Abortion and the Principle of Double Effect

Introduction and purpose 

Over the last few years, Roman Catholic terminology has become more common within public discussion of abortion. As just 22% of the US population is Catholic [1], the presence of uniquely Catholic terms and principles within abortion discourse can be confusing to the remainder of the population.

One such term is double effect, short for the Principle of Double Effect (also called the Doctrine of Double Effect). While double effect is a Roman Catholic doctrine, it has gained popularity among protestant and atheist segments of the pro-life movement. It is therefore important to understand and recognize this term/doctrine regardless of one's view on abortion or one’s religious/non-religious beliefs.

The purpose of this essay is to provide the reader with an understanding of the Principle of Double Effect and examples of its application. Criticisms of the principle are also provided at the end.

Outline 

1. Prerequisite terminology

1. Abortion

2. Direct abortion

3. Indirect abortion

2. The Principle of Double Effect

3. Applications

1. Pulmonary hypertension

2. Ectopic pregnancy

3. Miscarriage management

4. PPROM

4. Criticisms

Prerequisite terminology 

To understand double effect, it is helpful to first know the particular way in which the Catholic Church defines abortion and thus distinguishes between direct and indirect abortion. 

The term abortion came "into the English language around 1537" and was the general, morally neutral "term for any pregnancy that didn't come to term — human intervention or no" [2]. And the definition has changed very little since that time: abortion is an intent-free, medical term defined as the ending of a pregnancy before fetal viability [3] [4] [5], though "some medical dictionaries mention 20 weeks' gestation or 500 g as the limit" [6]. Like the Old English, the medical definition includes both induced and spontaneous abortions. You can read more here.

The Roman Catholic Church, however, does not use the official medical definition. Rather, the church established its own definition of the term: "the directly intended termination of a pregnancy before viability or the directly intended destruction of a viable fetus" [7]. 

The Catholic definition is based on intent and direct action.

"It should be everyone's business when unborn babies are being directly and intentionally killed (aborted)." - Live Action Ambassador

In his encyclical Evangelium Vitae, Pope John Paul II wrote, "I declare that direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder, since it is the deliberate killing of an innocent human being" [8] Thus the church considers a direct abortion to be an abortion that "is willed as an end (that is, as a goal) if one’s goal is to end the pregnancy," or an abortion that "is willed as a means if ending the pregnancy is the instrument one uses to obtain some other goal" [9]. Therefore, "whenever a child is actively killed, even as a means of protecting the mother’s life, that constitutes direct abortion" [10]

On the other hand, "an abortion would be indirect if it were used neither as an end nor as a means. If a pregnant woman has a cancerous womb that must be removed, removing it would produce an indirect abortion. The child would die after the womb is removed, but the child’s death would neither be an end nor a means" [11]

"No mother is allowed, under any circumstances, to permit the death

of her unborn infant, not even for the sake of preserving her own

life." - Bishop Spaulding of Baltimore (1869), Boston Medical and Surgical Journal, LXXV, No. 14

The Principle of Double Effect 

"The Principle of Double Effect is used to determine when an action which has two effects, one good and one evil, may still be chosen without sin" [13]. "Thomas Aquinas is credited with introducing the principle of double effect in his discussion of the permissibility of self-defense in the Summa Theologica (II-II, Qu. 64, Art.7)" [14]. While the Principle of Double Effect has been configured and reconfigured many times over since Aquinas's time, the Catholic Church's configuration is the sole subject of this essay.

"The double effect doctrine forbids the achievement of good ends by wrong means but it permits actions with a double effect, both good and bad, under certain conditions" [15] “Killing one’s assailant is justified, [Aquinas] argues, provided one does not intend to kill him" [16]. Double effect prohibits intentionally ending the life of one human to save the life of another.

