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Most Rev. Anthony Fisher O.P., Auxiliary Bishop of Sydney
The “Morning-After Pill”, Rape Victims
and
Ethical and Religious Directives
for Catholic Health Care Services
Anthony
McCarthy
September
2004
In 2001 the U.S. Conference of Catholic
Bishops issued their revised “Ethical and Religious Directives for Catholic
Health Care Services”. Directive 36 states:
“ A female who has been raped should
be 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 to recommend treatments that have as their purpose or direct
effect the removal, destruction, or interference with the implantation of a
fertilized ovum”.
[1]
The Directive does not specify what
constitutes “appropriate testing” or “evidence that conception has occurred”.
Consequently, Directive 36 has been subject to different interpretations.
One school holds that giving women a
pregnancy test followed by a “morning-after pill” if the test is negative is
morally permissible and in line with Directive 36. As pregnancy testing, at
present, can only reveal a pregnancy prior to any recent rape, and not whether a
recent rape has itself resulted in pregnancy, this school holds, for reasons
laid out below, that the only relevant factor to consider before giving a
morning-after pill is whether the woman patient has a prior-to-rape pregnancy
which would be endangered by the administration of a pill.
Opposed to this school is the
ovulation-testing school, which insists that, as well as a pregnancy test, a
simple urine dipstick test together with any personal data on the woman’s
ovarian cycle stage[2]
should be obtained in order to assess whether a) “emergency contraception” can
be appropriately used to prevent ovulation or sperm capacitation, and b) whether
such “emergency contraception” will be at all necessary in a given case. This
approach aims to avoid giving unnecessary and potentially dangerous drugs to
women, and further aims to take seriously the possibility that drugs
administered at mid-cycle or early post-ovulatory phases could endanger the life
of a newly conceived child.
Pregnancy-only testing
The influential journal of the Catholic
Health Association, Health Progress, published in 2002 an article
defending the “pregnancy-only-testing” strategy.[3] The following claims were made:
a) the risk of pregnancy resulting from
rape is very small.
b) the “scientific literature” indicates
that emergency contraceptive medications most likely act by preventing ovulation
or fertilization and do not have post-fertilization effects sufficient to
prevent the embryo from implanting in the womb.
c) the probable direct effect of
administering the medications is prevention of conception occurring from an act
of unjust sexual aggression rather than causing the death of a conceptus.
d) any conceptus that is present and
fails to implant will have been destroyed as an unintended and even unforeseen
effect given the “lack of evidence supporting abortifacient effects of the
medications”.
The piece further criticises adherents
of the “ovulation-testing”school.
Following this article, and consultation
with experts from both sides of the debate, a letter was privately circulated by
the Chairman (since retired from that position) of the Bishops’ Committee on
Doctrine, Bishop Donald W. Trautman, which said that, based on “the present
state of scientific and medical research”, the Committee had concluded that
testing only for a pregnancy unrelated to the sexual assault is not inconsistent
with Directive 36.[4]
However, in spite of this interim conclusion being made public, through a letter
not intended for publication, the Committee has made no public statement
concerning it, and will continue to study the issue and hold further
consultations with experts in the field. In the meantime, individual bishops in
the U.S. remain free to interpret Directive 36 as they see fit.
The leaked letter has led to a situation
that is troubling, not least because the Health Progress article
defending pregnancy-only testing is deeply flawed. Furthermore, groups
antipathetic to the Church’s general stance on life issues have seized on the
guidance given in the letter in their efforts to promote distribution of
“emergency contraception” in all hospitals.[5]
Flaws in the Hamel and Panicola article
a) Very little has been firmly
established as to how frequent conceptions are in the case of rape. Given this,
it is disingenuous to make bold empirical statements in this area. Moreover, our
concerns should not be about general probabilities, but more focused on the
likelihood of conception in a particular case, taking into account facts about
the individual rape victim.
