{"id":2200,"date":"2012-12-05T21:20:08","date_gmt":"2012-12-05T20:20:08","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=2200"},"modified":"2012-12-05T21:20:58","modified_gmt":"2012-12-05T20:20:58","slug":"double-effect-in-the-halappanavar-case","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2012\/12\/05\/double-effect-in-the-halappanavar-case\/","title":{"rendered":"Double Effect in the Halappanavar Case"},"content":{"rendered":"

In the wake of\u00a0Savita Halappanavar\u2019s death, a statement was issued by the Irish Catholic Bishops’ Conference. \u00a0The whole thing is available here<\/span><\/a><\/span><\/span>. \u00a0However, I think that a couple of paragraphs is particularly worth picking out:<\/p>\n

Where a seriously ill pregnant woman needs medical treatment which may put the life of her baby at risk, such treatments are ethically permissible provided every effort has been made to save the life of both the mother and her baby.<\/p>\n

Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby. Current law and medical guidelines in Ireland allow nurses and doctors in Irish hospitals to apply this vital distinction in practice while upholding the equal right to life of both a mother and her unborn baby.<\/p><\/blockquote>\n

I think that the first of these paragraphs is pretty unexceptionable, and describes something approaching the default setting for medical interventions anyway.\u00a0 We might want to talk about “reasonable efforts” rather than “every effort”, since the latter does perhaps tend towards the onerous; but the general gist seems OK to me – almost trivially so.<\/p>\n

Note, though, how a great deal rides on a distinction between different kinds of pregnancy-terminating procedure (PTP, from now on). \u00a0Notably, there’s a line drawn around abortion as a particular form of PTP.\u00a0 The statement admits that certain PTPs may be permissible: what matters is that there should be no intention to kill. \u00a0Thus certain PTPs may be permissible notwithstanding foetal death if that death is not intended.\u00a0\u00a0I take this to mean that, should the foetus survive, permissible PTPs would be those in which\u00a0there is no sense that the procedure had gone wrong.\u00a0 Abortion would be the kind of\u00a0PTP that is impermissible, precisely because the intention is to kill.\u00a0 (At the extreme, successful delivery is a kind of PTP, too, since it does end the pregnancy – it’s just that it’s the kind of PTP that we celebrate, rather than tolerate.)<\/p>\n

Fairly clearly, the Bishops’ statement relies on some form of the Doctrine of Double Effect: the idea that there’s a moral difference to be had between intending some outcome, and foreseeing it.\u00a0 If the Doctrine holds water, it would provide a way to say that acting in order to shorten a life may have one moral value or require one moral argument, but acting despite a foreseen shortening may have or require another.<\/p>\n

Now: put that slightly to one side, but keep it simmering while we look at something else.<\/p>\n

A couple of moths ago, the world was presented by something called the\u00a0\u201cDublin Declaration\u201d on maternal healthcare, which\u00a0states that<\/span><\/a><\/span><\/span><\/p>\n

[a]s experienced practitioners and researchers in Obstetrics and Gynaecology, we affirm that direct abortion is not medically necessary to save the life of a woman.\u00a0 We uphold that there is a fundamental difference between abortion, and necessary medical treatments that are carried out to save the life of the mother, even if such treatment results in the loss of life of her unborn child<\/strong>. We confirm that the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women. [emphasis mine \u2013 IB]<\/p><\/blockquote>\n

Once again, this statement seems to ride on there being a distinction between abortions and other kinds of PTP.\u00a0 Reading the Declaration in its own terms, it seems to me not so much to be predicting that abortion will never be necessary, as defining abortion as not medically necessary. \u00a0This then opens the way to saying that it’s impermissible, and maintaining that prohibiting it will – by stipulation – not make any difference to medical care. \u00a0Again, other PTPs may be permissible.\u00a0 Again, we’re dealing with the DDE.<\/p>\n

