Ectopic Pregnancy as Previable Delivery

Abstract

Inside and outside of a Christian worldview, bioethicists have discussed ectopic pregnancy at some length as a maternal-fetal vital conflict. Most bioethicists agree that methotrexate and salpingostomy are low-risk, successful interventions for this life-threatening pathology, and are thus beneficent, just, and wholly acceptable. A small cohort of Christian, largely Catholic, bioethicists have reservations about methotrexate and salpingostomy, but cannot resolve their internal disputes about these because of flawed casuistry. This paper aims to settle the issue about whether methotrexate and salpingostomy are acceptable within a Catholic worldview: despite the best arguments in favor of methotrexate as a moral option, it is morally unacceptable, and despite hesitation about salpingostomy related to analogies with previable delivery, it is the optimal procedure for ectopic pregnancy.

I. INTRODUCTION

Ectopic pregnancy, defined as any pregnancy located outside the endometrium, has been a focus of discussion among bioethicists for some decades. There has been longstanding agreement that salpingectomy is licit (analogous to a hysterectomy of a gravid, cancerous uterus), but papers in the 1990s and 2000s renewed debate about salpingostomy and methotrexate, options that were previously condemned (Anderson et al., 2011). The disagreement over salpingostomy and methotrexate stems from disagreement about medical facts and crucial moral distinctions, which leads to a continued impasse which some believe can only be resolved by the teaching authority of the Church (Anderson et al., 2011). An examination of the disagreement has led several medical authorities to express dissatisfaction with the entire framework of bioethicists’ discussion of ectopic pregnancy treatment options (Condic and Harrison, 2018).

This paper aims to portray a Catholic physician’s assessment of ectopic pregnancy and its treatment options. First, this requires a review of secular colleagues’ treatment of ectopic pregnancy, based on an overview of the medical facts. Second, this approach reviews ethicists’ unresolved differences on crucial moral distinctions related to this topic, including the status of the trophoblast, the nature of the pathology in this condition, and the direct or indirect nature of some treatments. Third, a physician’s approach proposes a different analogous case—ectopic pregnancy is not analogous to a gravid, cancerous uterus, but more closely resembles a case of previable delivery for chorioamnionitis. Based on this shift in perspective, this approach reclassifies treatment options according to how they bring about an end to the ectopic pregnancy, specifically by discussing how they bring about the separation of mother and child as if this were like other solved cases of previable delivery. Fourth, it lists the most persuasive arguments—secular and Catholic—in favor of each approach and tests their accuracy and implications according to Catholic teaching.

II. MEDICAL BACKGROUND INFORMATION

A pregnancy is defined as “ectopic” when an embryo implants outside of the endometrium, the inner lining of the uterus meant to receive a blastocyst. As best as we know, ectopic pregnancy represents about 2 percent of all pregnancies, but national statistics have not been collected since 1992, right after a 600 percent increase (Diamond, 1999; ACOG, 2018). Ectopic pregnancy can be thought of as a maternal-fetal vital conflict, since by pursuing normal actions of its life, the embryo can rupture its location, which is not designed to house a growing pregnancy, and this can cause maternal death. Most (at least 90 percent) ectopic pregnancies are located in the fallopian tube, and tubal rupture leads to 2.7 percent of all pregnancy-related deaths (ACOG, 2018).

There are multiple treatment options available for tubal ectopic pregnancy, including salpingectomy, salpingostomy, and methotrexate. Salpingectomy involves the removal of the entire fallopian tube containing the ectopic pregnancy, and salpingostomy involves an incision on the tube and removal of the embryo and structures derived from its trophoblast (ACOG, 2018). Rigorous comparisons of salpingectomy and salpingostomy have shown no difference in the rate of subsequent intrauterine pregnancy or subsequent recurrent ectopic pregnancy (ACOG, 2018).

Methotrexate is an injectable antimetabolite which can be given in one-, two-, or multi-dose regimens depending on the clinical scenario. Methotrexate does not have any discoverable adverse effects on fertility (ACOG, 2018). Methotrexate is a folic acid antagonist, and halts cell reproduction, favoring rapidly dividing cells such as those of the gastrointestinal lining, those of cancers, and those of the embryonic trophoblast. Methotrexate appears similar, or slightly superior to, salpingectomy in terms of future fertility outcomes (de Bennetot et al., 2012; Baggio et al., 2021).

The trophoblast is a unique tissue elaborated by the day 7 embryo in order to implant in maternal tissue. It shares the embryo’s genotype. Its goal is to develop a maternal-fetal blood barrier across an enormous surface area; to do this, it develops two layers, one that quickly churns out newly minted cells and one that forms as those new cells conglomerate into a gigantic multinuclear cell rapidly invading everything around it (Sadler and Langman, 2004). It is a rapidly replicating tissue, uniquely sensitive to methotrexate, more so than the remainder of the embryo (Bleyer, 1978).

This rapid review of the definitions of ectopic pregnancy, trophoblast, salpingectomy, salpingostomy, and methotrexate is a summary at best, but with this summary in mind, we may move on to how most of the world thinks of ectopic pregnancy.

III. SECULAR BIOETHICS ON ECTOPIC PREGNANCY

The bioethics of ectopic pregnancy in most medical literature is relatively quiet. The American College of Obstetricians and Gynecologists (ACOG) does not have a formal section on ectopic pregnancy in its comprehensive ethical handbook (ACOG, 2004b). This text does describe a professional obligation to prefer the woman’s autonomy over embryonic or fetal benefit (ACOG, 2004b), and the permissible nature of actively causing embryonic or fetal death for the sake of optimized outcomes (ACOG, 2004b). Over 90 percent of obstetrician/gynecologist (OB/GYN) residency program directors, the physicians who train new OB/GYNs, have negative reactions toward new residents who do not wish to prescribe methotrexate (Kalinowski et al., 2021).

