The state of Plan B and the CT bishop’s decision

This post will provide two services:

• As promised, it will present recent medical findings which make a compelling argument that Plan B does not, in fact, act abortifaciently
• Additionally, it will cite examples of a growing consensus among reasonable commentators that the recent decision of the Connecticut bishops was still not in the best interests of Catholic hospitals in the U.S.

Before I continue I must make this very clear: I am not claiming definitive knowledge about what I discuss. I am in the process of coming to decisions about the moral issues involved here, and I present below my current position on the questions - albeit a position that I have been researching and thinking through at some length. The main purpose of this post is to keep this debate in the public eye and not rest until we are satisfied with the conclusions that have been reached. That said....

First, the medical findings:

I have been corresponding with a practicing family physician who has reviewed the medical literature and concluded that levo-norgestrel as dosed in Plan B is probably not abortifacient, granted that it is very hard in this case to prove a negative. However, what is required here is moral certainty, not absolute certainty. There is the possibility, as yet undiscovered, that Plan B could act against an already-conceived human being. I think one of the problems in this debate is that previous reports, now contradicted, did claim to detect an abortifacient side-effect to Plan B in some cases. If those reports were in fact false, and had never been issued, we would be in a very different frame of mind when viewing this situation now.

First, some summarized background on the medical situation (and several facts you might not necessarily take into consideration immediately without prompting):

• A pre-implantation embryo is invisible, which means absolute moral certainty regardings its presence and survival is difficult to obtain
• While most oral contraceptives, when taken regularly, do in fact reduce the endometrial lining (typically from 5mm to even less than 2mm), Plan B apparently does not have enough time to begin reducing the lining of the endometrium. And since it is only administered once, nor does it have a chance to reduce the endometrial lining after implantation.
• There is also increasing evidence that Plan B operates primarily by preventing ovulation
• Furthermore, its secondary effect of thickening cervical mucus and altering uterine pH levels are also demonstrable
• One of the frequently-cited sources for the claim that Plan B acts abortifaciently has since been shown to have relied on unscientific methods for determining its findings
• Often people claim something to the effect that "clearly Plan B is an abortifacient because it says so on the label!" However, there is plausible reason to believe that this warning was placed on the label to avoid legal complications because the manufacturers did not know (and admittedly, probably did not care) whether the chemical effects the endomitrium.
• Other research into the effects of Plan B [like this notable one] seem to ignore the fact that Plan B, while similar to the contraceptive pill, does not have the same duration of time than the contraceptive pill has to deplete the endometrium.

Here is an extract of the physician's findings:

Plan B, levo-norgestrel does not appear to cause abortion by damaging the endometrium. A 1974 article and extrapolation from daily oral contraceptives have contributed to this common misperception.

Some “emergency contraception” such an IUD’s and mifepristone most likely do prevent implantation.

There is now good evidence that Plan B does prevent ovulation in some women. Plan B, given after ovulation has occurred, may still prevent some conceptions by making the uterine environment unfriendly for spermatozoa.

You can read the two-page summary of the medical findings (as well as a note regarding ovulation testing) in a Word Document here.

I think this short summary reveals that a very serious study of Plan B's effects needs to be undertaken to provide the Catholic medical community with the scientific data it needs to evaluate the morality of proscribing it to rape victims.

As a side-note, I'm also hearing reports than Plan B's effectiveness is drastically below the near-100% figures claimed by the manufacturer (as low as 60%). We can probably expect pharmaceutical companies to eventually develop a "99%" effective pill that may include endometrial thinning as one of the mechanisms for preventing sustained pregnancy. Such a pill, on principle, would have to be resisted once it is scientifically demonstrated that it in fact has the ability to act against an already-conceived human being.

Now, a look at the the emerging consensus:

Having analyzed the recent medical findings on Plan B, we must now take a look at the prudential nature of the CT Bishop's decision from the standpoint of legal precedent, and therefore, within a wider context. After all, this decision did not occur in a vacuum.

As I said at the time, I believe the National Catholic Bioethics Center statement on this question is best. I will re-iterate here the conclusion that I came to in my commentary on the document:

While the NCBC understands the judgement of the CT bishops regarding the claimed moral neutrality, as such, of allowing Plan B, the NCBC also brings up the point that because a) it is immoral to violate one's conscience and b) this law does not allow an exemption of conscience therefore .... c) this law immorally legislates that people violate their consciences.

