I am a diocesan priest in the parish of Cyrill and Method in the Archdiocese of Vienna, and a teacher at the Some time ago I posted on the principle of double effect, and mentioned cases of conflict that are not evidently resolvable by the principle of double effect, at least not in its usual sense. There is also a problem applying the principle of double effect to resolve an issue or dispute, if the very point in question is whether a given effect can or should be considered as an effect, that is, as a circumstance of the action, or whether it must be considered as a defining aspect of the object.
For example, when a live baby is delivered by the induction of labor or C-section before it is mature enough to live for long outside the womb, is the death of the child an effect of the action, so that it could fall under the principle of double effect, or does the action morally need to be described as the direct killing of an innocent child?
A discussion arose recently about the case in Phoenix, where a nun at a Catholic hospital approved an abortion that was considered medically necessary to save the mother's life, and when there was (apparently) not considered to be any reasonable hope of her carrying the child until viability. The bishop of the diocese of Phoenix declared the nun who approved the abortion to have been automatically excommunicated by her action.
The diocesan's Q and A on the situation (PDF) says, "If a necessary treatment brings about the death of the child indirectly it may be allowable. A Dilation and Curettage (D&C) or Dilation and Extraction (D&E), however, would never be such a treatment since it is the direct killing of the unborn child and is, morally speaking, an abortion." This suggest that such a procedure may have been done at the hospital. I have been unable to verify the facts on this question. But suppose that the abortion was carried out by C-section, delivered a live baby, who died hours or days later because it was as yet too immature to live outside the mother's womb. Would that change the situation?
The doctrinal commission of the USCCB's statement on this case, as well as the USCCB's Ethical and Religious Directives for Catholic Health Care Services (5th edition, 2009, PDF), seem to imply that it would not alter the situation morally. The ethical and religious directives say "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." The doctrinal comission's comment on this is: "Direct abortion is never morally permissible. One may never directly kill an innocent human being, no matter what the reason." In other words, it considers any "directly intended termination of pregnancy before viability" to be, morally speaking, the "direct killing of an innocent human being," even when physically it is indirect, as when a live baby is delivered before viability.
The same thing seems to be taught by a statement of the Holy Office:
Dr. Titius, when called to a pregnant woman, who was very ill, observed repeatedly that the only cause of her deadly disease was her pregnancy, i. e., the presence of a fetus in her womb. Hence there was but one way open to him to save the patient from certain and imminent death, namely, to cause abortion. On this course he usually decided in similar cases, taking care, however, to avail himself of such remedies and operations which would not of themselves, or not immediately kill the fetus in the womb, but, on the contrary, would, if possible, deliver the child alive, although, not being able to live, it would die soon afterward. But after reading a rescript from the Holy See to the Archbishop of Cambrai, dated August 19, 1888, that it was unsafe to teach the lawfulness of any operation which might directly kill the fetus, even though such were necessary to save the mother, Dr. Titius began to doubt the lawfulness of the surgical operation by which he had not unfrequently caused abortion to save pregnant women who were very ill.
Therefore, in order to set his conscience at rest, Dr. T. humbly asks whether, on recurrence of the like circumstances, he may resort to the aforesaid operations.
Response:
To this urgent request the Cardinals of the Holy Roman Congregation of the General Inquisition, after advising with the theological consultors, have decided to answer: No; according to other decrees, namely, those of May 28, 1884, and of August 19, 1888…. (Response of the Holy Office to the Archbishop of Cambrai, July 24, 1895; AAS 28, 383ff., Denzinger, n. 3298)
More related statements of the Catholic Church on Abortion
In response to the argument that the death of the child that is consequent upon delivery of the child is an effect of the delivery, and thus the delivery of a child through induction of labor or C-section before viability may fall under the principle of double effect, when without such an operation both mother and child will die, the position taken by the Holy Office at that time (the CDF has been curiously silent on the question in the past forty years in its various statement on procured abortion, respect for life, etc.) and by the USCCB seems to amount to: one may not consider the principle of double effect applicable; one must consider the death of the child as an essential, determining aspect of the act of delivering the child.
