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Colorado emergency contraception bill – comment
U.S. Catholic Hospitals and the Treatment of Rape
Most hospitals in the United States prescribe what is euphemistically called ‘emergency
contraception’ to rape victims who are diagnosed as not being pregnant. There are two
kinds of emergency contraceptives, one that contains both estrogen and progestogen
(Preven) and the other that contains progestogen only, (Levonorgestrel) – LNG. There is
evidence that both types of pill, also called the ‘morning-after pill’ (MAP) can act as a
contraceptive or alternatively, can cause an abortion by preventing the implantation of an
embryo in the endothelial lining of the uterine cavity.
The Colorado Emergency Contraception Bill
Governor Bill Ritter’s Bill (January, 2007) concerning the availability of emergency
contraception to a survivor of sexual assault requires hospitals to adopt protocols to
inform such a survivor of the availability of emergency contraception. The Bill does not
require hospitals to provide emergency contraception to a pregnant woman, nor does it
require a health care professional to provide either information about emergency
contraception or the emergency contraceptive itself, if the professional objects on
Three questions need to be asked. Will Catholic hospitals, if they provide
information on emergency contraception, include the scientifically proven embryological
fact that these contraceptives may also act as abortifacients, and will they impart Catholic
teaching in regard to emergency contraception? Secondly, If a Catholic institution
delegates the duty of providing such information to a person who had no moral or
religious objection to emergency contraception, will that person commit to teaching the
fact that emergency ‘contraceptives’ can possibly act as abortifacients, and will that
delegate commit to communicate Catholic teaching? Even if the answer to both of these
questions is ‘yes’, could not such activity still be morally wrong?
The Colorado Bill does not appear to require Catholic hospitals to educate rape
victims on the procedures used to determine ovulation, or to determine if the victim is
pregnant, though some hospitals may choose to do so.
The Biological/Theological Debate
Directive 36 of the Ethical and Religious Directives for Catholic Health Care Services
states that a female who has been raped may be treated with medications that would
prevent ovulation, sperm capacitation, or fertilization, “. If after appropriate testing,
there is no evidence that conception has occurred.” “Appropriate testing” is of two kinds.
One is known as the “pregnancy approach.” The patient is tested for a pre-existing
pregnancy unrelated to the assault, using a human chorionic gonadotropin (HCG) test.
The problem is that this test becomes positive only
at implantation of the embryo in the
endometrium of the uterus. This test may fail to demonstrate a pregnancy that had
occurred within eight to ten days before the rape. A pregnancy that occurred before the
The second kind of “appropriate” testing is known as the “ovulation approach.”
This tests for pre-existing pregnancy and in addition, also tries to ascertain whether the
woman is at the point in her cycle where conception might have occurred, that is, near the
time of ovulation. The MAP is offered if the HCG test is negative and personal and
impirical data indicate the woman is not at, or near, the time of ovulation. If she is near
The Peoria Protocol goes further in assessing ovulation. It requires care givers to
conduct (1) a urine dip-stick test to determine the presence of a luteinizing hormone (LH)
surge, a guide to ovulation, and (2) a blood test to determine the woman’s progesterone
level, another indicator of ovulation. Different courses of action are determined by the
results of these tests. A serious problem with this approach is that the LH assay may fail
to indicate the presence of a pregnancy and plasma levels of progesterone may fail to
distinguish whether a woman is in the phase before
ovulation.1 The fact that there
is no elevation of the progesterone level does not necessarily mean that ovulation has not
taken place. It takes a few hours before that increase shows up in the blood.