An important detail of the secular bioethical literature on ectopic pregnancy is that the embryo is labeled “nonviable,” but this term is used equivocally. Occasionally, it is used to mean deceased and, at other times, it is used to mean unable to survive. ACOG makes this explicit by describing “nonviable gestation” as “an early pregnancy loss or an ectopic pregnancy,” which equates a dead embryo with one doomed to die (ACOG, 2018, e92). The American Association of Pro-Life OB/GYNs (AAPLOG) helpfully describes this equivocation on “nonviable” as a “disturbing disparity in the language used to discuss ectopic embryos,” going on to say:

[E]ctopic embryos are completely unable to survive pregnancy at this time in history. But “inevitably going to die” is not the same as “not alive now,” and we should not dismiss all moral discussion about ectopic embryos simply because of their inability to survive their current situation (AAPLOG, 2020, 2).

AAPLOG goes on to cite the principle of double effect, for which they list five criteria: the primary act must be morally good or neutral, the bad effect must not be the means to the good effect, the good effect must be the only effect intended, there must be no other means to the good effect, and there must be a proportionately grave reason to tolerate the bad effect (AAPLOG, 2020). They find that salpingectomy and salpingostomy meet the criteria of the principle of double effect (AAPLOG, 2020). They discuss methotrexate, note disagreement among pro-life OB/GYNs on this matter, and do not provide a conclusive recommendation (AAPLOG, 2020).

In summary, most bioethical treatment of ectopic pregnancy in secular literature (except AAPLOG) lists the life of the embryo as lesser in value than that of the woman, either because of some partial dignity or because of its nonviable status. From perspectives like these, any and all treatments that preserve the life of the woman are acceptable, even by pro-life physicians.

IV. CATHOLIC APPROACHES

Catholic bioethicists agree that the embryo is in possession of complete human dignity, just as deserving of protection of his bodily integrity as is his mother (USCCB, 2018). Here, “human dignity” refers to the classical concept of internal and inviolable human worth, related to humans’ sharing a rational nature, even if some human beings cannot fully exercise that nature (Lee and George, 2008). Viewed from a theological perspective, human dignity for Catholics stems from human beings’ relationship with God—his origin as made in the image of God, and his destiny as in communion with God regardless of individual ability (Catholic Church, 1965). However, Catholics are split over multiple important foundational questions, such as the status of the trophoblast (the precursor to the placenta) and the source of the pathology, or problem, in ectopic pregnancy.

This paper uses a particular account of the moral object in which certain physical features of the act can be morally determinative, regardless of intent (cf. Jensen, 2013). For example, this paper assumes that dismembering an embryo unto his or her death, without the possibility of resuscitation or saving treatment, is always an act of intentional killing, regardless of the circumstances or the reason why this is done; thus, options that affect embryonic or fetal tissue in this way are characterized as intentional killing. This is not a universal view among Christian or Catholic bioethicists (see May, 2008; Kaczor, 2009; Tollefsen, 2015). It is beyond the scope of this paper to engage action theory deeply, so the remainder of the paper’s conclusions is limited by this assumption.

The Status of the Trophoblast

Human blastocysts can be divided into two parts, the trophoblast and the inner cell mass (ICM). The trophoblast is a thin, spherical layer of cells that coats the inner surface of the embryo’s zona pellucida and eventually develops into placental villi. The ICM is an organized group of cells located inside one pole of the sphere of trophoblast. The ICM goes on to form the amniotic sac, the umbilical cord, and all the organs that persist throughout the life of the new human being. The status of the trophoblast (and its mature configuration in the placenta) is crucial to the discussion of ectopic pregnancy. Trophoblast and placenta are unlike other organs; they seem designed to relate two people, not clearly to serve one person. In cases of maternal-fetal vital conflicts when the object of an act is pivotal to the determination of what is right, it is important to determine to whom the trophoblast “belongs,” to understand on whom is being acted, and to determine what sort of part the trophoblast is, in order to understand the gravity of that act.

Faithful Catholic bioethicists are divided over the status of the trophoblast and placenta. For example, William May (1998), Christopher Kaczor (2009), Marie Anderson (Anderson et al., 2011), Anthony Pivarunas (2003), and Timothy Collins (2003) hold that the placenta is a fetal organ or fetal part. Christopher Tollefsen (2013) and Kevin L. Flannery (2011) hold that it is a shared organ; Albert Moraczewski (1996) maintains that it is not a fetal organ without holding that it is shared, as does Gerard Magill (2011). Becket Gremmels, Peter Cataldo, Elliot Louis Bedford, and Cornelia Graves hold that it is a pseudosubstance in symbiosis with mother and fetus (Gremmels et al., 2014).

A brief review of these authors’ positions is relevant, because many Catholic bioethicists believe that the status of the trophoblast determines what acts are objectively problematic according to Catholic teaching. Most authors share a common definition of an organ, which is some part of an organism that performs a function on behalf of the organism (Oxford English Dictionary, 2022). This is a philosophically and medically useful definition, mirroring Aristotle’s De Anima (II, 412b5) and medical texts (NCI Dictionary, 2022). Gremmels et al. (2014) outline as many as seven possible metaphysical relationships between mother, placenta, and embryo, but three common ones are that the placenta or trophoblast (the early precursor tissue to the placenta) is an exclusively fetal organ, that the placenta is a shared organ, or that it is better represented with a more nuanced metaphysical understanding. Briefly, the placenta as a shared organ is a very intuitive position as the placenta appears to be a physical interface between two organisms, and the tissue that is shed at delivery and called “the placenta” has a thin layer of maternal cells adherent to many layers of fetal tissue. Review of the more nuanced metaphysical understanding of Gremmels et al. is beyond the scope of a brief introduction, but this position carefully maintains the effects of this tissue on mother and fetus, and its transitory purpose.

