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  • Writer's pictureDoctors for Choice

Explained: Double Effect, Ectopic Pregnancy, and Methotrexate

Updated: Jun 4, 2021

It is often stated that in Malta doctors may perform an abortion to save a woman's life under the principle of double effect.

This is not actually true because the Criminal Code prohibits abortion under all circumstances and any abortion is a criminal act and renders the doctors liable to prosecution. Double effect is a Catholic moral principle not a legal construct. But let's put this aside for a minute and imagine that adhering to double effect spares doctors from prosecution when performing an abortion, and examine how this relates to the treatment of ectopic pregnancies.

First, let's start off with the conditions that must be fulfilled to satisfy the principle of double effect:

  1. The action must be either morally good or neutral.

  2. The bad effect must not be the means by which the good effect is achieved.

  3. The intention must be the achieving of only the good effect; the bad effect can in no way be intended and must be avoided if possible.

  4. The good effect must be at least equivalent in proportion to the bad effect.

In ectopic pregnancy, the embryo implants outside the uterine cavity, most often in one of the Fallopian tubes, and needs to be removed as soon as possible. An untreated ectopic pregnancy can lead to rupture of the tube and likely death of the pregnant woman. In fact, complications from ectopic pregnancies are the leading cause of maternal death in the first trimester.

It is widely accepted that surgical treatment of ectopic pregnancy by cutting out the tube with the embryo inside is permissible under the principle of double effect for the following reasons:

  1. Removing a part of the body that is about to rupture and cause the death of the individual is a morally good action.

  2. The death of the embryo is not direct intention of the procedure.

  3. The death of the embryo is not willed and would be avoided if at all possible.

  4. The life of the mother is considered equal to the life of the embryo in Catholic doctrine.

All well and good, until methotrexate was introduced. In early cases of ectopic pregnancy where the tubes are still intact, an injection of methotrexate can terminate the ectopic pregnancy. In the majority of these cases, this means avoiding surgery and sparing both tubes, and is a preferable outcome from a medical point of view.

However, some would consider the use of methotrexate in such situations as not in keeping with the principle of double effect, because regardless of whether an embryo is alive or not at the time of treatment, methotrexate intentionally damages the embryo and is therefore not permissible. A more detailed analysis of this can be read here.

This, in a nutshell, is probably the real reason underpinning the red tape and bureaucracy in prescribing methotrexate for ectopic pregnancy in Malta, which may lead to unnecessary delays in treatment and possible loss of the Fallopian tube.

It is also important to remember that Maltese law criminalises all abortions under all circumstances, and doctors treating ectopic pregnancies may face prosecution, especially if they prescribe methotrexate. This is why, as an organisation, we advocate for the decriminalisation of abortion to facilitate the treatment of all sorts of complications in pregnancy. Doctors treating pregnant women must not face any legal repercussions for terminating the pregnancy on medical grounds.


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