Simply put, a law which requires Catholic hospital employees to violate their conscience in the practice of their medical profession is unjust. Numerous commentators have agreed.

Fr. Thomas J. Euteneuer, president of Human Life International had this to say:

"Acts of blatant coercion of Catholic consciences are already far advanced and will only continue unless the church is willing to stand up and rebuke the arrogance of these coercive measures and carve out strict realms of conscience which are unreachable by activist courts and corrupt politicians." {Source.}

The Catholic Media Coalition has been especially vocal about reversing the situation of compliance.

More recent related stories:

• Connecticut bishops' stand on emergency contraception draws criticism (CNS)
• Colorado Springs Bishop Says He Does Not and Would Not Permit Plan B in Catholic Hospitals (LSN)
• American Life League Urges Connecticut Bishops to Rethink Plan B at Catholic Hospitals (LSN)
• An Open Letter to the Bishops of Connecticut by Michael Augros of First Things
• A very illuminating historical look at this situation was published in The National Catholic Register.

From the proceeding I conclude:

• Medically speaking, it appears that prior claims regarding the abortifacient properties of Plan B, when administered once, are unable to be substantiated. Indeed, the best review of current research would seem to suggest that Plan B, when administered once, does not render the uterus inhospitable to new human life.
• That said, legally speaking, it is unjust for the Connecticut State Legislature to enact a law that a) contravenes the consciences of Catholic employees, b) legislates restrictions upon what testing may or may not be administered to rape victims and c) withholds pertinent information from these victims at a crucial time in their decision-making process.

As such, and in times such as these, we need to support the CT Bishops in reversing this unjust law.

Previous AmP coverage of this story - starting the day it happened - available here.

Constructive comments are always welcome. Emails receive greater attention and priority.

NCBC publishes statement on Connecticut Bishop's Plan B decision (with commentary)

The National Catholic Bioethics Center has published a statement on the Connecticut Bishops' decision to allow the use of Plan B without an ovulation test in cases of rape. The NCBC is, in my opinion and many others, the foremost institution on Catholic bioethics in the United States. Their quarterly journal is widely-read and highly regarded. I have read this journal extensively for various courses and have drawn on it heavily for bioethics papers and research.

I have always agreed with their positions and reasoning. I further take this statement to be normative for my own opinion about this matter, with the comments I include below. To fast-forward and summarize my conclusion: I believe that this document both a) is willing to admit the validity of the Bishops' prudential decision while simultaneously b) claiming that the law is essentially immoral because it requires health care workers to violate their conscience.

That said, I would encourage anyone who has been following this story closely to read the statement in its entirety.

I'll now excerpt the most important passages [my comments in brackets]:

... This is a complex moral matter and does not lend itself to brief explanation. This difficulty was rendered all the worse by inaccurate reporting and inappropriate, indeed misleading, terminology.

These are good initial observations, which I have previously voiced.

... The state does allow a pregnancy test. However, this test can have nothing to do with the sexual assault. This test only identifies a conception that had taken place before the assault. It takes an embryo 5 to 7 days to make its way down the oviduct and implant in the womb.

Correct. The pregnancy test does not provide the information needed by the health care workers or victim to make a fully-informed ethical decision.

... In other words, [under this new law] the physician would have to administer a drug preventing ovulation even if ovulation had already occurred. Frankly, that makes no medical sense. The state was preventing a physician from exercising his or her best medical judgment about a procedure he or she was considering.

Yes. The new law requires that health care workers not perform a scientifically-relevant and morally-necessary simple test.

... A second objection centered around the fact that the medication(s) might prevent an implantation if a conception had occurred. To intend and to do such a thing is immoral. However, there was considerable debate among medical and drug experts whether or not the drugs actually had that effect. And everyone agreed there was no test even to know whether a new life had been conceived.

In a situation of doubt, it is not prudent to forgo testing which might aid an honest decision-making process.

Finally, attention should be drawn to the fact that the Federal Drug Administration includes the intra-uterine device as “Emergency Contraception” which is a misnomer since it is known to have an abortifacient effect.