Like many physicians, this author holds that the trophoblast and later the placenta is simply an organ of the fetus that interacts with the mother. This position is pivotal to the rest of this discussion. To understand this position, it is helpful to clarify some histological features. The placenta is an organ shed at delivery by the mother and fetus. What is shed in a term delivery is largely (i.e., 99 percent) fetal tissue and fetal blood, adherent to a few cell layers of maternal tissue that was closely approximated to the fetal part in situ during the pregnancy. The fetal part is occasionally termed the chorion (the name of the ovulatory membrane from which the fetal part derives) or simply “the placenta.” The maternal part is a layer of the endometrium called the decidua basalis, and is not referred to as “the placenta” simply speaking. The two sides of the placenta are referred to as the fetal face and the maternal face, but these terms are cardinal terms for the pathologist, equivalent to “left” and “right,” and do not refer to cellular or functional halves.

Physician authors are more likely to hold that the placenta is a fetal organ, citing that it was made by the fetus and is genetically identical with the fetus (Pivarunas, 2003). Physicians also identify the placenta as a vital organ of the fetus for several reasons. First, the placenta carries out vital functions for the fetus, such as acid-base balance, respiration, ventilation, nutrient uptake, and waste excretion (Griffiths and Campbell, 2015; Herrick and Bordoni, 2021). Second, the placenta’s functions are replaced at birth by other vital organs of the neonate, and any effects the placenta had on the mother are replaced by the neonate himself. And third, the placenta acts on the mother on behalf of the fetus, for instance by stimulating breast milk secretion and blood volume increase (Lyons, 1969), but does not perform any function for her benefit. (In fact, the placenta is a chronic liability to maternal health; see McEntyre and Dean, 2004; Roberts and Escuerdo, 2021.)

The above arguments have been in terms of the placenta, but this paper relates to early pregnancy, so it relies on a discussion of the trophoblast. Happily, this is an even simpler discussion. “Trophoblast” refers not to a shared organ that has maternal and fetal cells, but solely to fetal tissue. The term “trophoblast” properly refers to the shell of cells that lines the zona pellucida in a human blastocyst, and is entirely formed by the embryo, before the embryo implants into maternal tissue. At this time, it already has the two layers that will persist throughout gestation in placental villi—syncytiotrophoblast, the working cell layer, and cytotrophoblast, the stem cell layer that gives rise to new working cells throughout pregnancy as these are sloughed off or damaged. At the time that most ectopic pregnancies are diagnosed, these two cell layers have already established their relationship with the maternal endometrium and are performing the vital functions of absorbing nutrients and disposing of wastes (Sadler and Langman, 2004). Even if there is still disagreement on the placenta, the trophoblast is entirely elaborated by the fetus and functions on behalf of the fetus, even if it relies on maternal tissue and has effects on the mother.

The trophoblast can outlast the presence of a living embryo. Even in adults, every cell does not die immediately after the death of the organism. Trophoblast cells are particularly tenacious, and their tenacity leads to conditions such as chronic ectopic (Pivarunas, 2003) and gestational trophoblastic neoplasia (ACOG, 2004a). This is probably why many ectopics do not contain an embryo, as the embryo has died and the trophoblast has continued to grow and poses a theoretical risk of tubal rupture (Condic and Harrison, 2018).

The Source of the Pathology

To understand how to treat ectopic pregnancy, it is important to determine what the fundamental problem (or “pathology”) is, so that ethicists and physicians can focus on solving the problem, and not circumventing it. Catholic bioethics has gone somewhat astray in identifying the fundamental problem in ectopic pregnancy.

“Tubal damage” was identified as the fundamental problem early in the bioethical literature on ectopic pregnancy, and was canon by the 1990s (Diamond, 2008). This theory is perhaps best summarized by Fr. Joseph Howard in 2009:

When it is certain that the tube itself is so pathologically damaged that medical intervention is required, the PDE [principle of double effect] provides the moral basis for licit action. The damaged maternal tissue (the tube which is pathological because of implantation by the embryo) may be surgically removed according to the PDE even though it is the site of an implanted embryo. The removal of the section of the fallopian tube which contains the embryo constitutes an indirect voluntary effect. By removing the pathological tube with the embryo in situ, the evil effect resulting in the death of the embryo is not an object of the act of the will, even though it is foreseen. (2009, 89)

This theory makes “tubal damage threatening maternal life” the fundamental problem, and thus the reason that physicians can resect the tube. Is this medically accurate?

Preexisting tubal scarring or dysfunction is probably the cause of the abnormal implantation location of most ectopic pregnancies (Pivarunas, 2003; ACOG, 2018). But the maternal life is not in acute danger because of the fallopian tube’s predisposition to ectopic pregnancy. Rather, the cause of the fundamental problem with ectopic pregnancy is not a predisposition—if this were the true threat to maternal life, that condition alone would threaten her life, and physicians would remove fallopian tubes simply for history of chlamydia or pelvic inflammatory disease. This is not done, because the chronic predisposition is not the acute problem.

