PHYSICIAN OR MORALIST?...

In a world where good and evil are intertwined, it's vital not to confuse the evil that is chosen with the evil that is suffered.

 

In one case, evil is willed as a means or an end: it makes the will itself evil [1]. In the other, evil is merely a harmful but unavoidable consequence: it can be tolerated under certain conditions[2].

Elaborated by moralists, the distinction between direct voluntariness (what is willed) and indirect voluntariness (what is tolerated) has been fully accepted by the Church's magisterium[3]. However, even eminent theologians sometimes lose sight of this distinction, at the risk of undermining the whole moral edifice[4].

 

A first debate between physician and moralist

On December 31, 1930, Pius XI published an encyclical “on Christian marriage considered from the point of view of the present condition, necessities, errors and vices of the family and society”. In it, the Pope criticizes, among other things, direct attacks on the life of the mother or child:

“It is necessary [...] to mention another extremely serious crime by which the life of a child still hidden in its mother's womb is attacked. Some want this to be permitted, and left to the good pleasure of the mother or father; others recognize that it is illicit, unless there are exceptionally serious causes to which they give the name of medical, social or eugenic indication. [...]

“As for “medical or therapeutic indication”, to use their language, we have already said [...] how much we feel pity for the mother whose natural duty exposes her to grave perils for her health, even for her life: but what cause could ever suffice to excuse in any way the direct murder of an innocent? For that is what is at stake here. Whether death is given to the mother, or whether it is given to the child, we are going against God's precept and against the voice of nature: “Thou shalt not kill!” The life of both is equally sacred; no one, not even the public authorities, can ever have the right to attack it[5].”

A few weeks later, L'Osservatore Romano opened its columns to Professor Ernesto Pestalozza, director of the obstetrico-gynecological clinic at the Royal University of Rome[6]. While criticizing abortion carried out for eugenic or social reasons, he suggests that so-called therapeutic abortion - that is, abortion to save the mother's life - is morally licit and does not contravene papal teaching.

Agostino Gemelli ofm published a corrective article in the same periodical[7]. Reproaching the practitioner for failing to distinguish between direct and indirect abortion, the founder and chancellor of the Catholic University of the Sacred Heart of Milan reminds us of the conditions to be observed for a double-effect action: “When from an action, indifferent or good in itself, derive two effects, one good and the other bad, if the will is directed only to the good effect, and if there are proportionately serious causes to allow the bad effect, the action is licit[8]”.

 

The controversy seemed to have died down, but it bounced back in the autumn when a medical journal partially published the opening speech of the XXX Congress of the Italian Society of Obstetrics and Gynecology, held in Milan from October 18 to 20, 1931[9]. While rejecting “abortion procured under eugenic and social pretexts, or out of misunderstood pity for the woman who fears scandal”, Professor Pestalozza repeats what he had already stated earlier in the year in L'Osservatore Romano. In his view, induced abortion for medical reasons “in no way aims to directly kill the innocent, as the text of the encyclical seems to presume, but has the sole purpose of saving the woman from a very great danger[10]”.

 

A later controversy between moralists

How did Professor Pestalozza come to this conclusion?

For Fr. Gemelli, “the illustrious doctor starts from an example (that of the removal of the uterus in a pregnant woman) classified by Fr. Vermeersch sj and other theologians as ‘indirect abortion’ and henceforth accepted as licit not only in the various manuals of moral theology and pastoral medicine, but also in a recent catechism[11] intended for the faithful[12]”. From this precise example, Professor Pestalozza concludes that all forms of so-called therapeutic abortion are morally licit. Present at the Milan congress, Fr. Gemelli engaged the practitioner in discussion and reported on the debates in two articles published in L'Osservatore Romano on October 28 and 29.

Confident, Fr. Gemelli maintains that “the removal of a pregnant woman's cancerous uterus is a direct abortion[13]”. This does not mean that other forms of so-called therapeutic abortion are licit. In his view, abortions qualified as therapeutic by the medical profession, such as the particular case dealt with by Fr. Vermeersch, are direct abortions that are condemned by the recent encyclical.

