Vital Conflicts in Medical Ethics: A Virtue Approach to Craniotomy and Tubal Pregnancies

I. The Problem

1 I The Problem 1. Two Methodologies for the Moral Evaluation of Action: The Principle of Double Effect (PDE) and the Weighing of Goods According to the doctrine of the Catholic Church, every deliberate, direct abortion is immoral because it involves the direct killing of an innocent human being. According to this doctrine, a doctor must try to save the lives of both mother and child in situations where the lives of one or both are stake. On this basis, Catholic moral theology traditionally teaches that the doctor cannot be held responsible if, in saving the child, the mother dies. Nor can he be held responsible if both the mother and child die, if the only possible means for saving the mother is to kill the child. Other therapeutic interventions that result in the possible or certain death of the child are considered morally licit, however, if the primary purpose of such intervention is not to destroy the life of the child directly , but to remove a pathological situation that is lifethreatening for the mother. Such interventions include, 2 • The Problem for example, a hysterectomy (the extirpation or removal of a cancerous uterus containing a living fetus), necessary chemotherapy for cancer treatment (with the undesired but anticipated side effect of killing the fetus), or a salpingectomy (the removal of an inflamed fallopian tube that is highly pathological and thus in danger of rupturing, and contains an ectopic, i.e., pathologically situated, pregnancy). The latter treatments are usually justified according to the principle of double effect (hereafter PDE).1 The validity of this principle has in recent years been relativized, questioned, or even denied; new formulations of it are also being sought.2 In general, the usefulness of the distinction between “direct” and “indirect” acts is rejected in favor of the principle of proportionate reason: one may directly cause a physical evil, such as the death of a human being, if there are proportionate reasons for doing so.3 This view, based on the universalization of the method of weighing of goods and presented in various forms such as teleological ethics, proportionalism, or consequentialism, was clear1 . This principle states that, if an action has an evil effect in addition to its good effects, the effectuation of the evil consequence is permissible if the following four conditions are met: first, the action itself must be good or indifferent with respect to its object; second, the good effect must arise directly from the action, such that the evil effect is not to be a means for attaining the good effect (or, the good effect should not follow from the evil effect); third, a proportionally serious reason is necessary for effectuating the evil effect; fourth, the intention of the action must be good. If these four conditions are met, it can be said that the evil effect is not willed but only “indirectly willed,” i.e., that it is a side effect for which one does not bear any responsibility. 2. E.g., the proposal, both interesting and instructive, of J. M. Boyle, “Toward Understanding the Principle of Double Effect,” Ethics 90 (1980): 527–38. 3. Cf. for example, P. Knauer, “Das rechtverstandene Prinzip der Doppelwirkung als Grundnorm jeder Gewissensentscheidung,” Theologie und Glaube 57 (1967): 107–33 (first published as: “La détermination du bien et du mal moral par le principe de double effet,” Nouvelle Revue Théologique 87 [1965]: 356–76); F. Scholz, “Objekt und Umstände, Wesenswirkungen und Nebeneffekte. Zur Möglichkeit und Unmöglichkeit indirekten Handelns,” in Christlich glauben und handeln—Fragen einer fundamentalen Moraltheologie in der Diskussion (FS J. Fuchs), ed. K. Demmer and B. Schüller (Düsseldorf: Patmos Verlag, 1977), 243–60; F. Scholz, Wege, Umwege und Auswege der Moraltheologie. Ein Plädoyer für begründete Ausnahmen (Munich: Don Bosco Medien Verlag, 1976); B. Schüller, “Direkte Tötung—indirekte Tötung,” Theologie und Philosophie 47 (1972): 341–57. Moral Evaluation of Action • 3 ly rejected by the Church’s Magisterium in the 1993 encyclical Veritatis splendor (VS). In particular, this encyclical states: “The weighing of the goods and evils foreseeable as the consequence of an action is not an adequate method for determining whether the choice of that concrete kind of behavior is ‘according to its species,’ or ‘in itself,’ morally good or bad, licit or illicit” (VS 77).4 Indeed, based on this method of weighing —if one attempts by it to...