In order for an action to be morally licit, it must meet four criteria [17]:

1. The action must be morally good, or indifferent, as to object, motive and circumstances.

2. The bad effect(s) may only be tolerated, not directly willed.

3. The good effect must be caused at least as directly as the bad.

4. The good effect(s) must be proportionate to compensate for the bad effect(s).

Regarding medically-necessary abortions, the four criteria above translate to the following [18]:

1. Treatment is directly therapeutic in response to a serious pathology of the mother or child.

2. The good effect of curing the disease is intended and the bad effect foreseen but unintended.

3. The death of the child is not the means by which the good effect is achieved.

4. The good of curing the disease is proportionate to the risk of the bad effect.

According to Catholic teaching, "neither the life of the mother nor that of the [embryo/fetus] can be subjected to direct suppression" [19]. Therefore, the "central requirement of the principle of double effect is point number three above, that is, that the bad effect (in this case, the death of the child), cannot be the means by which the good effect is achieved, which would place the bad effect under the agent’s overall intention" [20].

On the other hand, the principle of double effect "allows a surgeon to remove a uterus with a cancer, even though it contains a live fetus" [21]. In this scenario, the death of the fetus is considered "a side effect of the good action," the hysterectomy, "not the means of achieving it" [22].

The church contends that "...the excision of a cancerous, pregnant uterus, is sometimes ethically permissible and should not be called an abortion" [12]. Hence indirect abortion is considered not an abortion.

"Never and in no case has the Church taught that the life of the child must be preferred to that of the mother. It is erroneous to put the question with this alternative: either the life of the child or that of the mother. No, neither the life of the mother nor that of the child can be subjected to direct suppression. In the one case as in the other, there can be but one obligation: to make every effort to save the lives of both, of the mother and the child." - Pope Pius XII, Allocution to the Association of Large Families, AAS (1951), XLIII, p. 855.

Application 

Pulmonary hypertension 

"Consider a woman who will die with her fetus from eclampsia or malignant hypertension within hours, unless the fetus is aborted. An abortion will save the mother and deprive the fetus of just a few hours of intrauterine life" [23]. The principle of double effect forbids this [24].

In 2009, a Catholic hospital Phoenix performed an abortion to preserve the life of a pregnant patient who doctors had assessed as having a 100% chance of death were an abortion not performed [25]. The 27-year-old mother of four was in her first trimester of pregnancy and had been diagnosed with severe pulmonary hypertension [26].

Upon learning of the abortion, the bishop of the Catholic Diocese of Phoenix initiated talks with the hospital, seeking to secure a promise from hospital administrators that no more medically-necessary abortions would be performed at the hospital. When administrators did not comply, the bishop revoked the Catholic status of the hospital [27]. A Catholic nun who worked there as a nurse and had assisted in the procedure was excommunicated from the church, and her post at the hospital was subsequently resigned [28]. 

The bishop's actions later came to the attention of the public, sparking backlash [29]. Mistakenly, some suggested that the 2009 abortion was morally licit under the principle of double effect. A statement from the medical ethics director of the Catholic Diocese of Phoenix, Father John Ehrich, “Catholic morality and pregnant mothers who are at risk," was posted on the diocesan website and was reported on by other diocese [30]:

“The unborn child can never be thought of as a pathology or an illness,” the priest said. “That is, the child is not that which threatens the life of the mother, rather it is the pathology or illness (cancer, premature rupture of membranes, hypertension, preeclampsia, etc.) which threatens the mother’s life.” 

Adding that “no physician can predict what will happen with 100 percent accuracy,” Father Ehrich said, “What we should not do … is lower risks associated with pregnancy by aborting children. … When we try to control every possible situation in life, we end up playing the role of God.”

The hospital issued its own statement defending its actions and that of the excommunicated nun [31]. The statement said, in part [32]:

"Morally, ethically, and legally, we simply cannot stand by and let someone die whose life we might be able to save."

*You can read the hospital’s moral analysis here.

"It is hard to justify a principle which demands an avoidable extra death." - AB Shaw, "Journal of Medical Ethics"

Ectopic pregnancy

Ectopic means "occurring in an abnormal position or in an unusual manner or form" [33]. "An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. Almost all ectopic pregnancies—more than 90%—occur in a fallopian tube," but can occur intrauterine in a cesarean section scar [34]. "As the pregnancy grows, it can cause the tube to burst (rupture). A rupture can cause major internal bleeding. This can be a life-threatening emergency" [35]. 