Perhaps by “tubal damage” these ethicists mean the readiness for rupture that is threatening her life? This is more convincing. Now before we accept this at face value, we must ask: why is the tube about the rupture? Is it an intrinsic tubal problem that is causing imminent rupture? No. Rather, something inside the tube and not the tube is the problem, namely, the pregnancy. And not just any pregnancy is the problem, since an intrauterine pregnancy in this same woman would not have the same risk. The pathology at hand is ectopia, something is in the wrong place and it is threatening the woman’s health and life.

Ectopia is a phenomenon that occurs with other tissues in the human body. Some ectopias are dangerous, such as ectopia cordis and ectopia vesicae (Creasy, Resnik, and Iams, 2004). Others are more mild, such as ectopia lentis (McCreery, 2021), ectopic ureter (Baskin, 2020), or ectopic thymus (Bang et al., 2018). Perhaps the most useful example of ectopia for this paper is ectopic thyroid, in which the thyroid does not migrate during development to its usual place in the lower neck, and in some cases stops at the base of the tongue, which can lead to suffocation (Adelchi et al., 2014). Regardless of the initiating cause, the main problem that needs to be solved in suffocation due to ectopic thyroid (and in impending tubal rupture due to ectopic pregnancy) is the place of the ectopic tissue. The windpipe and the fallopian tube are the locations of the respective life-threatening problems, but they are not the cause of these problems. In suffocation due to ectopic thyroid, surgery on the neck is required to resect the ectopic thyroid; in ectopic pregnancy, surgery on the tube is required to resect the ectopic pregnancy.

It is worthwhile repeating this conclusion and clarifying it, because it represents a significant departure from the common Catholic bioethical framework. The problem threatening the embryo’s and the mother’s life is an attribute of the embryo’s trophoblast, specifically its location. This is an extrinsic attribute, not an intrinsic property; nevertheless, the ectopia is said of the trophoblast. If the trophoblast were located correctly (implanted in the endometrium), there would be no further discussion. Indeed, the common-sense name of the condition is “ectopic pregnancy,” not “acute tubal necrosis” or “tubal rupture syndrome.” The problem is an attribute of the otherwise healthy trophoblast, in a tube that may have shown a predisposition but that is not the acute cause of threat to maternal life. While the tube bore a predisposition, it is not the source of the new lethal pathology. This means that previous discussions couched in the premise that the tube is the acute problem are flawed. The tube is analogous to the neck containing the ectopic thyroid: by itself, it poses no acute threat, but now it contains a life-threatening ectopic tissue.

Most procedures for ectopia aim at replacing or removing the problematic tissue and leaving as much of the surrounding anatomy in place as possible. When any tissue is not problematic in itself, it is left alone or restored as much as possible, even if its predispositions contributed to the ectopia. This means that the focus of treatment of ectopic pregnancy should be leaving the tube alone, and addressing the cause of the problem: the ectopic trophoblast.

V. A NEW ANALOGOUS CASE FOR ECTOPIC PREGNANCY

The typical Catholic discussions of ectopic pregnancy usually begin with the idea that the tube is removable because it is problematic, and sort treatments into whether they address the tube (appropriate) or affect the fetus (inappropriate or at least more questionable). Such analyses often create an analogy between ectopic pregnancy and the previously settled case of a gravid, cancerous uterus. Just as a cancerous uterus can be removed to treat the cancer (even though the death of the fetus is anticipated and inevitable), so the tube can be removed to treat the damage that threatens rupture (even though the death of the embryo is anticipated and inevitable). This abides by the principle of double effect, and all that remains is to look for a procedure that operates on the tube and leads to an indirect death of the fetus, as in the case of the cancerous uterus.

Given that the fundamental problem in ectopic pregnancy is the ectopic location of the trophoblast (not the tube), the gravid, cancerous uterus case is too dissimilar to be helpful. In the case of a gravid cancerous uterus, there is a life-threatening peripheral pathology (cancer) present in the organ containing a functional pregnancy. This is completely different from ectopic pregnancy, where a non-life-threatening organ (the tube, predisposed but not life-threatening) contains a dysfunctional pregnancy that itself harbors the life-threatening pathology (the ectopia).

We can see how poor this analogy is as we think forward to treatments. Treatments of ectopic pregnancy (including any potential futuristic transfer procedure) do not aim at resolving a tubal pathology. Rather, the singular aim of all treatments for ectopic pregnancy is to remove the pregnancy. Removing the pregnancy resolves the ectopia by removing the embryo’s ectopic organ (the trophoblast) and necessarily removing the rest of the embryo as well, because we lack any procedure that could support an embryo without a trophoblast. Understandably, this sounds ethically terrifying: it sounds like abortion or homicide. To sort out fact from feeling, we must find a better analogy.

Any analogy must match the key facts of the case, which are:

1. The maternal organ harbors a non-acute predisposition to the acute problem.

2. The fundamental problem is one of the trophoblast and threatens maternal life.

3. There is no current way to treat the fundamental problem without the embryo being dead at the end of the treatment.

A better analogy is the case of previable of membranes and subsequent chorioamnionitis with a living fetus. Like ectopic pregnancy, previable rupture of membranes is a non-acute predisposition which does not in itself threaten the maternal or fetal life until it is further complicated by chorioamnionitis (ACOG, 2020). Once chorioamnionitis develops, the fundamental problem is one of the pregnancy, specifically the placenta and associated amniotic sac, which are infected and can lead to maternal death. And if this condition develops before the fetus is at a gestational age when resuscitation is possible, there is no way to treat the fundamental problem without the fetus dying after treatment.

