There are few words more terrifying for a woman (and her
husband) than “tubal pregnancy”. Whenever these words
are uttered to an expectant mother and father, it means
the loss of hope, and not just physical pain, but the
very real emotional pain of having to face the loss of
an unborn child, and fear that the mother might die as
well. To make matters worse, Catholic parents are thrown
headlong into a murky moral dilemma that, more often
than not, they will have face alone, having to make snap
decisions on the spot without the benefit of sound moral
or spiritual counseling, and with little or no
preparation to make sound moral choices.
Even though there has been disagreement over the years
concerning the right and wrong thing to do in the case
of an ectopic pregnancy, Catholic parents and their
doctors can turn to their Catholic faith for guidance.
While no parent wants to contemplate the possibility of
an ectopic pregnancy, it is something, nevertheless,
that is faced by 1 in 70 pregnant women. Knowing the
facts about ectopic pregnancy, and how Catholic moral
principles can be used to navigate the murky waters
surrounding it, may not mitigate the emotional and
spiritual pain, but it can still serve by helping
parents avoid making an on-the-spot decision that they
will come to bitterly regret. Knowing that you, as a mom
or dad, did everything you could to achieve the greater
good, preserve the life of both mother and child, and
that you sought the will of God throughout the course of
the tragedy, will facilitate healing afterwards.
Doctors and medical professionals also have a particular
obligation to understand the moral dilemmas faced by
their Catholic patients and their families. By coming to
a more thorough understanding of Catholic moral teaching
regarding the sanctity of life, and everyone’s moral
obligation to safeguard human life from conception to
natural death, medical professionals are better equipped
to provide all the ethical information their patients
will need when it comes time for them to make decisions
while under extreme physical and emotional duress.
Ectopic Pregnancy and the Catholic Church’s Teaching
Regarding the Unborn
An ectopic pregnancy is any pregnancy that occurs
outside of the uterus. An ectopic pregnancy occurs when
the movement of a fertilized egg is blocked or slowed in
the fallopian tube, causing the egg to implant in the
tube. This is commonly called a “tubal pregnancy”, but
ectopic pregnancies can occur, on rare occasions, in the
ovary, around or behind the uterus, or in the cervix.
There are various reasons why a fertilized egg can be
blocked or slowed in the fallopian tube, to include a
birth defect in the fallopian tubes, endometriosis
(uterine lining tissue occurring in the fallopian
tubes), complications caused by a ruptured appendix, and
scarring from past infections or surgeries. The risk for
ectopic pregnancies is significantly increased by age
(over 35), in vitro fertilization, having multiple
sexual partners, smoking, and getting pregnant while
using certain intrauterine artificial contraception
devices or after having a tubal ligation. Also
reconstructive surgery to the fallopian tubes
significantly increases the chances of an ectopic
An ectopic pregnancy is always a life-threatening
condition to mother and child. Without the removal of
the developing cells a rupture will occur, and the
resulting hemorrhaging will kill the mother. Obviously,
therefore, the baby cannot survive in such a condition,
either. An ectopic pregnancy must be treated immediately
in order to save the life of the mother, but the death
of the unborn baby is always a consequence of all
current ectopic pregnancy treatments.
The Catholic Church has always taught, since the first
century (the Didache, II. 2), in fact, that every
procured abortion is a grave moral evil, and this
teaching has not changed, nor can it be changed. Any
direct abortion, which is willed either as an end in
itself or as a means to some other end, even to save the
life of the mother, is grave matter that is contrary to
the moral law (Denzinger, 1183f and 1890a-c). Thus, an
ectopic pregnancy cannot be treated by a direct
abortion, even if the abortion is performed to save the
Must the Mother Die?
Does this mean that an ectopic pregnancy must be left
untreated, resulting in the death of both mother and
child? This is clearly an unacceptable moral conclusion,
especially if the means are available to the save the
life of the mother. The principle of double effect can
and should be applied when considering ectopic
St. Thomas Aquinas lays out the foundations of the
principle of double effect in his Summa Theologica
(IIa-IIæ Q. 64, art 7):
Nothing hinders one act from having two effects, only
one of which is intended, while the other is beside the
intention. Now moral acts take their species according
to what is intended, and not according to what is beside
the intention, since this is accidental.
The principle of double effect is employed in moral
reasoning when an action one thinks one ought to do in a
given circumstance has both good and bad effects,
causing an ethical dilemma. An action that has bad
consequences can be morally permissible if the good
effect is intended, and not the bad effect. However, St.
Thomas is careful to add in the same article that a
justification of the unintended effect is conditional.