“An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment” [36]. “The most common drug used to treat ectopic pregnancy is methotrexate. This drug stops cells from growing, which ends the pregnancy. The pregnancy then is absorbed by the body over 4–6 weeks. This does not require the removal of the fallopian tube” [37]. “For ectopic pregnancies, the use of methotrexate seems increasingly to be the preferred treatment” because this method  preserves the patient’s fertility and relieves the patient of incurring the added risks associated with surgery [38]. 

However, many Catholic theologians consider methotrexate treatment for ectopic pregnancy to be a direct abortion and thus a violation of the Principle of Double Effect.

According to the “Ethical and Religious Directives for Catholic Health Care Services,” a set of policy prescriptions published by the United States Conference of Catholic Bishops (USCCB) which govern healthcare in Catholic hospitals [39], "In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion" (Directive #48) [40] [41]. Therefore, instead of treating a patient with a noninvasive injection of methotrexate, “Catholic medical experts agree that women can undergo a partial salpingectomy, which is the removal of a portion of the Fallopian tube where the unborn baby is located… The intent and the direct action is to remove damaged tissue, not to end an unborn baby’s life" [42]. The Catholic Health Association of the United States explains [43]:

While salpingectomy results in the death of the embryo, the embryo's demise is not intended, nor is there any direct attack on the embryo. A pathological [fallopian] tube is removed that results in two effects — prevention of harm to the mother (the intended effect) and the demise of the embryo (the unintended effect). There is clearly a proportionate reason — the mother's well-being is preserved, and the embryo, though it dies, actually has no chance at survival. Virtually all theologians agree that salpingectomy constitutes an indirect abortion and so is morally licit. The demise of the embryo is foreseen, but not intended.

Miscarriage management

There are many different types of miscarriages (spontaneous abortions), including threatened, inevitable, incomplete, septic, and

Complete [44]; and despite common misconception, not all miscarriages involve an already deceased embryo/fetus. As such, "there are three treatment options for miscarriage — expectant management or watchful waiting, surgical evacuation of the products of conception and medical (chemical) evacuation" [45].

"Surgical intervention has been the conventional treatment for first-trimester pregnancy loss and is the treatment of choice for patients whose condition is unstable" [46]. "Surgical treatment (dilation and curettage or vacuum aspiration) is the fastest way to complete the miscarriage. It shortens the duration and heaviness of bleeding and avoids the pain associated with miscarriage" [47]. 

Medical (chemical) "management involves the use of a drug, generally misoprostol, to prompt the completion of the miscarriage. It has been shown to be as effective as manual vacuum aspiration, with complete evacuation rates of 95 percent to 99 percent after one or two weeks" [48]. Medical management also includes induction abortion, that is, "ending a pregnancy by using medicines to start (induce) labor and delivery" [49] before a fetus has reached viability, and is thus not expected to survive outside of the uterus [50].

Based on the Principle of Double Effect, two directives within the “Ethical and Religious Directives for Catholic Health Care Services" govern miscarriage management [51]:

• Directive 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.”

• Directive 48: “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…”

Regarding Directive # 47, the Catholic Health Association of the United States explains, “The direct purpose of the intervention is to save the life of the mother or protect her health, and not to terminate the life of the fetus. Second, the woman must have a proportionately serious pathological condition, and the intervention is a treatment or cure for that. Third, the intervention should be a last resort (i.e., waiting is not feasible, and lesser means have not been or will not be effective). Fourth, the directive recognizes that the intervention might result in the death of the fetus, hence, in some cases, the presence of fetal heart tones does not preclude an intervention” [52]

In cases where a fetal heartbeat can still be detected, which of the three treatment methods does the Catholic Church deem licit? 

“In a threatened miscarriage, expectant management is the morally acceptable treatment because the fetus remains alive and the pregnancy may continue on to term” [53]. On the other hand, medical (chemical) treatment through misoprostol, as well as surgical treatment would not “meet the requirements of Directive 47 or the conditions necessary for an indirect abortion”[54]

"When an inevitable miscarriage is at issue” and “if expectant management is not feasible,” then “the use of a pharmaceutical agent to induce labor” is deemed licit [55]. According to the Catholic Health Association of the United States, induction abortion in this scenario “is not a direct attack on the fetus, but rather a measure to evacuate the uterus in order to resolve a pathological condition. Evacuation of the uterus is the only way to ultimately resolve the pathological condition, in the situation of an inevitable miscarriage. The use of a chemical agent to induce labor… would be considered an indirect abortion, from a Catholic perspective" [56]. 

