Moral Principles and Medical Practice - Abortion [Imprimatur 1897]

[Stone]

Lecture IV: Views of Scientists and Sciolists

In my former lectures, gentlemen, I explained to you the principles condemnatory of craniotomy and abortion, viewing these chiefly from the standpoint of the ethical philosopher and the jurist. Not being a physician myself, I think it proper, on matters of so much importance, to quote here freely from a lecture delivered on this subject by a late professional gynecologist, an old experienced practitioner, who was for many years a professor of obstetrics in the St. Louis Medical College. I quote him with the more pleasure because of my personal acquaintance with him, and of the universal esteem for ability and integrity in which he was held by the medical profession.

Dr. L. Charles Boisliniere, to whom I refer, had by his scientific acquirements and his successful practice, during forty years of his life, become, to a great extent, identified with the progress of the science of obstetrics in this country; and a few months before his late demise, he had published a useful work on "Obstetric Accidents, Emergencies, and Operations."

In 1892 he read, before the St. Louis Obstetrical and Gynecological Society, a lecture on the moral aspects of craniotomy and abortion, of which a considerable portion is very much to our present purpose. The Doctor herein clearly demonstrates that, in this matter at least, Ethics and Medical Science are to-day perfectly concordant. He says:

"The operation of craniotomy is a very old one. The ancients entertained the belief that, in difficult labors, the unborn child was an unjust aggressor against the mother, and must, therefore, be sacrificed to save her life.

"Hippocrates, Celsus, Avicenna, and the Arabian School invented a number of vulnerating instruments to enter and crush the child's cranium. With the advance of the obstetric art, more conservative measures were gradually adopted, such as the forceps, version, induction of premature labor, and, finally, Cesarean section.

"Cesarean section is reported to have been performed by Nicola de Falcon in the year 1491. Nufer, in 1500, and Rousset, in 1581, performed it a great many times, always successfully; so that, Scipio Murunia affirms, it was as common in France during that epoch as blood-letting was in Italy, where at that time patients were bled for almost every disease. However, a reaction soon followed, headed by Guillemau and Ambrose Pare, who had failed in their attempts at Cesarean section. In our days a marked change of opinion on this interesting and delicate question is rapidly taking place.

"With these advances in view, the question now is:

"Are we ever justified in killing an unborn child in order to save the mother's life?

"This is a burning question, and the sooner and more satisfactorily it is settled, the greater will be the peace to the medical mind and conscience.

"In answer to the question, I, at the outset, reply No, and claim that, under no conditions or circumstances, is it ever allowable to destroy the life of the child in order to increase the mother's chances of living. And the day may arrive when, by the law of the land, the act will be considered criminal and punished as such. In support of this opinion, and to illustrate this position, allow me to take a purely ethical and medico-legal view of the subject, and to relate to you a parallel case, as also the decision arrived at by the Lord Chief Justice of England, Judge Coleridge, than whom there is not a greater jurist living.

"The case is that of the British yacht 'Mignonette.' On July 5, 1884, the prisoners Dudley and Stevens, with one Brookes and the deceased, an English boy between 17 and 18 years of age, part of the crew of the 'Mignonette,' were cast away in a storm at sea 1,600 miles from the Cape of Good Hope, and were compelled to take to an open boat.

"They had no supply of water, no supply of food, and subsisted for twenty days on two pounds of turnips and a small turtle they had caught. They managed to collect a little rain-water in their oil-skin capes.

"On the eighteenth day, having been without food for seventeen days and without water for five days, the prisoners suggested that some one should be sacrificed to save the rest. Brookes dissented, and the boy, to whom they referred, was not consulted. On that day Dudley and Stevens spoke of their having families, and of their lives being more valuable than that of the boy. The boy was lying in the bottom of the boat, quite helpless, extremely weak and unable to make any resistance; nor did he assent to be killed to save the others. Dudley, with the assent of Stevens, went to the boy and, telling him that his time had come, put a knife into his throat and killed him. They fed upon his flesh for four days. On the fourth day the boat was picked up by a passing vessel, and the sailors were rescued, still alive but in a state of extreme prostration.

"The prisoners were carried to the port of Falmouth and committed for trial, the charge being murder. Their excuse was that, if they had not killed the boy and fed upon his flesh, there being no sail in sight, they would have died of starvation before being rescued. They said that there was no chance of saving their lives, except by killing some one for the others to eat. The prisoners were committed for murder and sentenced to death, but appealed to the mercy of the court, pleading ignorance. It was found by the verdict that the boy was incapable of resistance, and authorities were then quoted to prove that, in order to save your own life, you have the right to take the life of an unjust aggressor in self-defence--a principle the truth of which is universally admitted.

