Tubal Ligation and Achondroplasia

Douglas P. McManaman
January 7, 2021
Reproduced with Permission

For over 30 years I've taught senior students - many of whom were on their way to medical school - about the moral difference between contraception and the legitimate use of Natural Family Planning, and why contraception as such is morally problematic. Although I was for the most part successful at helping my students to understand the moral difference, I wasn't always successful at convincing them that contraception is morally impermissible. That, however, was not and is not my problem; for the conscience of another person is outside my domain of responsibility.

Nevertheless, in the back of my mind was a moral problem that I'd hoped my students would never think to ask me about; the problem had to do with the case of a woman who for serious health reasons should not have another child. Is it morally permissible for her to have a tubal ligation? I hadn't thought about that question enough and had no interest in thinking about it further - I was more interested in other things; moreover, no student thought to ask me about it.

In recent years, however, I have begun to think about this problem more seriously - not to mention that a couple about to be married recently asked me about a real case that was, for them, close to home. What concerns me in particular is the case of a woman who has achondroplasia, which is a kind of dwarfism. A Little Person as a rule cannot have a vaginal delivery but can only give birth by C section. Moreover, she can only have a maximum of three C sections. Is it morally permissible for her to have her tubes tied after the third C section? In other words, is doing so a contraceptive act?

Intuitively I believed and continue to believe that this is morally acceptable, but I was unable to offer a rational explanation to support it. I first began to consider this issue shortly after my friend, Dr. Joseph Boyle, died - he was, in my view, the best analytical moral philosopher in the world and likely would have had little trouble with the issue. Unfortunately, I wasn't able to ask him. So, I thought about this on my own periodically for a few years. What follows is my own attempt at a resolution. I make the case that tubal ligation in this specific scenario involving a woman with achondroplasia is not contraceptive and so is morally permissible.

The Contra-life Nature of Contraception

What makes an act contraceptive is the contra-life will or intention. Contraception involves projecting a possible baby and taking steps to prevent that possible baby from becoming an actual baby. [1] As such, contraception need not involve the sexual act. A mother could project a possible baby after considering the prospects of her daughter engaging in sexual intercourse at an after-prom party, and then take steps to prevent that possible baby from becoming an actual baby by dropping a contraceptive in her daughter's tea. Such an act is essentially contraceptive on the mother's part; she wills that her daughter not become a mother, at least not at this time.

Other acts may appear to be contraceptive but are not so. For example, a woman who is taking the birth control pill to raise her estrogen level is not involved in contraceptive behavior as such; for she is not projecting a possible baby and taking the pill in order to prevent that possible baby from becoming an actuality. Infertility is outside of her intention ( praeter intentionem ). Whether using the pill as a medication in this context is sound medical advice is another matter altogether, outside the competence of a moral philosopher or theologian as such.

The central question here is whether a tubal ligation in this specific scenario amounts to a projection of a possible baby, followed by the decision to willingly prevent that possible baby from becoming an actual baby. An argument can be made that it does not, at least not necessarily. Allow me to begin with some basic but important distinctions.

Basic Distinctions on the Nature of a Human Action

Traditional Catholic morality distinguishes between three elements of the human action: the moral object, motive, and circumstances. This distinction, however, is insufficient to deal adequately with this issue. The reason is that the distinction does not go far enough - it is information deficient. It is the moral object of the act that needs further analysis - motive and circumstances are irrelevant at this point; for we will assume that the motive is good and the circumstances are demanding. [2]

The specific nature of an action (the moral object) cannot be understood solely through a consideration of what I will refer to as the husk of the act - what Joseph Boyle would refer to as a "hunk of behavior". For example, imagine someone picking up a gun and shooting another human being and killing him. The only information provided here constitutes the "husk" of the act, and that information alone does not tell us what is being done, that is, what kind of act it is. An act receives its specific nature from the relationship that exists between the will and the basic intelligible human good that the will bears upon. Hence, we simply don't know what is being chosen, for the relationship that exists between the shooter's will and the basic intelligible human goods that his will might bear upon is not manifest, and so we cannot pronounce on the morality of the act. It could be an act of murder, or an act of self-defense, or a matter of testing a bullet proof vest. What is included within the adopted proposal, that is, the intentionalness of what he is doing, is not on display for the senses to behold.

The "what" of an action describes its moral species. What gives an action its specific nature (what it is essentially) is what I will call the proximate end, to more clearly distinguish it from the ultimate end, which is the motive (which we have assumed is good). To get a better handle on this, consider the following analogy from the realm of production. I walk by a shop, look in the window and ask myself: "What" is that person making? We witness, through the window, a series of actions, such as picking up planks of wood, cutting the wood, applying glue, changing the router bits, sanding, etc. These acts are all parts of a series of actions that as a whole constitute the single act of making a bookshelf. The making process will cease at a certain point, and that point is achieved when the form (i.e., bookshelf) is in the matter (wood), or when the wood has taken on the form of a bookshelf. The proximate end of the manufacturing process is what the carpenter intends, which is the realization of the form in the matter. He also, at the same time, intends the ultimate end, which is the end of the generated product (as opposed to the end of the generation, or the proximate end). The ultimate end of the generated product may vary from person to person, but in this case a simple answer is to hold books. The proximate end, however, answers the question: What is he making?