I must admit, I am quite at a loss as to the logic that could be behind the position of the Holy Office and the USCCB (Dear readers, HELP!), and wish that the CDF would make a statement on the issue, either to say that this earlier decision of the Holy Office (assuming I'm rightly interpreting it) is correct, or that it is incorrect or misunderstood or not applicable, or that the question is an open one: the silence I find distressing, particular in view of the wide gap that seems to be present between the views of Catholic doctors and the views of many bishops.
I just finished reading Steven Long's "The Teleological Grammar of the Moral Act" and he gives two examples that I think help to illuminate why the Holy Office does not permit removal of a infant before viability. (Long himself thinks that removal of an infant is permitted in certain cases before viability, but he fails to address the magisterial statements cited in this article)
The first example is that of two men in a space shuttle returning to earth. Due to an accidental loss of some of their stored oxygen, there is not enough oxygen remaining on board the shuttle for both men to survive until the shuttle returns to earth. Furthermore, one of the men is extremely allergic to an anti-viral agent that is contained in the oxygen supply; because of this allergy, it is certain that within a week's time, before they return to earth, he will sicken and die. By that time, however, he will have used up enough oxygen so that the other man will not be able to survive until reaching earth. In these circumstances, is it right for the man who has some chance of surviving to ask the man who has not chance of surviving to eject himself from the space shuttle, so that at least one will live, or even to force him to leave if he is unwilling? After all, this does not directly kill him, it merely moves him from one hostile environment to another, and shortens his life by about a week, and saves the other man's life in the process.
The second case that Long gives is the similar case of two men in a submarine, with similar circumstances. One man cannot live for longer than a week, due to his allergies to the agents contained in the oxygen. There is not enough oxygen for both men to survive until they are able to replenish it. In this case, however, suppose there is no way of exiting the submarine outside. However, there is two feet of water in the lower level of the submarine. Can the one man who has no chance of surviving volunteer to place his head under the water and keep it there until he dies? Can the other man ask him to do this, or even if the one is unwilling to force him to do so by holding his head under water? Once again, the man dies due to being in a hostile environment, and for a similar cause to the other case, namely due to being in an environment where he is unable to breathe. His life is merely shortened by a week, and the other man is now able to live.
I think these two cases may shed light on how the Church is envisioning the case where it is precisely the infant's presence in the mother which is causing a problem for the mother, and nevertheless the infant cannot survive on its own anyway, and will be the cause of the death of the mother.
I would be interested in hearing comments on how these two cases relate to that of inducing early labor in the case of a pregnancy where the only way to save the mother is to remove the child from her womb, which does not kill the child directly, it merely shortens its life, since it was going to die anyway, and it dies by being moved to a hostile environment.
I think many people would admit that in the first case, the man with the allergy has the right to eject himself voluntarily. If so, then you would have to admit that the other person is not guilty of murder if he ejects him forcibly… whether or not this act is justified.
Also note that this type of argument depends on the time frame; if the person would die within the ship more quickly than outside, then it would be fully justified to eject him. And in some modern cases, it is quite possible that an infant who is not viable will be able to survive longer outside the womb, on account of technology, but with death still ensured, than it could survive inside the mother.
Joseph and I were discussing a case where a plane full of passengers is about to crash into a populated area. If the plane is a bit lighter, it will crash elsewhere, apart from the populated area. Since the passengers are going to die in any event, is it legitimate to eject the passengers so that the plane will not crash into the populated area?
Another question may cast light on this one. Is it legitimate to shoot the plane down with a missile? This would normally be considered a case of double effect. Let's suppose that it is legitimate. For the sake of argument, we can suppose that the missile is strong enough that it will cause instant death to everyone on the plane.
Now, is it legitimate for me to push a button that both ejects the passengers and fires the missile, at the same time? It would seem that it is, since it will prolong the lives of the passengers, who will remain alive as long as they fall, and in fact even give them a chance of survival, since in a few cases people have survived falls from airplanes.
Next, is it legitimate for me to push a first button that ejects the passengers, and a second that shoots the plane down with a missile? Seeing that the purpose of pushing the first is only to prolong the lives of the passengers, it seems that it is.
Next, after I push the first button, is it legitimate for me to omit pushing the second button, when I notice that it is no longer necessary, because the plane has lost weight? It seems that it is, since in fact there is no longer any reason to push it.
