Now we get to the really tough questions about abortion. Can we justify abortion in the really hard cases? Some might say that certain situations are so bad that even if we grant that the preborn are full human persons, we should still allow abortions to be legal (either for the sake of the woman, or because it is assumed that a child would not want to grow up in one of these situations).
Each of these situations are powerful emotionally. These are all very tragic situations in which we really feel for the woman and/or the child in this situation. However, the preborn are full human beings. Therefore, what the question really boils down to is can we justify killing a human being in this situation?
A couple of things need to be said. From a philosophical point of view, these arguments all fail because they commit a very specific logical fallacy, the appeal to pity. An appeal to pity is made when someone tries to win support for an argument or idea by exploiting your feelings of pity or guilt. An appeal to pity does not address a legitimate argument made. Despite this, I don’t recommend shouting out “appeal to pity!” whenever you encounter someone who asks one of these questions. First, if you’re out on the street it’s not really a formal debate setting, but second, the person bringing this up may be asking due to some painful event that occurred in their past or in the past of a loved one. Winning the person should always be more important than winning the argument, so we must use tact whenever we discuss these issues.
Additionally, if any of these hard cases justifies abortion, then we should note that abortion would only be justified in that case alone. None of these cases justifies abortion on demand being legal, which is what we currently have in the United States.  In this article I’ll respond to the case of fetal deformity. In a future article, I’ll respond to rape/incest and life of the mother cases.
I. Fetal Deformity
If we were to justify abortion for cases of fetal deformity, that would only justify it for cases of fetal deformity. So this argument does not justify the general right to abortion.
Even given that, this argument does not work to justify abortion. As I have written previously, the preborn from fertilization are living human organisms (even those who have some kind of deformity). So if we can’t justify killing a human outside of the womb due to having a handicap, then we can’t justify abortion for that reason, either. The issue is not whether the preborn entity in question is handicapped or how severe the handicap, but whether the preborn entity is fully human or not.
As Frank Beckwith writes, “...it is not clear that we can make sense of the notion that certain human beings are better off not existing...how can one compare non-existence with existence when they do not have anything in common? How can one be better off not existing if one is not there to appreciate the joy of such a ‘state’ (whatever that means)?”  Beckwith further notes that Former Surgeon General C. Everett Koop, who worked for years with severely deformed infants as a pediatric surgeon at Philadelphia’s Children’s Hospital, observed that ‘it has been my constant experience that disability and unhappiness do not necessarily go together.’” 
The simple fact of the matter is we don’t know what constitutes happiness for others. We have no right to kill a preborn child because we assume that they would rather die than live with that deformity, even if we, ourselves, would rather die in that case (though it’s really impossible to accurately make that claim, not actually being in that situation). Indeed, as Randy Alcorn notes, doctors’ diagnoses are even sometimes wrong: “Many parents have aborted their babies because doctors told them that their children would be severely handicapped. Others I have met were told the same thing, but chose to let their babies live. These parents were then amazed to give birth to normal children.” 
Of course raising a handicapped child is difficult. They require special care and attention. But we cannot morally justify killing someone just because they are a burden. It is better to suffer evil rather than inflict it.  If this moral precept were not true, then in our world the antidote would be worse than the poison, for people would have the right to harm another if it relieved them of a burden. All moral dilemmas could be solved by appealing to one’s own relief from suffering. 
But what about a preborn child with a very serious handicap, like anencephaly? According to the American Medical Association Encyclopedia of Medicine, anencephaly is the “absence at birth of the brain, cranial vault (top of the skull), and spinal cord. Most affected infants are stillborn or survive only a few hours.” It is important to remember that even in tragic cases like these, the preborn anencephalic human is still a fully integrated human organism (albeit a severely damaged one). Stephen Krason compares an anencephalic fetus to someone who has had their head blown off by a gunshot (a gruesome analogy but an apt one). This person is human and remains one until he dies.  As such, we are not morally justified in aborting this unfortunate child. The ethical thing to do is to allow nature to take its course.
As Edwin C. Hui notes, “In the event that such an unfortunate one is born alive, she is born a human person, and her short life as a person must be respected and treated with dignity as we would treat any irreversibly dying person. No heroic or futile treatments need to be provided, but neither should her organs be harvested for transplant. She dies and rests in peace as a person.” 
Christopher Kaczor would add that the expected lifespan of a human does not justify our killing them. We are not justified in killing death row inmates before their scheduled date of execution (be it for harvesting organs or other reasons). “The fact that a person at the end of life may have only a short time to live does not imply the permissibility of killing that person.” 
