Catholic Health Care Providers and the Issue of Emergency Contraception

Offering Compassion and Truth in Cases of Rape and Sexual Assault

Reproduced with permission

Fortunately, medical advances in the care of sexual assault victims have enabled doctors and hospitals to do much more to assist and protect these victims from unwanted pregnancy. However, drug regimens such as so-called "emergency contraception" ("EC") have blurred the line between true contraceptive and abortifacient processes. In addition to potentially ending the life of a newly conceived embryo, the effects of emergency contraception on women's physical health remain unclear, and much ambiguity surrounds the actual operation of the drugs in question. The lack of information available to women regarding the true nature of emergency contraception has impeded many victims' ability to make healthy, life-affirming choices in the aftermath of their assault. Many women are led to believe that emergency contraception is a "true contraceptive." This deception is a further affront that compromises the decision-making of a woman who has already been victimized. As the use of emergency contraception skyrockets among secular health care providers, the obligation of Catholic hospitals and doctors to provide complete and accurate information regarding the processes and procedures taking place reflect the Church's great respect for the dignity of women and its commitment to the sanctity of all human life, regardless of age or circumstance. In this manner, the Church in the modern world echoes Christ call to proclaim the Gospel in truth and love.

Most U.S. hospitals now regularly administer emergency contraception to women following a sexual assault, (provided she is not already pregnant), billing the method as "truly contraceptive" according to the revised definition of pregnancy put forth by the American Medical Association. This new definition reduces the term "pregnancy" to include only the processes following the implantation of the embryo. Because of the new phrasing, destruction of the embryo from conception until implantation is considered contraceptive. This shift also redefines the embryo prior to implantation as a "pre-embryo," a term invented to correlate to the redefinition of contraception. In essence, the term simply denies any semblance of personhood or moral status to the developing embryo. Dr. Ward Kischer comments, "All of the terms mean a reduced moral status and have no credible scientific justification. They are wholly arbitrary."[2] Using such definitions, there is no need to inform the woman that the use of EC is anything but contraceptive, despite widespread concern over this "rephrasing" of medical terminology and the moral qualms it raises.

In response to this moral crisis in the area of rape protocol, several documents have been put forward by national and state bishops' conferences in the United States in order to specify the appropriate Catholic response to these situations. As was noted earlier, the 1994 Ethical and Religious Directives for Health Care Services states clearly,

A female who has been raped should able to defend herself against a potential conception from the sexual assault. If after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum."[3]

The Pennsylvania Catholic Conference of Bishops has also issued a detailed statement entitled the "Guidelines for Catholic Hospitals Treating Victims of Sexual Assault," which addresses the specific medical, legal, and moral obligations of Catholic hospitals, and stresses the importance of the total well-being of the woman involved. These documents are at the core of Church teaching regarding this issue, and seem to state fairly clearly what is and is not acceptable for the care of victims. [4] However, their application has been skewed by competing interpretations and by continued uncertainty as to the methods by which EC achieves its end.

Emergency contraception, actually a high dose of "ordinary" birth control (usually a combination regimen of estrogen and progestin), works in much the same way as daily doses of birth control do. Manufactured under such names as Preven, Orval, and Plan-B, emergency contraception can be used up to 72 hours after an assault, and is administered in two doses taken twelve hours apart. The pills have three potential modes of action: the first to delay or inhibit ovulation if it has not yet occurred, the second to incapacitate sperm and sperm transport into the fallopian tubes, and failing those methods, the third mode of action is to alter the endometrium of the uterus in order to render it hostile to a newly conceived embryo who then is unable to implant. The first effect is actually contraceptive. The second, provided it works fully, is also contraceptive. However, its method of inhibiting fertilization is only useful if the woman has not yet ovulated. If she has ovulated, the sperm's rapid entrance into the fallopian tube (in perhaps as little as ninety seconds) and the short time required for fertilization make its effectiveness doubtful, considering the amount of time that may have passed between the actual assault and the use of EC. [5] Therefore, if the woman has ovulated, emergency contraception necessarily kills the already conceived embryo. This is confirmed by both the United States Food and Drug Administration [6] and the Alan Guttenmacher Institute, the research arm of the Planned Parenthood Federation. [7] Dr. Eugene Diamond elaborates,

