Methotrexate Direct Killing and Mutilation of the Unborn Child - Thesis Example

Methotrexate – Direct Killing and Mutilation of the Unborn Child Introduction Medical science has introduced various medical and pharmacological advancements which have been used by various health professionals to treat and manage different patient afflictions. These advancements have mostly been meant as life-saving interventions, treating different afflictions and prolonging people’s lives. Methotrexate is one of these drugs. This drug is an antimetabolite drug which controls the building of new cells and therefore used in the treatment of cancer, autoimmune diseases, and ectopic pregnancies. Unfortunately, it is also used to induce abortions. The same properties of the drug which are meant to stop cancer also prevent the growth of cells for fetuses, thereby leading to abortions. This paper shall discuss the thesis that: utilizing the cytotoxic drug Methotrexate to resolve an ectopic pregnancy is not a morally permissible option. This argumentative essay shall provide arguments in favor of the fact that using methotrexate to manage ectopic pregnancies is unethical because it is a drug which directly attacks the unborn child, ultimately killing it. Moreover, killing the killing of the unborn child is a direct and intrinsic effect of the drug, and for which reason, its use in resolving ectopic pregnancies must be prevented. This essay shall explore this debate, particularly focusing on the argument that the use of methotrexate for ectopic pregnancies is immoral and against the Catholic teachings and against ethical norms. Body Overview Ectopic pregnancies are serious health concerns. In these pregnancies, the embryo does not implant in the uterus, instead it implants in other areas which cannot safely and successfully sustain it. In these instances, it may implant in the fallopian tube, cervix, ovaries, and in some extremely rare cases, in the abdomen1. These pregnancies are life-threatening for both the mother and the fetus2. In the United States, ectopic pregnancies are considered one of the leading causes of maternal morbidity and deaths3. Moreover, most ectopic pregnancies occur in the fallopian tube, however, these pregnancies have a very low survival rate for the unborn child. Since fallopian tube ectopic pregnancies are the most common, they shall be the main focus for this essay. The primary remedies for ectopic pregnancies include salpingectomy, salphingostomy, and the use of the drug methotrexate4. The first two remedies are invasive surgeries which either remove or cut open the fallopian tube. The third intervention is a drug intervention5. As was mentioned above, this essay shall contend that using methotrexate is unethical. An initial description on pregnancies shall be discussed first, followed by an explanation of the mechanisms and uses of methotrexate. Third, a moral evaluation indicating the unethical use of methotrexate will be presented. Normal pregnancies versus Ectopic pregnancies In normal pregnancies, the fertilization of the fetus usually occurs in the fallopian tube. Three days from its fertilization, the egg then travels down the fallopian tube and implants in the uterus6. During implantation, the egg has now matured to a blastocyst7. During its development, the fertilized egg continues to divide and replicate as well as develop essential layers. When it is fully developed, the placenta provides a link between the mother and the fetus. The placenta is very much critical to the survival of the fetus as it ensures hormone production, immune protection, as well as blood flow8. The fetus continues to grow until it fully acquires and develop its inherent genetic properties. In instances of tubal ectopic pregnancies, the embryo of fertilized egg implants in the fallopian tube. This is a major problem because the fallopian tubes are very much narrow and cannot support the pregnancy. If allowed to continue, the tubes may be severed and cause internal bleeding for the mother9. There are various risk factors for this medical issue, including chronic pelvic inflammatory disease, history of ectopic pregnancy, using progestin contraceptives, having multiple sex partners, and tubal anomalies in the mother10. Damage in the structure or functions of the fallopian tubes have also been used to explain tubal implantations11. The pattern in the embryo’s development is usually very much consistent, however, in instances of damage to the tubes, implantation can take longer. In these cases, the development of the embryo is usually faster, but acquires no appropriate environmental changes. In the end, the embryo may implant even without reaching the uterus12. The causes of ectopic pregnancies have not been fully established; but various