The solution to a serious medical problem is not to kill the patient, but to study the problem and come up with a solution. The problem should be eliminated, not the human (born or preborn) who suffers from it.
In my next article I will address the circumstances of rape and incest.
 Due to Roe v. Wade and its sister case Doe v. Bolton, abortion is legal during all nine months of pregnancy for essentially any reason.
 Francis J. Beckwith, Defending Life: A Moral and Legal Case Against
Abortion Rights, (Cambridge: Universtiy Press: Cambridge, New York, 2007), p. 101.
 C. Everett Koop as quoted in Bernard Nathanson (with Richard Ostling), Aborting America, (New York: Doubleday, 1979), p. 235, as quoted in Beckwith, p. 101.
 Randy Alcorn, Pro-Life Answers to Pro-Choice Questions: Expanded & Updated, Multnomah Publishers, Inc., 2000, p. 223.
 Peter Kreeft, The Unaborted Socrates, (Downers Grove, IL: InterVarsity, 1982), p. 40.
 Beckwith, p. 102.
 Stephen Krason, Abortion, p.387, as cited in Beckwith, pp. 103-104.
 Edwin C. Hui, At the Beginning of Life: Dilemmas in Theological Bioethics (Downers Grove, IL: InterVarsity Press, 2002), pp. 366.
 Christopher Kaczor, The Ethics of Abortion: Women’s Rights, Human Life, and the Question of Justice, (Routledge: New York, New York, 2011), p. 181
Is abortion justifiable in the hard cases? Part II
Perhaps the most emotionally charged questions that come up when discussing abortion revolve around rape and incest. Certainly the circumstances surrounding a woman obtaining an abortion after she is raped is, at the very least, understandable. Rape is a terrible crime, one which no woman should ever be subjected to. It’s one of the worst things a human being can ever do to another human being. Approximately 54% of rapes are never even reported, and of the remaining 46% only about 3% of rapists ever serve any jail time.  Women need to be encouraged to come forward and prosecute the rapist to the fullest extent of the law. I also believe that rapists aren’t punished severely enough.
 Dr. Warren Hern, Abortion Practice, p. 84.
 Bauman, Dr. Michael, "Verbal Plunder: Combatting the Feminist Encroachment on the Language of Religion and Morality," paper presented at the 42d annual meeting of the Evangelical Theological Society, New Orleans Baptist Theological Seminary, New Orleans, Louisiana, Nov. 15-17, 1990, 16.
 Paraphrased from Kaczor, Christopher, The Ethics of Abortion, (Routledge, 2011), pp. 184-185.
Is Abortion Justifiable in the Hard Cases? Part III
In fact, Alan Guttmacher, past president of Planned Parenthood, acknowledged: “Today it is possible for almost any patient to be brought through pregnancy alive, unless she suffers from a fatal illness such as cancer or leukemia, and, if so, abortion would be unlikely to prolong, much less save, life.”  A powerful quote, especially considering Dr. Guttmacher wrote it in 1967.
But what about the rare cases in which the pregnancy does become life-threatening? The most common example of this is an ectopic pregnancy, in which the human zygote implants itself somewhere other than the uterus, most commonly in the fallopian tube. If the zygote implants itself in the fallopian tube, this is highly dangerous to the mother. Once the embryo grows big enough, the fallopian tube will burst, causing the mother to hemorrhage internally. This is an extremely dangerous situation for the mother, and almost always fatal for the embryo.
Some pro-choice advocates claim that we should keep abortions legal because abortions are always an act of self-defense -- the pregnancy may end up threatening her life. However, very few women die in childbirth and pregnancy. Additionally, we can’t justify abortions because of the extremely unlikely possibility of the pregnancy becoming life-threatening, otherwise we could justify infanticide in the off chance they may grow up and kill their parents.
I take the position that life-saving abortions are morally permissible as long as the child is not yet viable. Once the child becomes viable, a caesarian section should be performed to save both mother and child. This is not only the ethical choice, it is also faster and safest for the mother. Late-term abortions are a three-day procedure, and a c-section takes about thirty minutes. This is a position consistent with my pro-life views. The mother and child are equally intrinsically valuable human beings. The mother and child should both be treated as patients, and it’s not always possible to save both.
