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  April 2019  
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Direct and Indirect Abortion

The main point of directive 45 of the Ethical and Religious Directives for Catholic Health Care Services is the unequivocal truth that abortion is never morally right, and therefore no abortions are to be done in Catholic health care institutions. The directives add, significantly, that when speaking of the intentional termination of pregnancy, which is wrong, and not permitted in Catholic institutions, such pregnancy, “in its moral context, includes the interval between conception and implantation of the embryo.”

This means that the Directives do not accept the attempt of some to redefine the embryo at this stage as a “pre-embryo,” and so in effect locate conception later in the gestational process. Rather, at this stage of development, the human embryo must be treated as a human person.

The evidence clearly indicates that conception occurs with the fertilization of the ovum by the sperm, and so from that point on there is a distinct, human individual, containing within itself all of the organizational information needed to actively develop itself to the mature stage of a human being. The embryo, from fertilization on, is a distinct, complete, though immature, human being. Moreover, even if there were doubts, morally speaking, the choice to kill what may be a human person would be consenting to murder.

Given the seriousness of these considerations, the Directives instruct Catholic health care institutions never to materially cooperate with those who perform abortions. “In this context, Catholic health care institutions need to be concerned about the danger of scandal in any association with abortion providers.”

Direct vs. Indirect Actions

Directive 47 states that in some cases, although not all, procedures that result in the death of the unborn child as a side effect (my phrasing) are permissible. In other words: it is never right to directly kill the unborn child, or directly terminate the pregnancy, which happens in direct abortions. But it is sometimes right to perform an action which indirectly results in the unborn child’s death. Obviously, the key distinction is that between direct and indirect.

Let’s begin with a clear-cut example. Suppose during war some soldiers are sitting around a campfire when an enemy soldier tosses in their midst a live hand grenade. One of the soldiers thinks quickly, and jumps onto the grenade. His body blocks the exploding shrapnel. He saves the lives of his comrades, but he dies in doing so. Was he a suicide?

Was his act morally right?

This act illustrates the distinction between direct and indirect killing. Suicide is always morally wrong, and it cannot be justified by a good end—the end does not justify the means. But in this case the soldier did not commit suicide. His death was not a means chosen for the sake of a good end. Rather, his end was saving his comrades, and his means, what he chose to do, was to block the shrapnel with his body. His death, or his being killed, was neither an end nor a means. Rather, it was a side effect of what he did. He directly blocked the shrapnel, but he only indirectly killed himself.

Indirect Killing

What we directly do (or what we intend) is the end and the means. The end is what we desire because we view it as good in itself. The means is what we desire to bring about because we view it as attaining or helping to attain the end. The soldier’s death was not an end, since it was not desired for its own sake. Nor was it a means, since he did not view it as attaining or helping to attain his end, the saving of his comrades. His death was not the cause of his saving his comrades, instead it was his blocking the exploding the shrapnel—if miraculously he had lived, his act would still have succeeded.

Similar situations arise in regard to some procedures that result in a child’s death. For example, in an ectopic pregnancy, a condition which can threaten the mother’s life, it is permissible to cut the diseased section of the fallopian tube, with the child in it, and remove that section; the child dies as a consequence. This is permissible because it is not a direct attack on the child. Rather, what one does is remove a pathological section of the fallopian tube: the child’s death is not part of what one does, but is a side effect of what one does. Also, there is a proportionately grave reason to perform the operation, since otherwise the mother’s life is in danger and there is no possibility of saving the child, say, by waiting.

Likewise, if a woman has a seriously cancerous uterus, it is permissible to remove the uterus with the child inside, the child’s death being a side effect, and there being a proportionately grave reason (since, again, the child could not be saved by waiting). Of course, where there is a possibility of saving the child, then the question whether there is a proportionately grave reason is less easily answered.

Some Indirect Killing is Immoral

Another important point is made about direct abortions in #45. It defines “abortion” as: “the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus.” This phrasing covers both those cases in which the child is expelled before he or she could survive outside the womb and the same act after viability. Both are equally wrong. One could not reason, for example, that the early induction of labor or the use of an abortifacient drug prior to the time of viability is morally acceptable because one is only indirectly killing the child. Such indirect killing would still be direct abortion.

Suppose someone tires of taking care of his aging parents, drives them to an isolated forest and leaves them. Although one might argue that the parents’ death would not be directly intended, the act would be as murderous as if he had poisoned them. Similarly, deliberately expelling a nonviable child and causing his death with the intention of terminating pregnancy is as wrong as directly poisoning the child. So not only is abortion wrong when it is a direct killing, it also is wrong when what is directly intended is the termination of pregnancy before viability.

This type of case is quite different from the case in which a procedure has as its “direct purpose the cure of a proportionately serious pathological condition of a pregnant woman,” a procedure which directive 47 says is permissible. An example of this would be an extrauterine pregnancy (mentioned in #48) or the removal of a cancerous uterus of a pregnant woman.

In these cases the termination of the pregnancy is a side effect, not the direct object or reason for the operation. If the termination of pregnancy is the direct object of the act, that is, if terminating the pregnancy is the reason why one is performing the action that causes the child’s death, then there can never be a proportionately grave reason for the operation. However, if the object of the act is the cure of a proportionately serious pathological condition, which in this case would mean an imminently life-threatening condition for the mother and child, then the termination of the pregnancy and the child’s death are side effects, and there is a proportionately grave reason for causing the child’s death.

A Proportionately Grave Reason

An instructive case was reported in the Linacre Quarterly two years ago, of a physician who in 1915 successfully removed an embryo from a diseased fallopian tube and implanted the embryo in the uterus (C. J. Wallace, “Transplantations of Ectopic Pregnancy from Fallopian Tube to Cavity of Uterus,” 62 [February 1995] 67-69). Since the physician had just removed a fibroid from the uterus, it had a small lesion; he placed the embryo near this lesion and the embryo survived, was later born, and grew to adulthood. This case, it seems to me, incontrovertibly shows that the intention to treat a pathological condition is not the same as the intention to kill, nor the same as the intention to terminate the pregnancy.

Directive #47 says that procedures which cause the death of the unborn as a side effect are permitted only if “their direct purpose [is] the cure of a proportionately serious pathological condition” of the pregnant woman. For example, it would violate justice if one performed an action that caused someone’s death if the only reason for the action was to avoid discomfort, or even a slight risk of ill health.

In general we can say that if what one contemplates is an action that indirectly causes someone’s death, the action can be justified only if it is done to avoid a comparable harm. In the context of births, it would seem that only real and imminent threat of death would justify performing an action which indirectly causes the child’s death.

Significantly, directive 46 adds that Catholic health care providers, “should be ready to offer compassionate physical, psychological, moral and spiritual care to those persons who have suffered from the trauma of abortion.” Abortion is terrible, of course, partly because millions of innocent, defenseless lives are lost. But even worse, perhaps, is the various harms, and especially the moral harm, this does to those who with responsibility participate in these acts. Since as Catholics we are dedicated to the whole person, we must be ready to look to these deeper harms of abortion. Also, for moral maladies, we must try to bring others to the Divine Physician and bring Him to them.


Patrick Lee, Ph.D.
Professor of
Franciscan University
of Steubenville
Steubenville, Ohio