theories on chromosomal abnormalities on the embryo have also been considered one of its probably causes, however, limited studies have been carried out exploring such cause13. For the moment, the previously mentioned risk factors are being supported by experts on the subject matter. Methotrexate Methotrexate is a drug which is administered in order to treat health issues like cancer and psoriasis. Its action primarily is on slowing down the regeneration of cells, stopping cancer cells from replicating or skin cells from growing14. Since this drug impacts on cell growth and development, it is also used to manage ectopic pregnancies. There are various discussions on how methotrexate specifically resolves these pregnancies. Experts nevertheless agree that it impacts on all rapidly developing cells in the body15. For which reason, certain conditions among women make them ineligible for this treatment. Experts also agree that this drug causes the resorption of the cells and/or the abortion of the fertilized egg16. Methotrexate is not only used for ectopic pregnancies, it is also used to induce intrauterine pregnancies. Abortions induced via methotrexate usually inhibit new cells from replicating, thereby stopping the embryo from forming into a new being17. This process eventually leads to the embryo’s termination. After a few days of intake of methotrexate, bleeding akin to miscarriages occur signaling the expulsion of the embryo18. Abortion providers admit that when combined with misoprostol, a drug which induces contractions, methotrexate can be toxic to the trophoblast and successfully causes abortion19. This drug is also considered a folic acid antagonist as it acts against folic acid functions in producing the body’s new cells20. It has also been known to prevent DNA synthesis and has been used in managing gestational trophoblastic disease21. Due to these function, methotrexate has been used to resolve ectopic pregnancies and other unwanted intrauterine pregnancies22. In a study by DeLoia, et.al, the authors concluded that methotrexate stops the normal development of the trophoblast and also decreases lymphocyte development in the decidua23. Evidence of the drug’s impact on the trophoblast has been seen especially in instances when it has been administered in unsuccessful salpingostomies. In failed salpingostomies, more often than not, not all of the trophoblasts have been removed and therefore have been allowed to grow. In these cases, methotrexate has often been administered in order to counteract such effect24. Studies have also indicated that in instances where methotrexate has been given to pregnancies with embryonic heartbeat, methotrexate was usually not as effective25. High levels of HCG and progesterone have also led to failures in methotrexate use26. Moral Analysis The issue of ectopic pregnancy can be assessed in the following manner: The embryo is naturally doing what it is expected by its inherent nature to do, and that is, its implantation; however, it is doing it in a place where it should not be implanting (fallopian tube, ovaries, cervix, etc)27. If there is no medical remedy, the mother and/or the infant may die. However, if something is done, the available medical options allow the mother to be saved, and the infant to die. The issue lies on the question which considers whether or not it is ethical or moral to remedy a contentious situation. An action is considered ethical if the action is not evil, most importantly when a person does not do evil in order to bring about the good deed28. Methotrexate is an unethical option in remedying ectopic pregnancies because it ends the life of an innocent being; moreover, it does not fulfill the elements of the Principle of Double Effect. Direct act of killing According to the Catechism of the Catholic Church, the killing of innocent beings is seriously condemnable29. All human life is valuable and sacred from its very inception as it is borne out of the act of God and it is forever bound in a special link with God until its very last breath. God is the source of life and He governs over life from its beginnings to its ends. No being can therefore ever morally claim to directly destroy any innocent being30. John Paul II also relates in the Evangelium Vitae that abortion is to be considered a deplorable practice and that it is an act which involves the deliberate and direct killing of a human being31. Regardless of the means utilized in the killing, the act is still to be considered a deplorable practice. Based on God’s authority therefore, Pope Paul II declared that direct abortion is a grave and moral disturbance. The act of administering methotrexate indicates an intentional and deliberate act of killing. It is usually given to a woman via an intramuscular