In contrast, surgical treatment is often prohibited as a direct abortion [57].

In practice, however, have been known cases of Catholic hospitals delaying or denying evacuation of the uterus in cases of miscarriages and PPROM [78].

"...the child may never be killed on the pretext of saving the mother's life." - Rev. E. M. Robinson, O. P., "Exception: To Save the Life of the Mother"

PPROM

Preterm premature rupture of membranes, that is, "when the amniotic sac breaks before 37 weeks of pregnancy and labor has not started within 1 hour," [58] is a serious pregnancy complication that "is responsible for, or associated with, approximately one-third of preterm births and is the single most common identifiable factor associated with preterm delivery" [59]. "In PPROM, the fluid in the sac leaks or gushes out of the birth canal. This is also known as a person's water breaking" prematurely [60].

PPROM "poses a serious risk of chorioamnionitis — an infection of placental tissues which can lead to the death of both the mother and fetus within a very short time" [61]. Once an infection is detected, "progressive, severe infection of the mother and the fetus can be expected within hours, a life-threatening situation for both" [62].

Comparisons of maternal morbidity outcomes following expectant management and induced abortion for PPROM show that “Expectant management for preterm premature rupture of membranes at” less than weeks’ gestation is “associated with a significantly increased risk of maternal morbidity when compared to termination of pregnancy” [63]. Women treated through expectant management have an increased risk of developing chorioamnionitis and of postpartum hemorrhage [64]. Furthermore, the following outcomes only occurred after expectant management: admission to the intensive care unit, unplanned hysterectomy, and cesarean deliveries [65]. To decrease maternal morbidities, labor induction abortion (inducing labor and delivery prior to fetal viability) "for maternal benefit is commonly recommended in practice, even though the fetus cannot be expected to survive" if it has not yet reached viability [66].

According to the Catholic Health Association of the United States, "Ethically, if infection develops… labor and delivery may be induced. This would constitute an indirect abortion because it fulfills the conditions of the principle of double effect” [67]. Catholic bioethicists Peter J. Cataldo, Ph.D., and T. Murphy Goodwin, MD explain [68]: 

"In the case of PPROM with evidence of infection in the uterus, the intention of the physician inducing labor is to cure the infection by removing the infected placenta and membranes of the gestational sac. The good effects of curing the mother of … PPROM are not caused by the death of the baby [third condition]. … [T]he removal of the offending organ, the placenta and membranes, allows survival of the mother, which would otherwise be in doubt [fourth condition]."

Criticism

While the Roman Catholic Church condemns consequentialism, "many criticisms of the principle of double effect do not proceed from consequentialist assumptions or skepticism about the distinction between intended and merely foreseen consequences" [69]. Rather, "they ask whether the principle adequately codifies the moral intuitions at play in the cases that have been taken to be illustrations of it. One important line of criticism has focused on the difficulty of distinguishing between grave harms that are regretfully intended as part of the agent’s means and grave harms that are regretfully foreseen as side effects of the agent’s means. Since double effect implies that the latter may be permissible even when the former are not, those who wish to apply double effect must provide principled grounds for drawing this distinction" [70]. The Stanford Encyclopedia of Philosophy notes, "The application of Double Effect to explain the permissibility of performing a hysterectomy on a pregnant woman and the impermissibility of performing an abortion to save a woman’s life is often singled out for criticism on this score" [71]. Does a principle which prescribes omissions in patient care, instances of which are well documented [78], truly encapsulate morality? Ethics?

"The doctrine allows a doctor to remove a cancerous uterus containing a fetus, because the death of the fetus is just a side effect of the hysterectomy," even though, if the hysterectomy were to be delayed until the fetus was viable, fetal life might be saved [72]. In contrast, in the case of life-threatening preeclampsia, the doctrine prohibits a abortion to save the patient’s life and withholding care would result in the deaths of both the pregnant patient and the fetus.  "A doctrine which allows the fetus to be killed in this case but not in the previous case, is implausible" [73]. "It is hard to justify a principle which demands an avoidable extra death" [74].

