AMA Journal of Ethics^®

Clark PA. Methotrexate and tubal pregnancies: direct or indirect abortion? Linacre Q. 2000;67(1):7-24.

Peter Clark is correct in identifying ectopic pregnancy as a serious medical and moral concern in his 2000 article "Methotrexate and Tubal Pregnancies: Direct or Indirect Abortion" [1]? As a major cause for reduced childbearing potential and the leading cause of maternal morbidity and pregnancy-related deaths during the first trimester, ectopic pregnancy is an acute medical problem. For many it is an equally serious moral problem because resolving the medical crisis results in embryonic death. The moral concern is complicated by the fact that maternal morbidity and possible mortality from ectopic pregnancies are significant.

Clark's article provides a model for interdisciplinary analysis of complex clinical and ethical problems. First, Clark presents a detailed explanation of relevant medical information. Second, he applies a moral analysis to each of the possible medical scenarios. Third, he provides two traditional ethical models to help resolve the gap between the clinically and morally desirable outcomes. Fourth, he responds carefully and respectfully to opponents and critics of his position. Finally, he concludes thoughtfully, that methotrexate represents a complex challenge within Roman Catholic moral theology that requires further dialogue and debate.

Clark himself believes that the use of methotrexate is morally acceptable because it attacks the trophoblast, which is the set of embryonic cells that become the placenta. His argument is that, since the drug attacks these cells and not those that will become the embryo proper, it is attacking the source of pathology and not the new life [2]. Based on Clark's reasoning, the embryonic death is indirect and unintended (although foreseen) and thus permissible in Roman Catholic moral theology.

Clark applies the three-font principle and the principle of double effect, complemented by the use of proportionate reasoning, in his ethical analysis. I find the principle of double effect and especially its proportionate reasoning argument more convincing, primarily because of its broad appeal. Second, the reasoning is more straightforward, particularly in Clark's insistence that his resolution of the ectopic pregnancy crisis does not undermine the value of human life.

The method of proportionate reasoning as developed by Richard McCormick, SJ, has three elements that are less esoteric than many other ethical models, and the criteria can be applied relatively easily and debated without an in-depth understanding of major philosophical presuppositions and tenets. The criteria for moral justification of an act under proportional reasoning, as correctly noted by Clark, are that the means used will not cause more harm than necessary to achieve the value in question, no less harmful way exists to protect the value, and the means used to achieve the value will not undermine it [3]. In the case of an ectopic pregnancy the use of methotrexate preserves a woman's fallopian tubes so she remains fertile, methotrexate is overall the least harmful treatment because it is less invasive and less costly than the alternatives, and, finally, because its use directly affects the trophoblastic cells, methotrexate does not undermine the value of human life.

But there is another side to this discussion that is not highlighted in any of Clark's arguments. In the case that Clark describes, as in many others, the ectopic pregnancy occurs in the context of a desired pregnancy; that is, a couple is seeking to have a child, to establish a family. This is the assumed overarching intention that should be kept in mind as one thinks this case through. This couple wants a child. The methotrexate solution honors this intention by preserving the integrity of the fallopian tube and making future pregnancies possible. The current pregnancy would be lost, indirectly as Clark argues, but the more critical issue is that the methotrexate solution is the one that is most life-affirming and life-enhancing and that it makes possible future pregnancies.

I offer this, not as a criticism of Clark's analysis, but as a complement to it; a highlighting of a circumstance that often gets overlooked in our zeal to give equal protection to all pregnancies. By noting the importance of the intention to create a family, moral analysis can incorporate another significant, if not controlling, element in the moral evaluation of this critical problem.