Sorcha’s post<\/span><\/a><\/span><\/span> on the Halappanavar case mentioned the DDE, too; but\u00a0her treatment of it is the one respect in which I take issue with her.\u00a0 She\u00a0writes that the DDE<\/p>\n

would only make sense if you wanted to justify abortion under certain circumstances (i.e. where it is an unintended but necessary consequence of some other morally good or morally neutral outcome). Reframing such an abortion as \u201cmedically necessary treatment that also destroys the foetus\u201d undermines the need for the DDE at all.<\/p><\/blockquote>\n

I don’t agree. \u00a0Partly this is because, at least in the context of these statements, causing but not intending the death of the foetus would not count as abortion, and so the debate would have been shut down before it’s begun.\u00a0 But let’s put that terminological point aside.\u00a0 What’s important to keep in mind is that the DDE isn’t something that one would invoke in order to<\/em> justify abortion (or any act) anyway; it’s something to which one subscribes rather than something that one invokes, and makes justification possible. \u00a0It provides a lens through which to read the world. \u00a0As such, it isn’t a method of justification. \u00a0Reframing a procedure that ends the life of the foetus in a case like this doesn’t undermine the need for the DDE; this is partly because the doctrine isn’t a response to a need (which would be question-begging, and would leave it guilty of Mackie’s charge that it “purifies the intent”), and partly \u2013 and, I think, more importantly \u2013 because such framing is possible precisely because<\/em> of the DDE.<\/p>\n

More importantly for my purposes here, the DDE won’t tell us that action A<\/em> is permissible and B<\/em> not; all it does is say that the arguments that apply to one don’t apply – or don’t apply straightforwardly – to the other.\u00a0 Both, whatever A<\/em>\u00a0and B<\/em>\u00a0are, might turn out to be OK; both might turn out to be wrong.<\/p>\n

The point is this: even if you don’t agree with the definition of abortion offered by the Bishops or the Declaration, it does play a role in what I take to be a formally valid argument.\u00a0 Even if you think abortion is permissible, the argument seems to me still to be formally valid.\u00a0 You might think that it reaches the wrong conclusion because the word “abortion” is misused, or because of a misattribution of value to the embryo\u00a0– but that speaks to the soundness of the conclusion of the argument about what is and isn’t permissible, not its validity.\u00a0 (For the non-philosophers, think of this analogy: if you put the wrong variables into an algebraic\u00a0equation, you’ll end up with a misleading answer.\u00a0 But the calculation that got you there could be perfectly accurate.)<\/p>\n

This is a roundabout way of saying this: disputes about the permissibility of deliberately killing a foetus don’t have to have any direct impact on situations like this.\u00a0 If you think that the DDE is bunk but that killing\u00a0a foetus is permissible, there ought to have been no problem with ending Halappanavar’s pregnancy.\u00a0 If you think the DDE is sound but that killing a foetus is permissible, there would have been no problem (though you probably wouldn’t feel that the DDE had any relevance).\u00a0 If you think the DDE sound and that killing the foetus is impermissible, you could quite coherently deny that there’s a problem with ending the pregnancy even at the cost of the foetus’ life.\u00a0\u00a0Ending Halappanavar’s pregnancy – and so saving her life – would have been impermissible only if<\/em> you think both that killing the foetus is wrong, and<\/em> that the DDE is unsound.<\/p>\n

In other words, you’d have to be considerably more restrictive than even the Catholic Church.<\/p>\n

OK so far?\u00a0 Right.\u00a0 Moving on…<\/p>\n

Let’s go back to the Bishops’ Conference statement.\u00a0 Jen Gunter isn’t happy with it<\/span><\/a><\/span><\/span>.<\/p>\n

I spent quite sometime trying to understand how one could possibly translate this statement into medical care. I\u2019ve been a doctor for 22 years and an OB\/GYN for 17 years and I admit that I am at a bit of a loss. My three interpretations are as follows.<\/p>\n