Part 5

The doctrine given in all the leading medical works at present concerning the treatment of extrauterine pregnancy is this:

1. As soon as an extrauterine pregnancy is discovered remove the foetus through an opening made in the mother's abdominal wall. Do not use electricity or the injection of poisons into the foetal sac, or the incandescent knife. Emmet and a few others approved of the use of electricity at times, but this is against the teaching of the great majority of writers at present. The reason for removing the foetus at once is that it is apt at any moment to cause rupture and fatal hemorrhage before surgical aid can be effective.

2. In a case of rupture with free hemorrhage and collapse the only operation advised is an immediate coeliotomy to stop the bleeding by ligatures. The rupture should not be approached through the vaginal wall according to the common doctrine, but through the abdominal wall.

3. If there is a rupture in which the bleeding is confined and there is no collapse, do not operate at once unless the haematocele increases steadily or shows signs of suppuration. Sometimes evacuation of the haematocele through the vaginal wall is possible.

4. In the later months of an extrauterine pregnancy, whether the case is intraligamentous or abdominal, perform coeliotomy as soon as the diagnosis has been made, and remove the foetus, because there is always danger of sudden and fatal hemorrhage before the surgeon can reach the source of the bleeding. What is to be done in a case where the surgeon is certain before operating that the foetus is {11} dead, has interest only for the physician, and it involves no moral question.

Operating for extrauterine pregnancy maybe a simple coeliotomy, if any coeliotomy is really simple, but it commonly is the most dangerous operation for the mother that the gynaecologist is called upon to perform.

The discussion of the moral questions that arise in cases of ectopic gestation which began in volume ix. of the American Ecclesiastical Review was very valuable, but as the moralists had not full data to work on their decision as a whole is not satisfactory. The original cases presented are in part obsolete in the medical practice of to-day, and important physical conditions were not disclosed in some of the other parts of the cases. Father Holaind tentatively agreed with Father Lehmkuhl in one decision, Fathers Eschbach and Sabetti directly attacked Father Lehmkuhl's reasons, and Father Aertnys indirectly opposed Father Sabetti's chief argument. These men are all eminent authorities, but as each, except Father Holaind, was dissatisfied with the arguments advanced by the others, and as their data were incomplete, we can not rest the case on their decision.

In Father Holaind's fifth question, if I understand it correctly, he seemed to think it possible to baptize a foetus through the opening in the mother's abdominal wall while it lies in the abdominal cavity before surgical removal. He mentions antiseptic precautions in the baptism, which would have no meaning if the foetus were out of the abdomen.

Baptism would not be possible in that case: the priest could not get at the foetus, he ordinarily could not even see it, and certainly no surgeon would permit the attempt. There would be no time for the attempt in a rupture case, even if the foetus could be seen; and there would be no advantage gained by baptizing the foetus in the abdominal cavity where the conditions gave time to do so. If it is alive it will live long enough for baptism after removal from the abdomen, provided, of course, it is baptized immediately in the operating room. That it does not breathe is no proof of immediate death. It is not unusual for a full-term child not to breathe for even an hour or longer after birth.

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If Father Holaind had not in view baptism within the abdominal cavity, the question has this meaning: What is the most effective method after the foetus has been removed from the abdomen to open its enveloping membranes so as to give it a chance for a life lasting long enough to allow baptism?

The best method is to slit the membranes with a scalpel or scissors as quickly as possible. The envelopes, cord, and placenta are essential parts of the foetus itself, and they grow from itself, not from the mother. They take the place of the lungs and the alimentary tract, which do not come into action until after normal birth. It would be worth discussing whether a baptism on the intact foetal envelopes is valid, were it not that we may not apply probabilism in such a case. The remaining matter brought out in Father Holaind's questions will be considered in the course of this article.

Before presenting the cases of ectopic gestation that occur in medical practice, the fundamental ethical principles that are to be applied in judging the morality of the surgeon's interference should be given.

The morality of any action is determined, (1) by the object of the action; (2) by the circumstances that accompany the action; (3) by the end the agent had in view.

1. The term object has various meanings, but here it means the deed performed in the action, the thing which the will chooses. That deed by its very nature may be good, or it may be bad, or it may be indifferent morally. In themselves to help the afflicted is a good action, to blaspheme is a bad action, to walk is an indifferent action. Some bad actions are absolutely bad, they never can become good or indifferent (blasphemy or adultery, for example); others, as stealing, are evil because of a lack of right in the agent: these may become good by acquiring the missing right. Others are evil because of the danger necessarily connected with their performance,--the danger of sin connected with them, or the unnecessary peril to life. An action to have the moral quality must be voluntary, deliberate; and mere repugnance in doing an act does not in itself make the act involuntary.