It must be proportional to the intended good
consequence. In other words, the good effect must be
equal to or greater than the unintended bad effect.
Here is the New Catholic Encyclopedia on the rules for
determining whether or not the action one thinks one
ought to do when both good and bad consequences will
1. The act itself must be morally good or at least
2. The agent may not positively will the bad effect but
may permit it. If he could attain the good effect
without the bad effect he should do so. The bad effect
is sometimes said to be indirectly voluntary.
3. The good effect must flow from the action at least as
immediately (in the order of causality, though not
necessarily in the order of time) as the bad effect. In
other words the good effect must be produced directly by
the action, not by the bad effect. Otherwise the agent
would be using a bad means to a good end, which is never
4. The good effect must be sufficiently desirable to
compensate for the allowing of the bad effect. (1021)
In the case of an ectopic pregnancy, the action that is
directly willed is to save the life of the mother by the
removal of a pathological mass of tissue (not unlike a
malignant tumor), which unfortunately contains, but not
exclusively, an unborn baby, which has implanted in the
wrong place. The bad effect, the death of the unborn
baby, is not directly willed. Just as it would be
morally permissible to remove a cancerous tumor from the
mother, even if such treatment will kill the unborn
child, so it is also morally permissible to remove a
pathological and abnormal mass of tissue that contains
an unborn child in order to save the life of the mother.
The death of the child is an unwilled, indirect and
unfortunate effect of a treatment used to save the
mother’s life, and is further proportional in that if no
action were taken, not only would the mother die but so
would the unborn child.
Therefore, according to the principle of double effect,
treatment of an ectopic pregnancy that results in the
unintended death of the baby can be morally permissible.
However, not all treatments are morally permissible. It
is in evaluating the various treatments offered by
modern medicine that we find confusion and moral
Moral Considerations of Various Treatments for Ectopic
Surgical removal of the pathological tissue that
contains the unborn baby is the least problematic
treatment from a Catholic moral perspective. This
treatment usually consists of the use of mini-laparotomy
or laparoscopy surgery to confirm the ectopic pregnancy,
remove the abnormal tissue mass containing the unborn
child, and repair (salpingostomy) or remove (salpingectomy)
the fallopian tube. This surgical procedure is intended
to directly treat a pathology, thwart life-threatening
conditions such as hemorrhaging or damaged tissue, and
to stabilize the mother, all of which is done to save
the life of the mother. This directly willed effect, to
save the life of the mother, is proportional to the
unintended bad effect.
Surgery also has the positive intention of confirming
the ectopic pregnancy. One of the aspects of ectopic
pregnancy that exponentially complicates treatment and
moral reasoning is that an ectopic pregnancy can be very
difficult to diagnose. Symptoms of an ectopic pregnancy
can include more than normal vaginal bleeding, cramping
and lower back pain. However, these can also be common
symptoms of normal pregnancies.
Early diagnosis of ectopic pregnancy is usually limited
to monitoring hCG (human chorionic gonadotropin) levels
in the blood and ultrasound examinations. In a normal
pregnancy hCG levels should double roughly every
forty-eight to seventy-two hours. If hCG levels are low,
or fail to double normally, this can indicate an ectopic
pregnancy, but not necessarily. Early ultrasound
examinations are also used to diagnosis ectopic
pregnancies. At an hCG level of 1300 to 1500
international units per milliliter (mIU/ml), at the very
least the gestation sack containing the fetus should be
visible to a vaginal ultrasound examination. If the
gestation sack is not seen on the ultrasound, this could
indicate an ectopic pregnancy, but not necessarily.
There are other reasons that the gestation sack may not
There are only two reliable methods of diagnosing an
ectopic pregnancy: either the tube has burst and is
causing hemorrhaging, which is visible to ultrasound
imaging (other symptoms of a rupture is fainting,
intense abdominal pain, low blood pressure, pain in the
shoulder area, and intense pressure on the rectum), or
confirmed in the course of a mini-laparotomy or
laparoscopy. In some rare cases, a rupture can occur
without immediate hemorrhaging or other symptoms. For
these reasons, even without a rupture, exploratory
surgery is morally permissible if an ectopic pregnancy
is strongly suspected. However, such an exploratory
surgery, like all surgeries during pregnancy, runs the
very real, though unintended, risk of injuring or
killing the unborn baby. Uncertainty in regards to the
diagnosis is an important consideration in moral
reasoning as we consider other treatments.
