Why Opposition to Abortion Requires Precision about Intention 

Since the Dobbs decision in 2022, opponents of legal abortion have not been successful in statewide referenda. Eleven states have approved ballot measures to include a right to abortion in the state constitution. Only one state (Nebraska) has approved a state constitutional amendment that restricts abortion, but it applies only to abortions in the second and third trimesters.  

Why has the pro-life movement failed to persuade voters? Political pundits can offer many different explanations, but I believe one plausible answer is that abortion opponents have not provided a good answer to the objection that restricting abortion will endanger pregnant women. To answer this objection, we need to explain why saving a woman from a life-threatening pregnancy does not require intending to kill or harm the child.  

The unique connection between a pregnant woman and her child raises difficult questions. Suppose, for example, that a hepatic pregnancy (an ectopic pregnancy attached to the liver) will result in the deaths of both the woman and her child. Nothing can save the child, and the only way to save the woman is by a surgery that will cause the child’s death. Must physicians allow both the woman and child to die? One way to answer “no” is to say that abortions are morally permissible when the mother’s life is in danger, but this answer raises questions of its own: how serious does the danger need to be? What if the danger doesn’t come from the child at all, but from the child’s father, who threatens to harm the mother if she does not have an abortion? Without principled answers, exceptions like “life of the mother” will seem arbitrary, paving the way for proponents of abortion to use confusion about life-threatening pregnancies to oppose all restrictive abortion laws, even those that include exceptions. 

Instead of making seemingly arbitrary exceptions, abortion opponents can defend the following principles: 

Ethical principle: We may never intend to kill an innocent person, including an unborn child. 

Psychological principle: When we act, we intend nothing more or less than the changes we think we need to bring about to achieve our goals. 

To understand and apply these principles, however, we must first be precise about our intentions. For example, does the ethical principle stated above prohibit saving women from life-threatening pregnancies if the medical procedure necessary to save the woman will kill the child, as in the hepatic pregnancy case? Not according to the psychological principle.  

Suppose, for example, that a surgeon saves a woman with a hepatic pregnancy by cutting the child away from the liver, knowing that the surgical cuts will kill the child. We can determine whether the surgeon “intends to kill” the child by asking, “What are all the changes that the surgeon believes are required to save the woman?” A complete answer need not include “killing the child” or “harming the child,” because the separation of the child from the woman’s liver, not the child’s being killed or harmed, is what saves the woman.  

This analysis is similar to my analyses of other pregnancy cases, including the “Phoenix case,” in which surgeons performed a dilation and curettage procedure (D&C) to save a pregnant woman’s life. In this case, a woman who was eleven weeks pregnant was in imminent danger of dying from cardiogenic shock resulting from the combination of pulmonary hypertension and the physical changes caused by the pregnancy. The physicians knew that the child would not survive outside the womb at such an early gestation. They saved the woman’s life by dilating her cervix and cutting out the child, which ended the child’s life. According to some abortion opponents, including those at the National Catholic Bioethics Center, the physicians in this case intended the child’s death as a means of saving the mother. The conclusion one can draw from this position is that the physicians should have allowed both the mother and child to die instead of performing the only procedure that could have saved at least one of them. In other words, not intervening, and thus letting both the mother and child die instead of saving one of them, was the only morally acceptable choice the physicians could have made. 

I disagree with this interpretation: the physicians in this case did not intend to kill the child. As in the hepatectomy case, the woman’s being separated from her child, not the child’s being killed or harmed, is what saved the woman. Separating the child from the woman’s body and reducing her risks of cardiogenic shock is what saved her; the child’s death was a tragic effect of these lifesaving measures, not a necessary means to the end of saving the woman. 

Now consider a more common case in which a physician performs an abortion so that the pregnant woman can avoid the responsibilities of motherhood. In this case, the child’s death, not merely the separation of the child from the woman, is what relieves the woman of the responsibilities of motherhood. Unlike in the Phoenix case, the child poses no imminent medical danger to the mother that requires a separation between the bodies; the mother wants the child to die so she doesn’t have the responsibility of caring for him or her. Another way to explain the difference between this more common case and the hepatic pregnancy and Phoenix cases is to ask what would happen if everything stayed the same except that the child somehow survived. In the more common case, the child’s survival would prevent physicians from achieving their goal of relieving the woman of the responsibilities of motherhood. In the hepatic pregnancy and Phoenix cases, however, the child’s survival would not impede physicians from achieving their goal of saving the woman, because she is saved by her child’s being separated from her, not by her child’s being killed. 

Note that according to the psychological principle that I am defending, the relevant question for determining what a person intends is what changes the person actually believes will achieve his or her goal, not how the person describes the action or attempts to rationalize it. For example, in the more common case, the physician and woman can say that they did not intend to kill the child, but rather, they intended to help the woman proceed with her life without the burdens of motherhood. But the truth is that there is no way that the abortion will relieve the woman of the responsibilities of motherhood unless the abortion kills the child. So, in this case, the physician and mother intend to kill the child as a means of achieving their goal.  

Why accept the psychological principle? The most important reason is that it is true, as I have argued elsewhere. One reason to believe that it is true is that it is consistent with the basic principle that a person’s intention is an answer to the question, “Why?” 