The most commonly used emergency contraceptive is levonorgestrel, a
progestogen. The Catholic Health Association of the United States, (CHA), proponents of
the above pregnancy approach to testing rape victims, and many others as well, tell us
that levonorgestrel, rarely if ever, prevents implantation of the embryo, that is, causes an
abortion, and that there is no scientific evidence to show that it can.2 This statement is
still a matter of serious debate. The World Health Organization has reported that the
morning after pill (MAP), for example, Preven, which is a combination of oestrogen and
progestogen, can act as a contraceptive by inhibiting ovulation, or it may cause an
abortion by preventing implantation. Some studies indicate that the emergency
contraceptive that acts as a progestogen only, levonorgestrel, (LNG) acts primarily
Although there is no direct experimental
evidence that links oral contraceptives
with embryo loss, oral contraceptives are
known to thin the endometrium, and to alter its
biochemical and protein composition. An endometrium of average thickness of 5 –13
mm. is needed to maintain a pregnancy. The average endometrial thickness in women
In another study LNG taken before the LH surge altered the luteal phase secretory
pattern of glycodelin in serum and the endometrium.5 Furthermore, treatment with
emergency contraceptive pills containing only LNG during the peri-ovulatory phase may
fail to inhibit ovulation but, nevertheless, reduce the length of the luteal phase and the
total luteal phase LH concentrations. This observation suggests a post-fertilization effect.6
Levonorgestrel, whose action is more abortifacient, is the more commonly used pill today
because it is more effective and causes less nausea and vomiting.
Further studies suggest that LNG may have an anti-implantation effect. In one
study 243 women took LNG on a day in the cycle when ovulation could not be inhibited,
one day earlier or one day later than the moment of expected ovulation. LNG
effectiveness was 88%: 46% of the women took the pill within 24 hours after
intercourse, 36% within 24-48 hours, 19% between 48-72 hours.7 Other studies have
shown continued effectiveness of LNG even when taken between 72 and 100 hours after
intercourse. This makes it highly likely that LNG was taken on days when it was
impossible to block ovulation, given that a woman’s fertile days are up to 5 days before
Stanford and Kahlenborn state that evidence based on alterations in endometrial
biochemistry and histology, endometrial thickness, and receptivity from research
studying in vitro fertilization and endometrial integrins all support the possibility of peri-
implantation or post-implantation effects (abortion). However, few data assisted in
quantifying those post-fertilization effects. For the perfect use of the combined oral
contraceptive, a post-fertilization mechanism would be likely to have a small, but not
negligible role. For progestin only pills (levonorgestrel), post fertilization effects are
likely to have an increased role. The medical literature does not support the hypothesis
that post-fertilization effects of oral contraceptives do not exist.11
An editorial in the journal Contraception
12 states that Croxato et al.13, 14, have
argued that most, if not all, of the contraceptive effect of both combined and progestegen
only emergency contraceptive pills (MAPs) can be explained by inhibited or
dysfunctional ovulation. Based on their studies on humans and animals, some are tempted
to conclude that there is no post fertilization effect, no prevention of implantation. It is
unlikely, the editorial stated, that this question can ever be unequivocally answered, and
we therefore, cannot conclude that MAPs never “prevent pregnancy after fertilization.” 15
Such ‘prevention’ is of course, abortion and not contraception.
A further question presents itself; if there is no sure test to show that ovulation
has, or has not, occurred in a victim of rape, and the Director of Communications for the
Archdiocese of Denver admits that this could be so, then why use an ovulation test in
order to administer the morning after pill?
The favourite CHA approach to ‘appropriate’ testing for rape cases, the
so-called pregnancy approach, is morally unacceptable. It may fail to detect a pregnancy
that has occurred either before or after the rape. In 1998, a World Health Organization
study of 2000 women were given an emergency contraceptive after blood or urine had
been taken for a pregnancy test at enrolment. However, pregnancy did not exclude
participation in the study. Of the women later found to be pregnant, about 10% (4 out of
42) were discovered to have been pregnant before taking the pill! The Preoria Protocol
may give a greater degree of probability that a woman is not pregnant, but it too may fail
to detect a pregnancy that resulted from the rape. As Dr. Robb Barbieri, Chief of
Obstetrics and Gynecology at Brigham and Women’s Hospital, Boston, has said, “. by
measuring hormone levels, doctors can often determine whether a woman has ovulated or
whether implantation has occurred, but that it is really impossible to pin-point
fertilization, the step in between.”16
Earlier in this paper, the question was asked if it would be morally wrong to
administer MAPs to rape victims or to give them information about MAPs. Those who
support administering MAPs do so by stating that rape is a violation of justice that allows
their administration. Could not a similar argument be made for the use of a condom to
prevent the spread of sexually transmitted infection, which might also be called a
Brother Daniel Sulmasy, Director of Ethics for St. Vincent’s Hospital in New
York, says that the Peoria Protocol “.goes beyond the normal protection given to any
unborn child” and that it “lays upon the faithful an almost impossible burden.”17 Msgr.