2. Circumstances sometimes, though not always, can add a {13} new element of good or evil to an action. The circumstances of an action are the agent, the object, the place in which the action is done, the means used, the end in view, the method observed in using the means, the time in which the deed is done. If a judge in his official position tells a sheriff to hang a criminal, and a private citizen gives the same command, the actions are very different morally because of the circumstances of the agent giving the command. The object--it changes the morality of the deed if a man steals a cent or a thousand dollars. The place--what might be merely a filthy action in a house might be a sacrilege in a church. The means--to support a family by labour or by thievery. The end in view--to give alms in obedience to divine command or to give them to buy votes. The method observed in using means--kindly, say, or cruelly. The time--to do manual labour on Sunday or on Monday. Some circumstances aggravate the evil in a deed, some extenuate it. Others may so colour a deed that they specify the deed, make the action some special virtue or vice. The circumstance that a murderer is the son of the man he kills specifies the deed as parricide.

The end also determines the morality of an action (see St Thomas, Sum. Theol. I. 2., q. xviii., a. 4 and 7). Since the end is the first thing in the intention of the agent, he passes from the object wished for in the end to choosing the means for obtaining it. Without the end the means can not exist as such. There are occasions when an end is only a circumstance: for example, if it is a concomitant end. When an end is a, finis extrinsecus operantis, when it is in keeping with right reason or discordant thereto, it may become a determinant of morality.

In every voluntary, or human, act there is an interior and an exterior act of the will, and each of these acts has its own object. The end is the proper object of the interior act of the will; the exterior object acted upon is the object of the exterior act of the will; and as this exterior act specifies the morality, so does the interior object--which is the end--specify it, and even more importantly than the exterior object does.

The will uses the body as an instrument on the external {14} object, and the action of the body is connected with morality only through the will. We judge the morality of a blow, not by the physical stroke, but from the intention of the striker. The exterior object of the will is, in a way, the matter of the morality, and the interior object of the will, or the end, is the form. Aristotle (Ethics, lib. v., cap. 2) says: "He that steals that he may commit adultery, is, absolutely speaking, more an adulterer than a thief." The thievery is a means to the principal end, and it is this principal end that chiefly specifies or informs the action.

The means used to obtain an end are very important in a consideration of the morality of an act. There are four classes of means,--the good, the bad, the indifferent, and the excusable.

Good means may be absolutely good, but commonly they are liable to become vitiated by circumstances,--almsgiving is an example. Some means are bad always and inexcusable,--lying, for example. The excusable means are those which are bad, but justifiable through circumstances. To save a man's life by cutting off his leg is an excusable means.

The existence of excusable means whereby some good actions are effected does not establish the assertion that the end justifies the means. The end sometimes may incriminate or sanctify indifferent means, but it does not in itself justify all means. The means, like other circumstances, are accidents of an action, but they are in an action just as much as colour is in a man. Colour is not of a man's essence, but you can not have a man without colour.

The effect of an action, the result or product of an effective cause or agency, may in itself be an end or an object or a circumstance, and it has influence in the determination of morality. Sometimes an act has two effects, one good and the other bad; and that such an action be lawful it is necessary (1) that the action itself be good or indifferent; (2) that the good effect be intended and the evil effect be not intended (chosen) but only reluctantly permitted; (3) that the evil effect be not a means to secure the good effect; (4) that there be present a motive sufficiently grave to excuse or counterbalance the bad effect. {15} St. Thomas (Sum. Theol. 2. 2. q. 64, a. 7) Speaking of killing a man in self-defence, says: "Nihil prohibet unius actus esse duos effectus, quorum alter solum sit in intentione, alius vero sit praeter intentionem. Morales autem actus recipiunt speciem secundum id quod intenditur, non autem ab eo quod est praeter intentionem, cum sit per accidens."

That an act, therefore, be morally good, or justifiable, (a) the whole train of the tendency of the will must be good; that is, (1) the object, (2) the end, (3) and the circumstances must be good; or (b) the intention should be good, and the remaining elements in the train of will-tendency are to be indifferent. That an act be morally bad it is enough that the object, the end, or the circumstances be inexcusably bad.

There may be honest doubt as to the existence of evil in the circumstances or the end, and here enters the matter of probability; but apart from this, some general rules of morality that govern all cases may be formulated:

1. An intention or end which is gravely evil always makes the entire action evil and unjustifiable.

2. An intention or end which is slightly evil, if it is the entire end of an action, makes the whole action evil but not gravely evil--makes it, say, a venial sin and not a mortal sin.

3. If an intention or end which is venially evil accompanies secondarily a good intention or end, and is rather a motive than the real effective agent in attracting the will, this venial evil does not vitiate the whole goodness or righteousness of the main action. Compare the remarks made above in discussing an action that has a double effect, partly good and partly bad.