Craniotomy as a surgical procedure used in the delivery of a fetus is subject to various moral judgments, some positive and some negative. This article gives consideration to two arguments offered for the moral legitimacy of the craniotomy. Each argument is closely examined and each is found to be flawed and hence inconclusive.

When William May first wrote Catholic Bioethics and the Gift of Human Life, his position was that to perform a craniotomy on a child to save the mother’s life constitutes a direct abortion and is not justifiable. In later editions, May rejected his earlier position in favor of one he originally argued against, most notably by Germain Grisez. The author maintains that the argu­ments surrounding craniotomies on the unborn are still of major relevance today, because they relate directly to (...) certain controversial techniques used to manage ectopic pregnancies. He also argues that May’s original conclusion ought to be upheld, and that May’s later conclusion places too much weight on the interior intention of the actor and not enough on the act itself. (shrink)

It can be confusing to define the object of an action because it may be unclear if there is a per se or a per accidens order to the end. Three common difficulties in distinguishing between these are that the per se ordering must be either in the nature of the end or in the act, that this ordering to an end is a real and not merely a logical one, and that technology has a tendency to ignore the teleology (...) of natures by breaking things down to their parts for manipulation. Having drawn these distinctions, craniotomy is then compared to lethal self-defense. National Catholic Bioethics Quarterly 13.4 : 611–616. (shrink)

By analogy to justifications offered for craniotomy by Catholic moralists (e.g., Germain Grisez and Rev. Martin Rhonheimer), a recent instance of casuistry (by the moral theologian M. Therese Lysaught) attempts to apply double-effect reasoning and, separately, the concept of a vital conflict to justify dilation and curettage in order to preserve the life of a pregnant woman. This paper examines and rejects these bases for justifying craniotomy and D&C. It concludes with a consideration of Pope John Paul II’s (...) discussion of moral martyrdom in Veritatis splendor. National Catholic Bioethics Quarterly 11.3 (Autumn 2011): 453–463. (shrink)

I argue that physicians can save women from life-threatening pregnancies by performing a craniotomy, placentectomy, or salpingotomy without intending death or harm. To support this conclusion, I defend the relevance thesis about intentions (a person intends X only if X explains the action). I then criticize the identity thesis (if a person intends X and knows that X is identical to Y then the person intends Y) and three mistakenly strict moral principles: (1) one may not intend something that (...) is a serious harm for an innocent person, (2) one may not intend to terminate pregnancy before viability, and (3) one may not act on a person’s body in a harmful way in order to benefit another person. (1) would prohibit procuring organs from living donors, (2) would prohibit treating hepatic pregnancies and other ectopic pregnancies, and (3) would prohibit procuring organs from living donors and performing many prenatal surgeries. (shrink)

I present the strict definition of intended effects and pose two questions for its critics: Apart from rationalizing moral intuitions about the craniotomy and other controversial cases, why classify an effect as intended if it does not explain the action? What definition of intended effects can people use to guide their actions? These questions show that broad definitions of intended effects have no basis in action theory and are too vague to guide people’s actions. I suggest that broad definitions (...) seem plausible because people confuse what someone intends and what someone is responsible for causing. (shrink)

There are some interesting similarities between Aristotle’s ‘mixed actions’ in Book III of the Nicomachean Ethics and the actions often thought to be justifiable with the Doctrine of Double Effect. Here I analyse these similarities by comparing Aristotle’s examples of mixed actions with standard cases from the literature on double effect such as, amongst others, strategic bombing, the trolley problem, and craniotomy. I find that, despite some common features such as the dilemmatic structure and the inevitability of a bad (...) effect, Aristotle’s mixed actions do not count as cases justifiable through application of the Doctrine of Double Effect because they fail to meet the crucial necessary condition of the Doctrine according to which the bad effect can only be a merely foreseen side-effect and not an intended means. (shrink)