Accordingly, what happens if I notice this in advance? Can I push the first and not the second? It would seem that I can, since if I cannot, I will be forced to push both, and for no reason.
The case you give seems to be quite different in a number of respects from both the case of a pregnant mother who is in imminent danger of death, and from the cases I gave of the men in the submarine and space shuttle.
The most important difference is that the ejection of passengers from the plane does not seem to place them in a situation essentially different from the one they were already in. I mean this not with respect to the fact that they are nearly certain to die in either case, (namely being thrown out of the plane or remaining within it) but with respect to the fact that in both cases the cause and situation of peril remains essentially the same, and some new and different cause of death is not introduced or caused. In both cases they are on a high speed collision course with the ground; whether or not they are in or outside the airplane seems to be immaterial to the essence of the situation.
Suppose in the example you gave that the button which ejects all the passengers ejects each passenger in an individual escape pod. 95% of these escape pods are known to be of faulty construction so that poison gas from their engines slowly seep into the pod. After about 25 minutes or so, the occupant will invariably die if he is within a faulty escape pod. Those 5% who are within the non-faulty escape pods have a 100% chance of survival.
Now, it will be the case that pressing the button that ejects the passengers will indeed prolong the life of the passengers, for the reason that they are able to live for at least another 25 minutes, instead of being blown up immediately by a missile.
Nevertheless, even though pushing this button would prolong the life of the passengers, it would not be permissible to push it, since you would be choosing as a means of preventing the plane crashing into the populated area, to move the majority of them into what is essentially a death chamber, which is quite different from merely altering their accidental situation in regard to one cause of death.
Hence it does not depend so much upon allowing them to live longer, or even whether or not more of them will be saved, but on the fundamental nature of the act you are doing. Since in your example, you are not essentially placing the passengers in a situation ordered towards their death (they are already in such a situation, your action only alters certain accidents of that situation), it would be permissible to eject the passengers, since it does prolong their life and might save some of them.
However, if the act contains within itself some new and per se cause of death, it would be impermissible, in the same way that it would be impermissible to eject the passengers if they were unwilling to be ejected, and to do so involved slicing their throats to subdue resistance. Hence, if there were no possibility of using a missile, and the only way to eject the passengers was first to slice their throats and then remove them, that could not be done no matter how many people would be saved by doing so, and regardless of whether they have a 100% chance of dying otherwise, and at least 10 of them can stay on the plane without it being too heavy.
In fact, this last example with the throat slitting is precisely what is happening in the example with the faulty escape pods; you are choosing to directly kill 95% of the passengers, while allowing 5% to live. Neither one is permissible.
Even without analyzing the situation, what you say about putting people into faulty escape pods where they are likely to die due to the faulty construction, but are certain to die otherwise is totally uninstinctive, at least to me, and I imagine, to many persons. And since in theory it could fall under the principle of double effect–you don't put them in escape pods to kill them, but to increase their chances of survival and to save other person's lives, with the consequence that many of them die by reason of the escape pods–what reason do you have to deny that it falls under the principle?
There is sometimes a difficulty with the imagination in cases that seem implausible, so let's imagine the kind of case that actually occurs not infrequently. A person has a 99.5% chance of dying within a few weeks or even days without a medical operation, such as chemotherapy or transplant of multiple major organs. Further suppose that this operation carries an extremely high risk of death due to infection, allergic reaction, or the like, a rate as high as 90%. If the operation is sucessful, the patient will be able to live for years. I am quite confident in saying that most Catholic patients and doctors would have no moral hesitation to perform or to undergo such an operation in order to save their lives, even though the chance of saving it is only 10%, and even though the cause of death if death occurs in the operation would be different than the cause of death otherwise.
This is a pretty standard and unproblematic application of the principle of double effect. The risks of the operation are accepted, in order to save the life of the patient, or at any rate to increase the chances of survival.
