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What We Do » Ethics » Ethics Resources » Rape Treatment Protocol » Moral Considerations About Ethics
Emergency Contraception and Catholic Health Care: Moral Considerations
Summary: Ron Hamel, PhD, CHA senior director, ethics, offers a brief moral analysis of the two approaches employed by Catholic hospitals to providing Audioconferences
emergency contraception to women who have been sexually assaulted. Rape Treatment
What is "emergency contraception?" What medications are used and what is their effect? What is the effect of emergency contraceptives on the endometrium? Is it morally permissible for Catholic hospitals to offer emergency contraception to women who have been sexually assaulted? What are the "moral limits" for Catholic health care providers when administering emergency contraception to a victim of sexual assault? So what is morally permitted? What is "appropriate testing" and how can we determine that "there is no evidence that conception has occurred"? Is it morally permissible to refer a woman who has been sexually
assaulted to another facility or physician? 1. What is "emergency contraception?"
The medical and popular definition of emergency contraception is the use of a drug or device to prevent pregnancy after unprotected intercourse. Pregnancy is understood to begin with the completion of implantation. Hence, emergency contraception includes any drug or device that prevents ovulation, sperm capacitation, fertilization, or implantation. CHAUSA: The Catholic Health Association of the United States From a Catholic perspective, however, a pregnancy exists once fertilization is completed; anything that contributes to the demise of a fertilized ovum would be considered an abortifacient. Consequently, according to the Catholic perspective, emergency contraception is any medication that prevents ovulation, sperm capacitation, or fertilization. Any interference with the implantation of a fertilized ovum is judged to be morally wrong. 2. What medications are used and what is their effect?
The most common medications used after a sexual assault are high doses of existing oral contraceptives such as Ovral (a combination of estrogen and progestin). There are, however, two products available in the United States and approved by the FDA designed specifically for emergency contraception. The first is Preven, a combination of estrogen and progestin. The second is Plan B, a progestin-only contraceptive. With all of these, the first dose should be taken as soon as possible after the sexual assault, but no more than 72 hours afterward. The second dose is taken 12 hours after the first. The sooner they are taken, the more effective they are. These medications are sometimes referred to as the "morning after" pill. Emergency contraceptive medications and the term "morning after pill" should not be confused with RU-486, a medication intended to cause the demise of an implanted embryo or fetus. The precise mode of action of emergency oral contraceptives is not yet known, but there is evidence of effects at several critical points in the reproductive cycle—prevention of ovulation, effects on the cervical mucous, sperm and egg transport, sperm capacitation, and fertilization. Some believe that these medications also make the endometrium "hostile" to the implantation of a fertilized ovum. There is no conclusive scientific evidence to support this claim, however (see, #3 below). Combined oral contraceptives. The prevention of ovulation is
considered to be the primary contraceptive effect of combined oral
contraceptives. There is also evidence that they affect cervical mucus,
thus inhibiting sperm penetration. These medications reduce the risk of
pregnancy by about 75 percent.
Progestin-only oral contraceptives. These also suppress ovulation, but not as consistently as combined oral contraceptives. In addition, progestin-only oral contraceptives cause a cervical mucus that is "hostile" to sperm so that there is little or no sperm penetration. In the rare instances when penetration does occur, the sperm's ability to move is reduced, virtually eliminating the possibility of fertilization. These medications reduce the risk of pregnancy by about 89 percent. 3. What is the effect of emergency contraceptives on the
CHAUSA: The Catholic Health Association of the United States As noted above, some hypothesize that one of the effects of combined oral contraceptives is to make the endometrium hostile to implantation. While these medications do have an effect on the endometrium and "many sources mention endometrial effects as a possible mechanism of the contraceptive action of combined oral contraceptives, insufficient evidence exists on whether cellular or biochemical changes in the endometrium could actually prevent implantation." Progestin-only oral contraceptives also cause changes in the endometrium. While these changes may reduce the possibility of implantation, "there is no direct scientific evidence showing that implantation is prevented by progestin-only oral contraceptives." 4. Is it morally permissible for Catholic hospitals to offer emergency
contraception to women who have been sexually assaulted?
Yes, it is morally permissible to do so within certain moral limits. Sexual assault is an egregiously violent act against a woman inflicting horrendous trauma upon her, especially if a pregnancy results. The woman is justified in defending herself against this act of aggression and its consequences, including a possible conception. This is recognized and supported by Directive 36 of the Ethical and Religious Directives for Catholic Health Care Services that reads, in part: "A female who has been raped should be able to defend herself against a potential conception from the sexual assault." 5. What are the "moral limits" for Catholic health care providers
when administering emergency contraception to a victim of sexual
First, it is never permitted to directly terminate an established
pregnancy (Directive 45). This would constitute an abortion.
Second, as Directive 36 states, it is never permissible to administer any medications that "have as their purpose or direct effect the removal, destruction, or interference with the implantation of the fertilized ovum" (emphasis added). Hence, steps can be taken to prevent a conceptus from coming into existence, but once it has come into existence nothing can be done that would result in its demise either prior to or post implantation. Directly bringing about the demise of a conceptus is also considered to be an abortion (Directive 45). 6. So what is morally permitted?
