DIFFICULT MORAL QUESTIONS

Question 48: May a woman agree to inducing delivery of her nonviable defective baby?

We married last year and were very happy when I became pregnant. Now I am nearly five months along. Two weeks ago, my obstetrician did an examination, including various tests, and yesterday he had us come in about the results. He said our baby, a girl, is seriously defective, and even if I went to term she would not survive long, probably only a few hours and certainly not more than a few days. I have diabetes, and, though the pregnancy has not been going too badly, the doctor had planned from the beginning to deliver the baby about a month early. But since she will not live long anyway, he wanted to induce labor at once. He explained that he thinks it best, when the mother is diabetic, “to terminate the pregnancy as soon as it becomes clear that the baby has nothing to lose.”

We were surprised, since we picked this obstetrician partly because he was recommended by prolife friends. He left us alone for a while, and we talked it over. When he returned, we told him we would not have an abortion even to save my life, both because we believe abortion is wrong and because we want our baby to be born alive. We want to have her baptized and give her all the love and care we can, no matter how short her life is. The doctor said he never does abortions, but in cases like mine he does not regard inducing labor early as abortion. He also said the baby almost certainly would be born alive, so that she could be baptized, though she might live only a few minutes. And he told us that it would risk my life to go on with the pregnancy and he would not be responsible for what might happen if I do not follow his advice. We told him we needed more time to think it over.

We talked with our parish priest about it, and he referred us to a Sister Luke, who has studied health care ethics and works in the chaplain’s office at the local Catholic hospital. After listening to our story, she told us to follow the obstetrician’s advice and get the pregnancy over with. That is the right thing to do, she explained, because there is “a proportionate reason.” If we were sure her advice is sound, we would follow it. However, we are not sure, because my husband read that the Pope condemned something called “proportionalism” in his encyclical, Veritatis splendor. We want advice about what to do, and we want to make sure we do not get mixed up in something the Pope condemned.

Analysis:

The question is whether it would be morally acceptable to induce labor at once in this case. Even if a baby never will be viable, it is abortion to induce labor in order to end his or her life, and it is unjust to do anything without a grave reason that will result in shortening an unborn baby’s life. So, if the pregnancy can be continued until near term without grave risk to the questioner, she should not consent to the induction of early labor. If early delivery were necessary to save the mother’s life, her consenting in order to save her own life would not involve the intention to kill the baby or shorten her life. Saving the mother’s life could be called a “proportionate reason” for accepting the baby’s somewhat accelerated death. This use of the expression proportionate reason differs from that of the proportionalists whose opinion John Paul II condemned in Veritatis splendor.

The reply could be along the following lines:

Your letter is deeply moving. So often you speak of we! It is a sign of the love with which you, less than a year married, joyfully welcomed the prospect of your first child and now, with grief but evident faith, face the prospect of losing her so soon. Telling the doctor you would not have an abortion even to save your life also showed courageous and praiseworthy readiness to accept martyrdom. Moreover, you show your Catholic sense of values: you picked an obstetrician recommended by prolife friends; you want your baby to be born alive and baptized; you sought advice from your parish priest and Sister Luke to whom he referred you; and you question the soundness of the advice, which you otherwise would follow, because you fear it might be inconsistent with papal teaching.

There seems to be an increasing tendency for obstetricians to recommend the abortion of babies found to be seriously defective. As you have discovered, even some physicians who usually reject abortion consider it morally acceptable to induce early labor as soon as it becomes clear that the baby probably will not live long even if the pregnancy goes to term.¹⁶⁵ Often they give the excuse that the “baby has nothing to lose.” That, of course, is false. The baby loses his or her life, and life, even of a very severely handicapped or dying person, remains good and is sacred. Moreover, in most such cases, labor is induced to achieve some purpose precisely by ending the baby’s life—for example, the pregnancy is terminated to spare parents psychological stress. With such an intention, inducing labor early simply is a method of abortion.¹⁶⁶

Your physician has a more serious reason. Your diabetes could make continuing the pregnancy seriously harmful to you. Your question, therefore, really amounts to asking whether inducing labor now so as to forestall that harm must be regarded as abortion and excluded.