It is not a question of putting people into escape pods where they are likely to die, it is a question of putting people into escape pods where they are certain to die. The stipulation was that 95% of the pods are known to be faulty in such a way that they invariably (100% of the time) cause the occupant to die. It does not even matter whether or not the exact pods are known, it comes to the same thing, because if you load everyone into those pods, you know full well that you are loading 95% of these people into death chambers which will inevitably poison them to death. It is clear that you are choosing a means which will kill these 95% for the sake of the 5% and the people on the ground.
This is very different from the case of the operation which only has a 10% chance of success. In that case you really can perform the operation in order to increase the man's chance of survival, and it does not involve choosing to kill anyone as a means to an end.
You seem to be conflating here "choosing a means which will kill [people]" with "choosing to kill anyone as a means to an end" (my emphasis, obviously). Isn't this tantamount to a complete rejection of the principle of double effect, which is based in part on the premise that these things are not always the same?
Suppose there are 100 persons in that situation, where they are certain to die without the operation, and that 90 of them are deathly allergic to something involved in the operation–but if they tried to test them for the allergy, it would take so long that they would have already died. The morality of the operation is exactly the same as in the case of an individual.
Given that the doctors do not know who are allergic and who are not, they are increasing the chance of any given individual's surviving from 0% to 10%.
In general, it is irrelevant what the actual physical probability (or certainty) of a given act's being life-saving or death-dealing, but what the probability is insofar as that act is an object of choice, and there the knowledge of the agent is decisive.
Also, the idea that changing the cause of someone's death is killing them is simply ridiculous. For example, someone is dying from cancer. He is also bleeding to death, which will naturally happen much quicker. If you stop the bleeding, you will be "putting him in a death chamber" by putting him in a situation where he will shortly die of cancer, when before, he was not in such a situation, but in a situation where he would bleed to death. Therefore it is not licit to stop the bleeding… which is absurd.
Steven Long himself refrains from stating his opinion regarding the first case, but is apparently satisfied with making very suggestive questions and remarks that tend in the direction of equating the first case (having the person allergic to an anti-viral agent in the oxygen leave the space capsule) with the second case (drowning the person):
Having given reasons why moving the person outside the capsule is not the same as killing him with a knife or with poison, he goes on to say: "But, there is a salient and crucial objection: by moving him, do we not in fact hasten his death? If we deliberately hasten the death of another—and let us suppose we do so against his will—do we not then commit murder?"
I wonder why Long argues by means of rhetorical questions rather than a formal argument. Anyway, in these suggestive questions, Long passes from "in fact hasten his death" to "deliberately hasten the death of another", ignoring the distinction between "deliberately hastening" and "knowingly acting in a manner that hastens" a person's death. This seems to assume either (1) that the morality of acts in general is determined by the physical process taken purely in itself, without reference to the choice of the agent, or (2) that in this particular case, the physical act of moving the person outside is decisively defined morally by the fact that it hastens the person's death, and therefore any choice of this act is, as such, a deliberate choice to hasten the person's death, and thus murder (if against the person's will). The first assumption is at odds with Veritatis Splendor, "In order to be able to grasp the object of an act which specifies that act morally, it is necessary to place oneself in the perspective of the acting person", while the second assumption begs the question at hand. If the point in dispute is whether moving a person from one deadly situation to another, more quickly deadly situation, is murder, one cannot establish this point by assuming the very point one wants to prove.
In his comparison of the two cases, Long again overlooks the decisive importance of what a person chooses to do, taking the morality of the act to be determined by the physical consequences alone:
"If it is licit to ask the person in the spaceship to leave the ship rather than to stay and die of allergic reaction, or even licit to force the person leave the ship; then is it not likewise licit to make the person in the submarine put his head in the water and drown? … Further, isn’t the person asphyxiated in exactly the same way, namely by putting him where he cannot access breathable oxygen?"
If the person leaves the ship, he chooses to put himself in a situation where he cannot use up the oxygen in the ship, knowing that this hastens his death; similarly if another forces him to leave the ship, this would be to prevent him from using up the oxygen in the ship by putting him outside the atmosphere of the oxygen, knowing that this hastens his death. In this case the hastening of death is accepted as a consequence of the means chosen to preserve the oxygen in the ship and thus the life of the other person. Whether one is justified in accepting this consequence is another question, but in any case, this consequence is not directly willed. In the second case, he chooses to drown himself, or the other person chooses to drown him, so that he will be unable to use up the oxygen in the ship. In this case his death is willed as a means to the end of preserving the oxygen in the ship. His death is directly willed, though secondarily (as a means).