injection or through oral intake32. It is introduced directly into her body not as a means of treating any illness, but with the purpose of getting into growing infant’s body. In some unfortunate cases, the drug has also been administered directly into the fetus33. It may be claimed that even as it is unethical to administer the drug into the embryo, giving it orally or intramuscularly may not be considered unethical because in this instance, the drug would target the trophoblast, thereby causing the infant’s death34. There is however no evidence that methotrexate differentiates between trophoblast and the mother’s body. In actuality, it covers all rapidly growing cells in the body – both the infant’s and the mother’s. Outside this consideration, the trophoblast is the main system for the child which is outside the embryo. Trophoblasts are crucial in the success of pregnancies and they keep the fetus supplied with the essential nutrients for its growth35. In effect, even with methotrexate targeting only a part of the body, its use is still immoral. An embryo may survive without some of its parts, like a foot or an ear, however, it cannot survive without the trophoblast. Destroying and attacking the trophoblast is akin to mortally wounding a person. Methotrexate eliminates the tissues in the trophoblast and in the process, directly kills the infant. Since the growth of the trophoblast will usually lead to serious issues with the fallopian tubes, the question on whether or not administering methotrexate can be seen as a woman defending herself against an aggressor may be forwarded36. It may be possible to argue that methotrexate acts to defend the life of the mother, not to kill the unborn child. However, the valid right to self-defense cannot be used as an exception to the murder of innocent human beings, even those which may need killing37. Self-defense can produce a double effect: preserving the life of the mother and killing the aggressor. In these instances, one is intentional and the other is not38. In order for the defense to apply, the infant needs to be seen as an aggressive being. However, the unborn child is not an aggressor, it is an innocent being. Based on its level of development, the unborn child cannot yet choose between right and wrong, harm or benefit. Under these circumstances, they are very much innocent. It may be argued that the unborn child may not knowingly choose to be an aggressor, and yet his actions may still be deemed aggressive39. In other words, the fetus is merely doing what it is supposed to be doing. It is growing and developing and implanting itself as it is meant to be doing. The abnormal part of its development is its site of implantation. Its site of implantation cannot be blamed on the child. Issues with tubal function and other structural abnormalities cause ectopic pregnancies. In fact, there is nothing wrong with the development of the infant, but there is something wrong with the mother’s body40. Even without adequate information on the cause of ectopic pregnancies, it is possible to reason that as women do not directly cause the ectopic pregnancy, neither does the fetus. Pope John Paul II did not support the argument that the child is an aggressor41. He argued that the unborn child is at the beginning of his life and is more innocent than can be imagines. There is therefore no way that the unborn infant can be classified as the aggressor. The infant is weak and defenseless and cannot even express his feelings except by crying. The child is also under the protection of the woman carrying the child42. The fact that the unborn child is in the fallopian tube does not diminish its value and its innocence; and it does not change the responsibility of the mother to protect such child43. However, the mother also has the duty and right to protect her right to life. In instances where conflicts in these duties conflict with each other, the actions of the person must be based on argument that it is better to suffer the evil than to act in an evil manner44. Suffering or doing evil is a moral dilemma and principle which can be demonstrated in the following instance: A woman and his child have been taken hostage and the hostage-taker orders the woman to kill her child else be killed herself45. It would be wrong for the mother to kill her child, even as it would likely save her life. Even if the end goal of preserving her life is important, such goal cannot be gained by carrying out an evil task – killing her own child. Even if the woman had other children, it still would not justify her saving her own life by killing her child46. Killing her child would make her responsible for her child’s death and if the guard would kill her child, the hostage-taker would be responsible for the killing. In the