Dobbs as a Porcupine, and Other Surprises
Be careful what you wish for
Two years ago the Supreme Court, in Dobbs v. Jackson, stripped abortion rights of constitutional protection. The issue was returned to the states, 21 of whom soon narrowed or eliminated any such right.
The results have been politically surprising. Almost two thirds of Americans oppose criminalizing abortion, a fraction that increased as the consequences of Dobbs became clear. Efforts to outlaw abortion are no longer a winning strategy for the GOP. Like a dog who chases a porcupine, the party didn’t realize the price of success.
The surprises are more than political. Another is the number of doctors who have left states that criminalize abortion. Idaho, for instance, has lost half its high-risk obstetricians. Labor and delivery units are closing; obstetric deserts are forming. Someone in labor might need to drive 100 miles or more.
Doctors leave because the complications of pregnancy are so many, so individual, and so unpredictable. Doctors are trained to make professional decisions about what is best, both for pregnant patient and future child. Now doctors must also calculate the risk to themselves: Years in prison? Loss of license? (The old dangers also persist: Abortion providers are sometimes attacked and killed.)
Some anti-abortion states allow exceptions for the life of the mother. Calculating that risk is endlessly complex. Is she near enough to death for us, legally, to abort the pregnancy? If not, how long must we wait? What if the danger to her is indirect, if, for instance, continuing the pregnancy would require postponing chemotherapy because it would endanger the fetus? Or what if the danger is long-term: worsening heart disease, but not yet causing a heart attack? What if this pregnancy is doomed anyway, and if allowed to continue, will make a future pregnancy impossible? What if a desperate patient is on the verge of suicide? The scenarios are unlimited; the choices are rarely black and white, and decisions are always wrenching.
It’s no surprise that doctors prefer to practice in states where they, not the courts, make such decisions; and where the calculus can be focused on the patient, not on danger to the doctor. It was also predictable that maternal death rates increase in the states they leave.
So, there have been many surprises: to politicians whose anti-choice stance is now an electoral handicap; to voters newly aware of real-life complexities in pregnancies; to states that are losing doctors.
I’ve been surprised myself, on another front. I’ve learned that Catholic doctrine does not always prohibit abortion. For several reasons I should have known this, but I didn’t. I suspect most people don’t.
Abortion to save a mother’s life
Catholic doctrine allows a pregnancy to be terminated to save the life of the mother. The death of the fetus is justified if it is an unintended side effect. The basic principle is called the doctrine of double effect, about actions that have two results, one intended and good, the other something which it would be wrong to seek for its own sake. The second becomes acceptable only when it is an unintended result of the first. For example, it's legitimate to give opioids to dying patients in order to ease their suffering, even at doses that may hasten their deaths. Reversing the cause and effect — killing someone in order to end their suffering — is not allowed.
And so for abortion. It is legitimate to end a pregnancy to save the mother’s life, even when doing so kills the fetus. It is not legitimate to kill the fetus in order to end the pregnancy. In standard practice the fetus is physically attacked in order to be more easily extracted; its death ends the pregnancy.
The Church therefore requires that in these dire situations the fetus must be taken out whole. Labor, for instance, can be induced, even when the fetus is non-viable. C-sections or hysterectomies are allowed. All of these entail more risk and complication for the patient than do standard techniques. No matter where one stands on abortion and abortion rights, the issue is serious.
Ectopic pregnancies raise particularly poignant questions. In an ectopic (“out of place”) pregnancies, a fertilized ovum implants outside the uterus, generally in a fallopian tube, where it cannot grow to viability. Fairly soon its growth will burst the tube; the embryo will die, and the patient may, too.
Catholic doctrine allows the tube containing the embryo to be removed. Death of the embryo is seen as an unintended side-effect. Standard medical procedure, in contrast, scrapes out the tube rather than removing it. This leaves the patient with a normal chance of conceiving again. Removing the tube reduces that chance (or eliminates it, if the other tube or ovary is compromised).
Often the only hospital in an inner city or rural area is Catholic, bought by the Church from floundering non-profits, out of a commitment to justice. These hospitals will not offer services standardly provided by secular hospitals.
It’s clear that patients in Catholic hospitals must be told this, in advance. (And, I would argue, some organization, public or private, should provide information and transportation to secular, full-service, hospitals.)
Conversely, as my favorite bioethicist argues, in secular hospitals patients should be offered not only the standard procedure (scraping out the tube, leaving it in place) but also the other possibility: removing the tube, knowing the embryo will die, but not directly causing its death, but also reducing the chances of a future pregnancy.
Finally, something that should not be a surprise, but is: It’s not only Catholics who sometimes choose the second procedure. The pregnancy may have been deeply desired, and conception difficult. The thought of directly destroying that embryo may be unbearable. For some, reducing their chances of a future pregnancy is easier.
As I’ve been saying, it’s complicated.
Catholic doctrine is a carefully worked out version of absolutism, whose attractions and limitations I’ve written about before. As I have about the moral and legal aspect of abortion; and about the vagaries of intention. Sometime soon I hope to say more about that last.
Thank you for such an informative piece that clarifies many common misconceptions about Catholic doctrine as it relates to abortion. FYI, regarding the issue of ectopic pregnancies in Catholic health systems, note that led by Washington, some states are considering or have passed legislation requiring Catholic systems to publicize all areas of medicine in which they will not offer procedures that are considered legal or even standard in other health systems. In addition to abortion (in the absence of extremis), that would include tube-preserving procedures for ectopic pregnancy and physician-assisted dying in states where that is legal.
Thank you. I sincerely appreciate the time and effort put into this piece. I always learn something from you.