In the spring of 1932, Fr. Vermeersch sj published an article on direct and indirect causality in a journal edited by the Pontifical Gregorian University[14]. The following year, the Nouvelle revue théologique - edited by the Society of Jesus and printed in Brussels - opened its columns to the two controversialists. Fr. Gemelli opened the fire with a lengthy two-part article on what he meant by indirect abortion[15]. Fr. Vermeersch responded by stressing the difference between direct and indirect abortion[16]. Fr. Gemelli takes up the pen again to clarify a few points raised by Fr. Vermeersch[17] before the latter concludes the exchange with an articulet[18].

One principle, three arguments and one consequence

Fr. Gemelli's position is clear: “I declare illicit the extirpation of the cancerous uterus during pregnancy, as equivalent to directly procuring abortion[19]”. To support this position, the Franciscan invokes a principle (1), develops three arguments (2-4) and draws a consequence (5).

(1) It is incoherent to consider morally illicit any form of so-called therapeutic abortion and licit the ablation of the cancerous and gravid matrix: “If the extirpation of the cancerous uterus during pregnancy is to be considered licit, because the abortion provoked in this case is indirect, we must also consider as indirect abortions, and therefore licit, other cases which commonly take the name of therapeutic abortions in medicine[20]”.

To demonstrate that the removal of a cancerous and gravid uterus is a direct and therefore morally illicit abortion, three arguments are put forward.

(2) An abortion can only be qualified as indirect and accidental if the fatal outcome for the fetus is the result of chance: “An abortion that occurs as an operating accident is undoubtedly an indirect abortion[21]”. But “[the death of the fetus during a hysterectomy performed on a pregnant woman] is an effect that the operation necessarily causes of its own accord[22]”. So the removal of a cancerous, gravid uterus is a direct abortion.

(3) For an action with a double effect to be morally licit, the good effect must precede the bad effect. Now, “the extirpation of the uterus chronologically follows the killing of the fetus [by prior ligation of the arteries and veins which put it in communication with the internal maternal organism][23]”. The removal of a cancerous and pregnant uterus is therefore illicit.

(4) In accordance with the principle of totality, it is lawful to sacrifice a part (limb, organ or function) in order to save the whole[24]). The good effect here benefits the mother, while the bad effect affects the fetus: “The use of a remedy which, while saving the life of a sick person, causes him some inconvenience and weakens him temporarily, is justified by the good effect, which is greater than the first. Note: we are talking here about the same person; in our case, on the contrary, we are talking about two different people[25]”. So the removal of a cancerous, gravid uterus is an evil act.

(5) To illustrate the indirect violation of human life, moral theology textbooks used a few classic examples[26]. Consistent with his opinion, Fr. Gemelli maintains, on the contrary, that in this case we are dealing with direct attacks on life, and that these are licit by virtue of orders given by public authority:

“The general who attacks an enemy town, while foreseeing with certainty the death of innocent children there, finds himself justified by the justice of his cause; moreover, in times of war, it is in the name of the State that he kills; in our case, it is the private person of the doctor who kills. In the same way, the soldier who sets fire to the enemy ship, while surely knowing that he too will die in the fire, is carrying out an order given to him by the authority of his leaders; in our case, public authority does not intervene[27].”

 

A series of confusions

Let's see how Fr. Vermeersch responds to the principle (1), arguments (2-4) and consequence (5) set out by Fr. Gemelli.

(1) Many practitioners believe that the good intention - to save the mother's life - is enough to legitimize all forms of so-called therapeutic abortion. They are wrong, because the end does not justify the means. To convince them of this, it is necessary to provide them with a solid philosophical training, and not to attack the principles or conclusions of morality: “[Father Gemelli] will readily agree that possible abuse does not allow us to alter the truth, in a matter of capital importance, nor to conceal a conclusion of common teaching (as we shall see) and which serves others than medical professors. The real way to prevent possible abuses would be to encourage young aspiring doctors in Italy to make more contact with philosophy[28]”.

(2) An action is not morally specified by its effects - known or unknown, certain or uncertain - but by its object and its end: “It is the direction of the action that must inform us about direct or indirect causality. Now, the certainty or uncertainty of an effect or result does not modify or influence this direction[29]. Indeed, “in philosophical language, an effect, even if foreseen and certain, is said to be accidental when it is due to the concurrent action of two causes[30]”.