Why do you assert that the man who puts his head under the water wills his death as a means of preserving the oxygen in the ship any more than the man who exits the ship wills to kill himself to preserve the oxygen? In both cases the goal is the same, to preserve the oxygen in the ship, and in both cases the same means is chosen, namely, placing oneself in a situation where one is unable to use the oxygen. In the first case, one leaves the ship to do this. In the second case, one is unable to leave the ship, but is able to place oneself somewhere within the ship where one cannot use the oxygen. Perhaps it would be clearer if one of the rooms on the ship is filled with water–this is the only place the man can go to separate himself from the oxygen on the ship. Or again, suppose that the man can enter the air lock and have all the oxygen pumped out and remain there in order not to use up the oxygen. Is this different from the case with the water, or exiting the ship?
As Joseph said, Long "overlooks the decisive importance of what a person chooses to do, taking the morality of the act to be determined by the physical consequences alone." You are overlooking the same thing. It is quite true that the physical consequences of the cases are similar, but what is chosen is not.
You recognized yourself that what is chosen is not the same in the two cases when you said that the man on the submarine chooses "to hold his head under water until he dies." It is not important that he be in place where he cannot breath, even though he is. The important thing is that he is soon dead, and therefore cannot breath. So he is choosing "to drown myself so that I will not be able to use up the air." In contrast, the man who leaves the spaceship is not "going out in space until he dies." He is simply going somewhere where he cannot use up the air on the ship, and this also happens to be a place where he will in fact die. His plan would not be affected at all if he happened to survive, while if the man with his head under water survived, he would start breathing the air in the ship again.
And yes, locking yourself into an airless airlock would be the same as going out in space, if you had the precise intention of "going where I cannot use the air." Similarly, locking yourself into the water-filled room in the submarine would be the same, if and only if your intention was to "go where I cannot breath the air on the ship." But if your intention was to "go where I will drown, and therefore not be able to breath the air," then you would be killing yourself. Likewise, if the man on the spaceship had the intention, "to go where I will soon die and so not be able to breath the air," he would be killing himself.
Note that it depends on the person's intention. It depends on this because his intention is determining what he is choosing to do, whether it is "to drown myself" or "to go somewhere".
I am not considering only the physical aspects of the act performed, although it is true that I am not considering the intention with which the act is performed, since I am holding that these concrete acts are of the kind mentioned by Veritatis Splendor n.79 and following, which acts can be determined to be always evil "apart from a consideration of the intention for which the choice is made or the totality of the foreseeable consequences of that act for all persons concerned."
It seems to me that this is perhaps one of the disagreements between us. You wish to judge (at least partially) what should be done based on the consequences of the act–for example, whether 100% of the people die, or only 95% die, whereas I am saying that consequence is irrelevant, because what you are choosing is evil in itself, and without consideration of either the intention, consequences, or circumstances. (VS 79-80)
You are making a very serious mistake regarding Veritatis Splendor: when they say that there some acts are evil regardless of the intention etc., the idea is that "murder, as long as it is murder, is always wrong, regardless of what a person's intention is." They are not saying that you can define murder without reference to intention; you cannot define murder in such an intentionless way, nor any moral act, since all are defined by their relationship with reason and will.
In addition, your response analyzes (incorrectly) my comment, but does not reply to it.
Let's suppose that we have the case where ejecting the passengers ejects 95% of them in a faulty escape pod.
You have a button which will simultaneously eject the passengers with the poison gas pod, and will shoot down the plane with a missile. Can you press the button?
If you say no, because the passengers will die of poison gas, then you should also say that you cannot use the missile at all, because being killed by a missile is quite different from being killed by a crashing plane.
Ordinary double effect reasoning implies that you can shoot the missile, and therefore that you can also press the single button that does both.
Now suppose there are two buttons: one that ejects the passengers, and one that fires the missile. Can you press both buttons? If not, then you will be forced to press only the second, thus killing 100% of the passengers instead of 95%. Do you think this is what you should do?
