1

Did the Doctrine of Double Effect kill Savita Halappanavar? Catholic

reasoning on obstetric emergencies and the Savita case Heike Felzmann

Abstract: After the death of Savita Halappanavar it was argued that following Catholic reasoning on

obstetric emergencies imposes restrictions on medical practices that are unsafe for women. The

Irish Catholic Church rejected this claim but did not provide a clear argument to support their claim.

This paper will engage with Catholic reasoning on obstetric emergencies and will reflect on the

impact of such reasoning on the practical management of such emergencies in Catholic hospitals in

the US. In light of these findings and facts about the case, it will be concluded that the official

statements of the Irish Catholic Church on obstetric emergencies were at the very least misleading.

The news about Savita Halappanavar’s death in University Hospital Galway in November 2012

started a passionate public debate on the Catholic influence on obstetric and maternity services in

Ireland. The debate initially focused strongly on the Catholic aspect due to the report that a member

of the healthcare team had stated to Savita Halappanavar that an abortion could not be performed

because Ireland was a Catholic country. In light of the subsequently emerging evidence of significant

clinical systems failures and the particular shape of the debate around the new abortion legislation

with its focus on suicidality, the original question whether the refusal of a timely termination of

pregnancy was indeed due to or in keeping with Catholic thinking increasingly faded into the

background, despite not having received satisfactory answers. Irish Catholic voices offered

statements that nearly uniformly conveyed the impression that the restrictive interpretation of the

Catholic position was erroneous and that from a Catholic standpoint a timely termination would

have been permissible. However, the exact scope of those assertions and the reasoning behind them

remained largely unclear.

This paper explores the question whether it is indeed plausible that addressing obstetric

emergencies according to Catholic guidance does not pose particular risks for patients, and

ultimately answers this question in the negative. A brief discussion of general arguments in Catholic

moral theology on obstetric emergencies highlights that the predominant position supports highly

restrictive practices not just in relation to elective abortion, but even in relation to urgent life-saving

treatment. Such theological restrictions also shape Catholic health care practice to some extent, as

recent research with practitioners in Catholic healthcare institutions in the United States shows.

However, while significant restrictions are in place, there is some variability between institutions,

and actual practices in Catholic healthcare institutions in relation to obstetric emergencies appear

overall somewhat less restrictive than would be expected on the basis of the predominant

arguments in moral theology. Yet the Irish Catholic discourse on obstetric emergencies following the

case of Savita Halappanavar completely avoided engagement with those complicating aspects of

Catholic doctrine on obstetric emergencies and instead claimed easy compatibility with safe practice

– inappropriately as this paper argues.

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1. The case of Savita Halappanavar and the Irish legal situation on abortion Savita Halappanavar was admitted to hospital in October 2012 with signs of an impending

miscarriage at 17 weeks gestation. At this early stage in pregnancy the foetus is not viable; before 23

weeks gestation there is no chance of the foetus surviving outside the womb. Given the patient’s

dilated cervix and ruptured membranes it was considered impossible that the foetus could be

brought to viability. Once it had been made clear to the patient that there was no chance of foetal

survival, she requested an immediate termination of pregnancy, but was told that this was not an

option and that while there was still a foetal heartbeat she had to wait for the miscarriage to occur

naturally. However, the risk of contracting an infection after rupture of membranes increases

exponentially with time, and so does the risk of serious complications. As the wait for natural

delivery extended over several days, a serious infection did indeed develop. When it was finally

diagnosed and an action plan had been finalised, the patient had already reached the state of severe

sepsis, an immediately life-threatening state of systemic infection, and despite spontaneous delivery

at that stage and intense medical interventions, the patient died a few days later in intensive care.1

Two weeks after her death, an article describing her case appeared in the Irish Times, focusing

specifically on the denial of abortion in her case.2 One of its internationally most widely discussed

claims was that the denial of abortion had been explained to the patient as due to Ireland being a

Catholic country. While some suspected personal Catholic motivation by those responsible for this

decision, many took the denial of a termination in this situation to be a consequence of the Irish

legal situation with a constitutional framework on the “right to life of the unborn” that closely

mirrors Catholic doctrine in some crucial respects, especially the basic assumption of equality of

status between the woman and the foetus. While Irish law on abortion is not entirely congruent with

Catholic dogma and, following the controversial X case decision, is more permissive in some

respects, significant overlap between the Irish legal framework and Catholic dogma remains.

Historically the Catholic Church had considerable impact on the shape of Irish law on abortion, most

prominently in its role in inserting article 40.3.3 into the Irish constitution, an amendment to the

constitution that established a constitutional right to life of the foetus or “unborn”, and also the

subsequent stalling of the introduction of abortion legislation to transpose the constitutional

amendment into law, following the Supreme Court X case judgment. Article 40.3.3. states:

The State acknowledges the right to life of the unborn and, with due regard to the equal

right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its

laws to defend and vindicate that right.

1 A detailed description and analysis is provided in two official reports into the case: Health Information and

Quality Authority (HIQA), Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar,(2013), <http://www.hiqa.ie/publications/patient-safety-investigation-report-services-university-hospital-galway-uhg-and-reflect> [Accessed March 18, 2014] and National Incident Management Team (NIMT), Investigation of Incident 50278 from time of patient’s self referral to hospital on the 21st of October 2012 to the patient’s death on the 28th of October, 2012, (2013), <http://www.hse.ie/eng/services/news/nimtreport50278.pdf> [Accessed March 18, 2014]. 2 Kitty Holland and Paul Cullen “Woman, ‘denied a termination’ dies in hospital”, Irish Times, 14 November

2012, p.1 <http://www.irishtimes.com/newspaper/frontpage/2012/1114/1224326575203.html>.