Antibiotics are given for chorioamnionitis to limit the effects of disease, but definitive treatment is to remove the source of the infection. This is sought immediately, and expectant management is not an option (Tita and Andrews, 2010). Definitive treatment options for previable chorioamnionitis include dilation and evacuation (D&E), induction of labor, and rarely C-section. D&E dismembers a living fetus, and is illicit according to this paper’s view of the definitive object of an act, since intentional killing of innocent persons is not acceptable. Notable bioethicists disagree with this conclusion and defend some dismemberments as not intentional killing (see Tollefsen, 2015 on the Phoenix case), but this paper assumes that the object of chosen dismemberment of a living human person unto their death without plan or option for life-saving treatment is intentional killing.

Induction of labor and C-section represent forms of delivery that address the root cause of the problem, delivering the infected pregnancy and ending the threat to maternal life. Catholic bioethicists and secular pro-life OB/GYNs have both defended delivery in this case as a morally acceptable option. Catholic physicians and ethicists who have weighed in on the liceity of previable induction in chorioamnionitis include Dr. Robert Walley (2013), Peter Cataldo, Dr. T. Murphy Goodwin, Dr. Robin Pierucci (Cataldo et al., 2020), Dr. Sean O. Domhnaill (2014), Dr. Ian Jessiman (2014), Dr. Michael Jarmulowicz (2014), and Dr. James Gerrard (2014), among others. Catholic ethicists agree on this case, even before viability, since it involves expulsion of infected tissue rather than aiming at pregnancy termination for its own sake, or fetal death for its own sake (see, e.g., White, 2009; Magill, 2011; NCBC 2015).

Secular OB/GYNs within AAPLOG also agree, and explain that removal or delivery (ending of the relationship we call pregnancy) is not an abortion because the fetal death is not the desired outcome nor the means by which maternal life is preserved (AAPLOG, 2022). AAPLOG specifically addresses chorioamnionitis as a morally acceptable reason for previable delivery by a method that does not dismember the fetus (AAPLOG, 2022).

At this juncture, it is important to point out that induction of labor is a well-accepted case of Directive 47 in the Ethical and Religious Directives even before viability. This is true, even though Directive 45 can be read as prohibiting previable deliveries which may amount to terminating fetal life and abortion. Briefly, Directive 45 specifies that:

Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo. (USCCB, 2018, 45)

Directive 47 then clarifies this prohibition with language about morally neutral operations to save the life of the mother, which have the unwanted effect of the death of the unborn child. Directive 47 reads:

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. (USCCB, 2018, 47)

Using Directives 45 and 47, many Catholic authors have accepted the use of induction of labor (without fetal dismemberment) for chorioamnionitis even before viability, using double effect reasoning (NCBC, 2015). A more sophisticated analysis of Directive 45 and its implications for previable induction of labor is beyond the scope of the present work, but has been attempted by others (Buskmiller, 2021).

Perhaps bioethicists constructed the analogy between ectopic pregnancy and the gravid cancerous uterus out of a fear to admit the need to remove the embryo from its place (Clark, 2000, 7–24). Following the work of scientists who hold that the ectopic pregnancy itself is the problem and it is licit to end this pregnancy (Condic and Harrison, 2018, 245), this author admits that treating ectopic pregnancy aims to change the location of the embryo, because its location is the pathology. This shift in the ethical view of ectopic pregnancy requires a new classification of the available treatments, because the previous ethical analyses were based on a flawed understanding of the fundamental problem at hand.

VI. CLASSIFYING TREATMENTS FOR ECTOPIC PREGNANCY

Given that all available treatments aim at removing the ectopic trophoblast, one way of categorizing these treatments is which person’s tissue is acted on in order to solve the fundamental problem. The logical options include affecting fetal tissue or maternal tissue. Since this piece is a physician’s perspective, let us examine the options in the order of greatest preference by a gynecologist: least invasive to most invasive.

Methotrexate

Methotrexate is the best option on paper: it is nonsurgical, highly effective, and preserves fertility. However, this paper argues that it is not appropriate to resolve ectopia with methotrexate, because of what methotrexate does, and what the trophoblast is. The trophoblast is like a combined kidney and lung for the embryo, so it acts as a vital organ. Methotexate halts DNA synthesis (and thus, tissue growth) in rapidly dividing tissues. Some bioethicists, notably Albert Morazcewski (1996, 2), have thought this a perfect solution to ectopic pregnancy: halting the ingrowth of the ectopic trophoblast targets the pathology directly, while also not overtly killing the embryo. William May, before a change in his position, wrote in response:

Even if the [embryo’s] death is not precisely the means chosen, one cannot exclude from the means chosen the intentional violation of the bodily integrity of the unborn child and the causing of its death . . .. (1998, 3)

May points out that even if methotrexate does not actively cause necrosis of the trophoblast, it completely stops its function, which is to grow an ever-larger interface for the increasing demands of the embryo. Without a growing trophoblast, an embryo dies from lack of nutrients and oxygen. In short, methotrexate is a chemical action on a vital organ that makes the organ unable to function. Administering methotrexate to a woman with a living ectopic embryo is a lethal act on that embryo. Given that intentional killing of the innocent is not acceptable, it follows that methotrexate is unacceptable. This conclusion is obtained with up-to-date knowledge of the status of the trophoblast and the pharmacology of methotrexate, and sidesteps the many difficulties over methotrexate that stem from misunderstandings of pharmacology and shared organs.