There is overwhelming evidence that oral contraceptives can have post fertilization effects. The evidence is indirect based on the thinning of the endometrium, depletion of integrins, and increased ectopic pregnancies that have been shown to be important in the success or failure of in-vitro fertilizations. While there is no direct experimental evidence that these effects are crucial in vivo, the prudent course is to institute laboratory surveillance of the victims of sexual assault. To the extent currently possible, this will assure emergency contraception will not be used when the patient is ovulating or immediately pre-ovulatory… [8]

Here Diamond alludes to the crux of the issue: if the woman is immediately pre-ovulatory or has ovulated, there is a possibility that she could have or has become pregnant, and the use of emergency contraception will end the life of the newly conceived embryo. EC is usually administered after a pregnancy test has been given to determine if the woman was pregnant prior to the rape incident, but this test does not determine whether she has ovulated and has or will immediately conceive because of the assault. However, some theologians and ethicists argue that it is still morally acceptable to provide emergency contraception even if the health care provider is unsure as to whether the woman has ovulated. This is generally referred to as the "pregnancy approach" to the administration of EC, and is backed by ethicists such as Dr. Ron Hamel of the Catholic Health Association and Dr. Michael Panicola of SSM Health Care. Such beliefs are based on two mistaken presuppositions.

The first of these presuppositions is an implicit acceptance of the "revised" definition of pregnancy agreed to by the American Medical Association, which holds that pregnancy begins at implantation rather than conception, as earlier discussed. Hamel argues that the pregnancy approach is all that is needed in order to provide EC, claiming that even if EC is too late to suppress ovulation, it will still result in sperm incapacitation or prevention of fertilization. [9] Unfortunately, this statement cannot be true because of the problem of rapid sperm transport if the woman has already ovulated and because the "prevention of fertilization" only corresponds to the redefined understanding of contraception, as can be identified in Hamel's own primary sources. [10] It appears that Hamel is attempting to ignore the connection between significant changes in the endometrium and the failure of the embryo to implant in order to sidestep the abortifacient effects of EC. As it is morally impermissible to do a direct study of the effects of the altered endometrium, it is not possible to directly determine that it is this hostile environment that prevents implantation, but as noted above this conclusion has been supported by the research for in-vitro fertilization and the statements of groups such as the Alan Guttenmacher Institute, which certainly have no ties the Church or her ethical certitudes, and no ethical reason to deny EC's abortifacient mode of operation. While Hamel claims that neither he nor the Catholic Health Association accepts the revised definition of pregnancy, his conclusions seem to ignore the ethical dilemma of rendering the endometrium inhospitable to the developing embryo. This is no more ethical that a direct destruction of the embryo itself.[11]

The second misconception is that it is morally acceptable to run the risk of the abortifacient use of EC because the chances of pregnancy are so small. [12] This error is based in some fact: the incidence of pregnancy from one forcible act of rape is estimated to less than one percent to five percent. Factors contributing to this low chance of pregnancy include the high rate of sexual dysfunction among rapists, the rate of ejaculation during forcible rape, and the reduced risk to about seventy percent of rape victims because they are on contraceptives, are pregnant, are post-menopausal, pre-menarchal, or were surgically sterilized. [13] However, some risk remains, and as the administration of the initial pregnancy test makes clear, EC does have detrimental effects on a developing embryo. [14] As Kevin McMahon notes in his article, "Why Fear Ovulation Testing?",

Any doubt about the abortifacient effects of EC must be resolved in favor of avoiding serious evil. As Grisez notes: 'A person who purposely does what might destroy … a particular human good [life] is actually willing to do so.'" [15]