"But the evidence clearly showed that the defenceless boy was not an unjust aggressor against their lives, and, consequently, their only plea was that of expediency.

"In a chapter in which he deals with the exception created by necessity, Lord Hale, quoted by Justice Coleridge, thus expresses himself:

"'If a man be desperately assaulted and in peril of death, and cannot otherwise escape, except by killing an innocent person then present, the act will not acquit him of the crime and punishment of murder; for he ought rather to die himself than to kill an innocent.'

"In the case of two men on a plank at sea, which can only support one, the right of one occupant to throw the other overboard to save his own life, and in the instance of sailors, to save themselves, throwing passengers in the sea, are equally condemned by Lord Coleridge as unjustifiable homicide. So that under no circumstances is it allowable to kill an innocent aggressor to save your own life. I say innocent aggressor; but it is allowed, in self-defence, to kill, if necessary, an unjust aggressor against your life.

"This case is exactly analogous to that of the child lying helpless in its mother's womb. She causes its death by her consent to the act of her agent, the physician in attendance.

"Remark that Brookes, one of the sailors, dissented to the killing of the sailor-boy. This may happen in consultation, when one of the consultants does not admit the right to kill an unborn child. Please also remember that the sailor-boy lay helpless at the bottom of the boat when his assailants killed him to save their own lives.

"The child is not an unjust aggressor against the mother. It is placed in the womb without its consent and is defenceless. It is the mother who is, as it were, the aggressor from the obstacles caused by a deformed pelvis, tumors, etc.; and she has not the right to ask or consent to the killing of the child who does not attack her.

"Therefore, I repeat that the two cases are analogous; and if, as remarked by Justice Coleridge, murder was committed in the first instance, so is murder committed in the analogue. So, we see, the principal points of the opinion enunciated by the learned judge, and the principles therein laid down, can, with equal force, be applied to the non-justification of craniotomy, by which the life of a defenceless child is sacrificed to save the mother.

"Notice also that two of the perpetrators of the deed claimed that they had families, and that their lives were more valuable than that of the murdered boy. By craniotomists this reason or excuse is frequently given with much sentimentality to justify the killing of the child. The child, they say, has no social value, the mother is the idol of her husband, the pride of the household, often an ornament to society, the mother of living or possible children. Therefore, her life is more valuable than that of the unborn child. But who is to be the judge of the value of life? Were not Scipio Africanus, Manlius, was not Caesar, from whom the very name of the operation, delivered by section from their mother's womb? The operation was familiarly known to Shakespeare, who tells us: 'Macduff was from his mother's womb untimely ripped.'

"There can never be a necessity for killing--except an unjust aggressor and in self-defence--unless the killing can be justified by some recognized excuse admitted by the law. In the case of the murdered sailor-boy, there was not such an excuse, unless the killing was justified by what has been called necessity. But, as stated above, there never is an excuse for killing an innocent aggressor, and the temptation to the act and its expediency is not what the law has ever called necessity. Nor is this to be regretted; for if in this case the temptation to murder and the expediency of the deed had been held by law as absolute defence of the deed, there would have been no guilt in the case. Happily this is not so. The plea of necessity once admitted might be made the legal cloak for unbridled passions and atrocious crimes, such as the producing of abortion, etc.

"As in the case of this young sailor, so in the killing of an unborn child, no such excuse can be pleaded; the unborn child cannot be the aggressor, no more so than the defenceless sailor-boy was.

"To preserve one's life is, generally speaking, a duty: but it may be the plainest duty, the highest duty, to sacrifice one's life. War is full of such instances in which it is not man's duty to live, but to die. The Greek and Latin authors contain many examples in which the duty of dying for others is laid down in most glowing and eloquent language.

"'Dulce et decorum est pro patria mori,' says Horace. Such was heathen ethics, and it is enough in a Christian country to teach that there is not always an absolute and unqualified necessity to preserve one's life.

"Thus, as a parallel case, is the situation of a woman in a difficult labor, when her life and that of her unborn child are in extreme danger. In this instance, it is the mother's duty to die rather than to consent to the killing of her child.

"In a subject of such delicacy and importance I have avoided all argument based upon the doctrines of any particular religion, and considered the subject upon its purely ethical and scientific basis. I am aware that I am taking a position quite at variance with that occupied by many men influenced by former teachings and prejudices.