The problem of closeness was posed by Philippa Foot in the article “The Problem of Abortion and the Doctrine of Double Effect”. Foot criticizes the classic version of the principle of double effect which distinguishes direct from indirect intention. On this basis, she considers it justified to cause bad effects which were foreseen but not intended. She believes that if we consider causing a bad effect to be justified then the way we do it is irrelevant, while the reference to (...) the direct/indirect distinction may lead to absurd solutions in some cases that allow us to distinguish two events in one action. These constitute, respectively, the object of direct and indirect intention and they are much too close for an application of the principle of double effect, such as when a doctor performs a craniotomy. The root of the problem of closeness is the question about the possible criterion that would allow us to determine which of the effects of an action are intended and which are merely foreseen. The starting point of the analysis of the problem of closeness in this article is the manner in which Foot outlines it in her article. In the second and more extensive part of the article, a number of contemporary attempts to solve the problem of closeness are presented, while the third section is an attempt to answer the question of why the discussion of the problem of closeness seems to remain deadlocked. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Now?Mike AbellThe cry broke the church’s uncomfortable silence. It actually was more of a moan than a cry. It was deeper, coming from her core. I’d heard it only once before and knew it as a sound caused by a loss that will never be recovered. No one in the church had to turn to discover its source. We all knew the mother had entered to say goodbye (...) to her 19–month–old son.We watched as the now composed mother, along side her husband, followed the small casket—a family rendered incomplete. As they passed our pew, my wife clutched my arm and we wept tears of sympathy, guilt and fear.Just 15 months earlier our now, 2–and ½–year–old son, Jun, had been diagnosed with a brain tumor not dissimilar from the child in the casket. The tumor has a different name, but it’s equally complicated, and comparably rare and aggressive.Over nine months, Jun endured two craniotomies, three rounds of induction chemo, three rounds of high dose chemo with stem cell rescue, 28 days of proton radiation, a sub–dural shunt placement, a port placed and removed, a broviac placed and removed and many, many blood and [End Page 16] platelet transfusions. As of his last scan, there was no evidence of tumor.Jun has now been out of treatment for six months. His hair has grown back. He’s stronger. The meals have stopped arriving. And we no longer are the recipients of sad eyes at playgrounds and restaurants.In many ways we have returned to a somewhat normal life. If you didn’t know Jun was in remission for a brain tumor, you wouldn’t know. Despite all this, cancer still strangles us with fear.Brain tumors often come back. Too often. We’ve heard a few different numbers on the likelihood. And while we’ve never paid too much attention to statistics, they are too scary to ignore. Especially knowing that should it recur, there is no cure. This is our day–to–day reality.A lot of our time is spent analyzing, over analyzing and obsessing. We watch him closely. Every time he stumbles, coughs, or sleeps fifteen minutes longer than normal, we wonder if it’s something more. I’ve called our oncologist about a 99–degree temperature. Something I wouldn’t have done during treatment (I usually waited to 100). I’ve questioned whether hiccups are a sign of recurrence. Admittedly, I’ve even Googled that last one just to be sure.All the anxiety builds the closer you get to an MRI date. My son has scans every three months so I’m beginning to recognize the cycle. It starts a couple weeks out. Normally it begins as a twinge the moment the date is set. But each day it grows, occupying more and more of my mind. This is not to say, I don’t think about it everyday. I do. But the thoughts become more paranoid and frequent. Worst–case scenarios play out. It’s different from the time during treatment. We always had the comfort of knowing that there is still more treatment.By the time we reach MRI day, bring Jun back to the machine room, watch the anesthesiologist put him under, and leave him to be scanned for the next two and half hours, I feel close to nauseas. In my mind, at this point, someone knows. I know they may be a technician and are not necessarily trained to read an MRI. But they know. They’ve seen it before.There usually is a waiting period between the time of the scan and the time you can meet with your oncologist or someone else qualified to read and interpret the scan. I do whatever I can to make that window as narrow as possible. I leave radiology with a disc in hand and head directly to the clinic to pass it off. I’ve heard of people waiting days for an appointment. That’s not an option for me. There would be no eating, no sleeping, and no resting heart rate without knowing. Fortunately, our oncologist is... (shrink)

