Bioethics Observatory Ectopic pregnancy. Ethical dilemma
All the interventions directly aimed at inducing the death of the embryo, despite attempts to justify them in order to protect the mother’s life are ethically reprehensible.
What is an ectopic pregnancy?
On very rare occasions, the embryo that begins its life after the fertilisation of an egg by a sperm does not reach the uterus and implants in the Fallopian tube, the passage towards the uterine cavity, which is not biologically equipped to sustain a pregnancy. Since the elasticity of the wall of this tube is limited, the increased mass of the growing foetus will inevitably cause its rupture, threatening the life of the mother as well as causing the death of the foetus.
When the embryo implants in the wrong place, whether the Fallopian tube or the abdomen, the pregnancy receives the name “ectopic” (out of place). Ninety-seven percent of all ectopic pregnancies occur in the Fallopian tube.
What solutions are there to manage ectopic pregnancy?
Of the four procedures most commonly used to treat ectopic pregnancies (in Fallopian tube), three of them present certain ethical difficulties.
- The first treatment involves the use of methotrexate which, when used, targets rapidly growing cells, causing their death; they particularly target the trophoblastic cells (precursors of the placenta), which are the cells that attach the embryo to the wall of the Fallopian tube. There are those who believe that this drug may preferentially target these cells, different from the rest of the embryo, and so it could be considered that they only “indirectly” end the embryo’s life. Others, however, think that these trophoblastic cells are, in fact, part of the embryo (produced by the embryo, not by the mother), so that, in reality, the methotrexate affects one of the embryo’s vital organs, causing its death.
The argument that this drug acts only on the trophoblast, a precursor of the placenta, and not on the embryo, is difficult to sustain, given that considering the trophoblast as something other than the
2. Another morally problematic technique is salpingostomy, which consists of making a cut along the Fallopian tube and removing the embryo — which of course will die immediately — before closing the tubal duct with a suture. This solution, like the use of methotrexate, leaves the Fallopian tube largely intact for possible future pregnancies, but it also raises serious moral objections since the intervention is directly aimed at removing the embryo from the tube, causing its death.
Unwanted effects, it is accepted that these techniques generally leave scars on the Fallopian tube, thereby increasing the chances that the next pregnancy could present the same problem of ectopic nesting.
3. A third is an ethical correct solution that consists of removing the tube itself, which contains the embryo nested within it. This procedure is called salpingectomy. The time to perform this — given that almost half of the cases of ectopic pregnancies resolve by themselves with no need for any intervention, when the baby dies naturally — is indicated by evidence of thinning in the wall of the tube that facilitates its rupture, due to the increased pressure exerted by the growing embryo and trophoblast.
In this case, the death of the embryo is not the effect directly sought with the intervention, which is to remove the tube before it ruptures. This case could be considered as a double effect action, one positive and the other negative but undesired. Therefore, it could be regarded as ethically correct, as the doctor’s intention is to achieve the good effect (to remove the damaged tissue of the tube), while the bad effect is only tolerated (death of the ectopic foetus). Accordingly, it is important to highlight that the doctor is acting directly on the Fallopian tube (part of the mother’s body) and not directly on the foetus. Another important element in order to establish an ethical judgement is that death of the foetus is not the means that makes the cure of the mother possible. The same curative procedure would be used if what was inside the Fallopian tube was a tumour and not a foetus. What cures the mother is the removal of the tube, not the subsequent death of the baby.
4. Finally, a fourth solution is so-called “expectant management”, which consists of monitoring the pregnant mother, with the intention of operating urgently when the tube ruptures, in order to minimize her risk. This solution, although avoids surgery before rupturing of the tube avoiding the embryo’s death, subjects the mother to a high-risk requiring a close follow-up and emergency out-of-hours back-up.
The ethical dilemma of ectopic pregnancy treatments. A licit end, in this case, to cure the mother, does not justify an illicit means.
All the interventions directly aimed at inducing the death of the embryo or foetus, despite attempts to justify them in order to protect the mother’s life, are ethically reprehensible. A licit end, in this case, to cure the mother, does not justify an illicit means, to directly cause the death of her child.
Both salpingostomy, removing the embryo located in the tube while conserving it, and the use of methotrexate directly cause the death of the embryo, which would make their use morally illicit.
The argument that this drug acts only on the trophoblast, a precursor of the placenta, and not on the embryo, is difficult to sustain, given that considering the trophoblast as something other than the embryo itself is clearly questionable. Moreover, the methotrexate acts not only on the trophoblast cells but on any cell population that presents division processes; this also includes those of the embryo itself, although its rate of cell multiplication is distinctly inferior to that of the trophoblast.
“Expectant management” or abstaining from intervening until tubal rupture occurs, could present the ethical difficulty of subjecting the mother to a unnecessary high risk.
It seems that salpingectomy, is the one that offers least doubts about its ethical goodness, even while accepting the inevitable double effect and not seeking to cause the indirect death of the embryo as a consequence of the removal of the Fallopian tube in which it is nested.
See Biologic Status of Human Embryo
Julio Tudela and Justo Aznar
Catholic University of Valencia