Ectopic pregnancies don’t always implant in the fallopian tubes. If the embryo implants elsewhere and it is generally safe to continue the pregnancy, I don’t think abortion would be justified in that case (although constant physician observation may be required). But if the unborn implants in the fallopian tube, I believe that abortion is justified. There has been a case in which a zygote implanted inside his mother’s fallopian tube, later bursting the tube and implanting himself in the uterus, later to be born completely healthy.  However, I don’t think we can justify leaving ectopic pregnancies in the fallopian tube hoping that the woman and child will both survive. What would you think of a father who learns his son has pains in his appendix, waiting until the appendix bursts to finally seek medical treatment? With technology the way it is now, there’s a good chance of surviving a burst appendix. But the father would be negligent in waiting until his son’s appendix bursts to seek medical help. Since tubal pregnancies are dangerous and potentially fatal, I don’t believe a doctor is justified in leaving the embryo to develop there.
It is a tragedy when this happens, but to the best of my knowledge there is no way to transfer the developing embryo from the fallopian tube into the uterus for it to implant. If that were medically possible then that would be the ethical course of action. Since there is little evidence that this transfer could be done right now, abortions are justified in that instance. Sometimes the embryo dies on its own, before putting the tube at risk. In that case, there is no moral dilemma.
Life-saving abortions can be justified through three lines of reasoning.
Triage -- Triage is when two people are mortally wounded and only one can be saved. Say two soldiers are on a battlefield, dying of bullet wounds. The medic will survey the two dying soldiers, determine which one stands a greater chance of survival, and save that person. If he works on the more severely injured person he may lose them both. By saving one he is not declaring that the other is not human or not valuable. In the case of a life-threatening pregnancy, the child can’t survive without the mother and the mother stands a 100% chance of survival. Since it is better to lose one life than two, the doctor will save the mother who has the best chance of survival.
Double effect -- Double effect reasoning is a set of ethical criteria that we can use for evaluating the permissibility of acting when one’s otherwise legitimate act would also cause an effect one would normally be obliged to avoid. 
In this case, the legitimate act is saving the life of the mother and the act one would normally be obliged to avoid is the death of an innocent human being. Essentially, four conditions must be met before an act is morally permissible:
1) The nature-of-the-act condition. The action must be either morally good or indifferent.
2) The means-end condition. The bad effect must not be the means by which one achieves the good effect. (This is because the ends do not justify the means.)
3) The right-intention condition. The intention must only be the achieving of only the good effect, with the bad effect being only an unintended side effect.
4) The proportionality objection. The good effect must be at least equivalent in importance to the bad effect.
Most life-saving abortions satisfy all four conditions. 1) The action is saving the mother’s life, which is morally good. 2) In most life-saving abortions (removing a cancerous uterus or the fallopian tube in which a zygote implanted itself) you don’t achieve the saving of her life by directly killing the embryo, itself. 3) The intention is only to save the mother’s life, not to kill the unborn human. If there were a way to save the unborn human, that would be the ethical course of action. And 4) The good effect is equal in proportion to the bad effect. You are saving the woman’s life although the unborn child will die, and the unborn child will die even without doctor intervention.
If the woman has a cancerous uterus and can’t wait for the child to become viable, the ethical thing to do would be to remove the uterus, with the unintended (but foreseen) side effect that the unborn child will die. This would only justify one method of action during ectopic pregnancy (though the other methods can be justified using the other lines of reasoning -- triage and third-party defense of an innocent aggressor).
Third-party defense of an innocent aggressor -- The preborn human has no intention of implanting itself in the wrong place or threatening the mother’s life. They have become an innocent aggressor. If the woman were to have the abortion herself, this would be justified by self-defense. But does the doctor have a right to step in? I would argue that he does.
Consider the case of a man at a bar who, unbeknownst to him, has his drink spiked with a hallucinogenic drug. He flips out and next thing you know is aiming a gun at five people, threatening to shoot. The police arrive and an officer has a shot, but a fatal one. I think the police officer would be justified in taking the fatal shot to protect the people whose lives are at risk.
As I indicated earlier, pregnancies are generally very safe. Most abortions cannot be justified as self-defense. But in a case where the woman will die if the pregnancy is left alone, then defense measures are justified.