In human action, the accidental can arise from either the intelligence or the will. What is accidental by reason of intelligence is that which is the fruit of chance[31]. What is accidental because of the will is that which, in an action, is chosen neither as a means nor as an end[32]. St Thomas thus deals separately with homicide resulting from bad luck[33] (accidental by reason of the intelligence) and self-defence[34] (accidental by reason of the will). In both cases, homicide is accidental, but not for the same reasons.

(3) The anteriority of the good effect over the bad effect is not chronological but causal: “Chronological order has no influence on whether the effect is mediate or immediate. - The effect is immediate if the bad effect did not serve as a means to obtain it. Now, [...] the extirpation of the uterus is carried out without touching the fetus; it would be done in the same way, if the uterus were empty[35]”.

Chronologically speaking, civilians may die before the bombardment destroys the city wall. From a causal point of view, collateral victims are always a consequence of the bombardment, since their death is not intended by the besiegers as either a means or an end.

(4) In double-effect actions, the good effect and the bad effect may affect the same person[36], but they may also affect different people[37]. Regardless of the accidental circumstances that distinguish them, the solution to the problems posed to consciousness by these situations remains the same.

Those who act must take into account both their duties towards themselves and their duties towards others. In doing so, he must avoid, as far as possible, both the harm that he himself might suffer and the harm that his neighbor might suffer. Whether the good effect and the bad effect affect the same individual or separate persons makes no difference.

(5) Troubled in his understanding of indirect voluntarism, P. Gemelli comes to undermine the most assured principles and conclusions of morality. In order to prevent a few doctors from abusing a particular case - of which they are unaware - to justify all forms of so-called therapeutic abortion, Fr. Gemelli ends up suggesting, horresco referens, that public authority can sometimes directly dispose of the lives of the innocent.

Yet morality has always maintained that public authority cannot directly dispose of the lives of the innocent: “[Saint Thomas] denies public authority any right over the lives of the innocent and any power to order or authorize suicide[38]”. Pius XI says the same in the above-mentioned encyclical: “Life [of mother and child] is equally sacred; no one, not even the public authorities, can ever have the right to violate it[39]”.

 

An error of method

Having responded to Fr. Gemelli's arguments, Fr. Vermeersch summarizes the error of method committed by his contradicter:

“To judge whether the action is good, it must be separated from the bad effect. To make this effect an element of appreciation for the action itself would be to forget the question, which is to know whether, because of this effect or consequence, an action that would otherwise be blameless does not become morally bad.

“Consequently, in order to ascertain whether a cancerous uterus can be removed with a view to saving a human life, even though this uterus might be that of a pregnant woman, we must not, from the outset, take the concrete case of a pregnant uterus, but on the contrary confine ourselves first to the essential content of the action, i.e. the removal of a uterus eaten away by a fatal tumour ; and then add the accidental circumstance of pregnancy to make a definitive overall judgment[40]. ”

 

The lessons of a controversy

Beyond its twists and turns, this controversy is of great interest to those who discover it a century later. The lessons it teaches are, and remain, highly topical.

The controversy between theologians has its roots in the debate between Professor Pestalozza and Father Gemelli. But this debate was disrupted by epistemological questions. The physician's approach is not the moralist's approach. For the physician, accident is only that which is the result of fortune, chance or misfortune. For the moralist, accidental is also that which, although foreseen, is neither intended as an end nor as a means. Both physician and moralist, Fr. Gemelli favored the physician's approach to such an extent that he ended up losing sight of the moralist's[41]). Although he intervened as a moralist, Father Gemelli reasoned, spoke and wrote as a doctor, to the point of opposing his moralist colleagues, of whom Father Vermeersch was ultimately only the representative.

To convince the medical profession of the immorality of so-called therapeutic abortion, Fr. Gemelli restricted the category of indirect abortion to cases where chance and misfortune explain the death of the fetus. In doing so, he came into conflict with his colleagues who, in keeping with the moralist's own approach, had retained the full moral extension of the qualifiers indirect and accidental.

In his desire to convince doctors, Fr. Gemelli was led by logical consistency, on the one hand, to restrict the domain of indirect attacks on human life to what results from chance, and, on the other, to extend the domain of direct attacks on human life by legitimizing the State's right to dispose of innocent lives. The shifting of these two tectonic plates has provoked a moral earthquake of which its initiator seems to have been unaware. Science and prudence do not always go hand in hand[42], even among moralists.