"A fundamental flaw is its failure to recognise that the person affected by an action is the one who must evaluate the harm and benefit arising from it" [75]. "Consider ectopic pregnancy. The doctrine permits the removal of the fetus with the fallopian tube. But it is sometimes possible to spare the woman surgery by giving her an intramuscular injection of methotrexate... The doctrine does not allow this. It insists on the surgery” [76]. Is it ethical to unnecessarily rob a patient of her fertility and force her body to endure the risks of invasive surgery? "A principle which makes the mother suffer extra harm without any advantage to the fetus, is unreasonable" and cruel [77].

CITATIONS

[1] Ghose, Tia. “By the Numbers: Who Are Catholics in America?” LiveScience, Purch, 13 May 2022, https://www.livescience.com/52236-who-are-american-catholics.html. 

[2] Beckerman, Jim. “Abortion Is the Word of the Hour. but Where Did It Come from?” North Jersey Media Group, NorthJersey.com, 10 May 2022, https://www.northjersey.com/story/news/2022/05/06/abortion-definition-history-word-roe-v-wade-law/9646606002/. 

[3] “Chapter 11: First- and Second-Trimester Pregnancy Loss.” AccessMedicine, https://accessmedicine.mhmedical.com/content.aspx?sectionid=263815963&%3Bbookid=2977#263816185. 

[4] “Abortion: Taber's Medical Dictionary.” Abortion | Taber's Medical Dictionary, https://www.tabers.com/tabersonline/view/Tabers-Dictionary/766365/all/abortion. 

[5] Grimes, David A., and Gretchen Stuart. “Abortion Jabberwocky: The Need for Better Terminology.” Contraception, Elsevier, 21 Oct. 2009, https://www.contraceptionjournal.org/article/S0010-7824%2809%2900415-6/fulltext. 

[6] Ibid. 5

[7] Seeds, John W. “Direct Abortion or Legitimate Medical Procedure Double Effect?” The Linacre Quarterly, U.S. National Library of Medicine, Feb. 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6027086/. 

[8] Catholic Answers, Catholic Answers. “What's the Difference between Direct and Indirect Abortion?” Catholic Answers, Catholic Answers, 2 Oct. 2019, https://www.catholic.com/qa/whats-the-difference-between-direct-and-indirect-abortion. 

[9] Ibid. 8

[10] Ibid. 8

[11] Ibid. 8

[12] Robinson, E M. “Exception: To Save the Life of the Mother: EWTN.” EWTN Global Catholic Television Network, https://www.ewtn.com/catholicism/library/exception-to-save-the-life-of-the-mother-12052. 

[13] “The Principle of Double Effect: EWTN.” EWTN Global Catholic Television Network, https://www.ewtn.com/catholicism/answers/principle-of-double-effect-23224. 

[14] McIntyre, Alison. “Doctrine of Double Effect.” Stanford Encyclopedia of Philosophy, Stanford University, 24 Dec. 2018, https://plato.stanford.edu/entries/double-effect/#:~:text=According%20to%20the%20principle%20of,about%20the%20same%20good%20end. 

[15] Shaw, A B. “Two Challenges to the Double Effect Doctrine: Euthanasia and Abortion.” Journal of Medical Ethics, Institute of Medical Ethics, 1 Apr. 2002, https://jme.bmj.com/content/28/2/102. 

[16] McIntyre, Alison. “Doctrine of Double Effect.” Stanford Encyclopedia of Philosophy, Stanford University, 24 Dec. 2018, https://plato.stanford.edu/entries/double-effect/#:~:text=According%20to%20the%20principle%20of,about%20the%20same%20good%20end. 

[17] “The Principle of Double Effect: EWTN.” EWTN Global Catholic Television Network, https://www.ewtn.com/catholicism/answers/principle-of-double-effect-23224. 

[18] Condic, Maureen L, and Donna Harrison. “Treatment of an Ectopic Pregnancy: An Ethical Reanalysis.” The Linacre Quarterly, U.S. National Library of Medicine, Aug. 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6161225/. 