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No legislation had been passed to clarify article 40.3.3 for nearly 30 years, until the passage of the

Protection of Life During Pregnancy Act 2013.3 The only specific decision on the scope of lawful

abortions was the 1992 Supreme Court X case judgment that established that risk to the woman’s

life had to be “real and substantial” in order for abortions to be lawful under the Irish constitution

(and also had, controversially, established that suicide risk was one such risk). Crucially, no more

specific criteria for ascertaining whether a real and substantial risk was present had been

established, neither in law nor in professional regulation or ethical guidance, and even with the

commencement of the Protection of Life During Pregnancy Bill 2013 in January 2014, such guidance

has not yet been provided. In the medical profession, the only professional guidance document that

addresses abortion with any degree of specificity is the 2009 Guide to Professional Conduct and

Ethics by the Irish Medical Council.4 In relation to cases where there is a pregnancy-related risk to

the pregnant woman’s life while the foetus is still unviable it states under Article 21:

Abortion is illegal in Ireland except where there is a real and substantial risk to the life (as

distinct from the health) of the mother. … In current obstetrical practice, rare complications

can arise where therapeutic intervention (including termination of a pregnancy) is required

at a stage when, due to extreme immaturity of the baby, there may be little or no hope of

the baby surviving. In these exceptional circumstances, it may be necessary to intervene to

terminate the pregnancy to protect the life of the mother, while making every effort to

preserve the life of the baby.

It remains, however, silent on what constitutes these exceptional circumstances and in particularly

what efforts, if any, have to be made to preserve the foetus’ life once it is clear that its death is

unavoidable. The absence of further legal or regulatory clarification and the overall strong

similarities between Irish Catholic, legal and medical guidance statements on the matter of life-

saving medical terminations5 could easily encourage practitioners to take basic Catholic reasoning as

suitable model for guidance on their responsibilities in those cases. In the inquest of Savita

Halappanavar’s death the consultant responsible for the clinical decision-making in her case was

asked about her reading of the Medical Council Guidelines on terminations in medical emergencies;

while not betraying any personal Catholic convictions, she stated on cross-examination that in her

understanding this section referred primarily to a specific sub-class of cases like cervical cancer, the

paradigm case used in Catholic reflections on the matter of medical terminations, and not Savita’s

3 Irish Statute Book, Protection of Life During Pregnancy Act 2013 (No.35 of 2013), (2013),

<www.irishstatutebook.ie/pdf/2013/en.act.2013.0035.pdf> [Accessed March 18, 2014] 4 Medical Council, Guide to Professional Conduct and Ethics for Registered Medical Practitioners, 7th ed.,

(2009), <http://www.medicalcouncil.ie/News-and-Publications/Publications/Professional-Conduct-Ethics/Guide-to-Professional-Conduct-and-Behaviour-for-Registered-Medical-Practitioners-pdf> [Accessed March 18, 2014] 5 The psychiatric case is another matter and its inclusion in Irish law has been fought most vigorously by the

Catholic Church since the X case as incompatible with its teaching and was the primary issue for Catholic contributors in the debate on the Protection of Life During Pregnancy Bill 2013. While the Church has been opposed to the introduction of formal abortion legislation in general, due to the inclusion of some cases of “direct” abortion among the life-saving terminations and the assumptions that the perceived legitimacy of terminations might be extended beyond those emergency cases once legislation had been brought in, in 2002 they lent their explicit support to a proposal for a constitutional amendment (that was rejected by the narrowest of margins) which was linked to a legislative proposal that was going to exclude suicide, but include life-saving terminations for medical reasons.

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case prior to the actual establishment of an immediate life-threatening infection, indicating that her

understanding of the Irish law and professional guidance was informed by Catholic distinctions.6

The case of Savita Halappanavar galvanised public opinion to demand an end to the legislative

uncertainty and the passing of abortion legislation, two years after the European Court of Human

Rights in the decision on A, B and C vs Ireland had demanded from Ireland in strong terms to finally

create legal clarity on the matter.7 The legislative process for the passing of the Protection of Life

During Pregnancy Bill 2013 was almost certainly sped up by the public reaction to the case. During

this process several official investigations into the case established that there were serious

shortcomings in the clinical care that Savita Halappanavar received, especially regarding the

monitoring of her condition and the pathways of clinical communication and decision-making.8

Although the NIMT report clearly identified the legislative framework as a key factor inhibiting safe

obstetric practice, for some commentators the fact that substantial clinical failures had been

identified was proof that the connection made between Catholicism, the Irish legislative situation,

and an unreasonable risk to women in Savita Halappanavar’s situation was erroneous. In order to

explore whether this assessment is accurate, key elements of Catholic reasoning on emergency

obstetric interventions will be explored and then applied in relation to questions of concrete delivery

of Catholic healthcare.

2. Catholic reasoning on emergency obstetric interventions that affect a

pre-viable foetus How is the legitimacy of interventions in obstetric emergencies assessed in Catholic doctrine? This

section will outline mainstream concerns in the Catholic literature on obstetric emergencies. It

engages with relevant philosophical literature in the field without, however, claiming special

expertise in Catholic moral theology. The primary focus of the argument is on the general shape of

Catholic reasoning on the matter and the question how those arguments have shaped the guidance

given to healthcare professionals on the matter and which areas of uncertainty remain. Deeper

engagement with the finer points of moral theology beyond the material needed to interpret

guidance given to healthcare professionals is not deemed necessary, insofar as healthcare

professionals themselves are no moral theologians and are reliant on the translation of theoretical

arguments into practical guidance in order to be able to implement Catholic values in their practice.

Guidance given to them needs to be practical and the distinctions that are relevant for their moral

practice need to be spelt out in sufficient detail so that they can be action guiding. As will become

apparent in the following, the seemingly clear distinctions presented in Catholic guidance

documents are rather difficult to apply in practice once they concern cases that do not correspond

to the clear paradigm cases generally used to educate health professionals on the matter. That

uncertainty has moral significance for the dealing of the Catholic Church with obstetric emergencies,

as will be argued in the final section of the paper.