Let’s have a look at the three different methods used to treat ectopic pregnancies. Some pro-life people I have talked to justify these by claiming that they are not really abortions, since medically they are called something else (Methotrexate, salpingectomy, salpingostomy). However, this does not affect the morality of the situation. They still result in the death of the preborn human. Plus, we can make the argument that all abortions are called something else (e.g. Dilation & Evacuation, RU-486, etc.). Even miscarriages are called “spontaneous abortions.” Shakespeare once wrote, “that which we call a rose by any other name would smell as sweet.”  Well, that which we call an abortion by any other name would still result in the death of an innocent human being.
Sometimes an ectopic pregnancy may correct itself. If it doesn’t and if no intervention is taken the embryo will grow large enough that the tube will rupture, causing hemorrhaging in the woman and a severe risk of death. I do not believe a doctor is justified in waiting around to see what will happen, since the tube rupturing severely harms the woman (possibly fatally). To expound on an analogy I used earlier, suppose a boy approaches his father complaining of pain in his abdomen. The father realizes his son may have appendicitis, but decides it’s not an emergency so he waits. The son’s appendix soon bursts and his father rushes his son to the hospital. With today’s technology his son has a good chance of survival, but the father was still negligent in his parental duties by waiting until the son’s appendix burst to seek medical attention.
Salpingectomy -- In this procedure, the section of the tube with the zygote inside it is removed and the embryo dies on its own. This is seen as satisfying double effect since you are not directly killing the embryo, you are allowing it to die on its own. This satisfies the second criteria, where the bad effect (the death of the embryo) is not used as a means to bring about the good effect (saving the woman’s life).
Salpingostomy -- In this procedure, an incision is made in the fallopian tube and the embryo itself is removed. This has the added advantage of preserving the woman’s fertility. Christopher Kaczor actually argues that this procedure likewise satisfies double effect. The effect of removing the embryo itself from the fallopian tube is not an intrinsically evil act, otherwise we would have to oppose removing it to attempt to transfer it into the uterus, if such a procedure ever becomes perfected. 
Methotrexate -- Methotrexate is a drug that inhibits the cellular reproduction in rapidly growing tissue; it is also used to treat some forms of cancer. It works by inhibiting the growth of the trophoblast, the forerunner to the placenta and the embryo proper. 
Now, I personally believe that salpingectomy does not, in fact, satisfy the principle of double effect. Even if you are not directly killing the embryo itself, you are still the agent responsible for its death by removing the fallopian tube. You are removing it from the only environment in which it can live, which will result in its death. Someone might respond that you are simply removing the tube, which has been damaged and will result in hemorrhaging if left untreated. But I find this unconvincing. The reason the tube is damaged and will burst is because the embryo has implanted itself there and will burst it when it grows large enough. The embryo is the agent, not the fallopian tube, that is threatening the woman (albeit unintentionally).
I would actually argue that salpingectomy is morally impermissible in treating ectopic pregnancies. First, it is causing unneeded harm to the woman. By removing the fallopian tube, you are reducing the chance of her conceiving another child in the future by 50% (and if she had one before, you are effectively sterilizing her). Second, the embryo will die regardless of which method you use. Even if you don’t kill the embryo itself, you are still responsible for its death by removing it from its natural environment. So you are effectively responsible for the embryo’s death in any case. It seems that due to the unneeded harm and the fact that the embryo will die anyway, salpingectomy is actually morally worse than salpingostomy and using Methotrexate.
There’s some evidence to suggest that transferring an embryo implanted into the wrong place may be possible.  If this is correct, then this may change the ethics of the situation. Some may argue that this course of action would be morally required to be taken. Others, like Christopher Kaczor, argue that, as with saving other humans, this action may not be morally required. As he writes, “we need not make use of every treatment available in every circumstance. In each case, the burdens and benefits of the treatment must be considered, and treatments that are more burdensome than beneficial may be foregone.” 
So I would argue that abortions are morally permissible if the woman’s life is in immediate jeopardy but the child is not yet viable. Regarding the other hard cases, fetal disability/defect, rape, and incest, abortions are not morally permissible. On top of that, even if they were, they could not be used to justify general abortion-on-demand. Saying that we should make abortion legal because of a rare instance it may be justified is like saying we should eliminate all traffic laws because you may have to break one rushing a loved one to the hospital. 
 Shakespeare, William, Romeo & Juliet, Act II, Scene II.
 L. Shettles, “Tubal Embryo Successfully Transplanted in Utero,” American Journal of Obstetrics and Gynecology, 163 (1990): 2026.
 See Kaczor’s article.
 Scott Klusendorf makes this observation in The Case For Life, (Crossway Books: Wheaton, Illinois, 2009), p. 175