The Emergency Contraception Question: When is it licit and when is it not?
A Feb. 21 decision by German bishops to allow emergency contraception to be administered to victims of sexual assault was a surprise to many Catholics, who saw it perhaps as an opening in the church’s monolithic rejection of contraception. They may have been further surprised when church officials quickly endorsed the German conference’s decision. Bishop Ignacio Carrasco de Paula, the president of the Vatican’s Pontifical Academy for Life, said the church has accepted the possibility of preventing ovulation in a woman who has been raped via medication as an "unassailable rule" for 50 years. He said the church does withdraw that option if there is a possibility that ovulation may have already occurred.
"To consider the possibility of using a drug whose active ingredient is a contraceptive in the case of a woman who has been raped seems acceptable to me," the bishop told Vatican Insider, the online news supplement to the Italian newspaper La Stampa. "In the case of rape, one can do what is necessary to avoid a pregnancy, but you cannot terminate it," the bishop said.
Richard Doerflinger, associate director of the U.S. bishops’ Secretariat for Pro-Life Activities and a member of the pontifical academy, agreed that "you are not violating the teaching on contraception by seeking to stop ovulation or fertilization." Rape "is not an act of unitive love, it is an act of violence [and] the woman has a right to defend herself against this attack," he said.
It may be yet another surprise to learn that here in the United States, Catholic hospitals are already allowed to administer "morning after" treatments in the case of sexual assault. The matter is treated in "Ethical and Religious Directives for Catholic Health Care Services" (36): "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."
According to Sister Carol Keehan, D.C, president and C.E.O. of the Catholic Health Association, "misunderstanding" surrounds the issue. Some, despite emerging scientific evidence to the contrary, insist that "morning after" treatments act as abortifacients, and others allege that rape victims cannot receive proper care at Catholic hospitals in the United States. Neither is true, said Sister Keehan. The church's E.R.D. is clear on the permissibility of treating rape victims with contraceptive drugs. Sister Keehan said, "Frankly I am not sure of any [U.S. Catholic] hospitals that do not allow it."
According to Sister Keehan, hospitals that maintain rape treatment centers, both Catholic and non-Catholic, are the best places for rape victims to be taken because they specialize in treatment for sexual assault and they will provide emergency contraception and preventive care for sexually transmitted diseases and HIV. They will also be more experienced in evidence collection and counseling.
“It may be because of a confusion about the E.R.D. and a lack of experience in treating rape victims that some Catholic hospitals may not offer contraception,” she explained.
Emergency contraception, the so called morning-after drugs, have become major sticking points in the current dispute between the U.S. bishops and the Obama administration over new mandates included in the Affordable Care Act. Though the A.C.A.’s new requirements for women’s health care excludes an indisputable abortifacient, RU-486, specifically, they do include Plan B and ellaOne. Many who oppose the new mandate describe these drugs as abortifacients.
"Hospitals and care givers sometimes get pressure and misinformation," said Sister Keehan. "[But ] Catholic hospitals need to be places where a woman experiencing this horrible trauma gets the best and most compassionate care."
The confusion begins in the term abortifacient itself. The Food and Drug Administration holds that Plan B and ellaOne are not abortifacients. That’s because to the government both drugs work before a pregnancy begins, whether that means suspending ovulation or interfering with the implantation of an embryo in the uterus. But to the church, the latter possibility constitutes an abortive feature, and consequently church officials consider Plan B a possible and ellaOne a probable abortifacient.
But now some researchers insist that recent studies have demonstrated that Plan B does not act as an abortifacient, either according to the church’s or the government’s understanding of the term, and that the same is likely true of ellaOne. They have urged a labeling change to reflect that view. Erica V. Jefferson, an F.D.A. public affairs deputy director acknowledges that "the emerging data on Plan B suggest that it does not inhibit implantation." She adds, "Less is known about ella, however, some data suggest that it also does not inhibit implantation.