Salpingostomy

Next in the order of physician preference for the patient is salpingostomy. When defining salpingostomy to an audience who cares about the physical bodily integrity of a living embryo, it is not enough to simply state that an incision is made in the tube and the products of conception are removed. Technique is extremely important to preserve the bodily integrity of any living embryo or fetus, and salpingostomy is not performed the same way by all physicians. It is possible to not disturb the products of conception and keep the embryo intact.¹ A pro-life approach to ectopic pregnancy might prefer salpingostomy when intact removal is possible (Puthoff, 2016; Thompson, forthcoming), and abandon salpingostomy for salpingectomy when this is impossible. Other physicians, in contrast, may use less care and dismember the embryo, and videos of such salpingostomies available online have made some ethicists reject this procedure as dismemberment. AAPLOG finds a parallel between salpingostomy and previable C-section, since in both cases, the maternal reproductive tract is opened and the products of conception can be removed without directly ending the life of the unborn child (AAPLOG, 2020, 2). AAPLOG is aware of the danger of dismembering the embryo and declaratively cautions against it:

Salpingostomy invites slightly more discussion than salpingectomy, since it is possible to remove the embryo and its . . . membranes in pieces. A pro-life physician endeavors not to dismember a living fetus. (2020, 4)

From a physician’s perspective looking at bioethical literature, the significant disagreement among ethicists and physicians can be explained by this heterogeneity in the performance of the procedure. Some salpingostomies are licit deliveries, in which a previable embryo is removed from its mother’s reproductive tract like any other previable child delivered by C-section for chorioamnionitis, in accordance with the guidelines for Catholic hospitals (USCCB, 2018). Other salpingostomies are equivalent to dilation and curettages on living previable fetuses, which many Catholic bioethicists believe to be prohibited by Catholic teaching (USCCB, 2018). Again, this paper is written within a view that the object of an act can definitively determine its moral status, but some ethicists disagree. Rather than caution against salpingostomy wholesale, it is better to accept it if a gynecologist is morally certain she can remove the embryo and its derivative structures intact.

Salpingectomy

Finally, salpingectomy remains the most invasive and disfiguring option for the physician, leaving a woman without a fallopian tube which could still contribute to future fertility and could undergo restorative treatment for any predisposition it harbors to future ectopic pregnancy. Salpingectomy is protective of the fetus, but in the mind of this Catholic physician, should not hold the pride of place that it does in Catholic bioethical literature as the gold standard agreed-upon treatment.

Transplant or Transfer

Of course, transplant of the ectopic embryo is the truest solution for ectopia. This would resolve the ectopia by placing the embryo in his proper place, and hopefully spare the mother significant medical or surgical effects. This procedure, while under investigation (Camilleri, Buskmiller, and Sammut, 2021), is still far from evidence based, and cannot be seriously entertained from a physician’s perspective. However, it would be in principle ethical if there were informed consent about the risks, benefits, and alternatives. From the author’s experience in fetal intervention, no surgery on the fetus during pregnancy is mandatory, according to traditional Catholic ethics, given that they are all extraordinary rather than ordinary means. The proposed ectopic transfer procedure under study in an animal model by Camilleri, Buskmiller, and Sammut (2021) requires a significant uterine incision that would predispose a mother to uterine rupture in the current and future pregnancies, which is associated with a 50 percent risk of fetal loss. It would also mandate a lifetime of Cesarean sections. Given this early information, this procedure would likely constitute extraordinary means. More than this conjecture is beyond the scope of the present inquiry.

VII. REPLIES TO OBJECTIONS

Conjoined Twins Is a Better Analogy

Separation of certain sets of conjoined twins is a very apt analogous case for ectopic pregnancy and previable delivery in general. In the ideal analogy, two twins, fully invested with human dignity even if they lack some full expression of it (e.g., perhaps one has an incompletely formed brain), are joined by some vital tissue and the life of one is endangered by the other. The famous “Maltese twins” make a perfect analogy where double effect reasoning, or the perspective of the acting person, makes clear that the death of a twin who is unable to survive separation is not intended, but sadly tolerated.

However, not all forms of ending pregnancy are like separating conjoined twins. It has been argued (Tollefsen, 2015) that the Phoenix D&C and the separation of the Maltese twins are morally identical. Tollefsen’s explanation is based on a first-person account of morality typical of a new natural law theorist. I deeply empathize with this first-person account as a pro-life obstetrician, as I watch colleagues aim at the well-being of maternal patients while doing D&Cs. Tollefsen writes, speaking particularly of Austriaco’s colorful analogy to a Mayan priest:

[The Mayan priest wishes] to propitiate the gods. But what does [he] take to be needed, practically, to bring about that benefit? [T]he gods have demanded the . . . lives, of many innocent victims, and the priest intends to provide that [by] removal of the beating heart . . . It is thus clear that his proposal is a proposal to kill, not because of the equivalence of the two descriptions, killing and removing a vital organ, but because from his standpoint as an agent, it is death that he seeks as a means to his end. But [in the Phoenix case] from the standpoint of the mother, it is not death that is understood as the means by which the strain on her heart may be relieved, but removal of the connection between her child and her body; the child is putting inordinate strain on her heart, thus causing a risk of life (to the point of almost certain death), and removal of that connection is itself what is recognized as necessary in order to achieve the otherwise permissible end of self-preservation. (Tollefsen, 2015, 414)

Certainly, removal of the strain on the maternal heart is the goal in the Phoenix case, and separation from the child is the means to this end. It is true that the mother may “understand” separation and not death as the means to this end. However, as a physician who has dismembered (deceased) fetuses up to 20 weeks, this author cannot “understand” this as a separation, rather than a termination of life via vivisection, coupled with or followed by a separation when the uterus is completely evacuated.

Purely removing the embryo from its site, for example, by previable induction is completely licit (Buskmiller, 2021), and this is analogous to cutting Mary’s body away from shared organs—it is a separation at the interface between two persons, although the interface is much easier to identify in the case of an embryo and his or her mother. This separation of two persons (in ectopic pregnancy, along the surface of the placenta which faces maternal decidua) is not dismemberment. Cutting apart organs of the embryo (as a D&C may divide limb buds or head from trunk, or corpus from placenta), whose body could easily remain intact, is unnecessary to moving him or her. Analogously, amputating uninvolved parts of Mary would be unnecessary to separating her from her twin.

