Catholic Medical Quarterly

The Journal of the Catholic Medical Association (UK)

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Catholic Medical Quarterly Volume 65(3) August 2015

ETHICAL REFLECTIONS ON ECTOPIC PREGNANCY

Fr Daniel Icatlo, JCD Colombo, SRI LANKA

Ectopic pregnancy is case wherein the embryo implants itself outside the uterus, more specifically, in the fallopian tubes. In recent years, there has been a notable increase in the incidence of ectopic pregnancies due possibly to the following causes: damage resulting from tubal ligation or pelvic-abdominal inflammatory processes and other infectious diseases, hormonal contraceptive use, the in vitro fertilization techniques, use of IUD, etc.

As regards the percentage of incidence arranged from highest to lowest, the embryo can implant in:

 

1. the sections of the fallopian tube called "isthmus" and "blister" (approximately 95% of cases),
2. the intramural section of the tube at the height of the uterine body, also called "intramural oviduct" (about 2 to 4% of cases),
3. the ovary (approx. 0.5%),
4. the cervix of the uterus (approx. 0.1%),
5. abdominal cavity (approx. 0.03% of cases), and in rare cases elsewhere. The number of ectopic pregnancies is increasing almost everywhere in the world, and today is between 1 and 2% of pregnancies.

Following the findings and ethical evaluation of Prof. Monsignor Angel Rodriguez[1] in his paper (Pro manuscripto), under those conditions the embryo will not be viable since it will never reach term. Moreover, there is a serious risk of tubal rupture that can be life threatening to the mother.

There arises an ethical issue as regards the proper medical treatment. Abortion has become the common solution, either through medication or surgical intervention. On one hand, some doctors infer that since the embryo will never reach a viable stage, nonetheless, there is no point in carrying on with the pregnancy.

They argue that what would eventually happen is simply brought forward. Moreover, the consequent risk to the mother’s health is circumvented.

On the other hand, other doctors believe that it is better not to intervene and they would rather wait because in many cases the embryo dies and is expelled spontaneously.

It appears that in about 15-20% of those implanted in the fallopian tube, the ectopic pregnancy more often than not ends in the death of the embryo. But it may also continue to grow until it ruptures the structure containing it, resulting in severe bleeding requiring emergency surgery consequently causing the death of the embryo and its unavoidable extraction from the body of the mother.[2] If this happens, surgery is ethically permissible.

In cases where ectopic pregnancy is detected early, some doctors resort to a medication called methotrexate. It stops the fertilized embryo from developing. The pregnancy tissue then gets engulfed and absorbed by the woman’s body. In about 50% of cases, however, methotrexate is not needed as the embryo dies by itself.

If the ectopic pregnancy has progressed to a later stage of development by time it is detected, surgery will be needed to remove the embryo. If growth of an ectopic pregnancy is not prevented, the growing embryo could rupture the fallopian tube and cause dangerous internal bleeding.

Such medical approach may be explained by various reasons: a) there are doctors who practice routine abortion of perfectly healthy embryos or fetuses; obviously, they see no reason why they should not do it in this particular case; b) doctors are afraid to suffer lawsuits for failing to ensure early removal of an imminent danger to the mother; c) one must also consider that an early intervention is preferable since this does not involve the removal of the tube not only to avoid inconvenience and danger to the mother but also to preserve as far as possible future fertility.

Early extraction of nonviable embryos does not seem justified either from the medical vantage point nor from the ethical viewpoint.[3] From the medical point of view, in these cases it is preferable to wait, because a significant percentage of these pregnancies resolve spontaneously with the death and expulsion of the embryo without any surgical intervention.

A third option of tubal pregnancy treatment is active monitoring. When there are only mild symptoms, chances are the pregnancy will resolve itself. The fertilized egg will die and then be absorbed into nearby tissue.