In his book Vital Conflicts in Medical Ethics: A Virtue Approach to Craniotomy and Tubal Pregnancies, Martin Rhonheimer offers a virtue approach to vital conflicts in medical ethics. These vital conflicts are those medical situations involving pregnancy in which, if nothing is done, both the mother and her child will die. When analyzed by means of his understanding of the virtue of justice, Rhonheimer concludes that the so-called direct killing of children in the womb or in the fallopian tube (...) is permissible since the child’s death is neither a means to saving the mother’s life nor an end sought for itself and is, therefore, not unjust. Because such a death is not unjust, it is also not a moral evil since only an unjust death can be called a moral evil. The author offers a critique of both his understanding of justice and what constitutes the “object” of the moral act. National Catholic Bioethics Quarterly 10.3 : 471–480. (shrink)

The principle of double effect is often used in bioethics as a tool to evaluate significant cases in obstetrics and gynecology. In this article the author, a Catholic priest, presents and interprets St. Thomas Aquinas’s delineation of the principle and discusses several classical applications, namely, to hysterectomy during pregnancy, ectopic pregnancy, and craniotomy. He explains the medical anatomy and physiology of the conjoined Maltese twins, Jodie and Mary, and then examines the arguments of four moralists on their separation. He (...) concludes by arguing that the principle morally justified the surgical separation of Jodie and Mary. National Catholic Bioethics Quarterly 9.1 : 85–96. (shrink)

Rev. Kevin Flannery, SJ, has helpfully drawn attention to some key sources for magisterial teaching on “vital conflicts,” where interventions to save a mother’s life would involve or lead to the death of her unborn child. However, former responsa by the Holy Office on this topic from 1884 to 1902 need to be interpreted carefully and understood in relation to the context of the time. Recent teaching has indeed clarified that the condemnation of direct abortion is de fide. Nevertheless, in (...) the last forty years, the magisterium has, de facto, tolerated debate among faithful Catholic scholars over the ethics of craniotomy. Appeal to former magisterial teaching is not sufficient to settle this contemporary debate over what constitutes direct abortion. National Catholic Bioethics Quarterly 14.1 : 81–104. (shrink)

According to H. M. Giebel, at least three difficulties arise for my view of intention, foresight, and mutilation. First, I must either give up my account of the intention/foresight distinction or conclude that obstetric craniotomy does not constitute mutilation. Secondly, my account of the intention/foresight distinction leads to counter-intuitive conclusions such as that surgical sterilization is impermissible but removal of non-functioning limbs against the will of the possessor is morally permissible. Thirdly, she suggests that my account of mutilation is (...) incomplete for it rests on an understanding of “health” that is not adequately specified. In this paper, I argue that my original accounts of both the intention/foresight distinction and mutilation can, nevertheless, still be defended. (shrink)

Contrarian ways of thinking are generally good for the intellectual life and clinical ethics is no exception. This essay introduces the papers in the 2003 issue on clinical ethics of the Journal of Medicine and Philosophy , each of which goes against the grain in interesting and important ways. Considerations of identity predominate, in discussions of cloning, separation of conjoined twins, and the coming into existence of human beings. Whether viewing organ donation as admirable sacrifice is an altogether good thing (...) is considered, as is the justification of fetal craniotomy. Finally, there is a review essay about From Chance to Choice , an important new book for the philosophy and ethics of molecular medicine. (shrink)

