A Moral Dilemma

by Thomas A. Szyszkiewicz


Thomas A. Szyszkiewicz examines the moral and ethical dilemma Catholic hospitals treating rape victims face: should they prescribe emergency contraception to these women? Controversial 'emergency contraception' protocols developed by certain Catholic hospitals do not adhere to Church teaching. Faithful Catholics may be left wondering why the use of emergency contraceptives in Catholic hospitals should be shocking when complaints about them distributing contraceptives and doing sterilizations abound around the country. And yet there seems to be no effort from US bishops to seek a change on that front anywhere on the horizon.

Larger Work

The Catholic World Report


28 - 30

Publisher & Date

Ignatius Press, San Francisco, CA, November 2005

When a woman is raped and is taken to the emergency room of a Catholic hospital, it creates a moral dilemma for the hospital: Will she be given so-called emergency contraception (EC) or not? While the answer may appear to be simple — Catholic teaching forbids the use of artificial contraception, and so-called emergency contraception is known to be abortifacient — the reality is not so simple.

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, Illinois, 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 emergency room (ER) personnel to determine through various tests whether 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 ovulation within close proximity to a rape could bring about a conception and the contraceptive would actually act as an abortifacient.

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 ovulation has occurred.

The controversy 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 impeding the proper implantation of a newly fertilized ovum and causing the child to die due to a chemical abortion.

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

But there are those who are questioning whether any contraceptive should be given at all if a rape occurs early in a woman's cycle. 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 Catholic hospitals should 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 was once vice president for medical affairs at the Focus on the Family organization.

The trio wrote to Archbishop Myers, now in Newark, New Jersey, asking him to consider changing the Peoria Protocol in light of the research they did. But Kahlenborn reports that Myers told 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 from CWR requesting comment.

A request for comment from the Pennsylvania Catholic Conference was also 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 implantation . . . it cannot be ethically employed by a Catholic physician or administered in a Catholic hospital in cases of rape."

A Fine Line of Morality

There are some who contend that the question of whether 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 by, among others, 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. Hamel and Panicola claim that from their review of the literature, EC works only to suppress ovulation and / or to inhibit the movement 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.

Hamel and Panicola say that this is essentially the principle of double effect — doing something that is good but that has an unintended and evil consequence, such as 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 one of the foremost moral theologians in the US and one of the most well-regarded 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, DC, 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 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.

The reactions of Catholic hospitals to this controversial issue are mixed. According to the pro-abortion group Catholics for a Free Choice, 28 percent of Catholic hospitals offer EC, which Planned Parenthood criticizes on its website as being too few. But that may actually be a close reflection of what happens in hospitals generally. In June, the ACLU published a report showing that the majority of hospitals in Florida do not provide EC consistently. According to the Miami Herald, "Thirty-five 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 at 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 be left wondering why the use of emergency contraceptive in Catholic hospitals should be shocking when complaints about them distributing contraceptives and doing sterilizations abound around the country. And yet there seems to be no effort from US bishops to seek a change on that front anywhere on the horizon.

Thomas A. Szyszkiewicz writes from Minnesota and is a frequent contributor to CWR.

© Ignatius Press

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