This is more likely if your blood tests show low levels of the human chorionic gonadotropin (hCG) hormone. Regular blood tests are required and, in some cases, ultrasound scans to assess the pregnancy's progress. If tests do not show a continued drop in hCG levels, more treatment would be needed (this usually happens in around one in three cases treated using active monitoring).

The advantage of active monitoring is that you won’t have to experience any side effects of treatment. A disadvantage is that there is still a small risk of your fallopian tubes splitting open (tubal rupture), even if blood tests show low levels of the hCG hormone. In the case of a life threatening rupture of the fallopian tube, the opinion of Prof. A. Rodriguez together with a number of experts in morals, is that the doctor should take a reasonable decision about when and how to intervene without having to wait until a critical level is reached. Moreover, the doctor should seek as much as possible to preserve the future fertility of the mother and minimize the collateral damage.

There are ethical principles that must be borne in mind in resolving ectopic pregnancies. Cases of pregnancies outside the womb requires the doctor to do his best to save the lives of both the mother and child. It would be illicit to resort to a simplistic approach of reducing the matter to choosing between two lives, or cause the death of one in order to save the other.

Owing to the nature of the pathology of the ectopic pregnancy, doctors are faced with only two alternatives: the death of the fetus, which he cannot save in instances of ectopic fallopian tube pregnancies, or run the risk of the mother’ death. Confronted with these possibilities, there is an ethical imperative to save the life of the one that could be saved.

In this regard, the surgeon can remove the fetus from the mother's body by a procedure that seems most appropriate medically, e.g. salpingectomy, linear salpingostomy or removing the only part of the tube containing the embryo. The extraction of the embryo or fetus is not intended to cause the death of fetus since its death is deemed inevitable. The intention of the doctor is rather to save the life of the mother, otherwise it would be a grave injustice against her.

The extraction of the embryo or fetus, on the other hand, does not constitute any injustice against fetus, because it simply cannot survive whether it be inside or outside the mother’s body. If the mother dies, the fetus will also die.

There are moral experts who maintain that the only legitimate medical intervention would be the removal of the entire tube containing the embryo. They regard the other possible interventions as direct abortion. Prof. Rodriguez (op.cit.) believe it would be hair-splitting to examine how the surgeon does the incision. Some claim that if the surgeon cuts the tube in linear salpingostomy it would constitute direct abortion. But if he cuts the whole tube containing the embryo (salpingectomy) this becomes indirect abortion. The manner of incision is ethically immaterial.

The distinction between "direct" or "indirect" abortion refers more to the intent and will of the surgeon in the process of extracting the embryo and not so much to the manner in which the embryo is removed from the body of the mother. Medical intervention in the above case is ethically correct because it is the act itself is deemed necessary in order to save the only life that can be saved without causing additional risk or harm to the fetus. While not willfully intending it, that act simply changes the place where the fetus dies and perhaps advances the time of his death, but by very little, which is inevitable anyway.

This same moral standard has been applied recently by the competent ecclesiastical authorities some severe cases of eclampsia and chorioamnionitis. [4] In this particular case of a tubal ectopic pregnancy, the moral problem lies more in the time (when) and the reasons (why) of those involved in the surgical intervention. There seems to be no important moral difference between removing the whole tube from removing only the section of the tube which includes the embryo, or from an incision in the tube to take only the embryo.

Finally, some ethical considerations on the lawfulness of the use of methotrexate. This drug operates by preventing cell division and inhibiting the growth of the trophoblast or the cell wall through which it feeds the embryo, thereby causing termination of pregnancy and expulsion of the presumably dead embryo. This drug is used only for ectopic pregnancies diagnosed early, it is generally assumed that its use does not include an initial waiting to see if the problem resolves without medical intervention. It works in some instances, but if it does not they proceed with surgery. Its use also prevents the possibility of conditional baptism. For these reasons, Prof. Rodriguez thinks that it should not be used, unless the assumption that is that it is the only way to avoid medically the possible death or serious danger to the life of the mother.

References