Sunday, January 15, 2006

Catholic hospitals and emergency contraception

A topic of great interest to me is the state of Catholic health care in the U.S. To me, it is one of two areas in the Church's life that are largely unreformed, the other one being social justice. Below is an article I wrote for the November issue of Catholic World Report on Catholic hospitals and emergency contraceptives (this is my original version, not the final printed copy). I hope at some point to write a book on Catholic health care as it needs to be treated rather exhaustively.

A Moral Dilemma
Catholic hospitals treating rape victims face a moral and ethical dilemma: Should they prescribe emergency contraception to these women?
By Thomas A. Szyszkiewicz

When a woman is raped and goes to the emergency room of a Catholic hospital, that raises a moral dilemma for the hospital – does she get emergency contraception (EC) or not? Here’s what the Ethical and Religious Directives for Catholic Health Care Institutions (ERDs) from the United States Conference of Catholic Bishops say about it:
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.
A hospital in the Diocese of Peoria developed a protocol for Catholic hospitals that face this situation. Called (appropriately enough) the Peoria Protocol, it was put together by the staff at OSF St. Francis Medical Center and theologians in the diocese working under then-Bishop John J. Myers.

That protocol calls for the ER personnel to try and determine through various tests whether or not the woman has ovulated. If she hasn’t, then the protocol calls for the woman to be given emergency contraception. If she has, then nothing is to be done because the contraceptive actually acts as an abortifacient. And ovulation within close proximity of a rape could bring about a conception.

In 1998, the Pennsylvania Catholic Conference issued a similar protocol for use in that state’s Catholic hospitals.

“The deliberate destruction of an innocent living human fetus – no matter how conceived – is unjustified,” the conference wrote. “Sexual intercourse involved in the act of rape, on the other hand, is an unjust assault and a non-consensual act. Therefore, appropriate means may be used in treating the rape victim to prevent conception. These means, as used, may not have the effect of an abortifacient.”

This protocol also calls for an indication of whether or not ovulation has occurred.

The question arises because oral contraceptives, both the regular and “emergency” types, are supposed to work by suppressing ovulation. However, it is well known that oral contraceptives have a secondary effect, that of making the uterine lining, called the endometrium, thin and therefore making it impossible for a newly fertilized ovum to properly implant. So the child dies due to a chemical abortion.

It should only be a question, then, of timing, like in the Pennsylvania Protocol. Find out where the woman is in her cycle and if she hasn’t ovulated yet, then give the emergency contraceptive and suppress the ovulation.

But there are those who are questioning whether or not there should be any contraceptive given at all if a rape occurs early in a woman’s cycle. The reason is that some studies indicate that contraceptives do not always succeed at suppressing ovulation, even when it’s given prior to ovulation. According to a 2002 article in the Annals of Pharmacotherapy (vol. 36, no. 3, pp. 465–470), “The evidence to date supports the contention that use of EC does not always inhibit ovulation” even if it is used prior to ovulation. Additionally, it can change the lining of the uterus “regardless of when in the cycle it is used, with the effect persisting for days.” So if ovulation is not suppressed and a child is conceived, then the child will die because the endometrium is too thin.

Because of these effects, the article, co-authored by Drs. Chris Kahlenborn, Joseph Stanford and Walter Larimore, calls into question whether or not Catholic hospitals should even use EC at all. “Catholic hospitals that do allow hormonal EC use prior to ovulation may wish to reassess their policies given the findings that EC use does not consistently stop ovulation and has the potential of causing a postfertilization effect even when used prior to ovulation.”

Of the three, Kahlenborn is the only Catholic. Stanford is a Mormon based in Salt Lake City, but on sabbatical until next year at the National Institutes of Health in Maryland doing research on Natural Family Planning, and Larimore is an Evangelical who used to be vice president for medical affairs at Focus on the Family.

The trio wrote to Archbishop Myers, now in Newark, NJ, asking him to consider changing the Peoria Protocol in light of the research they did. But Kahlenborn said that Myers responded to him that his experts think Kahlenborn is “alarmist” and, according to Kahlenborn, Myers said he “simply did not know what to do.”

Archbishop Myers did not return calls requesting comment.

A request for comment from the Pennsylvania Catholic Conference was declined.

But the evidence was enough to convince the Catholic Medical Association to pass a resolution at its 2003 annual meeting that said, “‘emergency contraception’ is a misnomer as it does not consistently prevent fertilization” and that since it “has the potential to prevent cannot be ethically employed by a Catholic physician or administered in a Catholic hospital in cases of rape.”

Morally picky?
But there are some who contend that the question of whether or not a woman has ovulated should not even be entertained. Rather, they say that the USCCB directive clearly states it’s a matter of whether or not the woman is pregnant.

This is the position held, among others, by Ron Hamel, senior director of ethics at the Catholic Health Association based in St. Louis, and Michael Panicola, who is in charge of ethics at SSM Health Care in St. Louis. In a 2002 paper published in the CHA’s Health Progress, the two spell out the differences between what they call the “pregnancy” approach and the “ovulation” approach. The pregnancy approach tests to see if the woman is pregnant and, if not, that allows for the hospital staff to administer EC. If she is, then they cannot.

The problem with the ovulation approach, in Hamel and Panicola’s view, is that, “Conception does not occur immediately after the ovum is expelled from the ovary; it can only be achieved after fertilization is complete. This is important if one recalls that fertilization is not a moment but rather a process that unfolds over at least a 24-hour period, with the possible result being a conceptus.”