As should be clear from my other comment, you cannot press the button which simultaneously launches the missile and ejects the passengers, since that involves a direct attack against the life of the passengers. Nor does it follow from this answer that you cannot use the missile at all, since the missile is aimed solely against the plane, and the presence of the passengers is, in itself, irrelevant to ones choice of stopping the plane. (Though accidentally related in this case) In other words, although being killed by a missile is quite different than being killed by a crashing plane, nevertheless, killing those passengers by means of the missile is not essentially tied up in the choice to fire the missile, since as was stated your choice to stop the plane must be made regardless of whether there are people in the plane.
In response to the last question: which is to be preferred, shooting a missile at a plane which kills everyone inside it in order to stop the plane from crashing into a populated area, or slicing the throats of 95% of the people on the plane and tossing them out of the plane in order to stop the plane from crashing into a populated area and save 5% of the people?
If you press the button that simultaneously ejects the passengers and launches the missile, there is nothing to prevent you from doing it solely because it launches the missile. In this case, "the button is aimed solely against the plane" just like "the missile is aimed solely against the plane". Just as the button both ejects passengers and destroys the plane with a missile, so the missile both hits the plane and hits the passengers, and just as in theory you could desire to kill the passengers with the button, so you could desire to kill the passengers with the missile. But likewise, just as you can desire to destroy the plane, but not desire to kill the passengers, with the missile, so you can desire to destroy the plane but not kill the passengers with the button.
In other words, the morality of pushing the simultaneous button is evidently the same as the morality of the missile.
The suggestion you make with your additional question is that in the two button case, you should push only the second, thus killing 100% of the people. Let's suppose you realize the above evident truth (about the simultaneous button), but still hold this about the two button case.
Let us now consider a third case. There are the two buttons, but there is also a third button, which both ejects the passengers and launches the missile. You will be able to press this button, desiring solely to destroy the plane and save lives, and killing people will not be relevant.
Going back to two buttons again; you look at the buttons. You consider that you could press the second, but according to Louis's ethics, it would be wrong to press the first. However, you could also press the second button with your foot. Doing so, however, would involve jamming on both buttons at once with your foot. Because of the position, if you use your foot, there is no way to avoid this. Now, this is equivalent to there being a third button which does both simultaneously. But we already showed that this is legitimate. Therefore it is legitimate to push both with your foot.
And I say it is evident that if so, then it is also legitimate to push the first and then the second.
Basically, as Michael said, you are rejecting the principle of double effect.
I'm a little confused by all the comments about buttons, etc. It would be useful for laymen if people would lay out the requirements of the double effect and how these various "thought experiments" fulfill them or not.
I would tend to agree with Louis here, especially in regards to Veritatis Splendor. It seemed clearly stated in there that some acts are always evil, it names abortion for example, without regard to intention or totality of consequences; it seems that it was for that reason that the nun administrator was excommunicated. (Is this case what is being referenced by the talk about passengers (the baby?) being ejected from the plane (the womb?)?
I presume that what Fr. Thomas (below) is referring to about acts of will etc, is the fact that you cannot be guilty of abortion if you don't know you're doing it.
As I read it, as a layman (i.e. the encyclical), you just cannot kill someone (for example by cutting their throat or holding their head under water) regardless of your reason for doing so. The reason is that such actions are not conformable to the dignity of the person as a child of God or to their eternal destiny (at least that's my impression from reading the paragraphs around no. 79). Or am I wrong here?
Normally four conditions are given for the application of double effect: first, the immediate action must be in itself morally good or indifferent; second, the evil cannot be directly intended; third, the intended good is not the direct effect of the evil; and fourth, that the intended good outweighs the evil in question. There could be some argument about any of these; for example, this already presumes you know what the "immediate action in itself" is, which is not always obvious. Louis in some of these cases has argued that the immediate action is "killing yourself", for example, which is evil, if you step out of a spaceship, whereas I said that it is "going somewhere", which is morally indifferent. Again, many people would understand the third condition to mean that the good cannot be the physical effect of an evil. In contrast, I would understand it morally, namely that you do not choose to do something evil in order to accomplish something good, even if there is an evil physical effect which causes the good physical effect.