This uncertainty brings us to a second treatment
consideration, which is to wait and see. The “wait and
see” approach works on the premises that many
pregnancies may start out as ectopic, but naturally work
themselves out. The fertilized egg could be slow in
passing through the fallopian tube, causing hCG levels
to rise at a slower rate. Ultrasound examinations may
not give an accurate picture. Because of this
uncertainty in diagnosis, and considering that an
exploratory surgery may harm a healthy pregnancy, it can
be decided to wait and see if a rupture takes place.
While this course of action is morally sound, if a
rupture does occur along with life threatening
hemorrhaging, to continue to “wait and see” will only
result in the death of the mother and the unborn child,
thus making continued delay of immediate treatment
irrational, to say the least. It must be noted, that in
extremely rare cases ectopic pregnancies have been known
to proceed without hemorrhaging or other life
threatening complications to a point that the fetus was
viable and could be surgically removed alive. While
extremely remote, I think that even this small
possibility justifies the “wait and see” approach, at
least up until such a time that a rupture occurs that
directly threatens the life of the mother and the unborn
The third and most common form of treatment for ectopic
pregnancies is the administration of methotrexate (MXT).
The use of MXT is so common due to its convenience. MXT
was developed as a treatment for cancer, and is still
used as part of chemotherapy in the treatment of
leukemia, lymphoma, breast and other cancers. Because
MXT inhibits the metabolism of folic acid, which is
necessary for cell division and the growth of the fetus,
MXT is used to terminate early pregnancies. Without the
normal metabolism of folic acid, the unborn child is
unable to develop, dies, and the mother’s body disposes
of the dead tissue. If used to terminate an ectopic
pregnancy, it is administered by injection, and
accompanied by routine monitoring to ensure that the
blood hCG level decreases, reflecting that the pregnancy
has been terminated and that the tissue in the fallopian
tube is dissolving.
The use of MXT as a treatment for ectopic pregnancy is
extremely troublesome from a Catholic moral perspective.
MXT is an abortifacient. The administration of MXT is
primarily for the purpose of terminating the pregnancy.
Thus, it would seem that the use of MXT to terminate the
pregnancy is in direct contradiction to the Church’s
teaching, namely that any direct abortion, which is
willed either as an end in itself or as a means to some
other end, even to save the life of the mother, is grave
matter for sin, and is contrary to the moral law, as
However, can the principle of double effect make the use
of MXT permissible in the case of an ectopic pregnancy?
In order for the principle of double effect to be valid,
the good effect must be produced directly by the action,
not by the bad effect. The use of MXT directly produces
the bad effect, the death of the unborn child, which in
turns causes the mother’s body to dispose of the
pathological tissue. Obviously this is a case of the
ends justifying the means, which is never allowed. MXT
circumscribes the pathology by terminating the
pregnancy. In the use of MXT, a direct chemical abortion
is willed as a means to an end, and such an action is,
indeed, contrary to the moral law. Double effect,
therefore, cannot be used as a justification for the use
of MXT because the bad effect, the destruction of the
fetus, the death of the unborn child, is directly
It has been argued that the use of MXT is simply a
chemical substitute for surgery. Instead of surgical
instruments, chemicals are used to the same effect. This
is not a sound argument, though, because the use of MXT
first seeks to destroy the life of the unborn child, and
then as a consequence of that action, the body disposes
of the pathological tissue. Surgery, on the other hand,
produces first the removal of the pathological tissue
containing the fetus, which in turn causes the
unintended death of the fetus. Also, because the
pathology has been circumscribed, rather than treated
directly, there is no guarantee that the pathology has
been completely removed or the medical condition that
caused the pathology repaired.
For example, the use of MXT does not treat a damaged
fallopian tube that may have been the cause of the
ectopic pregnancy. Because a damaged fallopian tube is
left untreated, another ectopic pregnancy could result.
In addition there is a risk that the body will not
dispose of the dead tissue, which can cause further
damage and even ruptures long after the administration
of the drug. If the tube has already ruptured, the
administration of MXT is useless, and is liable to cause
It should be highlighted that among all the medical
problems incumbent with the use of MXT, which makes it
not just immoral but impractical and even dangerous,
there is the risk of using MXT prematurely. Because of
the convenience of using MXT, and because of the
uncertainty in diagnosing ectopic pregnancies, MXT is
often used as a preventative rather than as a treatment,
and this behavior can have very severe moral and
physical consequences. The use of MXT in a
miss-diagnosed ectopic pregnancy can result in the
termination of a perfectly healthy pregnancy, or,
because MXT is a highly teratogenic drug, it can result
in severe birth defects if the baby should survive its
administration. MXT is a “cell toxic” drug, and can have
serious and broad adverse side effects for the mother.
