I am one of the few women in obstetrics and gynecology, a specialty ironically dominated by men, and I have a moral question to which I have not been able to find an answer. It is about cases in which a woman not really married but involved in an ongoing relationship asks for help to achieve a pregnancy desired by both her and her partner.
A great many couples today are not really married. Besides those simply living together, many of whom may eventually marry, there are Catholic couples who are only civilly married and, no doubt, many couples, whether non-Catholic or Catholic, who are divorced and remarried invalidly. Of course, I often have no way of knowing whether a patient is really married, and then I assume she is. But I know that certain of my sexually active patients are not. I am sure it is right not only to provide them with the gynecological care that even single women need but to see them through their pregnancies and deliveries, since they and their babies need care, regardless of their marital status. I also try, in a motherly way, to encourage unmarried women involved in ongoing relationships to end them or straighten them out, though I must be careful in bringing up the issue, since some patients are edgy and likely to feel that it is none of my business. I suppose that is true, strictly speaking, but in a few cases my meddling has encouraged a well-matched couple to marry, or a woman to end a bad relationship.
Even with non-Catholic couples, I never prescribe contraceptives. I point out the unsatisfactory aspects of oral contraceptives, including their bad side effects and possible abortifacient mode of action, and offer natural family planning (NFP). Taught properly, it is highly effective and is acceptable to a surprising percentage of couples (though some no doubt cheat by using nonprescription contraceptives during their fertile periods). However, teaching NFP to unmarried couples has bothered me a bit, since it facilitates their continuing illicit relations.
In dealing with infertility, I offer only diagnostic procedures and remedies that are in accord with the Church’s teaching.245 The diagnosis and treatment of the underlying causes of sterility seldom are simple. Occasionally, however, infertility is a symptom of pathology that would require treatment in any case. If such pathology is ruled out, the problem may be that a couple’s timing or other factors are unfavorable for conception, so that use of NFP and other simple adjustments can solve the problem. In trying to help couples have the babies they want, therefore, I almost always discuss their sexual activity with them, teach them fertility awareness, and instruct them when to engage in intercourse. Doing this for unmarried couples bothers me more than teaching them NFP as birth regulation, since in this case I am both telling an unmarried couple when to have intercourse instead of when to abstain from it and helping them bring into the world a baby who probably will be deprived of the stable parental cooperation children deserve.
If I did not help couples who are not married reach their goals of avoiding or achieving pregnancy, someone else would, and in the process very likely would offer and use morally unacceptable techniques. Still, I know that a good end does not justify doing anything wrong in itself, and so I am concerned that I may be going too far, especially in helping unmarried couples achieve pregnancy.
Several distinct moral questions are presented here. First, is teaching an unmarried couple how to practice NFP formal or wrongful material cooperation with their illicit sexual activity? Second, is helping an unmarried couple achieve pregnancy formal or wrongful material cooperation with their illicit sexual activity and/or their wrongful intention to have a child? In both cases, I think, the cooperation need not be formal and is unlikely to be so for this physician. But is the material cooperation justifiable? In the first case, it seems to me the material cooperation generally would be justified. Helping unmarried couples achieve pregnancy is more questionable, but I think even such material cooperation can be justified in some cases.
When an unmarried patient is involved in an ongoing sexual relationship and the couple wish to avoid pregnancy, you can teach them NFP without doing anything wrong in itself. You need not intend their illicit intercourse as an end or choose it as a means, but can merely accept it as a given. Teaching NFP to help the couple avoid pregnancy is an objectively good end inasmuch as, not being married, they should not have children. Your means also is good: teaching fertility awareness, including various methods of identifying fertile and infertile times. In most cases, your help probably does not in fact facilitate the couple’s illicit sexual relations. Even if you did not help them, couples involved in ongoing relationships very likely would continue their sexual activity, either irresponsibly risking pregnancy or using contraception to prevent it. However, if your help occasionally does have this result, you surely do not intend or choose it, but only accept it as a side effect.
Of course, though not wrong in itself, such involvement in others’ objectively wrongful behavior can be and often is wrong. Sometimes it is the occasion of oneself willing the wrong; sometimes it is unfair to those injured by the wrongful behavior; sometimes it leads others into sin or impairs witness to moral truth. However, teaching NFP to unmarried couples is hardly likely to lead you to will their illicit relations, that is, to intend them as an end or choose them as a means. Your involvement is neither unfair to the couple, who voluntarily injure themselves and each other by their wrongdoing, nor to any child they might have, since by teaching them NFP you reduce the likelihood of a child’s coming to be outside marriage. Finally, in most cases your involvement will not encourage the couple to sin and, indeed, will give you an opportunity to encourage them to repent—an opportunity of which you take advantage by your “meddling.” Moreover, in teaching NFP, you can propose sound attitudes both toward sexual intimacy itself and toward possible offspring, and thus help an unmarried couple gain insight into the inappropriateness of their intimate relationship and the wrongness of accepting any risk of procreating an unwanted baby. Moreover, even couples in illicit relationships who begin to practice NFP must exercise certain good habits, and doing so may lead to their ending the relationship or transforming it into a chaste friendship or marriage.
