doctors having to agree and sign a document, it remains illegal at law. Therefore, even endoscopic removal of the foetus caused problems and the Royal College of Obstetricians and Gynaecologists issued guidelines on when it ought to be used.

Conversely, many remember the controversy of the Gozitan Siamese Twins (known clinically as conjoined twins) born in Manchester in 2000. The courts ruled that the embryos should be separated as one depended on the other and they could not live conjoined more than a few months. The Bishop of Gozo had advised the parents that they could allow nature to take its course if they wished, allowing both babies to die naturally. Many articles were subsequently published after the surgery arguing that the DDE could have been used to justify the separation. The controversy was based on whether the killing of the weaker of the twins was a direct result of the surgery or an indirect one. Even moralists could not agree.

More recently we witnessed the case of Savita Halappanavar in a Catholic hospital in Ireland who, having a dying baby in her uterus, was refused a termination of the pregnancy, which she and her husband requested. She subsequently died of a Septic abortion. This could have been avoided with proper monitoring. However, the larger question begs whether a woman ought to be put through that risk anyway. The hospital doctors told the parents that since there was still a heartbeat they could not terminate on moral grounds. Subsequently, the Irish Episcopal Conference stated that if the intention is not to kill the baby, the principle of double effect should apply:

“Where a seriously ill pregnant woman needs medical treatment which may put the life of her baby at risk, such treatments are ethically permissible provided every effort has been made to save the life of both the mother and her baby.

Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby.”

However, doctors need the comfort and backing of the law. The DDE cannot be applied without prior approval – and even then, the law has to accept it. While methotrexate cannot be used for normal abortion, given the statement of the Irish bishops, we presume they meant that induction of labour would not have been seen as a direct killing because the outcome was proportionate and the intention was certainly not to kill the baby. If this be the case, we should accept the use of methotrexate in an ectopic pregnancy – a much less controversial area. The intention is certainly not to kill as this would still happen should one operate traditionally.

Medicine and science need moral guidance. No one contests that. It has to come from normative values and obviously culture and religion in various countries will play a role. But history has shown that people have had to die before things changed. We should now have the courage (which after all is a moral virtue) to prevent tragedies from happening. It is as; if double effect can be applied it should be applied, otherwise if we are to wait for all moralists to agree we will put patients at risk. There clearly are cases which will be controversial, such as the partial abortion of a baby caught in the passage during delivery, but, in my humble opinion, an ectopic pregnancy is not one of them. 

Pierre Mallia is Professor of Family Medicine and Patients’ Rights and teaches at the University of Malta. He Chairs the Bioethics Research Programme of the Faculty of Medicine and Surgery. He also chairs the Bioethics Consultative Committee. This article is his personal opinion and does not represent the opinion of any committee or Board he serves on.