For these reasons, Tollefsen’s categorization of the Phoenix D&C as an instance of the principle of double effect is incorrect, although separation of the Maltese twins and other similar separations are an excellent parallel case to separation of mother from child without dismemberment.

Methotrexate Is Not Wrong Simply Because It Acts on the Embryo’s Body

Christopher Kaczor (2009) astutely points out that arguments against methotrexate often mirror arguments against salpingostomy in his seminal article defending these two techniques. Kaczor’s defense of salpingostomy is outstanding—he rightly points out that salpingostomy is not wrong simply because it certainly results in a dead embryo, nor is salpingostomy identical to killing the embryo, nor is salpingostomy wrong simply because it acts on the trophoblast and results in death, and lastly, salpingostomy is not wrong simply because we have no option for embryo transplant at this time. Furthermore, Kaczor (2009) correctly points out that the timeline of methotrexate’s effect on the trophoblast versus embryoblast is unimportant, since both represent parts of one person, the embryo.

Kaczor makes several astute defenses of methotrexate. He cites Theophile Raynaud’s analogy of a man fleeing an unjust aggressor on horseback, whose path is blocked by an innocent non-aggressor. Raynaud allows the horseman to run over the innocent non-aggressor, even though the horseman can anticipate acting on his body lethally. This analogy differs fundamentally from ectopic pregnancy: in ectopic pregnancy, if the maternal life is emergently threatened such that people are metaphorically galloping to save her life, the treatment of choice is never methotrexate, but rather salpingectomy, or very rarely salpingostomy. Methotrexate is only an option when a physician and a woman have time (i.e., hours) to consider their treatment options and even more time (i.e., days) to ensure that their choice worked. This is analogous to a horseman galloping on a pleasure ride, with full ability to stop for an innocent non-aggressor, and yet choosing to gallop over that person. Anticipatory killing of an innocent non-aggressor by acting on his body is not licit when there is not an emergency and when careful consideration can be given to multiple options (i.e., steering the horse around the innocent person).

Kaczor later cites an analogy to the case of throwing a javelin in self-defense through an innocent non-aggressor used as a human shield, a case of non-intentional mutilation of a vital organ of an innocent person and not intentional killing. This illustration is not useful for the same reason that Raynaud’s is not useful: methotrexate is not used in emergencies, and the concept of urgent self-preservation does not apply. To make Kaczor’s analogy fit the actual circumstances of the use of methotrexate would be to make the javelin much more calmly thrown through a non-acutely threatening aggressor, perhaps in the setting of hostage negotiations when time may be available for discussion of options rather than needless mutilation of innocent persons. Outside of an emergency, mutilation is inferior in the presence of another option (which is always available).

Next, Kaczor points out that using methotrexate to halt damage to the fallopian tube from the growing trophoblast is in principle good, agreeing with Moraczewski that the “moral object is to stop the destructive trophoblast . . . this is not achieved by killing the trophoblast or the embryo proper. Rather, death follows subsequently” (Moraczewski, 1996, 4). This position recasts the action of methotrexate in terms of the benefits to the mother, but still admits that the trophoblast is acted on and that the main function of this organ (to increase surface area) is stopped. What is not mentioned by Kaczor and Moraczewski is that this death is due to methotrexate causing the trophoblast to fail to increase in surface area for diffusion, to support the growing embryo’s body. “Death following subsequently” is not necessarily damning, but death following after iatrogenic cessation of a vital organ’s function is.

Critically, Kaczor next makes a distinction between intentional killing and intentional mutilation. This is a valid distinction. Kaczor cites May, who writes:

Even if the death is not precisely the means chosen, one cannot exclude from the means chosen the intentional violation of the bodily integrity of the unborn child . . . (1998, 3)

Here, May acknowledges a slight uncertainty with the way methotrexate works (which this paper does not share), but maintains that even if it is not lethal but only static, it is contorting a body part to stop its growing, which is perhaps like nontherapeutic chemical growth suppression after birth. Kaczor proposes some cases of intentional mutilation of vital organs in innocent non-aggressors (see the javelin example above), but ultimately proposes his own previously created criteria for an intentional effect and shows that mutilation is intended in methotrexate use, and ultimately appeals to the only case of methotrexate use when this might be defensible, that is, when the embryo has already expired and only trophoblastic tissue remains. This case is ethically trivial (methotrexate can always be used when there is no embryonic life present) and is not under deep consideration in this paper.

Unlike May’s background sources, this paper is clear on the anti-functional role of methotrexate on a vital organ of the embryo. Trophoblast, unlike mature tissues (even placenta) that perform its functions of gas and nutrient exchange, must grow for the immediate survival of the embryo. Without an ever-increasing surface area, the embryo at the early gestational ages in ectopic pregnancy accumulates acids and carbon dioxide, and perceives a lack of nutrients. Only after overt tissue death does a physical separation of embryo from decidua occur. Stopping growth of this tissue is more like withdrawal of artificial nutrition and hydration for a healthy disabled person (ultimately causing death), and less like simple or justified mutilation.