In my judgment, the answer partly depends on whether going on with the pregnancy would be risking your life. Without adequate knowledge of the facts and lacking medical expertise, I cannot say how much basis there is for your obstetrician’s concern. However, it is possible that what he told you is unduly pessimistic, and he may also be taking too dim a view of your baby’s prospects. Therefore, the first thing I think you should do is obtain a second medical opinion. That is your right, and in no way calls into question the competence of the physician you have been seeing. Though he told you he would not be responsible for what might happen if you do not follow his advice—which seems to me to have put you under undue pressure—he should and probably will cooperate with you in obtaining a second opinion by sending your clinical records and test results to the physician you choose to review the situation. That should be an obstetrician who practices in full accord with Catholic teaching. To identify such a person, you might try calling the offices of the obstetricians on the staff of the Catholic hospital and asking: “Does the doctor prescribe contraceptives?” If the answer is yes, ask if he or she knows any obstetrician who refuses to do so. If this approach does not succeed, tell your parish priest about the difficulty and ask him to help you—and, if necessary, to get an appropriate diocesan office to help you—find the right doctor. Do not hesitate to press your parish priest and diocesan officials on this matter; you are prepared to lay down your life, if necessary, in order to do what is right, and you have a special claim to their help. Having identified a suitable obstetrician, tell him or her you need a second opinion, and explain the situation. After obtaining and studying your medical records and the test results, this physician probably will examine you and perhaps order additional tests. Then he or she will give you a fresh, independent evaluation and explain your options.

I hope the second opinion will be that any problems likely to develop probably can be dealt with easily or even forestalled, without significant risk of serious and lasting harm to you. If so, your problem will be solved. Perhaps, however, there will be a serious problem, impossible to forestall and difficult to deal with, that will impose some risk of harm on you. Even so, the second obstetrician may be able to suggest a plan of care and treatment that, without gravely risking your life, will delay inducing labor until the pregnancy reaches the stage at which inducing labor for a good reason is regarded as acceptable by all Catholic moralists. In that case, accept the plan and carefully cooperate in carrying it out, even if it is unlikely to result in your baby being born alive.

Someone might disagree and argue that the point at which a baby normally is viable is irrelevant in your case, because your daughter is so seriously defective that even if you go to term she will die shortly after she is born. Assuming the accuracy of what your obstetrician has told you about your daughter’s prospects, her life after birth will be extremely brief. However, her life remains good and she probably can live within your womb until the end of the normal period of pregnancy. Therefore, inducing labor early would deprive her of what little life she is likely to enjoy, and your responsibility is to bear and nurture her, if possible, until she is ready to be born.

I think it quite unlikely that both obstetricians will agree that you and your baby both probably will die unless labor is induced early. But suppose that is their judgment? Even in that case, unless the danger of death is imminent, you should not agree to proceed at once, but should delay, hoping and praying for a good outcome. In that way, you will prolong your baby’s life and keep open the possibility that, despite the dire predictions, things will work out so that no life-or-death choice becomes necessary. But if the time does come when you must choose between risking your life, which also would cause your baby’s death, and inducing labor early, then, I think, you should choose the latter. That choice plainly will not be to end or shorten the baby’s life, for, though she probably will die sooner outside your womb than within it, your reason for inducing early labor will be to prevent your own death and, if possible, to provide your baby with the benefits of living briefly outside your womb, namely, baptism and a brief period of loving care. Thus, you will not be choosing to shorten your baby’s life, but only accepting that as an unwanted side effect. That will be fair to her, not only because your life also will be preserved but because she, too, will benefit.

Because this motive for accepting the shortening of your baby’s life would be fair to her, one can call it “a proportionate reason.” Perhaps that is what Sister Luke meant—though, it seems to me, her advice was defective insofar as she neglected to suggest that you obtain a second opinion and put off a life-or-death choice. A proportionate reason in this sense, however, differs from what is called “a proportionate reason” by the proportionalists whose theory John Paul II condemned in his encyclical, Veritatis splendor. Since you are anxious to avoid confusing the two, I shall try to explain the distinction.

The Pope’s main purpose was to reaffirm “the universality and immutability of the moral commandments, particularly those which prohibit always and without exception intrinsically evil acts.”¹⁶⁷ The relevant commandment, of course, is “You shall not kill,” which always and without exception prohibits killing by private individuals—capital punishment and killing in just wars are a separate problem (see LCL, 469–81, 890–94, 897–911). The prohibited, intrinsically evil act of killing, however, is to be understood, not merely as an outward performance resulting in someone’s death, but as a freely chosen kind of behavior characterized by its “‘object’ rationally chosen by the deliberate will” or, in other words, by “the proximate end of a deliberate decision which determines the act of willing on the part of the acting person.”¹⁶⁸ Now, if, in the life-and-death crisis described above, you agree to induce labor early, you will not be rationally choosing by deliberate will to kill your baby or shorten her life; your act of willing will not be a deliberate decision that she die sooner rather than later. That harm, as already explained, will only be accepted as a side effect of what you will be choosing: preventing your own death and bringing about her birth so that she will live, though briefly, outside your womb.

