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COMMENTARY: Part I, the conflicting opinions on emergency contraception’s effects.
BY E. CHRISTIAN BRUGGER
Part II of this essay can be read here.
At the end of February, the Catholic bishops of Germany released a statement saying that women who are victims of rape should receive care at Catholic hospitals in Germany as a matter of course and that “this can include the administration of a ‘morning-after pill’ to the extent that is has a preventative and not an abortifacient effect.” They stated clearly that medications “that cause the death of an embryo still may not be used.”
Although some Catholics, including the president of the Pontifical Academy for Life, Msgr. Ignacio Carrasco de Paula, praised the decision as consistent with what the Catholic Church has taught for 50 years, others criticized the decision as naive.
The latter believe that the German bishops are factually mistaken, insofar as their statement implies that some types of hormonal emergency contraception (EC) do not cause abortions.
The two responses highlight a long-standing debate in Catholic pro-life circles over the question of whether EC sometimes acts as an abortifacient.
The debate is not over whether it is legitimate to administer abortifacient medications to rape victims.
Dignitatis Personae, published in 2008 by the Congregation for the Doctrine of the Faith, taught clearly that the use of such medications is always gravely wrong (23).
The debate is over the precise modes of activity of certain forms of EC, especially the drug known as Plan B. The question is whether certain forms of EC act as an abortifacent or a contraceptive. On this, the scientific literature has offered different and sometimes conflicting answers to the question.
Some medications marketed as EC indisputably cause abortions. For example, in 2010, the U.S. Food and Drug Administration approved the drug “Ella” (ulipristal acetate) for use as EC. The FDA states that Ella is a “progesterone antagonist”; that is, it blocks the action of progesterone. Suppressing progesterone results in a uterine environment hostile to an embryo. So, pharmacologically speaking, Ella is an abortion drug not a contraceptive. RU-486 (mifepristone) is the other common progesterone-blocking drug on the market.
Unlike Ella and RU-486, most forms of EC contain progestin, a synthetic form of the naturally occurring pregnancy hormone progesterone. Progestin mimics certain benefits of progesterone, but it also can prevent ovulation, which is why it is used as EC.
The most common progestin-only drug is called levonorgestrel (LNG), marketed under the name of Plan B. As scientific studies over the past decade have been published on the effects of Plan B, Catholic ethicists have had conflicting interpretations of the data and, consequently, have taken conflicting positions on whether Catholics, especially those in the field of health care, can in good faith use LNG for treating victims of rape.
Here are two of the more credible examples of the conflicting opinions.
Some of the material is rather technical and may need to be read a couple times. I have chosen to include it in order to invite readers (in outline form) into the main arguments that stand behind competing conclusions.
Position 1: LNG Is Not an Abortifacient
In 2007, Dominican Father Nicanor Pier Giorgio Austriaco, a professor of biology at Providence College and also a trained moral theologian, published an essay in the National Catholic Bioethics Quarterly arguing that mounting evidence suggests that LNG does not act as an abortifacient.
He begins his essay by considering “efficacy studies” supporting the conclusion that LNG does have an abortifacient effect. He notes that the studies propose an apparently statistically significant relationship between the drug’s ingestion and the reduction in number of expected pregnancies not attributable to the drug’s anti-ovulatory (contraceptive) effects alone.
The studies, he notes, conclude that LNG possibly has an abortifacient mode of activity by decreasing the thickness of the endometrium, which can adversely affect the implantation process.
Father Austriaco then moves to studies critical of the efficacy studies, studies that argue that the efficacy studies are unreliable because they are unable to determine the precise relationship between the time of intercourse, ingestion of Plan B and ovulation. The efficacy studies principally rely on a woman’s self-reporting of the timing of her menstrual cycle; and self-reports are notoriously unreliable. When blood hormone tests used to determine the timing of ovulation were compared with self-reports, the studies found “major discrepancies” between the two.
Father Austriaco thinks that separate implantation studies, although unethical, provide strong evidence against the conclusion that LNG acts as an interceptive (an effect that interferes with the embryo before implantation in the uterine wall) by decreasing the thickness of the uterine lining. In one study, researchers exposed human embryos created in vitro to two cultures of uterine tissue, one treated with Plan B (LNG) and the other left untreated. They found no statistically significant difference between the numbers of embryos that were able to attach to the two tissue samples.