Kaczor acknowledges that intentional mutilation is not always intentional killing, and he alludes to the possibility that methotrexate may be like removal of life support rather than like intentional killing. Indeed, the maternal decidua is (or is like) life support for the embryo, who cannot survive without this external support. This distinction between allowing an ongoing death to proceed and actively killing a person is a longstanding one among ethicists, because not every choice that shortens life is intentional killing. For example, discontinuing mechanical ventilation and palliative sedation are distinct from physician-assisted suicide (PAS; Furton, 2020). Likewise, Kaczor argues, if the embryo is already dying, methotrexate may simply “unplug” it from its mother at the site of the placenta, or act like palliative sedation and hasten death without being a direct cause of it.

First, it is important to note that physicians cannot tell which ectopic embryos are actively dying, and which are merely doomed to begin to die soon, and in the setting of such uncertainty, moving toward death is less certainly licit than clear end-of-life care, even if the embryo is always by definition dependent on maternal tissue for survival. AAPLOG makes this distinction clear and laments the equality many physicians (and ethicists) draw between an embryo doomed to die and one actively dying. This is similar to their lament that death is hastened by previable induction of labor unnecessarily, when physicians fail to pursue more appropriate treatments for other obstetrical conditions.

Second, methotrexate does not represent a clean “unplug” or an analogous case to palliative sedation. A true analogy with withdrawal of life support would require no active effects on the body, only the foreseen, passive effects due to the absence of life support for a critically ill person. Now methotrexate has active effects on a part of the body of the fetus, within the view of this paper and the facts laid out above, so methotrexate is not analogous to simply unplugging an embryo from its external support. Ironically, a medication that does purely disconnect embryos from the decidua exists—mifepristone, which affects hormonally responsive maternal tissue to cause decidual atrophy and allow sloughing of trophoblast without affecting trophoblast cells directly. Interestingly, mifepristone provokes a more uniform condemnation from ethicists than does methotrexate, without ever affecting the trophoblast. Mifepristone can resolve ectopic pregnancy with comparable success to methotrexate, but is not typically used in US clinical practice (Gazvani et al., 1998; Rozenberg et al., 2003; ACOG, 2018). This drug usually used for elective abortion is pharmacologically “cleaner” or more selective for maternal tissue, than methotrexate. If ethicists wish to advocate for pharmacological “unplug” of embryos, they should favor mifepristone (a drug created to detach embryos from decidua) over methotrexate (a drug created to ablate decidua and trophoblast).

Methotrexate also does not fit into an analogy with palliative sedation, which provides therapeutic benefit to a patient (pain control) and potentially brings about death sooner, while death was being caused by another pathology. At first blush, this looks similar to methotrexate: the natural history of ectopic pregnancy ends with embryo death, either due to chronic hypoxia from the relatively poorly perfusioned fallopian tube, or acute hypoxia at the time of tubal rupture. Methotrexate hastens death, which would otherwise be caused by the ectopic placement of the embryo, so it seems analogous to palliative sedation. But this is only a superficial resemblance. Methotrexate acts more like (not exactly like) PAS, in that PAS does not provide a therapeutic effect on the dying person and yet brings about death sooner regardless of the presence of a comorbid lethal condition. Methotrexate is useful precisely because death of the embryo is obtained outside of the natural history of the condition, that is, not due to consequences of ectopia (poor blood supply compared to the uterus, and thin wall compared to the uterus). In summary, methotrexate hastens death without a therapeutic effect on the dying person, making it less akin to palliative sedation and more akin to PAS.

At the core of his argument, Kaczor does not attend to the difference in the ways a physician acts on the trophoblast between the two procedures. In salpingostomy, a physician may act on the trophoblast in a benign separation to resolve ectopia (removing it from its location), or may directly dismember it in an act that more resembles a D&C. With methotrexate, a physician chooses a medication that leads to tissue dysfunction, acidosis, and death of the embryo as a way to solve the ectopia. This act is no longer benign or aimed at separation and tolerating later embryo death; it is destructive and aimed at embryo death to effect separation.

May Changed His Position, Why Do You Not Follow?

William May, a preeminent bioethicist, changed his position on methotrexate based on an analysis of the perspective of the acting persons (the treating physician and arguably also the woman seeking treatment). The author agrees with May that these persons do not desire the elective death of the embryo in the same way that women who seek abortion seek the death of an embryo as a means to their ends. However, in concert with the perspective of the rest of this paper which maintains that certain physical aspects of the act can make the act completely illicit, the author believes May’s use of the perspective of the acting person leads him away from consideration of the real object of the act of using methotrexate. The author confesses the inability to completely understand the reason for May’s change in position, which may limit the scope of this work. Considerable ink has been spilled on the distinction between the perspective of the acting person and what may be called the hylomorphic theory; fleshing out this decades-long discussion is beyond the scope of this paper. This author works within one view on action theory, as a physician on the “business end” of carrying out the acts justified by ethics committees, and unwilling to perform certain acts as means to even to good ends.

VIII. CONCLUSION

Misunderstandings about medical facts and other principles have muddled the issue of tubal ectopic pregnancy for long enough. Ectopic pregnancy is unlike cases of maternal-fetal vital conflicts involving normal pregnancy and incidental uterine pathology (e.g., gravid cancerous uterus), and is more like cases of severe placental pathology that require previable delivery (e.g., previable rupture of membranes with chorioamnionitis). In ectopic pregnancy, healthy trophoblast (not a predisposed tube, nor a severely damaged tube) is the source of the pathology because of its location, an accident that is only changed by removing the tissue. This tissue is vital to the embryo, who has human dignity and a right to bodily integrity. Treatment options for removal include salpingectomy, an imprecise but ethically safe technique; methotrexate, a precise chemical solution that assaults the embryo in an unacceptable way; and salpingostomy, which removes ectopic tissue similar to other previable deliveries according to the principle of double effect.

REFERENCES

Footnotes