All this indicates that the morally problematic nature
of using MXT as a treatment for ectopic pregnancy is
reflected in the physically problematic nature of MXT on
the mother and unborn child.
We can, conclude, therefore, that the use of MXT as a
treatment for ectopic pregnancy is not morally
permissible, and this is reflected in the physical
dangers incumbent in its use.
The Dangers of Reparative Surgery
The advance of medical science has further confused
moral reasoning in regard to reparative surgery of
damaged fallopian tubes. The most common form of
reparative surgery is the repairing of damaged fallopian
tubes in the course of treating an ectopic pregnancy (salpingostomy).
Another common reparative surgery is tubal ligation
reversal procedures. In both cases there are important
moral and practical aspects that need to be considered.
In the first case, many Catholic moralists in the past
have argued that a salpingostomy was immoral for two
reasons: (1) an ectopic pregnancy indicated a terminal
abnormality of the fallopian tube, that should,
therefore, be removed, and (2) the removal of the
fallopian tube was the only way to justify double effect
in the case of an ectopic pregnancy, as the tube,
considered the pathology, contained the unborn child.
We now know, however, that there are causes for ectopic
pregnancies other than damaged or defective fallopian
tubes. Furthermore, medical science has progressed to
such a point that reconstructive surgery can adequately
repair these same defects. Doctors do not act wrongly in
seeking to use their skills, knowledge and technology
(all of which are gifts from God) to restore to the
mother’s body a function that naturally occurs
Furthermore, double effect does not negate the
responsibility of the parties involved to mitigate to
the best of their ability the bad consequences incumbent
upon the moral action. If, for example, the doctor can
remove the pathological mass containing the fetus, and
is reasonably sure she can adequately repair the
fallopian tube, there is no moral imperative that the
fallopian tube be removed. Double effect does not
require that the doctor sterilize the mother, especially
since we know that it isn’t the fallopian tube that
contains the unborn child, but primarily a pathological
tissue mass, which happens to be inside the tube, that
contains the unborn child. In fact, it would seem to be
the more Catholic and “open-to-life” action that the
doctor does everything in her power to safeguard the
fertility of the mother, so that there might be future
children born to her.
However, seeking to repair the fallopian tube is not
unconditional. First, the tube may not be salvageable.
Secondly, even if the tube can be saved, if the mother
has suffered more than one ectopic pregnancy in the same
fallopian tube this may truly indicate that the
defective tube is beyond repair. In order to avoid
future ectopic pregnancies or other complications, the
tube should to be removed, if but for medical reasons
notwithstanding the moral implications. In any case, a
salpingostomy, the repairing and saving of a fallopian
tube in which an ectopic pregnancy has taken place,
should no longer be considered immoral, in and of
itself. It stands to reason that removing the fallopian
tube in which an ectopic pregnancy has taken place (a
salpingectomy) is not required to make double effect a
valid justification for the death of the unborn child.
A second reparative surgery that demands our
consideration is tubal ligation reversal procedures
sought out by women who have undergone tubal ligation
sterilizations. As a matter of course, tubal ligation
sterilization is contrary to the moral law, and gravely
sinful. However, it is such a common feature of modern
life that many women entering the Church or those who
are “re-verts” to the faith have had tubal ligations.
Sadly, this is often the case with women who come over
from mainstream Catholicism to traditional Catholicism.
Often enough, these women and their husbands bitterly
regret sterilizations and seek in one fashion or another
to have more children. As new medical advances emerge,
tubal ligation reversals are becoming less expensive,
and thus more commonly sought out as a fertility
procedure for these women. Often, in vitro fertilization
is offered by the medical establishment as a means for
sterilized women to have children. Obviously, in vitro
fertilization is morally unacceptable. Therefore, tubal
ligation reversal is definitely the better alternative,
but it is not without its problems.
Most troublesome is that tubal ligation reversal
significantly increases the chances of ectopic
pregnancy. Most women who have the procedure will
experience one or more ectopic pregnancies and the
likelihood of ectopic pregnancy only increases as time
passes after the reversal procedure (this latter point
is contested by some doctors in the field). Husbands and
wives who are considering tubal ligation reversal should
put this in the balance along with other possible risk
factors as part of their discernment process.
Pressure from medical professionals to act immorally is
common, especially in regards to the use of MXT. All
tubal ligation reversal clinics that I know of promote
early diagnosis of ectopic pregnancy and the use of MXT
as a treatment for suspected ectopic pregnancies. Unless
a couple is well versed in the uncertainties of early
diagnosis and the moral and physical dangers of MXT,
they may be persuaded by the nurses and doctors to act
in a manner contrary to their Catholic faith.