Background: Maximum safe resection of infiltrative brain tumors in eloquent area is the primary objective in surgical neuro-oncology. This goal can be achieved with direct electrical stimulation to perform a functional mapping of the brain in patients awake intraoperatively. When awake surgery is not possible, we propose a pipeline procedure that combines advanced techniques aiming at performing a dissection that respects the anatomo-functional connectivity of the peritumoral region. This procedure can benefit from intraoperative monitoring with computerized tomography scan and brain (...) shift correction. Associated with this intraoperative monitoring, the additional value of preoperative investigation combining brain mapping by navigated transcranial magnetic stimulation with various neuroimaging modalities has not yet been reported.Case Report: A 42-year-old left-handed man had increased intracranial pressure, left hand muscle deficit, and dysarthria, related to an infiltrative tumor of the right frontal lobe with large mass effect and circumscribed contrast enhancement in motor and premotor cortical areas. Spectroscopy profile and intratumoral calcifications on CT-scan suggested an WHO grade III glioma, later confirmed by histology. The aforementioned surgical procedure was considered, since standard awake surgery was not appropriate for this patient. In preoperative time, nTMS mapping of motor function was performed, combined with magnetic resonance imaging -based tractography reconstruction of 6 neural tracts and resting-state functional MRI connectivity of sensorimotor and language networks. In intraoperative time, DES mapping was performed with motor evoked response recording and tumor resection was optimized using non-rigid image transformation of the preoperative data to iCT data. Image guidance was updated with correction for brain shift and tissue deformation using biomechanical modeling taking into account brain elastic properties. This correction was done at crucial surgical steps, i.e., when tumor bulged through the craniotomy after dura mater opening and when approaching the presumed eloquent brain regions. This procedure allowed a total resection of the tumor region with contrast enhancement as well as a complete regression of IICP and dysarthria. Hand paresis remained stable with no additional deficit. Postoperative nTMS mapping confirmed the good functional outcome.Conclusion: This case report and technical note highlights the value of preoperative functional evaluation by nTMS updated intraoperatively with correction of brain deformation by iCT. This multimodal approach may become the optimized technique of reference for patients with brain tumors in eloquent areas that are unsuitable for awake brain surgery. (shrink)

To preserve postoperative brain function, it is important for neurosurgeons to fully understand the brain's structure, vasculature, and function. Intraoperative high-frequency electrical stimulation during awake craniotomy is the gold standard for mapping the function of the cortices and white matter; however, this method can only map the “focal” functions and cannot monitor large-scale cortical networks in real-time. Recently, an in vivo electrophysiological method using cortico-cortical evoked potentials induced by single-pulse electrical cortical stimulation has been developed in an extraoperative setting. (...) By using the CCEP connectivity pattern intraoperatively, mapping and real-time monitoring of the dorsal language pathway is available. This intraoperative CCEP method also allows for mapping of the frontal aslant tract, another language pathway, and detection of connectivity between the primary and supplementary motor areas in the frontal lobe network. Intraoperative CCEP mapping has also demonstrated connectivity between the frontal and temporal lobes, likely via the ventral language pathway. Establishing intraoperative electrophysiological monitoring is clinically useful for preserving brain function, even under general anesthesia. This CCEP technique demonstrates potential clinical applications for mapping and monitoring large-scale cortical networks. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:'Difficult Patient':A Reflective EssayDaniel McFarlandThe patient who sat across from me knew too much about all brain tumors. According to her, she would never know enough about the one sitting uncomfortably close to her brain's temporal lobe. In her quest for the 'right' answer to her meningioma problem, she became certain that its surgical removal would upend her life, leaving her in neurological taters.She was a small business owner (...) of a practice dedicated to medical massage. Indubitably, she had helped countless clients heal themselves of medical mishaps and avoid or recover from the tyranny of [End Page E13] a medical community that did not always provide respectable, hospitable care. She was certain a craniotomy would end her business, nullifying everything she had spent her life building. She became fluent in the legalese needed to transfer or sell her business in anticipation of surgery. To stave off losing her life's work from a surgical mishap, she sought opinions from a dozen neurosurgeons. They reassured her that a routine surgery like this would be effective with little chance of neurological collateral damage. She did not believe them. In her business she had treated numerous exhausted professionals. Many surgeons with whom she worked professionally frequently referred patients to her. She had seen the poor self-care that many surgeons and doctors brought on themselves in the form of unrelenting stress, drinking, bad eating habits, and even drugs. This made her nervous and untrusting about the care she could receive at the hands of an overworked or impaired surgeon. She scheduled appointments with every neurosurgeon she could find and interviewed them relentlessly, looking for the slightest sign of incompetence, unprofessionalism, antipathy, or lapse in compassion. Given her insistence and dogged nature, she usually found what she was looking for. She would bring her research to the appointments and interview the neurosurgeons on what other doctors had opined. If they were incredulous of research she brought or a technique on which she inquired, they were summarily dismissed.At first glance, which is likely all that she got from many of her visits, these encounters put a spotlight on a 'difficult' patient refusing care. The deeper look that my patient deserved revealed a personal narrative of the oldest child who survived a broken home riddled with drug use and prostitution. She learned to rely on only herself for protection. She took unapologetic control of her fate. Her own mother had at one time offered my patient work as a prostitute. Her father was no better in providing protection and a decent upbringing. He had left her as an eight-year-old with the neglectful mother and four younger siblings to fend for herself, which she did against the odds. She suffered physical, emotional, and spiritual abuse.As an adult, her strong sense of selfhood and boundaries allowed her to have a guarded relationship with both of her parents at a comfortable emotional distance. Her mission and passionate drive to help others heal saved her life. In healing others, she was healing herself. Importantly, her experience marked for her indelibly that while she could do this for herself, others were not reliable and could not heal her. She had only ever trusted and relied upon herself. She was the only one who had never let her down. She was terrified that this might be the first time. The potential surgery risked her cognition, physical capacities, and ability to care for herself. The risk was too great.We met numerous times, uncovering her past, reliving the stories of her tumultuous background, and examining how she established her place in the world away from the horrors of her insecure childhood. She took in my reaction to her stories and saw the horror on my face when I tried to imagine a world where one's parents were not only neglectful but the source of danger. Through my reaction, she may have begun to have some compassion for her own story and put the pieces together. One several occasions, she became enraged when I didn't meet her expectations, or I didn't entertain the diatribe of neurosurgical scholarly work.On one of those... (shrink)