[19] Robinson, E M. “Exception: To Save the Life of the Mother: EWTN.” EWTN Global Catholic Television Network, https://www.ewtn.com/catholicism/library/exception-to-save-the-life-of-the-mother-12052. 

[20] Condic, Maureen L, and Donna Harrison. “Treatment of an Ectopic Pregnancy: An Ethical Reanalysis.” The Linacre Quarterly, U.S. National Library of Medicine, Aug. 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6161225/. 

[21] Shaw, A B. “Two Challenges to the Double Effect Doctrine: Euthanasia and Abortion.” Journal of Medical Ethics, Institute of Medical Ethics, 1 Apr. 2002, https://jme.bmj.com/content/28/2/102. 

[22] Ibid. 21

[23] Ibid. 21

[24] Ibid. 21

[25] Oesterblad, J. (2022, July 25). We need to talk about 'life of the mother' exceptions in abortion law. America Magazine. Retrieved January 11, 2023, from https://www.americamagazine.org/faith/2022/06/27/abortion-dobbs-catholic-exceptions-243163.

[26] Gannett Satellite Information Network. (2010, May 18). "Hospital nun rebuked for allowing abortion in Phoenix". USA today. Retrieved January 11, 2023, from https://usatoday30.usatoday.com/news/religion/2010-05-18-nun-abortion_N.htm.

[27] Myers, A. L. (2010, December 22). Ariz. Hospital loses Catholic status over surgery. The Seattle Times. Retrieved January 11, 2023, from https://www.seattletimes.com/nation-world/ariz-hospital-loses-catholic-status-over-surgery/.

[28] Gannett Satellite Information Network. (2010, May 18). "Hospital nun rebuked for allowing abortion in Phoenix". USA today. Retrieved January 11, 2023, from https://usatoday30.usatoday.com/news/religion/2010-05-18-nun-abortion_N.htm.

[29] Kristof, N. (2010, May 27). Sister Margaret's choice. The New York Times. Retrieved January 11, 2023, from https://www.nytimes.com/2010/05/27/opinion/27kristof.html.

[30] Archdiocese of Baltimore. (2012, January 19). Nun excommunicated, loses hospital post over decision on abortion. Archdiocese of Baltimore. Retrieved January 11, 2023, from https://www.archbalt.org/nun-excommunicated-loses-hospital-post-over-decision-on-abortion/.

[31] Gannett Satellite Information Network. (2010, May 18). "Hospital nun rebuked for allowing abortion in Phoenix". USA today. Retrieved January 11, 2023, from https://usatoday30.usatoday.com/news/religion/2010-05-18-nun-abortion_N.htm.

[32] Catholic News Service. (n.d.). Phoenix Bishop Removes Hospital's catholic status. National Catholic Reporter. Retrieved January 11, 2023, from https://www.ncronline.org/news/phoenix-bishop-removes-hospitals-catholic-status.

[33] Merriam-Webster. (n.d.). Ectopic definition & meaning9-things-to-know-before-moving-to-nashville. Merriam-Webster. Retrieved January 11, 2023, from https://www.merriam-webster.com/dictionary/ectopic. 

[34] “Ectopic Pregnancy.” ACOG, https://www.acog.org/womens-health/faqs/ectopic-pregnancy. 

[35] Ibid. 34

[36] Ibid. 34

[37] Ibid. 34

[38] Catholic Health Association of the United States. Early Pregnancy Complications and the Ethical and Religious Directives, https://www.chausa.org/publications/health-progress/article/may-june-2014/early-pregnancy-complications-and-the-ethical-and-religious-directives. 

[39] Catholic Health Association of the United States. “Ethical And Religious Directives.” Ethical and Religious Directives, https://www.chausa.org/ethics/ethical-and-religious-directives. 

[40] United States Conference Of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf. 

[41] Yoder, Katie. “Is Abortion Ever Allowed for Catholics? for a 10-Year-Old Rape Victim?” Catholic News Agency, Catholic News Agency, 5 Jan. 2023, https://www.catholicnewsagency.com/news/251799/is-abortion-ever-allowed-for-catholics-for-a-10-year-old-rape-victim. 

