Is it ethical to terminate pregnancy to save the mother?

MANILA, Philippines—In the practice of Medicine, a physician is sometimes torn between medical pragmatism and a somewhat theoretical interpretation of ethics or what is deemed as morally right.

Several weeks ago, Dr. Joy Silao invited me to attend a case conference organized by the Department of Obstetrics and Gynecology of the Manila Doctors’ Hospital. Fr. James McTavish, who has a Master’s degree in Bioethics (summa cum laude) from the Regina Apostolic University, was the resource speaker.

The ethical issue discussed during the conference was that in cases where the medical team has to make a decision whether to lose both mother and fetus, or try to save the mother, is it ethical to terminate the pregnancy, hoping for a favorable outcome for the mother?

Fr. McTavish, who is also a neurosurgeon and a Fellow of the Royal College of Surgeons, dissected the case and presented several guidelines for the doctors just in case they encounter a similar case as in the highly publicized case at the former St. Joseph’s Hospital in Phoenix, Arizona. The Catholic affiliation of the hospital was revoked following an abortion allowed by its ethics committee—headed by Sister Margaret McBride, a Catholic nun—in an effort to save the mother’s life.

Facts of the case

Here are the facts as excerpted from Dr. Ereka Ricafranca’s discussion of the case in Vital Signs—a newspaper for doctors and healthcare professionals published by FAME Inc.

The case in question involved a mother in her 20s with a history of moderate but well-controlled pulmonary hypertension (increased blood pressure in the lung arteries). It is well known that pregnancy with pulmonary hypertension carries a serious risk of up to 50 percent chance of death in the mother, not only during pregnancy and delivery, but up to six months following delivery of the baby.

The woman, a mother of four, was admitted to St. Joseph’s Hospital and Medical Center with worsening symptoms. Tests confirmed a life-threatening pulmonary hypertension. Based on the assessment of her attending physicians, her risk of death was close to 100 percent if she continued the pregnancy.

Saving the mother’s life

After a few weeks of conservative medical management, Dr. Charles Alfano, St. Joseph’s chief medical officer, described the mother’s condition as “moribund” and the medical team believed that “her death was imminent.” The medical team believed they had exhausted all medical treatments to save both mother and baby, but to no avail. After consultation with their ethics committee, the mother was informed that if she approved it, the pregnancy could be terminated, and that it was appropriate since the goal was not to end the pregnancy but to save the mother’s life.

Several months after the “therapeutic abortion” was carried out, Bishop Thomas J. Olmsted, head of the Phoenix Diocese, rebuked all those who approved of the decision to terminate the pregnancy including Sister McBride. He also opined that the woman was “automatically excommunicated” because of the action.

Although the bishop does not have control of the hospital’s operations, he is the voice of moral authority over any Catholic institution operating in the diocese. “I am gravely concerned by the fact that an abortion was performed several months ago in a Catholic hospital in this diocese,” Bishop Olmsted said. “I am further concerned by the hospital’s statement that the termination of a human life was necessary to treat the mother’s underlying medical condition.”

Bishop Omsted stressed that an unborn child is never a disease. “While medical professionals should certainly try to save a pregnant mother’s life, the means by which they do it can never be by directly killing her unborn child. The end does not justify the means,” the bishop explained.

He added that if a Catholic “formally cooperates” in an abortion, he or she is automatically excommunicated. The Catholic affiliation of St. Joseph Hospital was revoked, and its name was changed to Trinity Hospital. Sister McBride was “reassigned”—actually a polite word for being demoted to a position of less responsibility and authority.

A set of ethical criteria

Fr. McTavish discussed the criteria for determining if the principle of double effect could justify the decision of the medical team and exonerate them from any charge of unethical conduct. The principle of double effect involves a set of ethical criteria for evaluating the permissibility of acting when one’s otherwise legitimate act (saving the mother as in the Phoenix case) will also cause an effect one would normally be obliged to avoid (terminating the pregnancy).

According to Fr. McTavish, a medical decision or action, which has foreseen harmful effects practically inseparable from the good effect, is justifiable if it satisfies the following:

The nature of the act is itself good, or at least morally neutral;

The agent intends the good effect and not the bad, either as a means to the good or as an end itself;

The good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect, and the doctor(s) exercise(s) due diligence to minimize the harm.

How they would have decided

Fr. McTavish asked the audience how they would have decided if they were the ones attending to this case. Dr. Nora Silao, department chair, said the focus of treatment should have been in treating the mother for her severe pulmonary hypertension, giving her whatever treatment she required to improve her hemodynamic instability. If the baby aborted in the process, then that was not directly induced by the physicians, and there can be no ethical question.

Dr. Lourdes Capito, head of the ethics committee of the Philippine Obstetrical and Gynecological Society (POGS), categorically said that in our country, such act is considered both unethical and illegal. Direct abortion for any cause is still abortion. “Even therapeutic abortion is not allowed in our country,” she emphasized.

Fr. McTavish did not give a categorical answer whether or not the decision to terminate the pregnancy in the Phoenix case is ethically tenable, but he enjoined the doctors to be very discerning, and act in the best interest of all patients involved in the case, and that includes the unborn child. He said application of the principle of double effect must also be done in a sincerely objective but holistic manner since similar acts having different intentional structures make for ethically different acts. There are also instances that one may have separate legal and ethical considerations in a case. “Just remember, that what is legal is not always ethical,” he pointed out.