"I respect the honest convictions of those opposed to the opinions presented in this paper. But it is hoped that thoughtful physicians will soon reconsider their views and adopt a more just and humane method of dealing with the rights of a living unborn child.

"As a hopeful sign, it is to be noticed that a gradual change is taking place in the opinions of the profession as to the propriety of performing craniotomy. Busey says: 'To state the issue plainly, the averment must be made that no conscientious physician would deliberately and wilfully kill a fetus, if he believed that the act was a violation of the commandment "Thou shalt not kill."' It has been well said by Barnes, the ablest and most conservative defender of craniotomy, that 'it is not simply a question for medicine to decide. Religion and the civil law claim a preponderating voice. In the whole range of the practice of medicine, there arises no situation of equal solemnity.'

"Having thus far considered the subject from a purely ethical standpoint, I shall now present its scientific and practical aspect.

"Parvin says that the improved Cesarean section has given in Germany results so satisfactory that, possibly, the day is at hand when craniotomy upon the living fetus will be very rarely performed, if done at all. Kinkead, a high English authority, states: 'To reduce the bulk of the child, or to extract it afterward through a pelvis of two and one-half or less conjugate diameter, is an operation of extreme difficulty, lengthy, requiring a very great experience, as far as the mother is concerned, requiring an amount of manual dexterity rarely to be acquired outside of a large city. While, on the other hand, the Cesarean section is an easy operation, capable of successful performance by any surgeon of ordinary skill.'

"Tait remarks that he 'feels certain that the decision of the profession will be, before long, to give up the performance of such operations as are destructive to the child, in favor of an operation that saves it, and subjects the mother to little more risk. The operation of Cesarean section, or the Porro amputation of the pregnant womb, will revolutionize the obstetric art, and in two years we shall hear no more of craniotomy; for the improved method will save more lives, and is far easier of performance. It is the easiest operation in abdominal surgery, and every country practitioner ought to be able, and always prepared, to do it.' So said Lawson Tait in 1888.

"I could quote many other authorities, showing the change that is taking place in the profession upon this important question. It is established by the consensus of professional opinion that craniotomy has been frequently performed in cases where delivery could have been safely accomplished by the forceps, turning, and even by the unaided power of nature (Busey); and there is no case known to him where a woman, on whom a section had been successfully performed, has refused to submit to its repetition in subsequent pregnancies. In Belgium the Cesarean section has been performed seven times on the same woman, and in Philadelphia three times. Doctor Bretoneaux, of Tours, has performed it six times on the same woman; and this woman his wife. 'The brutal epoch of craniotomy has certainly passed. The legitimate aspiration and tendency of science is to eliminate craniotomy on the living and viable child from obstetric practice.'--Barnes' words as quoted by Busey. Tyler Smith is in perfect accordance with Barnes. Barnes again writes: 'For the Cesarean section two very powerful arguments may be advanced. First, that the child is not sacrificed. Second, that the mother has a reasonable prospect of being saved.'

"Late reports of the Dublin Rotunda Hospital show that, in 3,631 cases of labor, craniotomy was performed only four times, and in three of these, positive diagnosis of the child's death was ascertained before the operation. In one of these cases the diagnosis was doubtful.

"More Madden, a celebrated obstetrician of forty years' experience, never performed it once.

"'The brilliant achievements in abdominal surgery give assurance that the Cesarean section is not only a legitimate operation, but one almost free from danger; also, that the tragic scenes heretofore witnessed in certain cases, in which the destruction of the child was resorted to, may be relegated to history (A. P. Clarke).'"

Further on, Dr. Boisliniere speaks more directly of abortion. He says:

"The principle once admitted that you are not justifiable in killing an innocent aggressor except in self-defence, equally prohibits any interference with early gestation.

"From the moment of conception the child is living. It grows, and what grows has life. 'Homo est qui homo futurus,' says an ancient and high authority. "Therefore, feticide is not permissible at any stage of utero-gestation.

"The killing of the defenceless fetus is sometimes done in cases of uncontrollable vomiting of pregnancy, in cases of tubal or abdominal gestation, and the killing of the fetus is done by electricity, injections of morphine in the amniotic sac, the puncturing of that sac, etc.

"This practice is too lightly adopted by thoughtless or conscienceless physicians. This practice is much on the increase. I once heard a known obstetrician of the old school say: 'I would as lief (willingly) kill, if necessary, an unborn child as a rat.' So much for the estimate he put on the value of human life! O tempora! O mores!

"Is it not time that this wanton 'massacre of the innocents' should cease?