6 Galway Coroner’s Inquest into the death of Savita Halappanavar. Cross-examination of Consultant Catherine

Astbury, Oral proceedings at Galway Courthouse, April 2013. 7 European Court of Human Rights, A, B and C v. Ireland Judgment (Application no. 25579/05), (2010),

<http://hudoc.echr.coe.int/sites/eng/pages/search.aspx?i=001-102332> [Accessed March 18, 2014] 8 HIQA, Investigation into the safety, quality and standards of services, and NIMT, Investigation of Incident

50278.

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What makes decisions for obstetric emergencies so fraught with problems in Catholic healthcare is

the basic assumption of equal moral status of woman and foetus from the moment of conception.

The assumption of equal status in Catholicism leads to the conceptualisation of care for pregnant

women as care for two persons with full individual rights. In the Irish context this is often referred to

by Catholic voices as the “two patient model of care”. In the case of obstetric emergencies where

intervention involves causing the death of the foetus, the foetus’ rights cannot automatically be

overridden in favour of the woman. No matter what the developmental status and prognosis of the

foetus is, until the foetus has died it is considered to be a full bearer of human rights. Accordingly, a

5 week old foetus in an ectopic pregnancy that has no chance of ever reaching viability and poses a

significant risk to health and life of the pregnant woman is nevertheless considered a person with

full human rights that need to be factored into any decision-making on the management of the

ectopic pregnancy, significantly complicating what interventions can be performed.

Catholic arguments on the permissibility of interventions in pregnancy which lead to the death of

the foetus generally rely on the specific distinction between “direct” and “indirect” abortions,

supported by the general doctrine of double effect (DDE). The DDE assesses the permissibility of

actions with combined morally good and bad characteristics. In the Catholic tradition the DDE

usually applies four criteria to assess whether such an action is morally permissible:

1. The act itself is morally neutral or positive, not intrinsically bad or evil

2. The evil that will be realised through the action is not itself a means to the good but merely

a side effect of a morally legitimate goal

3. The evil that will be realised through the action is not intended as the end of the action

4. There is a proportionate reason for allowing the evil effect, i.e. serious bad consequences

need to be matched by the avoidance of a similar or greater evil through the act

The DDE has traditionally been applied to two paradigmatic cases of life-saving interventions in

pregnancy, namely surgical intervention for cancer in the reproductive system and ectopic

pregnancy. In both cases, the standard approach in the literature has been the application of the

distinction between direct and indirect abortion in fairly straightforward physical terms. While direct

killing of the foetus, for example through physical destruction of the foetus, is considered clearly

illegitimate, indirect killing that results from the extraction of a diseased or damaged organ that

contains the foetus (the uterus or fallopian tube) can be morally justified under the doctrine.

However, even for those traditional paradigm cases, the development of more sophisticated and

less invasive medical interventions as well as a generally more complex understanding of the

physiology involved in such life-threatening conditions, has made the application of these criteria

significantly more challenging, as is evident in the increasing complexity and differentiation in recent

discussions on ectopic pregnancies.9

Two particular challenges arise in the application of the DDE and the distinction between direct and

indirect abortions that are relevant for assessing legitimate action for other classes of obstetric

emergencies. First, not all obstetric emergencies where life-saving intervention leads to the death of

the foetus are caused by a disease in the reproductive system itself. Different health conditions can

9 Christopher Kaczor, A Critical Reconsideration of Salpingostomy and Methotrexate, The Linacre Quarterly,

76(3) (2009), 265–282 <doi: 0024-3639/2009/7603-0004>. Christopher Kaczor, Moral absolutism and ectopic pregnancy, Journal of Medicine and Philosophy, 26(1) (2001), 61-74 <doi: 0360-5310/01/2601-0061>.

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exacerbate to life-threatening levels due to the indirect effects of the pregnancy on the woman’s

body without involving a disease in the reproductive system itself. However, without termination of

the pregnancy such conditions cannot be controlled. An intervention to deliver the foetus before

viability in those cases cannot easily be justified as “indirect abortion”, insofar as the pre-viable

delivery (albeit not the death itself) of the foetus is directly intended, and is not just a side-effect of a

different intervention. Yet, if no intervention occurs, the woman and the foetus are likely to die. The

complications this brings for the Catholic position on such cases are illustrated clearly in Coleman’s

article on the Phoenix case.10

This case occurred in a Catholic hospital in Phoenix, Arizona, in 2009, where a woman received a life-

saving abortion for life-threatening pulmonary hypertension when she was 11 weeks pregnant. She

suffered from life-threatening blood pressure levels as a consequence of her pregnancy, while

however her reproductive system itself was by all accounts healthy. She was authorised by the

ethics committee of her local hospital to receive an emergency termination to save her life, but the

local bishop considered this termination to be against Catholic teaching and excommunicated the

nun chairing the ethics committee, backed by the US Conference of Catholic Bishops Committee on

Doctrine.11 Coleman’s article outlines a wide range of attempts to grapple with the assessment of

this case by means of the DDE and the distinction between direct and indirect abortion. While it

presents several complex theoretical arguments for the moral legitimacy of such intervention under

Catholic doctrine, including arguments by the well-known theologian Germain Grisez who argues

that intending the removal of the foetus from the womb to save the mother’s life is morally distinct

from intending its actual death,12 the official interpretation of the Catholic Church in this matter

clearly differed from those interpretations, favouring a much more straightforward interpretation of

the requirements of the DDE, albeit in serious conflict with general public understanding of moral

requirements in such cases.

In comparison to the Phoenix case, cases like Savita Halappanavar can be more easily made to fit

into the traditional model of analysis in the DDE, but only once certain conditions have been fulfilled.

In protracted miscarriages the risk to life generally arises from an infection within the reproductive

system itself, with the ruptured membranes themselves as potential locus of infection

(chorioamnionitis). Once an infection has taken hold, the application of the DDE is less problematic,

insofar as the evacuation of the womb is required to extract the infected tissue that causes the

threat. This does, however, require that the disease process is already in place, meaning that while

curative intervention for inflammation in that location seem to fit into the DDE model, preventative

intervention would be substantially more difficult to justify within the DDE framework.