However, if it is indeed true that
pregnancy following rape is extremely rare, then this could be taken to
strengthen the argument against giving “emergency contraception” to rape
victims,[6]
on the grounds that giving unnecessary emergency contraception is harmful to the
woman, as well as sending out a message to the wider community of disregard for
the unborn child.
b) It is not true that no evidence
exists for an abortifacient effect of the various forms of emergency
contraception. The commonest regime of “pregnancy-only testing” is known as the
Yuzpe regime, which makes use of Schering PC4 “emergency hormonal
contraceptive”. If this drug acts pre-fertilisation, its effect is
contraceptive; if it acts post-fertilisation its action may be abortifacient (by
affecting the endometrium, or lining of the womb, and rendering it fatally
inhospitable to any newly conceived embryo). Evidence suggests that Schering
PC4, if taken over 24 hours prior to ovulation, can prevent or significantly
delay ovulation but later than this may produce an abortifiacient effect.[7]
Other types of “emergency contraception” include Levonorgestrel
(Levonelle 2), which is heavily advertised and used (without prescription) in
the U.K. While the mode of action of levonorgestrel is unclear at present, one
of the few studies carried out found that its preovulatory administration had no
effect on ovulation, but that it did affect the endometrium. In other words, it
could be that the effects of this so-called “emergency contraceptive” are purely
abortifacient.[8]
The present evidence for an abortifacient effect is significant and therefore
morally relevant.
Aside from these considerations, the
article, and those who support it, define fertilization as a process ending
in conception. This is highly questionable, not to say worrying, as it appears
arbitrarily to locate the moment of conception at the end of the fertilization
process (with the lining-up of chromosomes from the sperm and ovum), when many
would consider the individual to be already a day old.[9]
c) Given the above, the probable
“direct effect” in the vast majority of cases of administering a “morning-after
pill” following rape would be an unnecessary disruption of the woman’s
endometrium[10],
rather than preventing a conception which would not, in any case, have
occurred. However, without knowing the stage of the ovulatory cycle of the rape
victim, it is difficult to say what the “direct effect” of the morning-after
pill will be.
d) In view of (b), the
possible abortifacient effect of the “morning-after pill” cannot be classified
blithely as an “unforeseen” effect of its use. While it is true that a woman, in
taking a “morning-after pill” following a recent rape, need not intend to
cause an abortion, in bringing about this immediate side-effect of a fatally
inhospitable environment for any newly conceived child she, and those who treat
her, are morally obliged to take into account the risk at which they place such
a child. For this reason, efforts should be made to reduce this risk as much as
possible.[11]
Ovulation testing
The pregnancy-only testing method
therefore results in the administering of what will nearly always be unnecessary
and harmful drugs to women who have already gone through a terrible ordeal. It
also sends out a message that the possible lives of unborn children are to be
accorded no significant weight in calculating how best one should act in tragic
circumstances.
In contrast to this, the
ovulation-testing method tests for pre-existing pregnancy, and also attempts to
ascertain whether the raped woman is at or approaching the time of ovulation in
order to work out whether any new conception is likely to result from the recent
assault.[12]
In this method, “emergency contraception”[13]
is offered only if the pregnancy test is negative and empirical and
personal data indicate that the woman is not at or near the time of ovulation.
The simple testing gives medical staff the information to know whether they can
safely intervene to prevent the release of a woman’s ovum, or prevent the sperm
from reaching the egg. In this way, any child conceived is exposed to very
little risk indeed and a woman treated can be reassured that she was not
pregnant.
It is this empirically and ethically
sound approach that truly respects women and children, and it is this approach
that I believe is in keeping with the intention of Directive 36.
