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Prusak BG. Double effect, all over again: the case of Sister Margaret McBride. Theor Med Bioeth. 2011; 32(4):271–283.

Physicians and health care professionals involved in the care of patients with pulmonary arterial hypertension (PAH) have the difficult task of recommending that their young female patients avoid becoming pregnant, because of the exceedingly high mortality.1 An even more difficult task is the pregnant patient with PAH. A conflict between the recommendation for a medical abortion and patients' beliefs can be quite complicated and uncomfortable. To make matters more awkward, health care professionals may face the same conflicts in their own beliefs.

In November 2009, the ethics committee of St. Joseph's Hospital in Phoenix, Arizona, permitted the abortion of an 11-week-old fetus in order to save the life of the mother who had been diagnosed with PAH. In the article cited above, Professor Bernard Prusak from the Center for Liberal Education of Villanova, PA, uses the much discussed Phoenix case as an occasion to scrutinize the principle of double effect.2

To review the Phoenix case, the pregnant woman was suffering from acute PAH, which her doctors judged would prove fatal for both her and her previable child.3 The doctors, accordingly, advised that she have an abortion; the mother eventually and reluctantly agreed (she was also the mother of 4 children at home). The hospital's ethics committee believed abortion to be permitted in this case under the so-called principle of double effect. Thomas J. Olmsted, the bishop of Phoenix, disagreed with the committee and pronounced its chair, Sister Margaret McBride an excommunicated latae sententiae, “by the very commission of the act.” Under the principles of Catholic moral thought, the bishop argued that “while medical professionals should certainly try to save a pregnant mother's life, the means by which they do it can never be by directly killing her unborn child.... The direct killing of an unborn child is always immoral, no matter the circumstances, and it cannot be permitted in any institution that claims to be authentically Catholic.”4

The principle of double effect used by the ethics committee to guide their determination identifies 4 conditions that must be satisfied for an action that has 2 effects, one of which is evil while the other is good, to be morally permissible:

1. That the action in itself be good or at least indifferent

2. That the good effect and not the evil effect be intended

3. That the good effect not be produced by means of the evil effect

4. That there be a proportionately grave reason for permitting the evil effect

In this article, the author examines the third condition of the principle in its textbook formulation, and argues that the textbook formulation of the principle does not withstand philosophical scrutiny.

To demonstrate the argument, the Phoenix case is presented in a different approach, similar to the instance in which surgery to remove a cancerous but gravid uterus5–6 is viewed such that the death of the fetus is not “directly intended”; instead, what is directly intended is the cure of a proportionately serious pathological condition. If the Phoenix case is presented as if the pathological organ is the placenta, which “produces the hormones necessary to increase the blood volume in pregnant women,” then removal of the placenta itself would be acceptable, “even though the procedure would indirectly result in the loss of the pregnancy.”7 Therefore, the death of the fetus would not serve as the means to saving the life of the woman, but removing the placenta would do so and the procedure would be permitted and the case would fall clearly under the principle that evil is not to be done that good may come.8

The article details the moral concepts that determine that the act of abortion is necessary to save the life of the mother, trying at the same time to reconcile Catholic principles. Although the article is addressed to ethicists and philosophers more so than physicians, it touches on a crucially important aspect of our practice. Our role in guiding our patients to avoid pregnancy, and occasionally making “life and death” decisions when a PAH patient becomes pregnant and a medical abortion is warranted is an extremely complex and difficult one. In fact, the idea that there are several values that may be equally correct and fundamental and yet in conflict with each other, the very basis of moral pluralism, is a valid one. We can only hope that in times of difficult decisions, we health care professionals will have the wisdom, humbleness, and strength to deliver the best advice for our patients.