I had not heard this before, but I have heard that the FDA protocols often fall well-below standards acceptable to Catholics.

Unlike the state of Colorado, for example, the state of Connecticut would not allow physicians to exercise their best medical judgment and provided no conscience protection to physicians or hospitals to refuse to administer the drug when requested.

The crux of the matter: this law inhibits Catholic hospitals and workers to exercise good medicine and their conscience. This is a very dangerous precedent to allow in general.

The Connecticut Catholic bishops and hospitals, under strong protest, have allowed a new protocol to be used that was developed by Catholic health care institutions. Furthermore, they made it clear that if a test were ever developed that allowed one to detect a conception after an assault, and if it became clear (as is not yet the case) that the medication(s) would work as an abortifacient, they could no longer accept the protocol. Finally, the Connecticut bishops pointed out that the Doctrine Committee of the United States Conference of Catholic Bishops had studied this matter for years and could not come to the conclusion that the protocol previously allowed by the Connecticut bishops (the ovulation test protocol) would have to be used by all Catholic institutions.

I'm not sure here that it is necessary for the Connecticut protocol to be universally-applicable to other hospitals for it to constitute the moral course of action. The logic of the document in this paragraph is not quite clear to me. Just because the USCCB did not endorse the details of the previous CT protocol does not mean that the protocol was deficient. It simply meant that their prudential decision was well-founded enough, at the very least, to avoid challenge.

In matters that have not yet been decided definitively by the Holy See, The National Catholic Bioethics Center has refrained from adopting one or another position on a disputed question. However, in the matter of protocols for sexual assault, there is virtual unanimity that an ovulation test should be administered before giving an anovulant medication. The protocol the NCBC has supported requires the ovulation test because it provides greater medical and moral certitude that the intervention will have its desired anovulatory effect.

I think it is clear from this paragraph that the NCBC would have preferred the CT bishops to not abandon their previous requirement of an ovulation test (i.e., language such as "virtual unanimity"), but they do not state this explicitly here. Furthermore, their reasons for thinking the law is unjust are a bit more nuanced and the grounds for their reservations are more novel than the discussion have taken into account up to this point. But let's read on....

The NCBC objects strongly to state mandates, such as those passed by Connecticut and Massachusetts, that do not allow health care professionals and facilities to exercise their best medical judgment and which do not protect the consciences of all parties. We also object to state mandates that do not allow the victim of sexual assault to have all the information necessary for a medical intervention so that she might make an informed judgment.

This argument also seems to tend towards resisting the law. Indeed, what they are proposing here is that one might resist the law on principle alone, because it violated the consciences of Catholic hospital doctors and employees and furthermore acts against the interest of the victim.

However, the NCBC understands the judgment of the Connecticut bishops that the administration of a contraceptive medication in the absence of an ovulation test is not an intrinsically evil act. However, it is immoral to violate one’s conscience, including the corporate consciences of health care agencies, and the unwillingness of the state to allow an exemption of conscience makes the law unjust and onerous.

Back-to-back "However's" tend to set off warning bells in my mind that an author is trying to have it both ways. I think the first line here about the CT decision is acknowledging, for instance, that strictly-speaking the CT bishops have not acted against any specific moral norm. However, the second line formulates a premise upon which the law could be challenged because "it is immoral to violate one's conscience" ... and as such, the law is "unjust and onerous."

Conclusion: While the NCBC understands the judgement of the CT bishops regarding the claimed moral neutrality, as such, of allowing Plan B the NCBC is also bringing up the point that because a) it is immoral to violate one's conscience and b) this law does not allow an exemption of conscience therefore .... c) this law immorally legislates that people violate their consciences.

This conclusion prompts the next question, which this statement does not address: is it moral to accept a law that is immoral for the proportional good of allowing Catholic hospitals to continue treating rape victims? I think that's what the discussion must now explore.

As I've promised before in previous posts, I still hope to publish a summary of the medical details regarding Plan B by the end of this week (waiting for more input). Previous coverage of this issue can be found here:

• Bp. Lori issues clarification on CT Plan B decision
• Follow-up: Connecticut Plan B Bill goes into effect today
• Statement: Connecticut Bishops On Plan B and Catholic Hospitals
• Breaking: Catholic Bishops in CT to allow Plan B?!