In order to avoid the moral quandary that arises from the administration of EC, some theologians have suggested an alternative path, one that seems to adequately address the needs of the woman and also preserve the Catholic commitment to the dignity of life. In their article "Postcoital Intervention: From Fear of Pregnancy to Rape Crisis," Nicholas Tonti-Filippini and Mary Walsh offer the estrogen and progesterone tests as vital for precisely determining whether the woman has entered a potentially fertile phase, and for determining when ovulation occurs and the end of the potentially fertile phase, respectively. They state,

It is our view that a Catholic rape crisis center providing postcoital intervention would have an obligation to ensure that it had the capacity to undertake serum estrogen and progesterone tests or urine estrone glucuronide and pregnanediol glucurnide tests, or at least to have rapid access to the tests by another agency. Macroscopic analysis on internal examination can identify whether cervical mucus is present and whether it in a consistency that indicates possible fertility. [16]

This response has significant implications for the information provided to the woman in crisis and for honoring the commitment to life:

It is possible to offer women who are in distress … the possibility of identifying whether they are in fact infertile, or alternatively, whether they may conceive or may already have conceived . .. An examination is often done for forensic purposes after rape. If a woman had been charting her [cervical mucus] symptoms, it would be unnecessary to undertake further examination or testing, but she might want further confirmation…or may be ignorant of her symptoms and how to interpret them….Pathologists usually offer a service for serum and progesterone testing … the results can be available in the same time that it takes to receive the results of early pregnancy tests… [17]

Such a method would provide immense comfort and reassurance to the assault victim without compromising the Catholic ethic regarding life. Tonti-Filippini and Walsh explain that with the knowledge gained from these tests, one would have no need for further postcoital intervention if the woman is in either of the infertile phases. Further, doctors would be able to identify with some precision whether ovulation has occurred or is imminent, and therefore identify at what times the use of EC would be contraceptive rather than abortifacient. However, the authors offer yet another solution in lieu of the combination pill:

A double dose of a high-dose combined progesterone and estrogen pill might not be the treatment of choice if the aim were only to achieve contraceptive cover for the previous night's happening. It is relatively easy to delay or suppress ovulation beyond the stage at which intercourse in the previous twenty-four hours might result in pregnancy…an obvious agent would be a single, moderate dose of estrogen only. This would be unlikely to cause harm to the pregnancy if ovulation had already occurred and would be unlikely to cause significant problems for the woman, especially if a natural estrogen was used … It should …be born in mind that there is a dearth of well-researched information of the effects of the existing postcoital interventions and their actions. More is known about the ovulation-delaying effects of a moderate dose of estrogen, which were widely researched over an extensive period prior to the development of the combined pill… [18]

This solution - estrogen and progesterone testing with a moderate dose of an estrogen formulation when necessary (qualified with full explanation to the woman about what is taking place, the commitments of a Catholic hospital, and the level of reliability of such tests)--seems to overcome the difficulties surround the normal use of EC, which carries with it some risk of abortion because of the presence of progesterone. This seems to handle even the exceptions provided for in Grisez's theology, which states,

Rape is the imposition of intimate, bodily union upon someone without her or his consent, and anyone who is raped rightly resists so far as possible … it can scarcely be doubted that that someone who cannot prevent the initiation of this intimacy is morally justified in resisting its continuation … victims (or potential victims) of rape and those trying to help them are morally justified in trying to prevent conception insofar as it is the fullness of the sexual union ... provided their effects will not be abortifacient, antifertility drugs may be used before or after the rape, even with a slight risk of abortion accepted as a side effect. [19]

Advances in technology seems to make even the acceptance of this slight risk unnecessary. In a particular way, the notion if administering a moderate dose of estrogen seems to speak to the criticism that not administering EC is denying the woman the possibility of preventing conception, and does so without the risks causes by the presence of the progesterone.