In contrast, tissue exposed to mifepristone (RU-486) prevented all embryos from implanting (15 of 15 embryos). This argues for the conclusion that LNG does not adversely affect the receptivity of uterine tissue and consequently would not prevent the implantation of an embryo.
Position 2: LNG Could Be an Abortifacent
A second viewpoint does not challenge the conclusion that LNG does not decrease the thickness of the uterine lining, but proposes another hypothesis as to why it is reasonable to conclude that the drug sometimes acts as an abortifacient.
This second argument may be referred to as the “pre-ovulatory use — post-ovulatory abortifacient” (PU-PA) hypothesis. It has been set forth in two recent pieces of Catholic ethical literature. The first was published in 2009 in Catholic Health Care Ethics: A Manual for Practitioners by Patrick Yeung, Erica Laethem and Father Joseph Tham; and the second was published in 2011 as a white paper of the Westchester Institute for Ethics and the Human Person by Father Thomas Berg, Marie Hilliard and Mark Stegman.
The PU-PA hypothesis argues that in the case where both LNG is administered in the days immediately preceding ovulation (the “pre-ovulatory phase”), and an unexpected breakthrough ovulation occurs and subsequent fertilization results, a post-fertilization effect occurs that may interfere with the future of the pregnancy. It occurs because LNG administered before ovulation blunts the surge of a pregnancy chemical called luteinizing hormone (LH), which is important for regulating conditions after ovulation.
The post-fertilization effect is somewhat complicated. Defenders of the PU-PA hypothesis say that it has at least three dimensions:
1. Decreased luteal phase length: First, LNG administered in the pre-ovulatory phase has been found to decrease the length of what is called the luteal phase. The luteal phase begins with ovulation and continues until menstruation (or pregnancy). During this period, estrogen and progesterone increase, and there is a rise in body temperature, both of which are important for nurturing an embryo. A decreased luteal phase length means the uterine lining may shed before the embryo can implant (i.e., menstruation may begin prematurely), which lowers the chance of a successful implantation.
2. Decreased luteal phase progesterone levels: Second, the progesterone levels during the luteal phase have also been observed to decrease. Progesterone, of course, is necessary for successful implantation and uterine nurture. A decrease in progesterone levels may adversely impact pregnancy.
3. Decreased glycodelin levels: Third, there can be a reduction in the expression of a protein called glycodelin in the uterus. Glycodelin is important for suppressing the female body’s immune cells around the time of fertilization and implantation so they do not attack sperm or the newly conceived embryo. Glycodelin concentration is an important marker of endometrial receptivity. Reduced glycodelin levels correspond to reduced receptivity to a nesting embryo. Both papers argue that studies show that glycodelin concentration is lower around the time of implantation when LNG is administered in the pre-ovulatory phase.
Father Berg and his colleagues conclude that the preponderance of evidence at present supports the conclusion that Plan B administered close to the time of ovulation may cause a chemical abortion.
Reply to the PU-PA Hypothesis
In a lengthy letter to the editor of the National Catholic Bioethics Quarterly in 2011 entitled “Scientific Certitude, Moral Certitude and Plan B,” Father Austriaco replies to the PU-PA hypothesis.
He argues that LNG taken during the pre-ovulatory period does in fact blunt the LH surge. But reliable research demonstrates that when breakthrough ovulation occurs, post-ovulatory effects resulting from this blunting — effects that might interfere with the successful implantation of an embryo — do not in fact occur. He believes this data undermines the plausibility of the PU-PA hypothesis. He also thinks it can stand as a basis for sufficient moral certitude that the welfare of an embryo will not be placed into jeopardy.
He admonishes health-care practitioners to evaluate the evidence and decide for themselves.
E. Christian Brugger is writes from Denver, where he is
professor of moral theology at St. John Viannney Theological Seminary.
He is senior fellow in ethics and director of the
Fellows Program for the Culture of Life Foundation in Washington.