This brings us to the second larger concern, namely the issue of proportionality. Acting

proportionately means that any intervention that endangers or kills the foetus at least needs to

10

Gerald Coleman, Direct and Indirect Abortion in the Roman Catholic Tradition: A Review of the Phoenix Case. HEC Forum 25(2) (2013), 127-143 <doi:10.1007/s10730-013-9211-7>. 11

United States Conference of Catholic Bishops, Committee on Doctrine, The distinction between direct abortion and legitimate medical procedures, (2010) <http://www.lifesitenews.com/ldn/2010_docs/Phoenix_abortion.pdf> [Accessed March 18, 2014]. 12

Germain Grizez, The Way of the Lord Jesus, Volume 2, Living a Christian Life, Chapter 8: Life, Health and Bodily Inviolability, Question D: Is Abortion Always the Wrongful Killing of a Person?, Section 3.(d): Sometimes the baby’s death may be accepted to save the mother, Franciscan Press, Quincy University, Quincy, Illinois (1992/2008) <http://www.twotlj.org/G-2-8-D.html> [Accessed March 18, 2014],

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address a similarly significant danger to the woman. The requirement of proportionality leads to

some problematic consequences insofar as due to the equality of status between woman and foetus

the foetus’ life cannot be sacrificed for any less significant reason than saving the woman’s life.

Accordingly, for example severe health impairments resulting from pregnancy would not be

considered sufficiently serious grounds to end the foetus’ life; this is mirrored in Irish law where

serious health impairments without risk of death for the woman do not count as grounds for a lawful

termination.

The issue of risk further complicates the issue. While life-saving obstetric interventions involve

proportionate goods, namely the lives of foetus and woman alike, the level of risk to those goods

also needs to be considered. The mere likelihood of developing potentially life-endangering

complications does not meet the proportionality standard, as clearly apparent from the guidance

contained in the US Catholic Health Association manual13 that explicitly states that in the case of

ruptured membranes the mere potential of life-threatening complications is not sufficient to justify

an abortion. Generally, judging from discussions in Catholic moral theology as well as the specific

guidance given to health professionals, it appears that not much attention is paid to the question at

what risk levels the risk to the woman’s life is serious enough to warrant taking action. Instead these

discussions primarily address qualitative distinctions, indicating that risk, understood as a

quantification of the likelihood of certain outcomes, may not have a significant role to play at all.

Accordingly, it could be argued that in the case of ruptured membranes the official Catholic advice to

wait for an established infection may not even be linked primarily to the quantitatively higher risk

levels once an infection has been established, but could be merely due to the more straightforward

application of the DDE once infection of the reproductive system has been diagnosed.

Despite the comparative neglect of the issue of risk, it is very significant for healthcare practice,

because in certain disease processes risk can escalate very rapidly once a certain stage has been

reached. In the case of ruptured membranes, at the point of ruptured membranes the risk of death

is still minimal, while the risk of infection is already substantial. But once an infection has taken hold

the risk of serious health complications and death increases dramatically within a very short space of

time. Treatment success at that stage is dependent on rapid delivery of correct intervention. If any

obstacles occur during detection or treatment, leading to delays until optimal treatment can be

administered, the risk to life can quickly become very substantial; with an escalating septic disease

process this risk can increase from around 15% to 60% in a matter of just a few hours, as happened

in the case of Savita Halappanavar.14 A model of ethical decision-making on such cases that does not

explicitly take into account the aspect of risk and risk development is disregarding an essential

aspect of the disease process for those cases.

The absence of more specific considerations on risk is also a feature of the Irish situation where

neither legislation nor regulations specify the issue beyond the opaque Supreme Court standard of

“real and substantial risk”. One of the questions here is what makes a risk “real” and “substantial”: is

it a merely quantitative, probabilistic assessment of risk, unlike in Catholic doctrine, or is a more

13

Referred to in Lori Freedman, Uta Landy, Jody Steinauer, When There's a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals. American Journal of Public Health 98 (2008), 1774-1778 (p.1775) <doi:10.2105/AJPH.2007.126730>. 14

HIQA, Investigation into the safety, quality and standards of services, and NIMT, Investigation of Incident 50278.This issue was also discussed at length in the Galway Coroner’s Inquest into her death.

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qualitative distinction being made, more akin to Catholic doctrine? In the absence of clarification, an

intuitive distinction might be made between a “potential”, still merely theoretical risk of, for

example, of developing a disease, and the “real” risk arising from an actually established disease

where a direct causal pathway to death exists; why such a distinction should have the significant

moral status given to it would, however, require further argument, especially if one does not

subscribe to DDE reasoning. The neglect of the issue at the very least creates space for Catholic-

inspired interpretations of the criterion in relation to obstetric emergencies,15 as these are models of

moral reasoning that many Irish professionals would have been exposed to through the impact of

Catholic culture in professional training and everyday life.

3. Catholic healthcare practice for obstetric emergencies in the US In the Irish context no contemporary comprehensive official Catholic guidance documents for

healthcare practitioners are in place. In contrast, in the US, the Ethical and Religious Directives for

Catholic Health Care Services16 provide binding guidance for Catholic healthcare organisations. In

that document, Directive 45 states the general position on abortion and Directive 47 applies to the

question of emergency obstetric intervention:

45. Abortion (that is, the directly intended termination of pregnancy before viability or the

directly intended destruction of a viable fetus) is never permitted. Every procedure whose

sole immediate effect is the termination of pregnancy before viability is an abortion, which,

in its moral context, includes the interval between conception and implantation of the

embryo. Catholic health care institutions are not to provide abortion services, even based

upon the principle of material cooperation. In this context, Catholic health care institutions

need to be concerned about the danger of scandal in any association with abortion

providers. …

47. Operations, treatments, and medications that have as their direct purpose the cure of a

proportionately serious pathological condition of a pregnant woman are permitted when

they cannot be safely postponed until the unborn child is viable, even if they will result in

the death of the unborn child.

