Catholic Health Care Providers and the Issue of Emergency Contraception
Offering Compassion and Truth in Cases of Rape and Sexual Assault
Reproduced with permission
The Church, cognizant of her
duty to defend the sacredness of human life, can
never condone the use of any abortifacient drug
regimens or procedures, regardless of the
circumstances surrounding conception. However, this
stance must be distinguished from the administration
of contraception following rape or sexual assault,
which is not prohibited by natural law or by the
The tragic occurrence of a rape or sexual assault
is among the most traumatic experiences in the life
of any woman. Catholic hospitals and health care
providers are called in a particular way to minister
to the victims of sexual crimes with sensitivity,
compassion, and respect. Unfortunately, there is
much ambiguity both within and outside of the Church
as to what methods and procedures best exemplify the
kind of care befitting such difficult circumstances.
The Church, cognizant of her duty to defend the
sacredness of human life, can never condone the use
of any abortifacient drug regimens or procedures,
regardless of the circumstances surrounding
conception. However, this stance must be
distinguished from the administration of
contraception following rape or sexual assault,
which is not prohibited by natural law or by the
Church. The use of contraception is licit because
its object is not to impede procreation or to
contracept (an intrinsically evil act as defined by
Humane vitae), but rather to protect the
woman from further violence at the hands of the
rapist. As is stated in the 1994 Ethical and
Religious Directives for Health Care Services, a
woman is entitled to defend her body from an
aggressor: she is not obligated to allow his sperm
to penetrate her ovum.
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
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
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."
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.
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
if the woman has ovulated, emergency contraception
necessarily kills the already conceived embryo. This
is confirmed by both the United States Food and Drug
the Alan Guttenmacher Institute, the research arm of
the Planned Parenthood Federation.
Dr. Eugene Diamond
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
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.
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.
 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
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.
 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
However, some risk remains, and as the
administration of the initial pregnancy test makes
clear, EC does have detrimental effects on a
As Kevin McMahon notes in his article, "Why Fear
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
â€¦ a particular human good [life] is actually willing
to do so.'" 
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
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 â€¦ 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
confirmationâ€¦or may be ignorant of her symptoms and
how to interpret themâ€¦.Pathologists usually offer a
service for serum and progesterone testing â€¦ the
results can be available in the same time that it
takes to receive the results of early pregnancy
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 pregnancyâ€¦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 â€¦ It
should â€¦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 pillâ€¦
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
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 â€¦ it can scarcely be doubted that
that someone who cannot prevent the initiation of
this intimacy is morally justified in resisting its
continuation â€¦ 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.
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 gravity of this decision is rooted in the
Catholic understanding of the dignity of human life,
even in the most difficult of circumstances. As
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 â€¦
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
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
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.
Cataldo, P. and A. Moraczewski (eds.) Catholic
Health Care Ethics: A Manual for Ethics Committees.
Boston: National Catholic Bioethics Center,
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.
----------. "Rape Protocol." Linacre Quarterly.
August 1993. (Vol. 60) 8-19.
Emergency "Contraception" and Early Abortion.
United States Conference of Catholic Bishops. 4
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
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.
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.
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 â€¦ 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
'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
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
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
14. Hamel claims, "â€¦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
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
20. Ibid, 501.