In some of this discussion there has been an equivocation regarding intention, which can mean "what you hope to bring about in the long run," but which can also mean "what you intend to do," i.e. the action you are choosing to do. V.S. says that some actions are evil regardless of the intention in the first sense, but not in the second, since such actions are evil precisely because you are choosing to do something evil, and so in this sense intend to do something evil.
The talk about the passengers and the plane was not metaphorical, but yes, there is an analogy with the case of removing a child from the womb of its mother before viability.
When the Church defines that direct abortion is intrinsically evil, "abortion" is understood to mean "killing an unborn child." And so the definition means that it is always wrong to choose to kill an unborn child.
Likewise, if you choose to kill an innocent person, by throat cutting or drowning or by whatever means, this will always be wrong. But the situation is more complicated than it first appears. You might do something, and it might have the physical effect that someone drowns. This does not mean, necessarily, that you chose to drown someone. For example, you see a child who cannot swim fall into a deep pool. You turn your back and go in the opposite direction. This does not mean that you are choosing "to let someone drown"… for example, if you are going in the opposite direction because you also saw 5 children fall into the other end of the pool, and you are trying to save them. The same is true, in principle, of throat cutting; you might do something which has as one of its physical effects that someone's throat is cut, but it would not necessarily mean that you are choosing to cut someone's throat, or to kill someone, if you are choosing to do something else, for some other reason, and the cutting is an independent consequence.
"the position taken by the Holy Office at that time … and by the USCCB seems to amount to: one may not consider the principle of double effect applicable; one must consider the death of the child as an essential, determining aspect of the act of delivering the child."
It seems to me the reason why they say that the principle of double effect is not applicable here is because they are talking about delivery "before viability". When they say "Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted.", it seems to me that they are saying that the notion of "delivery before viability" intrinsically contains the effect of death. This would mean that you cannot intend delivery before viability without also intending the death of the child. If this is the case, then the principle of double effect would certainly not apply.
In every case where the definition of direct abortion being immoral is explicated, the Church has indicated that it means to say that you cannot deliberately kill an unborn child, it does not talk about delivery at all.
If you say that "delivery before viability" intrinsically implies "killing the baby" then much more does "cutting out the womb of a pregnant mother with the pre-viable baby inside" also intrinsically imply killing the baby. But all theologians admit that the cutting case is sometimes permissible, and the Church has never denied it. Therefore delivery before viability does not intrinsically imply killing the baby, nor does the Church intend to say this.
By chance I came across an article by John Tuohey ("The Implications of the Ethical and Religious Directives for Catholic Health Care Services on the Clinical Practice of Resolving Ectopic Pregnancies", Louvain Studies 20 [1995] 41-57) in which he points out that the USCCB's 1994 ethical guidelines, in comparison with the 1954 and 1971 guidelines, which named specific procedures as licit for resolving an ectopic pregnancy, refrains from doing so, saying only that "In the case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion," and going on to argue:
The primary consequence of this restriction of the scope of the moral law is that the Catholic moral theologian and the Catholic healthcare provider is now free to use the traditional moral categories of probabilism and Double Effect to evaluate the licitness of procedures which separate the embryo from it site, and leave the organ intact. That is, it is now possible to entertain the possibility that a legitimate doubt may be raised as to whether the scope of the moral law regarding abortion is such that it applies to all procedures which do not entail the removal of the "dangerously affected part." If such a doubt is successfully raised, the freedom then exists to form the probable opinion that the law does not apply, and that the procedure may be licitly performed if it conforms to the conditions of the Principle of Double Effect (PDE).
The Q and A of The Phoenix diocese regarding the case I referred to in the post — http://goo.gl/CrDT — says "If, however, a necessary treatment brings about the death of the child indirectly it may be allowable. A Dilation and Curettage (D&C) or Dilation and Extraction (D&E), however, would never be such a treatment since it is the direct killing of the unborn child and is, morally speaking, an abortion." This might suggest that such a procedure was involved at the hospital; it also might suggest that the author is right, and that the bishops don't intend to definitely say that any procedure that acts on the child or placenta (or in an earlier stage, trophoblast) and indirectly results in the death of the child is a case of direct abortion.