The text in these directives reiterates the importance of DDE reasoning, including the distinction

between direct and indirect abortions and the issue of proportionality. It also mentions the issue of

“material cooperation” and “scandal”, prohibiting forms of indirect, but active involvement of

Catholic institutions in abortion through the provision of abortion-related information, explicit

referrals to organisations that provide abortions or other significant forms of cooperation with such

organisations.

15

Even though the Supreme Court decision itself addresses suicide as legitimate risk to life and clearly runs counter to Catholic doctrine). 16

United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services. 5

th ed. (2009), <http://www.usccb.org/issues-and-action/human-life-and-dignity/health-

care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf> [Accessed March 18, 2014].

9

As reported in Freedman et al., the official manual for Catholic hospital ethics committees by the US

Catholic Health Association provides further, more specific guidance on the interpretation of

Directive 47, especially in relation to the assessment of risk and the question of proportionality. It

posits effectively that foetal prognosis is irrelevant and that merely potential risk to the women’s life

is not sufficient to justify intervention. It states very specifically that “[t]he mere rupture of

membranes, without infection, is not serious enough to sanction interventions that will lead to the

death of a child”.17 The US Conference of Catholic Bishops’ Committee on Doctrine statement on the

Phoenix case goes even further by stating explicitly that the risk to the woman’s life is entirely

irrelevant, insofar as any intervention that can be classed as direct abortion would be impermissible

regardless of the degree of risk to the woman – an assertion of Catholic doctrine whose bluntness

has certainly not been matched in the Irish context.18

How does this guidance impact on health care delivery for obstetric emergencies in Catholic

hospitals? A body of recent research into practices in Catholic health care institutions in the US

indicates that a significant proportion of medical practitioners in obstetrics and gynaecology in

Catholic institutions consider some practices in those institutions to be problematic and potentially

medically unsafe.19 In contrast to strongly worded statements like the Dublin Declaration or

statements by the Irish Catholic Bishops’ Conference which strongly deny that abortions could ever

be required for safe patient care,20 many specialist obstetricians consulted for this research clearly

feel that following Catholic guidance on the matter leads to unduly risky or unsafe practice. Stulberg

et al. report in their study of obstetricians and gynaecologists in religiously affiliated institutions that

52% of the respondents from Catholic hospitals had experienced conflicts regarding patient care;

this percentage was significantly higher than for any other religious affiliation.21 Examples reported

by Freedman in their qualitative studies included several cases similar to Savita Halappanavar’s,

where an inevitable miscarriage with persisting foetal heartbeat was diagnosed, but in keeping with

DDE reasoning and the manual’s interpretation of Directive 47 intervention was not deemed to be

17

Catholic Health Association 2007, as quoted in Freedman, Landy, and Steinauer, When There's a Heartbeat (p.1775). 18

United States Conference of Catholic Bishops, The distinction between direct abortion and legitimate medical procedures (2010). 19

Angel Foster, Amanda Dennis, and Fiona Smith, Do Religious Restrictions Influence Ectopic Pregnancy Management? A National Qualitative Study, Women’s Health Issues 21(2) (2011), 104-109 <doi:10.1016/j.whi.2010.11.006>. Lori Freedman and Debra Stulberg, Conflicts in Care for Obstetric Complications in Catholic Hospitals. AJOB Primary Research 4(4) (2013), 1-10 <doi:10.1080/21507716.2012.751464>. Debra Stulberg, Annie Dude, Irma Dahlquist, and Farr Curlin, Obstetrician–gynaecologists, religious institutions, and conflicts regarding patient care policies, American Journal of Obstetrics and Gynaecology 207(1) (2012), 73.e1-73.e5, <doi: 10.1016/j.ajog.2012.04.023>. Debra Stulberg, Ryan Lawrence, Jason Shattuck, and Farr Curlin, Religious hospitals and primary care physicians: conflicts over policies for patient care, Journal of General Internal Medicine 25(7) (2010), 725–730. <doi:10.1007/s11606-010-1329-6>. Also Freedman, Landy and Steinauer, When There's a Heartbeat. 20

Dublin Declaration on Maternal Healthcare, September 2012 <http://www.dublindeclaration.com/> [Accessed March 18, 2014]. Irish Catholic Bishops’ Conference, Bishops’ Pastoral Message for Day for Life 2012 (Day for Life leaflet), Choose Life 2012, October 2012, <http://www.chooselife2014.ie/wp-content/uploads/2012/09/DFL-2012-FinalForPrint.pdf> [Accessed March 18, 2014] and Irish Catholic Bishops’ Conference, Homily Notes for Priests, Choose Life 2012, October 2012 http://www.chooselife2014.ie/homily-notes-for-priests/ [Accessed March 18, 2014]. 21

Stulberg, Dude, Dahlquist and Curlin, Obstetrician-gynecologists, religious institutions and conflict, Table 2 (p.9).

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morally legitimate until infection had been diagnosed. Interviewed physicians expressed significant

distress regarding their involvement in such practices.22

At the same time, this literature also indicates that Catholic health care institutions do by no means

interpret the requirements of Catholic practice consistently. As Freedman, Landy and Steinauer

conclude “varying interpretations and executions of Directive 47 exist both at the individual

(practitioner) and institutional (hospital) level”.23 Generally, a slightly more permissive interpretation

of the requirements of Catholic dogma seems to be favoured in those hospitals, when compared to

the arguments in mainstream moral theology on the matter. (One may suspect that practical legal

concerns about avoiding malpractice litigation and concerns about public reputation play a role in

this widening of the scope of Catholic practice in relation to obstetric emergencies). In Freedman’s

examples, referrals to non-Catholic abortion providers in obstetric emergencies seem to be a

common solution in facilitating the patient to access management that are not allowed within the

hospital, in keeping with professional guidance on conscientious objection for US obstetricians,24 but

contrary to official Catholic guidance on avoiding material cooperation with evil. However, patient

transfer in emergencies is not just disruptive and burdensome for the patient, but can significantly

increase risk to the patient through potentially significant delays and the added stress of transport.