According to Directive 36, it is morally permitted to treat the woman with medications "that would prevent ovulation, sperm capacitation, or fertilization." In other words, it is morally permissible to use contraceptive agents to produce an effect that ultimately prevents fertilization from occurring. The Directive stipulates, however, that administration of these medications can occur only after "appropriate testing" and if "there is no evidence that conception has occurred." 7. What is "appropriate testing" and how can we determine that
"there is no evidence that conception has occurred"?
CHAUSA: The Catholic Health Association of the United States There is some variability among Catholic health care providers (as well as ethicists and theologians) in their interpretation of what constitutes "appropriate testing" and "evidence that conception has occurred." In fact, it would be fair to say that there is a significant debate about what is morally correct. Part of the reason for this theological debate is that there is no way of ascertaining that conception has occurred as a result of the sexual assault. In the face of this reality, two approaches have emerged. The first might be referred to as the "pregnancy approach" and the second as the "ovulation approach." As the name suggests, the pregnancy approach tests only for the existence of a pre-existing pregnancy, that is, one that occurred before and is unrelated to the sexual assault. This approach makes no attempt to determine whether conception has occurred because of the sexual assault on the assumption that no tests presently available or personal information supplied by the woman can provide evidence of conception from a recent sexual assault. The most that can be done is to rule out a prior pregnancy. If the pregnancy test is negative, the woman is offered emergency contraception. If it is positive, she is not given the medications because there is no chance of her becoming pregnant from the sexual assault if she is already pregnant. The ovulation approach tests for the presence of a pre-existing pregnancy and, in addition, also tries to ascertain whether the woman is at that point in her menstrual cycle when conception might have occurred. As previously noted, there is no current method for ascertaining that an ovum has been fertilized until implantation. All that can be determined is that the woman is at that point in her cycle where conception is a possibility (though a remote one, less than 1% to 5%). Those who espouse this approach believe that the presence of ovulation is an indication that conception might have occurred. This approach permits the administration of contraceptive medications only if the woman’s pregnancy test is negative and personal and/or empirical data (the results from tests for ovulation) indicate that she is not presently ovulating or in the early post-ovulatory phase of her menstrual cycle. The tests that are administered—a urine dip-stick test to determine LH (luteinizing hormone) surge, which is believed to be a reliable guide to the occurrence of ovulation and a blood test to determine the woman’s progesterone level, which is also an indicator of ovulation and helps categorize the timing of the woman’s ovulatory cycle—are an attempt to reduce the possibility that a fertilized ovum might be destroyed by the possible (though questionable) abortifacient effect of the contraceptive medication. There is reason to believe that the pregnancy approach is the one most often followed in Catholic hospitals. Many orthodox moral theologians have judged this approach to be consistent with Catholic moral teaching and to fulfill the requirement of Directive 36 when it calls for "appropriate testing." Other theologians argue for a "safer" course and propose what in effect is a more "rigorous standard" for testing. (It should be noted that some bishops have endorsed the ovulation approach). Apart from the theological issues, some Catholic health care professionals have observed that most Catholic hospitals are not able to provide all the testing required by the ovulation approach at the time of CHAUSA: The Catholic Health Association of the United States the woman’s visit to the emergency department. This is especially true of the blood test for progesterone levels. 8. Is it morally permissible to refer a woman who has been sexually
assaulted to another facility or physician?
Because of the assumptions of the ovulation approach, it would not be morally licit to refer (i.e., to send or direct for treatment) a woman who has been sexually assaulted to another provider for the sole purpose of receiving emergency contraception if she has ovulated recently. This would likely constitute formal cooperation because by referring, one is intending that the woman receive emergency contraception at a point in her cycle when the medication is believed to have an abortifacient effect. In the pregnancy approach, referral would not likely be an issue, unless this was done after implantation, in which case it would not be morally licit (because the woman would be seeking a termination of her pregnancy). It is morally permissible to refer a victim of sexual assault to a primary care physician or to an obstetrician/gynecologist for a follow-up visit. This constitutes good medical care. It is also morally permissible to refer a victim of sexual assault to another facility or to a clinic for more holistic care. The Catholic facility may not be able to provide all the care or the quality of care that the woman needs. This too constitutes good medical practice. It is also morally permissible (and always legally necessary) to inform the woman of all her medical options for treatment and which options for treatment are available in that particular hospital. 1Roberto Rivera, et.al., "The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices," American Journal of Obstetrics and Gynecology, Vol. 181 (November 1999), pp. 1263-69. 2 Ibid. The author cites a 1998 study which suggests that both regimens are most effective when administered within 24 hours of unprotected intercourse. The effectiveness decreases substantially and progressively when the medications are administered in the 24-48 hour and 48-72 hour intervals. The author concludes from this that "if endometrial effects that would prevent implantation played an important role, the same level of effectiveness of emergency contraceptive pills should continue beyond 24 hours, possibly until implantation is established."" The author believes that the primary effects of emergency oral contraceptives are the prevention of ovulation or fertilization. See also, Anna Glasier, "Emergency postcoital contraception," New England Journal of Medicine, Vol. 337 (October 9, 1997), pp. 1058-1064. Copyright 2007 CHA All rights reserved.
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