Notes
[1] The statement follows the Directives of
1994 and the statement by the Pennsylvania Catholic Conference “Guidelines for
Catholic Hospitals Treating Victims of Sexual Assault” (April 1, 1993),
Origins 22: 81D (May 6, 1993). The Pennsylvania statement (which refers to
ovulation testing (see below)) is cited in a footnote to Directive 36 as an
example of a policy that tries to respect ethical concerns about early human
life. In the UK and Ireland statements were made by the Joint Committee on
Bioethical Issues of Bishops’ Conferences of Scotland, Ireland, England and
Wales: “‘Use of the ‘Morning-After Pill’ in Cases of Rape”, Origins (Jan.
31, 1986), 15: 633, 635-638 (March 13, 1986); Joint Committee on Bioethical
Issues of the Bishops’ Conference of Great Britain and Ireland, “A Reply: Use of
the ‘Morning-After Pill’ in Cases of Rape” (1986), Origins 16: 237-238
(Sept. 11, 1986). This Joint Committee is in the process of investigating
further evidence on these issues.
[2] A simple urine dipstick test can be
done for the LH (luteinizing hormone) surge that triggers ovulation. This test
if it gives a negative result does not necessarily tell you whether the woman is
before the cycle’s LH surge (where drugs can be given to prevent ovulation) or
just after (in which case sperm and ovum may have already have joined and the
drug is likely to work as an abortifiacient). A progesterone blood test is then
recommended as a follow-up, in order to answer the question of whether
conception has taken place. Results from this test, however, can be difficult to
interpret.
Some have also recommended an
ovarian scan as a way of determining the stage of the woman’s cycle.
[3] Ronald P. Hamel, Ph.D., and Michael R.
Panicola, Ph.D., “Emergency Contraception and Sexual Assault”, Health
Progress (September-October 2002).
[4] Place, Michael, “ A Venue for
Theological/Ethical Issues”, Health Progress (July-August 2003).
[5] See for example http://www.mergerwatch.org/edfund_docs/ec_toolkit_docs/strategy-4_change.pdf
[6] See the study by R.B. Everett and R.F.
Jimerson, “The Rape Victim: A Review of 117 Consecutive Cases”, Obstetrics
and Gynecology 50: 88-90 (1977).
[7] Ling W Y et al, “Mode of action of DL-norgestrel
and ethinyloestraidol combination in postcoital contraception”, Fertility and
Sterility 32: 297-302 (1979).
[8] See Swahn M L et al., “Effect of
post-coital contraceptive methods on the endometrium and the menstrual cycle”,
Acta Obstetrica et Gynecologica Scandanavica 75: 738-744 (1996) and also
Eugene F. Diamond, M.D., “The Ovulation or Pregnancy Approach in Cases of Rape?”
(and citations therein), National Catholic Bioethics Quarterly 3: 689-697
(2003). Tests have suggested that Mifepristone (RU486), although not
licensed as “emergency contraception”, can prevent conception, but also has an
abortifacient effect.
[9] See Tonti-Filippini N., “Further
Comments on the Beginning of Life”, Linacre Quarterly 59: 76-81 (1992)
and Diamond op.cit.
[10] It is a matter of dispute whether the
drug’s effects on the endometrium are, in the majority of cases, sufficient for
a further abortificacient effect.
[11] A further possible abortifacient
effect of some drugs is that their use may slow the transport of the embryo down
the fallopian tube so that it arrives in the womb too late to find a receptive
endometrium. Moreover, slowing down the embryo’s journey is a risky procedure,
as it increases the likelihood of an ectopic pregnancy.
[12] Details of a widely adopted protocol
on ovulation testing are outlined in St Francis Medical Centre, “Interim
Protocol, Sexual Assault: Contraceptive Treatment Component”, Peoria, IL,
(October 1995).
[13] It has been suggested that a single,
moderate dose of estrogen may be sufficient to delay ovulation while at the same
time being very unlikely to bring about any harm to a pregnancy if ovulation had
already occurred, though this requires further investigation. If such were the
case, estrogen treatment would be the ethically preferable option. See
Tonti-Filippini N. & Walsh M., “Postcoital Intervention”, National Catholic
Bioethics Quarterly 4: 275-289 (2004).