In the context of human action, it is the proximate end that defines an act. The distinction between a) the end of the generation (the form) and b) the end of the generated (the purpose of the product) corresponds, in the realm of moral action, to the distinction between (a) the intentionalness of what one is doing (the moral object), and (b) the ultimate reason why it is being done (motive). It is very important that one distinguish between these two kinds of intention; the result of not doing so is that the essential meaning (species, nature) of the action will likely be missed. At that point, two acts that have an entirely different meaning will be equated simply because the "husk" of the one act is identical to the "husk" of the other, and so we erroneously conclude that picking up a gun and shooting a person amounts to murder, or swallowing a birth control pill amounts to contraception, or turning off a respirator amounts to murder, etc. Given only the husk of the act, it is not possible to determine the meaning of the act, its specific nature, that is, whether the act is murderous or not, contraceptive or not, etc.

Let us consider another illustration. I turn on the motor of my car simply in order to pump exhaust into the atmosphere. That's all that I am doing, pumping exhaust into the atmosphere in order to increase pollution in the air, which is a morally irresponsible act. That, however, is a specifically different action than turning on the motor in order to heat up the car (on a cold winter day), which in turn is a specifically different action than turning on the motor and driving to the hospital. In all three instances, I am still pumping exhaust into the atmosphere, but in the latter two instances, that's not "what I am doing". In other words, pumping exhaust into the atmosphere is not included in my proposal to warm up the cab of the car nor to drive to the hospital, but outside of it. My intention (proximate end) in the latter instance is to get to the hospital; turning on the motor is an act within a series of acts that on the whole constitute the single act of driving to the hospital (i.e., for an appointment). The polluting of the atmosphere is outside of my intention, not part of it, and the act as a whole is specifically different from the act of simply turning on the motor "in order to pollute the atmosphere".

Consider a series of acts that constitute a single act of defending against an aggressor. A person a long way off is approaching us in a tank, and his purpose is to destroy us. We begin the process of producing a weapon sufficient to repel it. The result will be the death of the aggressor operating the tank, but our end is to repel the aggressor (the tank has become an extension of himself), not kill the aggressor, even though his death is inevitable. Every act involved in the production of a weapon sufficient to repel the tank is part of the single act of stopping the aggressor (or preserving our lives). There is nothing murderous in the acts that are an essential part of this single act. Even the final firing of this weapon (anti-tank missile) is an act that is part of this series of acts, and that act is not necessarily murderous.

Tubal Ligation as a Part of a Single Medical Act

Just as there are a multitude of acts that are parts of a series of acts which as a whole constitute a single action with a determinate meaning, so too one may look at tubal ligation in the case we are discussing as part of a series of acts which together constitute a single act which is not necessarily contra-life. It is not an act of contraception, performed as a means to an end. The tubal ligation in this context is a different kind of action, although the husk of the act is indistinguishable from an ordinary case of tubal ligation sought for the sake of preventing a possible baby from becoming an actual baby. In the case of a woman with achondroplasia who has had three C sections, she would like to have more children, but her body does not permit it. She has a good reason to avoid another pregnancy that requires a C section. In fact, pregnancy considered simply as carrying a baby is not the problem. Delivery is the issue, and delivery by C section has become dangerous. In her mind, it is not the human life as such that is dangerous, nor is it the pregnancy considered idealistically. It is the delivery - if one insists that prevention of pregnancy is the object of the act, then it is pregnancy considered as a whole, which includes the delivery, and it is the conditions surrounding delivery that renders the state of pregnancy, in this case, somewhat pathological. She does not choose to act against a possible baby - that a possible baby is involved is incidental. [3]

But how is a possible baby in this case incidental? Consider the case of an ectopic pregnancy. Here, an actual baby is developing in a fallopian tube. The surgeon proceeds to remove the baby by clamping on the fallopian tube, cutting it, and removing what has been cut. The surgeon kills the embryo by clamping on the tube, but the killing of the embryo is praeter intentionem , that is, outside of his intention. That the "growth" within the tube is a child is incidental. He would have to do the same thing if it were a non-human growth that will in time cause a hemorrhage. In this case, the surgeon is acting against a life-threatening situation by removing the child in the fallopian tube. That what is growing in the fallopian tube and about to cause a hemorrhage is a developing baby is incidental; he wishes it were not so; nevertheless, the death of the child is not positively willed or intended. [4] Similarly, the mother with achondroplasia projects the state of having to deliver by C section and considers the negative repercussions of this fact on her health, and the choice to have her tubes tied is directed specifically against this state of affairs and its negative repercussions, that is, directed immediately to her life. [5] The fact that in tying her tubes a possible baby is kept from becoming an actual baby is outside of her intention. If there were no issues with this unique pregnancy brought on by her condition, that is, no life-threatening aspects, then her only reason to have her tubes tied would be to prevent that possible baby from becoming an actual baby, which amounts to contraception. But this is not what she is doing (it is not her moral object); she is acting to prevent a real state of affairs that is life-threatening, which she has a responsibility to do.

If the tubal ligation for some reason did not work and she became pregnant and was able to have a safe C section, it is possible that this would be received as welcome news. Not only did she not lose her life, she has another child to boot. [6] If, however, her intention were to prevent a possible baby from becoming an actuality, the new life conceived would not be welcome news, for her intention (the intentionalness of what she is doing) was to prevent a possible baby from becoming an actuality, thus her intention was frustrated. But that is not necessarily the object of her action. It is incidental, purely contingent, and morally irrelevant that there is only one reason to get a C section, namely, to deliver a baby; if we lived in a universe in which large 12-pound growths periodically made their way through the vaginal canal, she would still be in trouble and would have to intervene.

In cutting and tying the fallopian tubes, the surgeon is performing an act that is part of a series of acts that has as its proximate end the preservation of the life of the mother, or the prevention of a state of affairs that includes a dangerous delivery. Although it may appear to be a contraceptive action, a case of projecting a possible baby and preventing that possible baby from becoming an actual baby, it is not necessarily so.