"Without wishing to load this paper with elaborate statistics, I shall furnish the latest arrived at in the two operations of craniotomy and Cesarean section.

"In the combined reports of the clinics of Berlin, Halle, and Dresden, the maternal mortality in craniotomy was 5.8 per cent--of course, one hundred per cent of the children lost.

"In Cesarean section the maternal mortality was eight or eleven per cent; children's mortality, thirteen percent.

"Caruso, the latest and most reliable statistician, not an optimist, sums up the results from the different clinics, and comes to the conclusion that craniotomy shows ninety-three and one one-hundredth mothers recover, Cesarean section eighty-nine and four one-hundredths.

"Caruso, therefore, concludes that craniotomy on the living child is to be superseded by Cesarean section. He says, therefore, that the mother has three chances out of four, and her child nine out of ten, for life.

"Leopold, as stated above, shows a much better result, viz.: ninety-five mothers saved out of one hundred by Cesarean section, a result equal that obtained in craniotomy."

You notice, gentlemen, that the eminent physician whom I have been quoting speaks with much indignation of the killing of the embryo, when he calls it a "massacre of the innocents." By this odious term we usually denote the massacre of the babes at Bethlehem, ordered by the infamous Herod to de fend himself against the future aggression, as he imagined, of the new-born King of the Jews. A craniotomist would, no doubt, feel insulted at being compared with Herod. And yet, if we examine the matter closely, we shall find that the two massacres, Herod's and the craniotomist's, could only be defended by the same plea, that of necessity. "Necessity knows no law," writes Dr. Galloway, in his defence of craniotomy, to which I referred in a former lecture. "The same law," he writes in the "Medical Record" for July 27, 1895, "which lies at the basis of Jurisprudence in this respect justifies the sacrifice of the life of one person when actually necessary for the preservation of the life of another, when the two are reduced to such extremity that one or the other must die. This is the necessitas non habet legem."

Did not Herod look on the matter just in that light? Expecting Christ to be, not a spiritual, but a temporal ruler, as the Jewish nation supposed at the time, he looked upon it as a case of necessity to sacrifice the lives of the innocents for his own preservation. "Necessity knows no law" was his principle. True, many had to die on that occasion to save one; but then he was a king. Anyhow, their death was necessary, and necessitas non habet legem; that settles it: Herod must not be blamed, on that principle. It is not even certain that, cruel as he was, he would have confessed, with the modern obstetrician, "I would as lief (willingly), if it were necessary, kill an unborn child as a rat."

Such sentiments, revolting as they are, and a disgrace to civilization, are the natural outcome of rash speculations about the first principles of morality.

The principle "Necessitas non habet legem" has indeed a true and harmless meaning when properly understood; it means that no law is violated when a man does what he is physically necessitated to do, and that no law can compel him to do more than he can do. Thus a disabled soldier cannot be compelled to march on with his regiment; necessity compels him to remain behind. In this sense the principle quoted is a truism; hence its universal acceptance. Applying the same principle in a wider sense, moralists agree that human law-givers do not, and in ordinary circumstances cannot, impose obligations the fulfilment of which requires extraordinary virtue. Even God Himself does not usually exact of men the performance of positive heroic acts. But no such plea can be urged to justify acts which God forbids by the natural law.[1] When necessity is used as a synonym for a "very strong reason," as it is in the plea of the craniotomist, then it is utterly false that very strong reasons for doing an act cannot be set aside by a divine law to the contrary; what is wrong in itself can never become right, even though the strongest arguments could be adduced in its favor. It would be doing wrong that good may come of it, or making the end justify the means. Such principles may be found in the code of tyrants and criminals, but should not be looked for in the code of Medical Jurisprudence.

[1] See this point more fully treated in the Author's "Moral Philosophy," Book. I. c. ii., "The Morality of Human Acts."

There is but one plea left, I believe, on which, of late years, it is sometimes attempted to justify the murder of little children. It is the plea of some evolutionists who maintain that the infant has not yet a true human soul. I should not deign to consider this theory if it were not that I find it seriously treated by a contributor to the "Medical Record," in an article which, on September 4, 1895, concluded a long discussion on craniotomy published in that learned periodical. The writer of this article asserts: "Procuring the death of the fetus to save the life of the mother is, I am sure, to be defended on ethical grounds." And here is the way he attempts to defend it: "We may safely assume," he argues, "that the theory of evolution is the best working hypothesis in every branch of natural science. We are learning through Herbert Spencer and all late writers on ethics and politics, that the same principle will best explain the facts" (p. 395).