first case, the mother does the evil act, and in the second case, the mother suffers the evil act. It would however, not also be prudent for the mother not to respond at all47. Even if a person does no evil, it does not mean that she should not do anything at all. As the guard would now kill her and her child, she must do whatever is necessary to stop the attack. In these instances, her actions are actions for good, not for evil. The above situation can be associated with ectopic pregnancies. An aggressor may be absent, but the situation nevertheless demonstrates how two beings are in a life-threatening scenario. The unborn child may not be killed to save the mother, just as the above case demonstrates that the child must not be killed to save the life of the mother48. However, just because it is an evil act to give methotrexate, does not imply the lack of more ethically viable options. Removing the fallopian tube via salpingectomy is the better and more ethical option. First, the tube itself may have other issues or other problems which would require its removal to begin with49. It is therefore reasonable to remove the malfunctioning organ. Secondly, if one part of the body is not functioning properly, it may be essential to remove the entire organ. This has been the logic adopted for various surgeries being undertaken by medical professionals. Malfunctioning kidneys, gangrenous legs, failing livers, have been routinely removed and in some instances replaced because of the harm they are bringing to the rest of the body. In these surgeries, survival rate is usually high. Women can still survive and can still have babies in the future even with only one functioning fallopian tube50. Based on the principle of integrity, a part of the body may be sacrificed if it would mean saving the rest of the body51. This principle indicates how directly attacking the developing trophoblast is very much different from removing the fallopian tube. While methotrexate attacks the trophoblast, it results to the death of the fetus. Such act is tantamount to direct killing52. It is also immoral to directly kill the infant to save the mother. However, removing the tube is tantamount to sacrificing a portion of a woman’s body in order to support the existence of the woman53. The death of the embryo following the removal of the fallopian tube is an effect of a good action. It is equivalent to evil which is suffered, not evil which is done or inflicted on other beings. The principle of double effect can help further explain this situation54. Principle of Double Effect At the very core of this principle is the argument that a person may never commit evil, no matter how her intentions may be good. If a noble goal is enough to justify an evil deed, then drawing the ethical line is vague at best; and the standards by which they would be drawn would also be undetermined55. People can easily justify their wrong actions by arguing that they could prove how good can arise from the actions56. To choose a wrong action is to act against God’s teachings. Sin is a destructive act and Jesus Christ sacrificed his life in order to save man from the consequences of their sins. Sin must not therefore be used or chosen for its own end or as a means to achieve an end goal. The Principle of Double Effect acknowledges that when people carry out good deeds, there are negative and positive consequences57. A good end goal does not justify a bad means or a bad method; moreover a bad end does not make a good method or means bad. Individuals must therefore be analytical of their behavior, especially those which have good and bad effects58. The principle argues that various conditions must be present when opting for a good behavior which has positive and negative elements. First, the action itself must be a good or an indifferent action59. In other words, the action must not inherently be evil or the goal of the action must be one which is based on God’s teachings for one’s own good or for the good of others. Secondly, the good impact must not be founded on the bad impact60. The expected benefits must therefore not be gained through expected harmful impact. Thirdly, there must a balance between the good and the bad elements, meaning the expected benefits must be equivalent to or even greater than the harmful impacts61. Fourth, the goal of the subject must be geared towards the good, and on tolerating the bad. In effect, the direct impact must be on ensuring the benefits and avoiding harm. The harm, in other words, must only be indirectly expected. Lastly, there must be no other choice or option in achieving the desired good benefits62. In applying the above considerations to the use of methotrexate against salpingectomy, it is clear to see that methotrexate is very much