The gravity of this decision is rooted in the Catholic understanding of the dignity of human life, even in the most difficult of circumstances. As Grisez states,

Women who have been the victims of this crime [rape] have suffered a very great wrong. However, if pregnancy results, the unborn baby is entirely innocent of any wrong. Justice forbids this [an abortion], while mercy demands that the wrong already done be limited and overcome, so far as possible, with healing love … This requires correctly drawing the line between good and evil: the rapist's act was evil, but the woman who was raped remains good, and the baby, though unwelcome, proceeds in part from her, is innocent, and so belongs on her side of the line. To reaffirm herself, she must accept the baby's goodness, with the conviction that nothing that happened can make her and her baby bad. Nurturing the baby until its birth, she can then decide whether or not to accept the responsibilities of motherhood. [20]

Beginning from this ethic of life, it becomes apparent why it is unacceptable to allow the risk of abortifacient method of emergency contraception in any circumstances, if the potential is there for a better administration of the medical procedures that avoid the possibility of the destruction of innocent human life.

From the information available at this point in the ongoing discussion of the ethics of emergency contraception, the Tonti-Filippini/Walsh proposition appears to be the best application of Catholic teaching in a manner that is equally committed to providing for the health and well-being of the victim of rape or sexual assault. Such an integrated understanding of the physical, emotional, and spiritual well-being of all victims further illuminates the divine truth which is the foundation for Catholic moral ethics and reveals an adequate understanding of the dignity of every human life regardless of age or circumstance.

Bibliography

Cataldo, P. and A. Moraczewski (eds.) Catholic Health Care Ethics: A Manual for Ethics Committees. Boston: National Catholic Bioethics Center, 2001.

Colliton, William F., Jr. "Birth Control Pill: Abortifacient and Contraceptive." Linacre Quarterly. Nov. 1997. (Vol. 66) 26-36.

Diamond, Eugene F. "A Critique of the Pregnancy Method in the Aftercare of Rape Victims." Linacre Quarterly. May 2004.(Vol. 73) 168-173.

----------. "Games People Play with Abortion Data." Linacre Quarterly. November 1991. 37-38.

----------. "Rape Protocol." Linacre Quarterly. August 1993. (Vol. 60) 8-19.

Emergency "Contraception" and Early Abortion. United States Conference of Catholic Bishops. 4 December 2004.

Ethical and Religious Directives for Catholic Health Care Services, Fourth Edition. United States Conference of Catholic Bishops. 4 December 2004.

Fact Sheet: Emergency Contraception and the Treatment of Victims of Sexual Assault. United States Conference of Catholic Bishops. 4 December 2004.

Grisez, Germaine. The Way of the Lord Jesus: Living a Christian Life (Vol. 2). (Chicago, Franciscan Herald Press, 1986).

Hamel, Ron. "Rape and Emergency Contraception: A Reply to Rev. Kevin McMahon." Ethics and Medics. June 2003. (Vol. 28, No. 6) 1-2.

Hamel, Ron and Michael R. Panicola. "Low Risks and Moral Certitude." Ethics and Medics. December 2003. (Vol. 28, No. 12) 3-4.

Kischer, Ward C. "The Big Lie in Human Embryology: The Case of the Preembryo." Linacre Quarterly. November 1997. (Vol. 64) 53-59.

McMahon, Kevin T. "Why Fear Ovulation Testing?" Ethics and Medics. June 2003. (Vol. 28, No. 6) 3-4

Mulligan, Rev. Msgr. James J. "Peace of Conscience for Rape Victims." Ethics and Medics. December 2003. (Vol. 28, No. 12) 1-2.

Pennsylvania Catholic Conference. "Guidelines for Catholic Hospitals Treating Victims of Sexual Assault. Origins. 1993 (No. 22) 810.