I do not deny that a certain school of scientists is trying to rewrite all history and all Ethics and Jurisprudence. But the writer strangely misstates the case when he says that "all great writers on ethics and politics" agree with Mr. Spencer. Besides a multitude of others, Lord Salisbury for one, has clearly shown of late that the school of agnostic evolutionists is coming to grief; it has had its short day, and it is now setting below the horizon of ignominy and subsequent oblivion. The writer of the article in question does not attempt to prove the evolution theory; therefore I need not stop to disprove it. But he makes the following application of it to our subject--an application so shocking to humanity and so revolting to common sense that, if it is logical, it is by itself sufficient to refute the whole theory of Mr. Spencer and his school.

He argues that, if that theory be admitted, it must necessarily follow that, while the human embryo is from the first alive, it is not a human being until it has developed and differentiated to such a point as corresponds to that point at the birth of the race where the animal becomes a man. "I am sure," he adds, "I do not know when that occurred in the past, and I do not know at what point it occurs in the individual . . . . In inquiring for that distinct feature which distinguishes the man from the animal, I find none but mentality. If we wait for distinct mentality to appear in the development of the individual, it would be some time after birth."

According to this reasoning a child is not known to be a human being till some time after its birth. And this is not uttered by some speculative philosopher in his closet, but by a medical practitioner on his daily rounds, tools in hand, as it were, to carry out his theory and break the skulls of any and all luckless babes that may come in his way in the exercise of what he calls his legitimate practice. How long after birth the child remains without becoming a human being, he does not pretend to know; they remain non-human till they manifest mental action. Till then, not being human, he assigns them no human rights--no rights at all which we are conscientiously obliged to respect. Herod may have been right after all when he appointed the term of two years old and under as the limit of the butchery at Bethlehem. The writer pretends to lessen the horror inspired by his theory by referring to some restrictions of canon law. But what do he and his like care about canon law? He would be the first to scout the idea of letting canon law limit his freedom of action and speculation.

What would be the real results in practical life if we were to accept as rules of conduct these rash theories of agnostic philosophers and infidel scientists? Justly does the writer proceed to say: "I am well aware that the idea arouses antagonism and inflammatory denunciation in some minds." Certainly it does. He adds: 'That it [the idea] will prove to be the true one, however, depends only on the truth of the general theory of development.' If this be the logical consequence of evolution, or Darwinism, as he calls it, then all the worse for Darwinism. Society cannot get along on a theory that begets such principles of action; the more so since, in Spencer's and in Darwin's system, the human soul, even in grown persons, is only a material modification of the body and perishes with it in death. Hence there would be no responsibility after death. On this theory the physician is only a lump of very curiously evolved matter; he, too, like the embryo, is without an immortal soul, is not a free being, and therefore is incapable of having rights or duties.

Before we remodel our codes of Ethics and Jurisprudence by the admission into them of such destructive and revolutionary principles, we shall at least be allowed to challenge these aggressors and ask solid proof of their rash innovations. We may address to them the wise words uttered against similar speculators by one of the most logical of modern reasoners, the illustrious Cardinal Newman. "Why may not my first principles contest the prize with yours? they have been longer in the world, they have lasted longer, they have done harder work, they have seen rougher service. You sit in your easy-chairs, you dogmatize in your lecture-rooms, you wield your pens: it all looks well on paper; you write exceedingly well; there never was an age in which there was better writing, logical, nervous, eloquent, and pure,--go and carry it out in the world. Take your first principles, of which you are so proud, into the crowded streets of our cities, into the formidable classes which make up the bulk of our population: try to work society by them. You think you can; I say you cannot; at least you have not as yet, it is to be seen if you can . . . . . My principles, which I believe to be eternal, have at least lasted eighteen hundred years; let yours last as many months . . . . These principles have been the life of nations; they have shown they could be carried out; let any single nation carry out yours" ("Present Position of Catholics in England." p. 293).

Gentlemen, let no one trifle with the principles of Ethics and Jurisprudence; human society cannot get along without them. Morality is the heart of civilization: its principles are the life-blood, which it sends forth to feed and warm and strengthen and beautify all the organs of its earthly frame. A flesh-wound may be healed, a bone may be set, it may knit and grow vigorous again; but you must not puncture the heart, nor attempt to change the natural channels of the circulating blood, under the penalty of having a corpse on your hands. So you must respect the eternal laws that direct the current of man's moral actions, the principles of Ethics and Jurisprudence.