unethical and immoral. First and foremost, methotrexate is directly meant to terminate the growing fetus63. The primary and immediate impact of methotrexate is on the unborn child, with the primary goal of ending the pregnancy. Under these considerations therefore, it is intrinsically evil. On the other hand, salpingectomy seeks to target the fallopian tube. Methotrexate attacks an essential part of the infant in order to save the woman; salpingectomy on the other hand, only targets a non-essential body part of the woman in order to save the woman’s life. The second argument under this principle is based on the contention that the favorable end goal – mother not dying – can be gained directly from the bad act of killing the child. But for salpingectomy, the mother’s survival is based on the removal of the tube, not the killing of the child64. The mother is saved because a portion of her anatomy, which is in danger of killing her anyway, was removed. In salpingectomy, the child’s death is the effect, but for methotrexate, it is the means for the infant’s death65. In instances where it would become difficult to save the infant, methotrexate does not leave the medical experts a chance to save the child using medical advancements like resuscitation or reimplantation66. In salpingectomy however, it may be possible to move the infant to a safe place and it may also be possible to apply life-saving procedures for such infant. For salpingectomy, there is a balance between the good and the bad effect. Under methotrexate use, there is a significant difference between the good and the bad effect because the infant’s death is not caused by a good act, but instead, it is caused by a very negative and evil act67. In both methotrexate and salpingectomy, the health professional implementing the act may declare his goal which is towards achieving the “good” – mother’s survival – and losing the infant along the way may just be a tolerated after effect; methotrexate clearly negates such good end goal68. In considering the three elements of morality, which includes object, circumstances, and end, it is clear that methotrexate use is very much unethical, and salpingectomy is moral. In instances where any of these sources of morality are deemed bad, then the act would also be bad. In other words, for an action to be considered good, all three elements must be good69. For salpingectomy, taking out a vital organ (object), when its continued growth is a danger to the woman’s life, (circumstances) in order to save her life (end), is a good end goal. In methotrexate, targeting a major organ (trophoblast) of an innocent child (object), when the fallopian tube is endangering the woman’s life, (circumstances) to ensure her survival, is not ethical because the act involves the killing of the unborn child70. Other individuals may argue that methotrexate may support the Principle of Double Effect. Treatments and interventions which have the direct goal of managing serious conditions in a pregnant woman are allowed when they cannot be safely set aside until the child reaches a viable age, even in instances where the death of the infant may come about71. The direct goal of methotrexate is not on curing a pathological affliction in the pregnant woman; it is on targeting the trophoblast. Taken from another context, in chemotherapy treatments during pregnancy, if the pregnant woman could die from cancer, it is immoral for her to undergo cancer treatments as the treatments would lead to her infant’s death72. In these instances, cancer is a very serious condition for a pregnant woman and the cancer treatment is given to address the cancer cells in order to save the woman’s body. Since the unborn infant is in the woman’s body, the death is the effect of a good deed. However, the woman would not be saved with her child’s death73. Although methotrexate is considered a treatment option for cancer, it is not given to treat a woman’s affliction. In targeting the unborn child, methotrexate is given to the woman to inflict harm on the child—not to inflict harm on something which is inherently harmful to the woman’s or the child’s body74. In other words, the drug is administered to save the woman through the child’s death. Conclusion Methotrexate specifically focuses on the vital organ of the unborn infant, and in most cases, the infant’s whole body as well. It is therefore considered a direct act of killing, one which is an immoral, unethical, and evil act; as such it is against the teachings of Catholic Catechism. It is important to point out that this argument may not be easily accepted because negating the use of methotrexate also implies lost benefits. And its benefits are indeed significant. For one, it is not as invasive as the other options, and the patient can