Similarly, in relation to ectopic pregnancy the majority of voices in moral theology seem to argue for

significant restrictions to standard medical practice, especially regarding less invasive interventions

that do not involve the extraction of diseased tissue containing the foetus, like salpingostomy and

methotrexate.25 Yet only a minority of Catholic hospitals seem to restrict these interventions in the

management of ectopic pregnancies: for example, in Stulberg, Dude, Dahlquist and Curlin 5.5

percent of respondents from Catholic hospitals reported that in their institutions they encountered

rules that limited their management options for ectopic pregnancy;26 in Foster et al. respondents

from 3 out of 16 Catholic institutions stated that in their institution methotrexate, generally used as

standard of care for ectopic pregnancies in non-Catholic hospitals but a substance that directly

targets the physiology of the developing foetus, was not available for use in managing ectopic

pregnancies.27 While data does not seem to be available for obstetric emergencies unrelated to

disease states of the reproductive organs, given the public outcry regarding the Phoenix case and

the endorsement of a termination as a justifiable option in this case by a number of Catholic

theologians, it is probably safe to assume that at some least Catholic hospitals would perform

terminations for similar cases, regardless of the official endorsement of this course of action by the

Catholic Church.

22

Freedman, Landy and Steinauer, When There is a Heartbeat. Freedman and Stulberg, Conflicts in care for obstetric complications. 23

Freedman, Landy and Steinauer, When There is a Heartbeat (p.1776). 24

The American Congress of Obstetricians and Gynaecologists (ACOG) Committee on Ethics, ACOG Committee Opinion 385: The Limits of Conscientious Refusal in Reproductive Medicine, Obstetrics and Gynaecology 110 (2007), 1203-8 (Reaffirmed 2013). <http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Ethics/The_Limits_of_Conscientious_Refusal_in_Reproductive_Medicine> [Accessed March 18, 2014]. 25

Kaczor, A Critical Reconsideration of Salpingostomy and Methotrexate, and Kaczor, Moral absolutism and ectopic pregnancy. 26

Stulberg, Dude, Dahlquist and Curlin, Obstetrician-gynecologists, religious institutions and conflict, Table 3 (p.10). 27

Foster, Dennis, and Smith, Do religious restrictions influence ectopic pregnancy management (p.108).

11

4. Irish Catholic statements on abortion and the case of Savita

Halappanavar In light of these observations about Catholic doctrine and Catholic healthcare in the US, what was

the position of the Irish Catholic Church on obstetric emergencies in the case of Savita

Halappanavar? First of all, unlike the strongly worded statement of the US Conference of Catholic

Bishops Committee on Doctrine that affirmed in the face of considerable opposition that some

interventions to reduce risk to the woman’s life simply cannot be administered in Catholic

healthcare, there were no similar statements in reaction to the case of Savita Halappanavar. Instead,

the Irish Catholic Church reacted to the case by strongly rejecting the assumption that healthcare

informed by Catholic ethos would be in any way dangerous for women. The Irish Bishops’

Conference’s official statement on the Savita case states:

“In light of the widespread discussion following the tragic death of Mrs Halappanavar and

her unborn baby, we wish to reaffirm some aspects of Catholic moral teaching... The

Catholic Church has never taught that the life of a child in the womb should be preferred to

that of a mother. By virtue of their common humanity, a mother and her unborn baby are

both sacred with an equal right to life. 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. 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. … With

many other religious and ethical traditions we believe in upholding the equal and inalienable

right to life of a mother and her unborn child in our laws and medical practice. This helps to

ensure that women and babies receive the highest standard of care and protection during

pregnancy.”28

Evident in this statement is the usual prominence given in Catholic statements to the equality of

status between woman and foetus, and the distinction between the “direct and intentional

destruction of the unborn” and “medical treatments which do not directly and intentionally seek to

end the life of the unborn”. The way in which these issues are addressed in the statement is clearly

designed to counter the public outcry at the time by affirming that the critical public perception of

the stance of the Catholic Church on the matter is fundamentally mistaken.

In relation to the equality of moral status between woman and foetus the statement aims to counter

the widespread public perception following Savita Halappanavar’s death that Catholic thought

ultimately privileges the life of the foetus over the life of the mother, as Savita Halappanavar’s

mother had expressed: “In an attempt to save a 4-month-old fetus [sic], they killed my 30-year-old

28

Irish Catholic Bishops’ Conference, Statement by the Standing Committee of the Irish Catholic Bishops’ Conference on the equal and inalienable right to life of a mother and her unborn child, November 19, 2012. http://www.catholicbishops.ie/2012/11/19/statement-standing-committee-irish-catholic-bishops-conference-equal-inalienable-life-mother-unborn-child/ [Accessed March 18, 2014].

12

daughter..."29 The statement of the Irish Catholic Church provides a positively phrased statement

highlighting the deep value base of the equality assumption regarding woman and foetus, due to

their common humanity, but does not engage with the fact of the asymmetry of their dependence

before viability. But treating both as having equal claims, while completely disregarding prognosis

and the foetus’ dependency on the woman, effectively results in denying the claims of a woman at

high risk of death in order to keep alive a foetus that has no actual chance of survival at all, or at the

very least not without the woman surviving. While, theoretically speaking, avoiding a termination in

such situations could be seen as respecting the foetus equally to the woman, in practice it is not

unreasonable to understand it as a de facto privileging of the foetus over the woman.

The specific moral implications of treating both woman and foetus equally are also not clear. The

difference between the reasoning supporting the original High Court injunction in the X case and the

Supreme Court X case judgement that overturned it are instructive in this context (despite the

specific characteristics of the case), especially for those cases where the risk level for the woman is

comparatively low. The judge in the High Court had originally endorsed a strict interpretation of the

equal protection requirement for the foetus and argued:

“The risk that [X] may take her own life if an order is made is much less and is of a different

order of magnitude than the certainty that the life of the unborn will be terminated if the

order is not made."