Their view is that the possibilities are too remote even for pregnancy in the case of rape. The percentage of pregnancies resulting from rape is estimated to be between one and five percent. And in their review of the scientific literature, they find no evidence of what is called a post-fertilization effect, or what Kahlenborn, Stanford and Larimore name as early abortion. So Hamel and Panicola say that from their review of the literature, EC works only to suppress ovulation and or to inhibit the move of sperm from the cervix to the Fallopian tubes.

To keep this in perspective, according to the American Civil Liberties Union, there were 6,700 rapes reported in Florida in 2003. Assuming a pregnancy rate for rape between one and five percent, that would mean anywhere between 67 to 335 pregnancies resulted from these rapes. Kahlenborn and his co-authors quote a study that estimates between 13.5 percent and 38 percent of EC cases worked by some other mechanism than suppression of ovulation, that mechanism being, in their view, a chemical abortion. In that case, at a minimum, nine children conceived in rape could have been aborted through the use of EC in Florida in 2003, while at a maximum, 127 died.

While denying that they do it, Hamel and Panicola say that this is essentially the principle of double effect here – doing something that is good but that has an unintended and evil consequence, like removing an ovary because of an ectopic pregnancy. “[T]he intention in administering emergency contraception is to prevent conception and not to inhibit implantation. If a conceptus is present, but fails to be implanted and ultimately is destroyed, this would be an unintended and even an unforeseen effect, given the extremely low likelihood of conception occurring as a result of the sexual assault and the lack of evidence supporting abortifacient effects of the medications.”

But William May, considered the best moral theologian in the U.S. and one of the best in the world, said one “cannot exclude” the possibility that this can result in abortion from the moral consideration. “You may not intend evil,” he said, but “here you are conditionally intending abortion.”

Father Kevin McMahon, a moral theologian at St. Charles Borromeo Seminary in Philadelphia, said that he would like to see stronger evidence to back up what Kahlenborn and his colleagues wrote. However, he also agrees with May and believes this is not a case of double effect. “This would not do two effects – it’s either one or the other [suppress ovulation or abort]. And you don’t even know if the good effect (suppressing ovulation) is going to take place.”

The difficulty is, according to Dr. Stanford, that in medicine “No matter what you do, there will always be some grey area.” Black and white, “just won’t happen in medicine.”

For instance, no matter how much testing is done, the tests will only pick up reactions to what the body is doing, and those reactions take time. So if there is no elevated progesterone level, for instance, that doesn’t necessarily mean that ovulation hasn’t taken place because it takes a few hours before that increase shows up in the bloodstream.

Practical measures
One ER physician in Washington, D.C. wrote in Health Progress that she had been unaware there was even a debate on the matter. Dr. Margaret Barron at Providence Hospital said that the Peoria Protocol calling for tests of progesterone levels and other similar measures is simply too cumbersome. “In most hospitals,” she said, “there is no such thing as receiving ‘stat’ progesterone level information.”

But Dr. Stanford doesn’t think there’s a whole lot to that argument. When he was at the University of Utah hospital, he could get a progesterone level test back in one day. For him, it’s more a matter of logistics rather than practicalities. If a hospital is committed to this, he said, they will find ways to be sure they have the equipment and staff on hand to do a proper evaluation.

But he did concede that for a rural Catholic hospital it would be a difficult financial proposition to have all of that available.

Catholic hospitals not alone
Catholic hospitals are mixed on this issue. According to Catholic for a Free Choice, 28 percent offer EC, a fact which Planned Parenthood criticizes on its website. But that may actually be a close reflection of what happens in hospitals generally. In June, the American Civil Liberties Union published a report showing that the majority of hospitals in Florida do not give it out consistently. According to the Miami Herald, “35 percent of hospitals and treatment centers said they consistently provide rape victims with emergency contraception.” Another 47 percent are inconsistent in their offering of it, six percent don’t do it all and the remaining 12 percent didn’t know what their policies were.

But what the CFFC survey doesn’t reflect is the number of Catholic hospitals that refer rape victims to rape victims’ centers who then, in turn, refer their clients to physicians or hospitals that will dispense EC.

Still many faithful Catholics may even wonder what the debate is all about. Complaints about Catholics hospitals distributing contraceptives and doing sterilizations abound around the country and there seems to be no change on that front anywhere on the horizon.


Nate Harburg said...

It is a tremendous shame that pregnancy is sometimes seen as an evil. This ideology is the root of the culture of death. Indeed, it may be highly undesirable in the circumstance of rape, but this "evil" is trumped by the infinite goodness of the creation of a new human soul. God doesn't make mistakes. Many women have testified that raising the child conceived in rape has helped them to heal from the trauma of the rape. St. Thomas Aquinas said, "God permits evil in order to draw forth some greater good." St. Paul says, "Where sin increased, grace abounded all the more."

It is a shame that Archbishop Myers at that time did not take a stand against Emergency Contraception. It is a shame that Catholic doctors and medical experts do not trust in the moral authority of the Catholic Church on this life or death issue.
If EC's are potentially abortifacient, they must not be administered in Catholic institutions, period.

If there is only a tiny chance that hormonal birth control is sometimes fatal, ought not ALL pro-life groups and individuals emphatically discourage it's use? Is it morally right to randomly fire a gun in a large, dark room containing only one other
person because after all, there is only a tiny chance you might kill him/her?

I urge Catholics everywhere to form committees devoted to the moral reform of Catholic medical institutions; countless lives are possibly being lost in the meantime. We are forming such a committee here in Ann Arbor, Michigan, to challenge St. Joseph Mercy Hospital, which only a few days ago prohibited surgical abortions. (Thank GOD) For more info, email me:

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