Because tubal ligation reversal significantly increases
the chance of having an ectopic pregnancy, and because
of the moral quicksand surrounding ectopic pregnancy,
pastors and spiritual directors should be hesitant to
promote the procedure, especially for those just
entering the Church. Even though sterilization is a
grave sin, and even though it is a decision that so many
couples come to regret, jumping into a tubal ligation
reversal procedure may turn out to cause even more
physical and spiritual damage. The woman and her husband
who are new to the Church may not be equipped to make
all the necessary moral considerations, and may be
pressured by pain, fear of death and the council of
medical professionals to make a moral decision they will
regret more than the initial sterilization.
It should be remembered that having a tubal ligation
reversal procedure is not necessary for obtaining God’s
forgiveness for the sin of self-sterilization, or for
entering the Catholic Church. Priests place an undue
burden on their flock, and expose them to unnecessary
physical and spiritual danger, if they in any way
suggest that this procedure is necessary as a penance
There are, of course, many beneficial effects of
reparative surgeries and tubal ligation reversal
procedures beyond simply being able to get pregnant.
Women have reported better emotional and physical
well-being after reparative surgery, not to mention the
reversal of most or all of the adverse effects of
sterilization (i.e. tooth decay, hair loss, weight gain,
sever pain or prolongation of menstrual periods, etc.).
Setting things aright, as God intended them to be, has
many positive effects, not to mention the very real
possibility of having perfectly normal and healthy
pregnancies. The decision to have a tubal ligation
reversal or other reparative surgery is an admirable and
courageous choice if weighed prudently. Husbands and
wives, and their pastors, in their efforts to be open to
life, should investigate all avenues, including the
possibility of adoption, and take seriously the moral
quicksand surrounding ectopic pregnancy before coming to
a decision about having a morally permissible reparative
Why Should My Child Die Do I Can Live?
For those trying to get pregnant, who are not just
passively open to life but actively seeking new life,
the emotional and spiritual trauma of an ectopic
pregnancy is absolutely devastating. Parents are given
an impossible choice, either Mom will live and the baby
will die, or both Mom and the baby will die. No matter
what, it’s a lose-lose proposition.
Inevitably, even if all the right moral decisions are
made, and even if the doctors and medical professionals
are as supportive of those decisions as possible, the
death of a mother’s unborn child will throw her headlong
into sorrow the likes of which could only be experienced
by a mother who has lost a child. Coupled with this
sorrow will be the knowledge that the child died as a
necessary consequence of actions taken to save the
mother’s life. As a result, Mom will experience guilt as
well as sorrow. She will ask the unanswerable question:
“Why should my child die so I can live?”
Dad, too, will feel at least a portion of Mom’s sorrow
and guilt, and it will be beyond his power, at least
immediately following the tragedy, to console her or
make the pain go away. He will feel hopeless and
inadequate as he attempts to deal both with his own
grief and guilt and that of his wife.
Like all tragedies in this “veil of tears”, there are no
easy answers for those attempting to recover from an
ectopic pregnancy. All the crosses of this life, the big
and the small, are invitations from Our Blessed Lord to
enter into the mystery of His Passion, to share in His
sufferings and death. God gives us a share in the Cross,
to each according to the measure of her character, so
that each of us may rejoice with Him in the glory of the
Resurrection. The best remedies are time, prayer, and
the understanding, the wisdom, that is gained thereby.
As a practical note to the OBGYNs and gynecologists:
please realize that not all your patients will have
happy endings to their pregnancies. Small gestures go a
long way in helping your patients (and their families)
to physically, emotionally and spiritually recover from
an ectopic pregnancy. For example, reserve at least one
examination room in your office that isn’t plastered
from floor to ceiling with pictures of happy mothers
holding their new-born babies, so you can have a room
wherein to perform follow-up examinations of women whose
pregnancies ended in tragedy. Also consider keeping
advertisements for artificial contraception devices out
of the sight of mothers grieving the loss of their
unborn child, or better yet, get rid of them altogether!
Promoting a love for life that is especially central to
the Catholic faith, is the healthiest long-term
treatment you can provide your patients.
Finally, for all involved, knowing that you did all you
could to preserve life, achieve the greatest good, and
remain obedient to the will of God will be a soothing
thought once you are able, after time and much prayer,
to reflect back on the experience of your ectopic
pregnancy. You can at least take some consolation in the
fact that you need not have any regrets pertaining to
your moral decisions during that time of personal
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FAQs, Morality: Does the Church approve of surgery for
an ectopic pregnancy?