That means that under the assumption of the equality of rights to life of woman and foetus a mere

probability of the woman’s death is outweighed by the certainty of the foetus’ death if an abortion is

performed. He concluded that only an “immediate and inevitable” risk to the woman’s life would

adequately balance the risk to both woman and foetus. Even though a pre-viable foetus would die

once the woman dies, as long as the probability of the woman’s death is low or remote enough, the

rights of the foetus could be considered to override the legitimacy of an abortion until the risk to the

woman’s life becomes sufficiently immediate or inevitable. However, the Supreme Court judgment

endorsed a less strict interpretation of the equal protection requirement and decided that instead it

had to be established as a matter of probability that there was no more than a “real and substantial”

risk to the woman’s life to provide sufficient grounds for a lawful abortion. This disagreement

between High Court and Supreme Court mirrors the lack of clarity on the exact role of risk for

decision-making on abortion evident in Catholic healthcare practice.

Similar to the management of the equality of status issue, in the statement of the Irish Catholic

Church the discussion of the distinction between the “direct and intentional destruction of the

unborn” and “medical treatments which do not directly and intentionally seek to end the life of the

unborn” is similarly presented in as constructive and uncontroversial manner as possible. The

distinction is described as “vital” and as underpinning normal Irish healthcare practice through

“[c]urrent law and medical guidelines [that] allow nurses and doctors to apply this vital distinction”.

The overall tenor of this statement is that application of these assumptions and distinctions is

commonplace in health care practice and seemingly straightforward and unproblematic. The

29

Parents slam Irish abortion laws after woman dies, Associated Press News, November 15, 2012 <http://bigstory.ap.org/article/parents-slam-irish-abortion-laws-after-woman-dies> [Accessed March 18, 2014]

13

significant concerns and lack of clarity in relation to the issue that were discussed in the previous

sections are glossed over.

One particular concern is that the statement seems to simply equate “medical treatment [needed by

a seriously ill pregnant woman] that may put the life of her baby at risk” and “medical treatments

which do not directly and intentionally seek to end the life of the unborn”. The apparent implication

is that necessary medical treatments for seriously ill pregnant women will not involve the direct and

intentional killing of the unborn (in contrast to the Phoenix case statement of the US Conference of

Catholic Bishops). This generally implicit assumption is sometimes made explicit, for example in the

2012 leaflet of the Irish Choose Life campaign and the associated Homily Notes for Priests that state

that “[i]t is never necessary to target the life of the baby in the womb to save the life of the mother”.

This position was promoted further by the controversial “Dublin Declaration on Maternal

Healthcare”, a declaration published by a panel of pro-life medical practitioners in September 2012:

“As experienced practitioners and researchers in obstetrics and gynaecology, we affirm that

direct abortion – the purposeful destruction of the unborn child – is not medically necessary

to save the life of a woman. 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. We confirm that

the prohibition of abortion does not affect, in any way, the availability of optimal care to

pregnant women.”30

What exactly constitutes this fundamental difference is, however, not obvious. In some statements,

the distinction seems to be made between medical interventions for medical risks to the woman’s

life and abortions for any other reasons, for example in the statement by Monsignor Brendan Byrne

on the Protection of Life during Pregnancy Bill 2013: “We can all agree that it is at times right to

intervene medically during pregnancy. … There is broad support for the parts of the proposed

legislation intended to provide legal clarity on what can rightly be termed life-saving and necessary

medical treatment [i.e. presumably any lifesaving intervention allowed under the legislation outside

of psychiatric indications].”31 Similarly, in the debate on the Protection of Life During Pregnancy Bill

2013, the primary concern was the inclusion of suicide risk as a risk to life according to the Supreme

Court judgment in the X case. Reference to “direct and intentional killing” in that context was

frequently merely an implicit reference to the controversial suicide clause, the inclusion of suicide

risk as risk to the woman’s life under the constitution, as opposed to other risks to life, whereas all

other interventions seemed to be subsumed under “necessary medical treatment”.

However, this would assume that any intervention to save a woman’s life from significant medical

risk to her life would be considered morally legitimate. While this is in keeping with the Irish

Constitution, convincing from a secular perspective, and clearly supported by the majority of the

Irish population, it does not seem to concur with the extensive body of literature in Catholic moral

theology discussed above, and is also not supported by research on actual health care practices in

US Catholic hospitals. A certain degree of vagueness and careful phrasing in the official Irish

30

Dublin Declaration on Maternal Healthcare http://www.dublindeclaration.com/. 31

Irish Catholic Bishops’ Conference, Statement by Monsignor Brendan Byrne on the Protection of Life during Pregnancy Bill 2013, Choose Life 2013, May 2013 <http://www.chooselife2014.ie/statement-monsignor-brendan-byrne-protection-life-pregnancy-bill-2013/> [Accessed 18 March, 2014].

14

statements has been remarked upon by several authors32 and indicates that those complications are

deliberately bypassed in the statement. While a certain degree of vagueness in statements on

practical matters would usually be expected, the problem in this context is what was at stake in the

discussions on the case of Savita Halappanavar was exactly the issue that was being fudged, based

on extensive evidence that there were particular concerns relate to the Catholic position on the

issue.

The most plausible reading of these statements in light of the discussions in moral theology is

probably not to read them as meaning that by definition no pregnancy-related medical intervention

to save a woman’s life could ever qualify as “direct and intentional killing”. Instead these statements

could be read as empirical claim that while there are legitimate and illegitimate ways of intervening

to save a pregnant woman’s life, there is simply no need for the morally illegitimate approach of

deliberately terminating a pregnancy. But this comes with a serious disadvantage: unless one wants

to apply a rather sophistic reading of “necessary” as moral rather than empirical claim, this claim is

open to empirical disconfirmation. If direct and intentional targeting of the foetus is indeed

necessary to ensure the survival of at least some pregnant women, this position would need to be

reconsidered.