Still, in certain circumstances, teaching a couple NFP might encourage them to continue their illicit behavior and impair your witness to the truth about it. That could be so, for instance, if the couple’s or woman’s relationship with you were not merely that of patient with physician but that of a friend or relative whose illicit behavior you had a special responsibility to discourage. If you then judged that your involvement would be taken as approval, you probably would be obliged to make your disapproval clear by refusing all cooperation.
Though helping unmarried couples achieve pregnancy is more questionable than helping them avoid it, I do not think your effort to help an unmarried couple overcome infertility requires you to intend either their illicit sexual activity or the morally unacceptable aspects of their effort to procreate. The sexual activity of such a couple is habitual behavior in which they presumably will persist no matter what you do. So, though you teach fertility awareness and instruct them when to engage in intercourse, you intend only that they choose this time rather than that for intercourse; you take for granted, rather than choose or intend, their acts of intercourse themselves. As for the morally unacceptable aspects of their efforts to procreate, you need not will them. Nothing you do is specified by their being unmarried; indeed, your intention and choices can be precisely the same as when you help a couple whom you assume to be married while being ignorant of their true marital status.
The preceding point will be clarified by considering a possible objection. In helping an unmarried couple achieve pregnancy, you intend to satisfy their desire, and they desire not merely healthful functioning but its fruit, namely, a baby who will fulfill their sexual union. Now, the couple cannot rightly will that fulfillment, because their sexual intimacy, not being marital, is bad. So, the objection will conclude, in helping an unmarried couple achieve pregnancy, you intend part of what makes their act bad, and so share in their wrong willing. It is true that, in helping the couple overcome infertility, you do share their intention insofar as both they and you intend that a child be conceived. Note, though, that the child’s conception fulfills an unmarried couple’s sexual union in two ways: first, insofar as it is the natural consequence of healthy reproductive functioning; second, insofar as it is the desired culmination of an interpersonal relationship constituted by objectively bad human acts. As a physician dealing with the couple’s infertility, you necessarily intend the first, which is an intelligible good, but need not intend —indeed, need not even be aware of—the second, which is morally defective. Thus, in helping an unmarried couple overcome infertility, you need not will the morally unacceptable aspects of their effort.
Still, you could intend what the patient wrongly intends—for example, if you helped an unmarried woman achieve pregnancy so that her restless partner would continue their relationship. In view of your conscientious attitude, however, I assume you would refuse to cooperate in a case you knew to be of that sort.
Is your assistance to unmarried couples in achieving pregnancy unfair to the children who come to be? It might seem so, since an unmarried couple do an injustice to a child by procreating him or her out of wedlock. Your actions, however, do not cause or contribute to the consequence that the parent’s defective relationship has for the child (being born out of wedlock) but only to the consequence that their healthy reproductive functioning has for him or her (coming to be). Since it is good to be, the child’s coming to be, considered in itself, is good, not bad. Thus, unless your assistance is detrimental to the child in some other way, what you do benefits, not injures, him or her, and so is not unfair.
Will your assistance encourage unmarried couples to persist in their wrongful activity or impair your witness to relevant moral truths? Here, it seems to me, distinctions must be made regarding what you do, characteristics of the couple’s relationship, and their attitude toward the child who might be conceived.
Insofar as you try to discover and treat pathological causes of infertility whether or not the couple wish to have a baby, what you do pertains directly to your professional duty. You could not continue to serve patients while omitting care like this, and providing such care is not likely to lead those you treat or others into sin. At the same time, retaining such patients allows you to try to influence them for the good. So, it seems to me, such assistance is morally acceptable.
If a couple do not consider themselves married and are not regarded by others as a married couple, doing anything precisely to help them overcome infertility is likely to encourage them to persist in their relationship and wrongful sexual activities, and will tend to undermine the credibility of your witness to relevant moral truths. In such cases, it seems to me, your assistance to them would not be justifiable.
However, when a nonmarital relationship is regarded by the couple themselves and most other people as marital, you probably will not know—though you might suspect—that they are not married. But even if you are certain they are not, your further professional help in overcoming infertility is unlikely to have the bad effects that preclude helping other unmarried couples.
Still, such a couple or even a couple who are truly married might manifest an immoral attitude toward the child who might be conceived—for instance, by planning to have pregnancy tests and abort any fetus deemed unsatisfactory, wanting a baby to cement a troubled relationship, or desiring an otherwise unwanted baby solely to satisfy others’ expectations. In such cases and others in which desire for a child is patently immoral, helping the couple achieve pregnancy would, I believe, be unjustifiable, for it might well encourage them and others to sin or persist in sin, and certainly would impede your witness to the child’s inherent dignity.
245. For a summary of some morally acceptable steps, see Thomas W. Hilgers, The Medical Applications of Natural Family Planning: A Contemporary Approach to Women’s Health Care (Omaha, Nebr.: Pope Paul VI Institute Press, 1991), 123–49; John F. Kippley and Sheila K. Kippley, The Art of Natural Family Planning, 4th ed. (Cincinnati, Ohio: Couple to Couple League, 1996), 297–99 and 305–15.