In a recent IPQ article, Christopher Kaczor gave a promising argument in which he strove to reconcile the common belief that obstetric craniotomy (the crushing of nearlyborn fetuses’ heads) is immoral with his clear and intuitively attractive account of intention. One of Kaczor’s crucial assumptions is that intentional mutilation is morally impermissible. In this article I argue that Kaczor’s analysis has three potential problems: (1) the mutilating features of craniotomy do not appear to meet Kaczor’s criteria for being (...) intended, so his account doesn’t show craniotomy to be impermissible; (2) some commonly-accepted acts, including voluntary sterilization, are acts of intentional mutilation according to Kaczor’s definition and are thus forbidden on his account; and (3) some acts that intuitively seem to constitute intentional mutilation do not meet Kaczor’s definition of “mutilation” and are not ruled out by his account. I suggest slight modifications to Kaczor’s account that might address these difficulties. (shrink)

The principle of double effect has a long history, from scholastic disputations about self-defense and scandal to current debates about terrorism, torture, euthanasia, and abortion. Despite being widely debated, the principle remains poorly understood. In Intention, Character, and Double Effect, Lawrence Masek combines theoretical and applied questions into a systematic defense of the principle that does not depend on appeals to authority or intuitions about cases. Masek argues that actions can be wrong because they corrupt the agent's character and that (...) one must consider the agent's perspective to determine which effects the agent intends. This defense of the principle clears up common confusions and overcomes critics' objections, including confusions about trolley and transplant cases and objections from neuroscience and moral psychology. This book will interest scholars and students in different fields of study, including moral philosophy, action theory, moral theology, and moral psychology. Its discussion of contemporary ethical issues and sparse use of technical jargon make it suitable for undergraduate and graduate courses in applied ethics. The appendix summarizes the main cases that have been used to illustrate or to criticize the principle of double effect. (shrink)