[42] Ibid. 41

[43] Catholic Health Association of the United States. Early Pregnancy Complications and the Ethical and Religious Directives, https://www.chausa.org/publications/health-progress/article/may-june-2014/early-pregnancy-complications-and-the-ethical-and-religious-directives. 

[44] “Types of Spontaneous Abortion - Threatened [Image].” GrepMed, 24 May 2019, https://grepmed.com/images/5425/classification-spontaneous-types-diagnosis-abortion. 

[45] Catholic Health Association of the United States. Early Pregnancy Complications and the Ethical and Religious Directives, https://www.chausa.org/publications/health-progress/article/may-june-2014/early-pregnancy-complications-and-the-ethical-and-religious-directives. 

[46] Ibid. 45

[47] Ibid. 45

[48] Ibid. 45

[49] “Induction Abortion.” Induction Abortion | Kaiser Permanente, https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.induction-abortion.tw2562. 

[50] Borgatta, Lynn, and Nathalie Kapp. “Labor Induction Abortion in the Second Trimester.” Contraception, Elsevier, 31 Mar. 2011, https://www.contraceptionjournal.org/article/S0010-7824(11)00057-6/fulltext. 

[51] United States Conference Of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf. 

[52] Catholic Health Association of the United States. Early Pregnancy Complications and the Ethical and Religious Directives, https://www.chausa.org/publications/health-progress/article/may-june-2014/early-pregnancy-complications-and-the-ethical-and-religious-directives.

[53] Ibid. 52

[54] Ibid. 52

[55] Ibid. 52

[56] Ibid. 52

[57] Freeman, Lori R, et al. “When There's a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals.” National Center for Biotechnology Information, U.S. National Library of Medicine, https://www.ncbi.nlm.nih.gov/pmc/. 

[58] Winchester Hospital. “Preterm Premature Rupture of Membranes.” Winchester Hospital, https://www.winchesterhospital.org/health-library. 

[59] “Preterm Premature Rupture of Membranes: Management and Outcomes.” UpToDate, https://www.uptodate.com/login. 

[60] Winchester Hospital. “Preterm Premature Rupture of Membranes.” Winchester Hospital, https://www.winchesterhospital.org/health-library. 

[61] Catholic Health Association of the United States. Early Pregnancy Complications and the Ethical and Religious Directives, https://www.chausa.org/publications/health-progress/article/may-june-2014/early-pregnancy-complications-and-the-ethical-and-religious-directives.

[62] Ibid. 62

[63] Sklar, Ariel, et al. “Maternal Morbidity after Preterm Premature Rupture of Membranes at <24 Weeks' Gestation.” American Journal of Obstetrics & Gynecology, Elsevier, 1 Nov. 2021, https://www.ajog.org/article/S0002-9378(21)01185-6/fulltext. 

[64] Harris, Mickey. “PPROM Less than 24 Weeks and Expectant Management: What Are the Maternal Outcomes?” The ObG Project, 23 May 2022, https://www.obgproject.com/2022/05/11/pprom-less-than-24-weeks-and-expectant-management-what-are-the-maternal-outcomes/. 

[65] Ibid. 64

[66] Catholic Health Association of the United States. Early Pregnancy Complications and the Ethical and Religious Directives, https://www.chausa.org/publications/health-progress/article/may-june-2014/early-pregnancy-complications-and-the-ethical-and-religious-directives.

[67] Ibid. 66

[68] Ibid. 66

[69] McIntyre, Alison. “Doctrine of Double Effect.” Stanford Encyclopedia of Philosophy, Stanford University, 24 Dec. 2018, https://plato.stanford.edu/entries/double-effect/#criticisms. 

[70] Ibid. 69

[71] Ibid. 69

[72] Shaw, A B. “Two Challenges to the Double Effect Doctrine: Euthanasia and Abortion.” Journal of Medical Ethics, Institute of Medical Ethics, 1 Apr. 2002, https://jme.bmj.com/content/28/2/102. 

[73] Ibid. 72

[74] Ibid. 72

[75] Ibid. 72

[76] Ibid. 72

[77] Ibid. 72

[78] Health Care Denied - American Civil Liberties Union. 2016, https://www.aclu.org/sites/default/files/field_document/healthcaredenied.pdf.