easily be managed on an outpatient basis. Moreover, since the fallopian tube is not removed or cut open, the woman’s remains fertile and can still have other children. However, the ends do not justify the means, especially if the ends are not good. The issue in evaluating actions must focus on not what would bring the most benefit, but on what is right. Methotrexate cannot be administered to all women, however, it is often used to resolve ectopic pregnancies. This means that pregnant women should not use methotrexate in order to resolve ectopic pregnancies; it also implies that health professionals must not take part in administering the drug. This is a very difficult position to maintain. However, it also gives a standard and ethical directive to these professionals. In the current context where various medical technologies are being introduced into the health care system, new options and alternatives can be opportunities in advancing human culture, or these can also produce options which are not in keeping with the true worth of human beings. With science and technology, man can still understand God’s work and plans, and with technology, preserving and perfecting God’s goals can be made possible. References Michael S. Baggish and Mickey M. Karram, Atlas of Pelvic Anatomy and Gynecologic Surgery, 2nd ed. (Philadelphia: Elsevier Saunders, 2006): Ch. 21. Lillian Sholtis Brunner, et.al., Brunner and Suddarths Textbook of Medical-Surgical Nursing (Philadelphia: Lippincott Williams & Wilkins), 1432. Charles R. B. Beckmann et al., Obstetrics and Gynecology, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2006), 161. Jean Bouyer et al., “Risk Factors for Ectopic Pregnancy: A Comprehensive Analysis Based on a Large Case-Control, Population-based Study in France,” American Journal of Epidemiology 157.3 (2003): 190, 192. Catechism of the Catholic Church: Modifications from the Editio Typica, trans. United States Catholic Conference, Inc. (New York: Doubleday, 1997), 1789. Centers for Disease Control and Prevention, “Facts about Folic Acid,” (March 31, 2009), http://www.cdc.gov/ncbddd/folicacid/about.html (accessed July 9, 2009). Diego O. Cuevas, “Hysterectomy with Coerced Abortion: A Case Study in Psychological Coercion,” Ethics & Medics 33.6 (June 2008): 4. Julie A. DeLoia, Ann M.Stewart-Akers, and Mitchell D.Creinin, “Effects of Methotrexate on Trophoblast Proliferation and Local Immune Responses,” Human Reproduction 13.4 (1998): 1063. Keith Edmonds, ed., Dewhurst’s Textbook of Obstetrics and Gynaecology, 7th ed. (Massachusetts: Blackwell Publishing, 2007), 107. Feminist Women’s Health Center, “Methotrexate (MTX) for Early Abortion,” http://www.fwhc.org/abortion/mtxinfo.htm (accessed July 8, 2009). Furton, Edward, The Direct Killing of an Innocent. Ethics and Medics 35.10 (October 2010): 2 Gray, Stephanie. “Why Methotrexate is an Immoral Response to Ectopic Pregnancy”. National Catholic Bioethics Center, (accessed June 20, 2010). John Paul II, Evangelium Vitae: On the Value and Inviolability of Human Life (Washington, DC: U.S. Conference of Catholic Bishops, 1995), 62. Gary H. Lipscomb et al., “Predictors of Success of Methotrexate Treatment in Women With Tubal Ectopic Pregnancies,” The New England Journal of Medicine 341.26 (December 23, 1999): 1974. William E. May, Catholic Bioethics and the Gift of Human Life, 2nd ed. (Indiana: Our Sunday Visitor Publishing, 2008), 52. Keith L. Moore, T.V.N. Persaud, and Kohei Shiota, Color Atlas of Clinical Embryology, 2nd ed. (Philadelphia: W.B. Saunders Company, 2000), 5. Liberato V. Mukul and Stephanie B. Teal, “Current Management of Ectopic Pregnancy,” Obstetrics and Gynecology Clinics 34.3 (September 2007). National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 4th ed. (Washington, CD: U.S. Catholic Conference, Inc., 2001), n. 29. National Catholic Bioethics Center, “Principles of Medical Ethics,” National Certification Program in Health Care Ethics Module 2-1 (September 2008): 1. John A. Rock and Howard W. Jones, Te Linde’s Operative Gynecology, 10th ed. (Philadelphia: Lippincott Williams & Wilkins), 798. Jacque L. Slaughter and David A. Grimes, “Methotrexate Therapy: Nonsurgical Management of Ectopic Pregnancy,” West J. Med 162.3 (March 1995): 226. The Ethics of Treating Ectopic Pregnancy,” in Catholic Health Care Ethics: A Manual for Ethics Committees, ed. Peter J. Cataldo and Albert S. Moraczewski (Massachusetts: The National Catholic Bioethics Center, 2002), 10B/4. Ellen R. Wiebe, “Abortion Induced with Methotrexate and Misoprostol,” Canadian Medical Association Journal 154.2 (January 15, 1996): 166. United States Conference of Catholic Bishops, “Ethical and Religious Directives for Catholic Health Care Services” (November 17, 2009) (accessed June 20, 2012): 22 Read More