"It is often difficult at the time a drug is approved or even afterwards to pinpoint the mechanism of action of the drug," Jefferson says. "But when a drug is approved, based on the available data, the F.D.A. will work with a company to develop a label that accurately reflects the known information."
She explained, "Labeling of a drug may change as more becomes known about a drug after it is approved, usually at the request of a company, to reflect new information from clinical trials or other scientific sources. In other words, to change a product’s label, a company would need to submit data to support any additional information or claims that would be added to the label." Following F.D.A. procedures, she would not confirm or deny if such a request had been made or if, perhaps more tellingly, one had been rejected.
The International Federation of Gynecology & Obstetrics reported last year that Plan B type emergency contraceptives do not interfere with pregnancy and the National Institute for Health recently updated its definition of Plan B to exclude mention of a possible affect on implantation. But the various studies that have persuaded these medical authorities to update their views have not been enough to convince the National Catholic Bioethics Center, which still considers both Plan B and ellaOne as potential abortifacients (see N.C.B.C. rebuttal to N.Y. Times' article here). A Jan/Feb 2010 issue of the CHA publication Health Progress includes several evaluations of Plan B that conclude the drug does not act as an abortifacient, including a 2007 review of the scientific literature on Plan B by Father Nicanor Pier Giorgio Austriaco, OP, Ph.D., a priest, theologian and scientist, published by The National Catholic Bioethics Quarterly. Father Austriaco noted "mounting evidence that levonorgestrel [a Plan B generic] has little or no effect on post-fertilization events. In other words, given the limitations of scientific certitude, they suggest that Plan B, when administered once, is not an abortifacient."
According to Richard Doerflinger, while the manner that ellaOne may be effective in preventing pregnancy is the most problematic, the bishops still have concerns about Plan B. Doerflinger said that in addition to temporarily interfering with ovulation, it remains plausible that one manner Plan B may work is to prevent embryonic implantation. "There are warring studies and conflicting viewpoints on whether Plan B can act this way—some studies say yes, some say no, and some are simply irrelevant." But "on a matter affecting a fundamental right to life, that is enough to provoke grave concern."
So how do the church’s concerns affect the administration of contraceptive drugs to victims of sexual assault in Catholic hospitals? Doerflinger says he has not heard of a Catholic hospital using either ellaOne or a copper-releasing intrauterine device, whose abortifacient properties "are well established." But the church’s moral qualms do "make decisions about Plan B very complicated, particularly since preventing ovulation or fertilization in a case of rape is morally licit. The rape is an act of violence and the woman can defend herself from her attacker, including his semen. If fertilization has already occurred, however, there is now a second innocent victim, the unborn child, and that child should not be attacked."
Doerflinger says that some Catholic hospitals may include preliminary procedures to ensure that a dosage of Plan B would only prevent ovulation. The E.R.D. does not endorse a specific evaluative protocol before administering emergency contraception to sexual assualt victims. A simple urine test can determine a pre-existing pregnancy; some hospitals may follow the "Peoria protocol," which details procedures toward determining if Plan B can be administered. A policy paper from Ascension Health points out that “significant debate” persists “among Catholic ethicists and moral theologians regarding what constitutes ‘appropriate testing’"and describes the Peoria protocol, "burdensome" to implement, "insofar as it requires having the necessary lab capabilities and an endocrinologist on call 24 hours a day to perform the progesterone blood level test, which most Catholic facilities do not have."
"The U.S.C.C.B. Committee for Pro-Life Activities has held the view that because a defenseless human life is at stake, any serious doubt should be resolved in favor of taking care not to risk attacking that life," said Doerflinger. "But in the end, how this directive is to be interpreted and applied in the Catholic hospitals in a particular diocese is up to the bishop of that diocese. If the hospital has consulted the bishop on this, and he has determined that the protocol the hospital wants to use is consistent with the directive as he understands it, then the hospital has done what it is required to do."