Tonti-Filippini, Nicholas and Mary Walsh. "Postcoital Intervention: From Fear of Pregnancy to Rape Crisis" National Catholic Bioethics Quarterly. Summer 2004 (Vol. 4, No. 2) 275-288.

Wesley, Germaine. "Preven, the Newly-Released 'Emergency Pregnancy Kit': New Name, Same Old Stuff." Linacre Quarterly. November 1999. (Vol. 66) 48-47.

ENDNOTES

1. USCCB, Ethical and Religious Directive for Health Care Services, Fourth edition, no. 36.

2. Kischer, Ward C. "The Big Lie in Human Embryology: The Case of the Preembryo." 64 Linacre Quarterly (Nov. 1997): 59.

3. See footnote 1 above.

4. The Pennsylvania Catholic Conference document - otherwise excellent - closes with the caveat, "The above guidelines are given primarily from a moral perspective. No judgment is made or implied concerning the acceptable medical regimen or legal protocol." Such a statement seems to undermine the authority of the rest of the document, which does in fact address relatively specific points as to what may and not be done in terms of contraceptive and abortifacient remedies. While I did not find this point addressed anywhere in my research, such a statement seems to nullify the guidelines' practical application and reduce them to mere suggestions.

5. Mulligan, Rev. James J. "Peace of Conscience for Rape Victims." 28 Ethics and Medics 12 (December 2003): 1.

6. "EC pills … act by delaying or inhibiting ovulation, and/or altering tubal transport of sperm and/or ova (thereby inhibiting fertilization) and/or altering the endometrium (thereby hindering implantation)." (FDA Notice, 62 Fed. Reg. 861 [Feb. 25. 1997] as quoted in USCCB statement, "Emergency 'Contraception' and Early Abortion." (released October 1999, viewed 12/4/2004)

7. "Emergency contraceptive pills, also know as morning-after pills, are a postcoital hormonal treatment that appears to inhibit implantation of the fertilized ovum." (C. Harper and C. Ellertson, "Knowledge and Perspectives of Emergency Contraceptive Pills Among a College-Age Population: A Qualitative Approach." 27 Family Planning Perspectives (July-August 1995): 149 as viewed on USCCB website on 12/4/2004).

8. Diamond, Eugene F. "A Critique of the Pregnancy Method in the Aftercare of Rape Victims" 73 Linacre Quarterly (May 2004): 171.

9. R.P. Hamel and M.R. Panicola, "Emergency Contraception and Sexual Assault," 83 Health Progress 5 (September-October 2002): 17,18 as quoted in K.T. McMahon, "Rape and Emergency Contraception," 28 Ethics and Medics 6 (June 2003):2.

10. K.T. McMahon, "Rape and Emergency Contraception," 28 Ethics and Medics 6 (June 2003):2.

11. R.P. Hamel and M.R. Panicola, "Low Risks and Moral Certitude," 28 Ethics and Medics 12 (December 2003): 3.

12. Mulligan, 2.

13. Diamond, Eugene F. "Rape Protocol" 60 Linacre Quarterly. (August 1993): 12.

14. Hamel claims, "…it is not at all clear, indeed the evidence suggests otherwise, that EC harms a conceptus, should one be present." ("Low Risks and Moral Certitude", 3). While this may be technically true - EC is proven to harm the endometrium, not the embryo directly - if there was no reason to be concerned for the life of a growing embryo, the standard pregnancy test for any pregnancy prior to the assault would seem unnecessary.

15. McMahon, 4.

16. Nicholas Tonti-Filippini and Mary Walsh "Post-Coital Intervention: From Fear of Pregnancy to Rape Crisis" 4 National Catholic Bioethics Quarterly 2 (Summer 2004): 282.

17. Ibid, 283.

18. Ibid, 286-287.

19. G. Grisez, The Way of the Lord Jesus: Living a Christian Life, Vol. 2 (Chicago: Franciscan Herald Press, 1986), 512 and footnote 103.

20. Ibid, 501.