The case of Savita Halappanavar might have been exactly one such case. The overwhelming evidence

that a litany of clinical failures, especially regarding the quality of patient monitoring, had

contributed to a delay in the diagnosis of the infectious process was used by many Catholic

commentators as evidence that the public’s concerns were unfounded. They claimed that her life

would have been saved if only proper monitoring procedures for infection had been in place. The

detection of signs of infection would have triggered an intervention that would have been legitimate

under Catholic doctrine at a significantly earlier stage. However, as the microbiologist’s and

pathologist’s reports on the case made clear, the infectious process in her case was of a particularly

virulent nature. Waiting for such a septic process to assert itself as “real and substantial risk” – as

required within the Irish legislative framework and similarly under the Catholic Directive 47 as

interpreted by the Catholic Health Association Manual – before allowing intervention is a risky

strategy, significantly increasing the potential for serious complications. In particular, there is

comprehensive evidence that detection of sepsis in maternity patients is particularly challenging and

often detected at a later stage at which point the infectious process may have caused significant

damage or might not respond to intervention any longer.33 Even in organisations that come

significantly closer to realising best practice than Galway University Hospital, the compliance with all

sepsis detection and management tools still tends to be incomplete.34

32

For example Marge Berer, Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women. An analysis of the death of Savita Halappanavar in Ireland and similar cases, Reproductive Health Matters 21(41) (2013), 9-17 <doi: 10.1016/S0968-8080(13)41711-1>, or John Baker, Letter to the editor, Irish Times, November 21, 2012. 33

Royal College of Obstetricians and Gynaecologists. Bacterial Sepsis in Pregnancy. Green-top Guideline No. 64a, 1st ed., Apr 2012 <http://www.rcog.org.uk/files/rcog-corp/25.4.12GTG64a.pdf> [accessed March 18, 2014]. 34

Garret Schramm, Rahul Kashyap, John Mullon et al. Septic shock: A multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality, Critical Care Medicine 39(2) (2011):252-258 doi: 10.1097/CCM.0b013e3181ffde08>.

15

To rely on perfection in the execution of a complex process in order to make sure the requirements

of the Doctrine of Double Effect are fulfilled is a problematic choice, when the alternative of earlier,

pre-infection intervention is safer for the woman and the outcome for the foetus is certain or at the

very least near certain death, no matter what course of events will be chosen. To hide the reality of

this choice behind deceptively simple and positive sounding statements that misrepresent the

complexity of what is at issue to the population is ethically dishonest and practically irresponsible.

References: Berer, M. (2013). Termination of pregnancy as emergency obstetric care: the interpretation of

Catholic health policy and the consequences for pregnant women. An analysis of the death of Savita

Halappanavar in Ireland and similar cases, Reproductive Health Matters 21(41), 9-17, doi:

10.1016/S0968-8080(13)41711-1

Coleman, G. (2013). Direct and Indirect Abortion in the Roman Catholic Tradition: A Review of the

Phoenix Case. HEC Forum 25(2), 127-143, doi:10.1007/s10730-013-9211-7.

Dublin Declaration (2012). Dublin Declaration on Maternal Healthcare, September 2012,

http://www.dublindeclaration.com/

European Court of Human Rights (2010). A, B and C v. Ireland Judgment (Application no. 25579/05)

http://hudoc.echr.coe.int/sites/eng/pages/search.aspx?i=001-102332

Foster, A., Dennis, A., Smith, F. (2011). Do Religious Restrictions Influence Ectopic Pregnancy

Management? A National Qualitative Study, Women’s Health Issues 21(2), 104-109,

doi:10.1016/j.whi.2010.11.006

Freedman, L., Landy, U., Steinauer, J. (2008). When There's a Heartbeat: Miscarriage Management in

Catholic-Owned Hospitals. American Journal of Public Health 98:1774-1778.

doi:10.2105/AJPH.2007.126730.

Freedman, L., Stulberg, D. (2013) Conflicts in Care for Obstetric Complications in Catholic Hospitals.

AJOB Primary Research 4(4), 1-10, doi:10.1080/21507716.2012.751464.

Health Information and Quality Authority (HIQA) (2013). Investigation into the safety, quality and

standards of services provided by the Health Service Executive to patients, including pregnant

women, at risk of clinical deterioration, including those provided in University Hospital Galway, and

as reflected in the care and treatment provided to Savita Halappanavar.

http://www.hiqa.ie/publications/patient-safety-investigation-report-services-university-hospital-

galway-uhg-and-reflect

Holland, K., Cullen, P. (2012). Woman, ‘denied a termination’ dies in hospital, Irish Times, November

14, 2012. http://www.irishtimes.com/newspaper/frontpage/2012/1114/1224326575203.html.

Irish Catholic Bishops’ Conference (2013). Statement by Monsignor Brendan Byrne on the Protection

of Life during Pregnancy Bill 2013, Choose Life 2013, May 2013,

http://www.chooselife2014.ie/statement-monsignor-brendan-byrne-protection-life-pregnancy-bill-

2013/

16

Irish Catholic Bishops’ Conference (2012c). Statement by the Standing Committee of the Irish

Catholic Bishops’ Conference on the equal and inalienable right to life of a mother and her unborn

child, November 19, 2012. http://www.catholicbishops.ie/2012/11/19/statement-standing-

committee-irish-catholic-bishops-conference-equal-inalienable-life-mother-unborn-child/

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Life leaflet), Choose Life 2012, October 2012, http://www.chooselife2014.ie/wp-

content/uploads/2012/09/DFL-2012-FinalForPrint.pdf

Irish Catholic Bishops’ Conference (2012a). Homily Notes for Priests, Choose Life 2012, October 2012

http://www.chooselife2014.ie/homily-notes-for-priests/

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