Catholic Medical Quarterly Volume 63(3) August 2013

Practical Medical Ethics

Rape and The Morning After Pill
Yes or No?

Dr Charles O’Donnell A+E Consultant

You are a junior doctor in the Emergency Department seeing a woman who has been raped 4 hours ago.
She requests the Morning After Pill. 
What do you do?

Principles

In 2001 the U.S. Conference of Catholic Bishops issued their “Ethical and Religious Directives for Catholic Health Care Services”. Directive 36 concerning rape victims, 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”.

Consensual sexual intercourse is a profound invitation by God to voluntarily enter into his creative work. All sexual intercourse in fertile individuals has the potential to result in pregnancy. Accepting the invitation by engaging in intercourse is a major life decision despite the trivialization of sex that we see all around us. Consequently the use of progesterone or progesterone agonist medication to prevent conception or implantation is in such circumstances a profound rejection of the permissive will of God and is never permissible.

But non consensual sex is certainly a different situation. The teaching of the Church on married love (Humanae Vitae) does not apply to cases of rape. This is not complete love, fully giving and consensual. Rape is a violation of a woman which cannot require that woman to be open to life. And yet, if conception has taken place, then the Church does proclaim that the life of a created child should be respected and cherished however it was conceived.

So there are two very important rights that need to be balanced. The right to life of any conceptus versus the right of the women to defend herself against forced conception of a child.

The honest answer is the jury is out!

We live in a world where evil exists and we are called to use our wits (intelligence) to the best of our ability so as to do the will of God. This is how God decided for mankind to work out their salvation. The aim is to:

• Seek to do good
• Avoid directly doing evil so that good may come from it
• Recognize that many of our actions have foreseen but unintended evil side effects
• The test of yes or no is one of proportionality between the intended good and the foreseen evil

These steps are part of our day to day life in medical decision making. Cutting off a gangrenous leg has the unintended evil of disability but a life is saved-the proportionality test is passed. Cutting off a leg with varicose veins fails the proportionality test!

Practical  analysis

Levonorgestrol (Levonelle Onestep) or the progesterone receptor agonist Ulipristal (EllaOne), are the two commonly available preparations in the UK.

Their prescription is full of uncertainty:

• Uncertain exactly how they act at different points in the female menstrual cycle
• Uncertain exactly when ovulation has occurred
• Uncertain about the variability of the pre and post ovulation phases of the menstrual cycle
• Uncertain exactly how to practically ascertain if ovulation is imminent or has occurred in a busy Emergency Department.
• Uncertain how long the drugs once ingested take to act on the 4 potential “anti” mechanisms of action (anti ovulation, capacitiation, fertilization and nidation)
• Uncertain in the literature what is the relative proportion of activity in terms of either preventing conception or preventing implantation. The Drug Companies producing these tablets certainly list interference with implantation as a mechanism in their Data Sheets but the medical literature is unclear on the exact frequency of this effect
• Uncertain for each individual women how the medication will work in her body
  

When a woman is raped a terrible crime has been committed.  We do know for certain that overall about 1 in 20 rapes result in a pregnancy [1]. Consequently, fortunately 19 in 20 rapes do not result in pregnancy.

Reasonable options?

Given our current state of knowledge some may conclude the proportionality test between trying to do good (preventing forced conception) and avoiding evil (inhibiting the chance of the conceptus implanting) is passed if there is a reasonable chance ovulation has not occurred. In this situation it would seem likely if the drug is going to have an effect on preventing pregnancy this will occur pre conception.

Thus, two reasonable options possibly pass the proportionality test:

1. Urine Test for ovulation (LH level) is negative then prescribe.
2. An arbitrary line in the sand for less developed areas of the world where ovulation test kits are not available. A “Historical Test” that states prescribe the MAP if the day of presentation is less than the Length of normal cycle in days minus 17. Why 17? Because this permits a correction for the known variability in the Luteal Phase of the Menstrual Cycle. For a woman with a 28 day cycle this means day 1 to 10 prescribe, day 11 to 28 do not prescribe.

Unfortunately test for ovulation are not routinely available in the NHS, hence one is left with purchasing a dipstix for ones own personal use in this thankfully rare circumstance. This seems a reasonable thing to do in the quest for virtue.

Sometimes trying to do the most amount of good, it is called seeking virtue, in a fallen world that we live in can be tricky and sadly not as clear cut as we may like.

It goes without saying that the proportionality test will change as our knowledge base about these drugs increases. What is more, at present it remains a subjective decision and many doctors actively seeking to do the most amount of good will find the proportionality test wanting and thus correctly say No in all cases.

But we must remember all drugs are poisons, and some poisons can even cause death. For example nobody would question the use of the principle of double effect in the use of anaesthetic agents for essential surgery post trauma of the upper limb in the pregnant patient where the foetus is not yet viable in order to prevent serious long-term maternal disability even when the unintended but foreseen side effect may be abortion albeit in just a few percent of cases. Proportionality when there is no other good option to opt for is the best test we have for our moral compass.

Obviously other traditional techniques including vaginal douche and spermicidal creams per vaginum can be suggested.

Regardless of the yes no division the compassion this patient group deserves is immense. It is impossible for a male doctor to truly comprehend the pain being experienced by these women. The communication of our conscientious beliefs must be in a charitable way. Junior Catholic doctors should be prepared to face this communication challenge, there is no place for amateurship in this area of practice.