Suppose, for example, that someone observes the physician in the hepatic pregnancy case or the Phoenix case and asks, “Why is the physician making those surgical cuts?” Saying, “The cuts will kill or harm the child” does not bring the observer any closer to understanding why the physician is making the cuts. In the more common case, however, saying, “The procedure will kill the child” would bring an observer closer to understanding the physician’s action, because killing the child is a means of relieving the woman of the responsibilities of motherhood.  

The psychological principle also shows why it is possible to save a woman’s life during a life-threatening pregnancy without intending to kill a child. The threat in these cases comes from the physiological connection between the woman and child, not from the child’s being alive. Thus, the child’s very existence does not threaten the mother (a position that abortion proponents frequently hold in order to monger fear about restrictive abortion laws).  

Further, most objections to the psychological principle are appeals to intuition, but I have argued that the alleged intuition that a person intends to kill or harm someone is really a moral intuition that the person acts wrongly. If I am correct, and critics of the psychological principle have not explained how we can intuit another person’s intention, then we cannot use that intuition as a premise in an argument that the person acts wrongly. 

Someone might think that the psychological principle entails implausible conclusions about specific cases. What about a physician who performs an abortion before viability in order to relieve the woman of debilitating morning sickness, for example? According to the psychological principle, the physician does not intend to kill the child, because the separation of the child from the mother, not the child’s death, is what achieves the goal of relieving morning sickness. Does this analysis of the physician’s intention mean that this abortion is permissible? No, because we can treat a person unfairly without intending death or harm.  

For example, suppose that surgeons separate adult dicephalus conjoined twins to prevent the dependent twin’s stomach infection from nauseating the independent twin. The separation surgery foreseeably causes the dependent twin’s death. It seems uncontroversial to say that the surgeon treats the dependent twin unfairly, because preserving life is far more important than preventing someone else’s nausea. But if the surgeons were to separate the twins in order to save one twin’s life instead of allowing both to die, then they do not treat the twin who dies unfairly, even when their actions result in that twin’s death. The surgery that causes one twin’s death as a result of relieving the other twin’s nausea is analogous to the abortion that relieves the woman’s morning sickness; the surgery that causes one twin’s death as a result of saving the other twin instead of allowing both twins to die is analogous to separating the mother and child in the hepatic pregnancy and Phoenix cases. The point is that we do not need to say that physicians who perform an abortion or separate the twins merely to relieve nausea intend to kill or harm the conjoined twin or the unborn child to explain why they act wrongly. Assuming that saving a life is more important than relieving nausea, killing a person as a result of relieving someone’s nausea is unfair to the person killed; but taking an action to save one person that causes another person’s death as an unintended side effect is not necessarily unfair to the person killed.  

Other Principles 

One could argue that the surgeons in the hepatic pregnancy and Phoenix cases violate the following principle: it is never permissible to do something that we know to be a serious harm to an innocent human being, regardless of our intention.  

One objection to this principle is that if it prohibits the surgery in the hepatic pregnancy case and the Phoenix case, then it also prohibits a lifesaving fetal surgery if the surgery includes incisions that seriously damage the woman’s uterus. It also prohibits performing an emergency c-section that saves the child but shortens the woman’s life even if the only alternative is allowing both the woman and child to die. Few, however, would oppose either surgery, assuming that the woman gives her informed consent. 

Another alternative to the principles that I have defended comes from the United States Conference of Catholic Bishops (USCCB): “Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted” (Directive 45). The authors do not define “directly intended,” but the surgeons in the hepatic pregnancy case and the Phoenix case intend to terminate pregnancy before viability as a means of saving the women; so the directive prohibits the only procedures that can save the women in these cases. What about a more common case of tubal ectopic pregnancy, which threatens to cause bleeding that will kill both the woman and her child? According to the USCCB, surgeons may perform a salpingectomy because removing a damaged fallopian tube does not fit the definition of an abortion. Contrary to the USCCB, however, the fallopian tube is not always damaged, and saving the woman requires separating the child from the woman (i.e., terminating pregnancy), not merely removing a damaged tube (as explained by Maureen Condic and Donna Harrison). Further, I see no reason why the presence or lack of physical contact between surgical instruments and the child is relevant, as I see no plausible principle that would permit me to throw a person overboard from a sinking boat if I touch only the person’s life preserver and not the person’s body. 

Questions for Critics 

I conclude with questions for anyone who finds my analysis of the hepatic pregnancy case or Phoenix case implausible. What definition of intentions supports the conclusion that the surgeon must intend to kill or harm the child? (I have argued that a good definition must be one that conscientious physicians can use to guide their actions, not one that only a select group of philosophers can understand.) If the surgeon acts wrongly without intending to kill or harm the child, then what ethical principle does the surgeon violate, and why does this principle not prohibit the fetal lung surgery or the salpingectomy?  

I leave the job of writing laws about abortion to others, but we should not rely on imprecise definitions of intentions, overly strict principles of ethics, or false statements about medicine. If we do not get our act together, abortion proponents will find it easy to persuade people that restrictive abortion laws have no rational basis. 

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