William Smith, St. Joseph’s Seminary, Dunwoodie, N.Y., says “Catholic hospitals are not
free to prescribe of provide anything with abortifacient properties without contradicting
their witness.”18 The Pontifical Academy for Life, in a “Statement on the so-called
‘morning after’ pill”. Vatican City, 31 October, 2000, stated that “the absolute
unlawfulness of abortifacient procedures also applies to distributing, prescribing and
taking the morning after pill. All who, whether sharing the intention or not, directly co-
operate with this procedure are morally responsible for it.” Pope John Paul II, speaking to
Indonesian bishops on June 7, 1980, said “Contraception is to be judged objectively so
illicit that it can never, for any reason, be justified.” Whether the MAP causes abortion is
at present dubium facti
. An editorial in the journal Contraception,
2006, makes the point
that it is unlikely that the question whether the MAP causes an abortion can ever be
unequivocally answered.19 Action in regard to its use therefore requires one to be morally
certain that it does not cause an abortion. If that doubt cannot be solved, one is not
Glasier A. et al., “Comparison of mifepristone and high dose estrogen-
progestegen for a emergency postcoital contraception.” N Eng J. Med.
1031-4. Also; Webb A M C et al., “Comparison of the Yuzpe regime, danazol and
mifepristone in oral postcoital contraception.” B M J,
1992; 35: 927-31.
The Catholic Health Association of the U.S., Ron Hamel, PhD. and Michael R.
Fabian Grou, Isabel Rodrigues, “The morning-after-pill – How long after?” Am J
Dec. 1996, pp.1529-1534.
Bergh, J.B. et al. Sonographic evaluation of emergency contraception in in vitro
fertilization cycles; a way to predict pregnancy? Acta Obstet. Gynecol Scand.
Wai Ngai S. et al., A randomized trial to compare 24 hours vs.12 hours double
dose regimen of levonorgestrel for emergency contraception. Hum Reprod.
Durand M. et al. Late follicular phase administration of levonorgestrel as an
emergency contraceptive changes the secretory pattern of glycoledin in serum and
endometrium during the luteal phase of the menstrual cycle. Contraception
WHO Task Force on Post-Ovulatory Methods of Fertility Regulation,
Randomized controlled trial of combined oral contraceptives for emergency
Von Hertzen H. et al., (2002) Low dose mifepristone and two regimens of
levonorgestrel for emergency contraception: a WHO multicentre randomized trial.
Hamoda H. et al., A Randomized Trial of Mifepristone (10mg.) and
Levonorgestrel for Emergency Contraception. Obstet.Gynecol.
Walter L. Larimore, MD; Joseph B. Stanford, MD. MSPH, Post Fertilization
Effects of Oral Contraceptives and Their Relationship to Informed Consent, Arch.
Vol. 9, Feb. 2000, p. 126-133.
74 (2006) 87-89.
Croxato H B et al., Mechanism of action of hormonal preparations used for
emergency contraception: a review of the literature. Contraception,
Croxato H B et al., Mechanisms of action of emergency contraception, Steroids,
Liz Kowalczyk, “Groups, doctors, seek wider use of ‘morning after’ pill.” The
,Feb. 28, 2003.
Mary de Turris Poust, “A ‘morning after’ assault on religious freedom.” Our
Skip O’Neel, “Silence Greets Emergency Contraceptive Bill”, San Francisco
Articles July/August, 2002.
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