The proportionalists whose theory the Pope condemned also might recommend accepting your obstetrician’s advice, though probably without delay and certainly on a different basis. Instead of focusing on the object of the act and asking, for example, whether the shortening of life is only accepted as a side effect or is the proximate end of one’s choice, proportionalism “by weighing the various values and goods being sought, focuses rather on the proportion acknowledged between the good and bad effects of that choice, with a view to the ‘greater good’ or ‘lesser evil’ actually possible in a particular situation.”¹⁶⁹ Thus, proportionalists deny that there are intrinsically evil acts; they say, for example, that, while it is generally wrong to kill, exceptions can be justified when killing is the “lesser evil.”¹⁷⁰ Proportionalists, however, “are not faithful to the Church’s teaching, when they believe they can justify, as morally good, deliberate choices of kinds of behavior contrary to the commandments of the divine and natural law.”¹⁷¹ Moreover, they do not use a moral standard, such as fairness, to compare goods and bads; rather, they think benefits and harms, considered as premoral, can be compared directly. That suggestion, however, is absurd, for, as the Pope points out, “everyone recognizes the difficulty, or rather the impossibility, of evaluating all the good and evil consequences and effects—defined as pre-moral—of one’s own acts: an exhaustive rational calculation is not possible.”¹⁷²

In sum, if Sister Luke meant by proportionate reason what proportionalists mean by it, she thinks you would be justified, not only in accepting the shortening of your baby’s life in inducing labor at once, but even in choosing to kill her, on the theory that her death would be a lesser evil than the harm your obstetrician predicts you will suffer if your pregnancy proceeds. Since goods and bads cannot be rationally commensurated in that way, however, lesser evil here can have no definite meaning. It expresses only a subjective opinion based on feelings. On this basis, a proportionalist may regard an abortion as justified whenever the baby is expected not to live long after birth.

Your minds may be boggled by the preceding explanation of the difference between the proportionalism the Pope condemns and the legitimate use of proportionate reason. If so, do not worry about the details, for I am sure you will grasp the fact that the two are different. Looking at the matter in your clear-eyed way, you were prepared to stake your life on one of the truths proportionalists deny—that abortion is always wrong—but perhaps would have followed Sister Luke’s advice had your husband not read about the Pope’s condemnation of proportionalism. Without articulating the point, you saw correctly that, though choosing to kill a baby always would be a terrible wrong, accepting the baby’s death as a side effect could be right. Still, I hope and pray the crisis will not confront you, so that there will be no need to consent to inducing labor until your pregnancy is near term.

165. National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (Washington, D.C.: United States Catholic Conference, 1995), directive 45: “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 . . ..”

166. Jean deBlois, C.S.J., Patrick Norris, O.P., and Kevin O’Rourke, O.P, A Primer for Health Care Ethics: Essays for a Pluralistic Society (Washington, D.C.: Georgetown University Press, 1994), 235–38, note that pregnancy with an anencephalic fetus can put the mother at a somewhat increased risk and that the emotional trauma to the couple of a diagnosis of anencephaly can be considerable, assert (236) that the “condition uniformly is fatal, death usually occurring hours after birth from cardiorespiratory arrest,” claim (237) that “viability has no meaning as a moral marker in such cases” and that once the defect occurs integrated development is impossible due to absence of the cerebral cortex, and conclude (237): “On the basis of the above analysis it seems that once the diagnosis of anencephaly has been made the pregnancy may be terminated at any time.” This position is rejected—I believe rightly—by the Committee on Doctrine, National Conference of Catholic Bishops, “Moral Principles Concerning Infants with Anencephaly,” Origins, 26:17 (10 Oct. 1996): 276: “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.” Peter J. McCullagh, Brain Dead, Brain Absent, Brain Donors: Human Subjects or Human Objects? (New York: John Wiley and Sons, 1993), 105–42, and a child neurologist, D. Alan Shewmon, “Anencephaly: Selected Medical Aspects,” Hastings Center Report, 18:5 (Oct.–Nov. 1988): 11–15, make it clear that the diagnosis of anencephaly sometimes is mistaken and the extent of the affliction varies; if anencephalic babies are born alive, many live more than a day and a few a month or more; some such infants behave in many ways like normal babies and may be conscious; and the cause of death varies. For infants afflicted with anencephaly who could not possibly survive long after birth, viability is irrelevant as a moral marker, but that irrelevance does not entail that aborting those infants is permissible, since the relevance of viability as a marker is that, what would have been abortion before viability may be a permissible early induction of labor after it. The fact that anencephalic infants develop a more or less perfect body (apart from their brain defect) shows that the cerebral cortex is not essential for integrated development. I conclude that choosing to terminate pregnancy when anencephaly is diagnosed is homicidal if the intended end is to reduce parental emotional trauma and is unfairly discriminatory against the baby if the intended end is to avoid the slightly increased risk of a properly managed pregnancy and natural birth.

167. John Paul II, Veritatis splendor, 115, AAS 85 (1993) 1223, OR, 6 Oct. 1993, xviii.

168. Ibid., 78, AAS 1196, OR, xii.

169. Ibid., 75, AAS 1193, OR, xi.

170. See ibid.

171. Ibid., 76, AAS 1194, OR, xii.

172. Ibid., 77, AAS 1195, OR, xii.