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Further thoughts on "Plan B"

The Connecticut bishops have reversed themselves and will now allow Catholic hospitals to dispense emergency contraceptive pills, known as "Plan B" pills, to rape victims. See the Hartford Courant story here. This has naturally caused many tongues to wag. The Catholic World News story quotes a bishops' spokesman as saying that the hierarchy had undergone "an evolution in thinking." Beyond that, there is not much. One wonders how and why their thinking changed, and how this will affect many similar debates, or even what Rome thinks. Illumination welcomed.

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The Archdiocese of Hartford's website has the following official statement, which adds at least some additional gloss to the newspaper article:"The Catholic Bishops of Connecticut, joined by the leaders of the Catholic hospitals in the State, issue the following statement regarding the administration of Plan B in Catholic hospitals to victims of rape:The four Catholic hospitals in the State of Connecticut remain committed to providing competent and compassionate care to victims of rape. In accordance with Catholic moral teaching, these hospitals provide emergency contraception after appropriate testing. Under the existing hospital protocols, this includes a pregnancy test and an ovulation test. Catholic moral teaching is adamantly opposed to abortion but not to emergency contraception for victims of rape.This past spring the Governor signed into a law 'An Act Concerning Compassionate Care for Victims of Sexual Assault,' passed by the State Legislature. It does not allow medical professionals to take into account the results of the ovulation test. The Bishops and other Catholic health care leaders believe that this law is seriously flawed, but not sufficiently to bar compliance with it at the present time. We continue to believe this law should be changed.Nonetheless to administer Plan B pills in Catholic hospitals to victims of rape a pregnancy test to determine that the woman has not conceived is sufficient. An ovulation test will not be required. The administration of Plan B pills in this instance cannot be judged to be the commission of an abortion because of such doubt about how Plan B pills and similar drugs work and because of the current impossibility of knowing from the ovulation test whether a new life is present. To administer Plan B pills without an ovulation test is not an intrinsically evil act.Since the teaching authority of the Church has not definitively resolved this matter and since there is serious doubt about how Plan B pills work, the Catholic Bishops of Connecticut have stated that Catholic hospitals in the State may follow protocols that do not require an ovulation test in the treatment of victims of rape. A pregnancy test approved by the United States Food and Drug Administration suffices. If it becomes clear that Plan B pills would lead to an early chemical abortion in some instances, this matter would have to be reopened."

As David notes, the decision by the Connecticut bishops has "caused many tongues to wag." Catholic-oriented websites seem to be buzzing with commentary about this story, with some people accusing the three bishops--Archbishop Henry Mansell of the Archdiocese of Hartford, Bishop William Lori of the Diocese of Bridgeport, and Bishop Michael Cote of the Diocese of Norwich--of being traitors to Catholicism. Whatever the merits, and public perception of the timing of the bishops' decision (the CT law goes into effect on Monday, 10/1), these are not prelates that anyone would consider liberals. All are JP II appointees. Bishop Lori is the supreme chaplain of the Knights of Columbus, and Archbishop Mansell, formerly Bishop of Buffalo, was reportedly Cardinal O'Connor's favorite to succeed him as Archbishop of NYC. (Ironically, Bishop Lori is Cardinal Egan's immediate successor as Bishop of Bridgeport.) Whether the decision was rightly or wrongly made, it was no doubt carefully made by prelates strongly tied to Rome. However, the eleventh hour timing of the decision will no doubt be viewed by some Catholics as capitulation to secular authority.

I'm guessing that, given the prelates involved, the reasoning hinges not on a distinction between conception and pregnancy, but between ordinary measures (pregnancy test) and extraordinary measures (ovulation test).

Kathy--I don't know that I'd consider it an ordinary/extraordinary measures distinction. Rather, it seems to me to be a distinction between scientific certainty (an embryo releasing unique chemical signals that can be detected with a high degree of accuracy by a pregnancy test) and scientific uncertainty about what whether a positive ovulation test can be used to identify whether and when conception may have occurred. It seems important to place the bishops' rationale and decision in the limited context of rape. I highly doubt they would extend the decision to the context of consensual sex; otherwise, they would be providing support for the argument that methods of contraception that prevent fertilization (condoms, the birth control pill, etc.) are morally acceptable for Catholics.

William,You're right, I don't know the lingo, but I think we're in basic agreement. As a total speculation I just posted this elsewhere:I find the idea of this law, and the act it implies, heartbreaking.However, just to think through this out loud, I would ask whether the arguments against the pill (as probably distinct from IUDs) have ever traditionally rested strongly on the abortifacient possibilities of the Pill. I am guessing no. If this is true then the ovulation test is something rather extraordinary in many ways. First of all, it is not evaluative or diagnostic of the current situation of the patient but it is predictive of the future state of the patient. It is also an inexact predictor: it determines a greater likelihood of conception. But a positive ovulation test does not guarantee that there will be a conception--so that even a positive test might not cause an abortion, because conception might not occur even under fertile circumstances. Conversely, a negative test does not guarantee that no conception will take place.To speak very inexactly, it seems to me that a pregnancy test is an ordinary means, while an ovulation test could be seen as an extraordinary means. It is morally, absolutely necessary to determine whether there is a pregnancy that has already occurred. But the responsibility of making a predictive test of the greater possibility of a potential pregnancy might be arguably less binding.What this reasoning doesn't safeguard is the life of the embryo. Of course this is completely tragic. But I think a case could be made that it is not absolutely morally binding.

From the Bishops' Statement:"Nonetheless, to administer Plan B pills in Catholic hospitals to victims of rape a pregnancy test to determine that the woman has not conceived is sufficient. An ovulation test will not be required. The administration of Plan B pills in this instance cannot be judged to be the commission of an abortion because of such doubt about how Plan B pills and similar drugs work and because of the current impossibility of knowing from the ovulation test whether a new life is present. To administer Plan B pills without an ovulation test is not an intrinsically evil act."http://www.bridgeportdiocese.com/story_Plan%20B%202.shtml

Sorry, that was duplication, but I think that's the center of the reasoning.What I don't understand is, what don't they understand about how Plan B works?

Kathy--I see now how you were using ordinary and extraordinary. The unreliability of an ovulation test in and of itself as a predictor of pregnancy is even greater than you posit. As we know, many fertilized eggs do not implant for whatever biological reason. The state of "pregnancy" would seem to require implantation. In fact, pregnancy tests measure the level of HCG (human chorionic gonadotrophin) in the mother's blood or urine. HCG is not rleased by the embryo until it implants and the chorion--a membrane that interacts with the inner lining of the uterus--begins to grow. Thus, a non-implanted fertilized egg would be undetectable with the administration of either an ovulation test or a pregnancy test. The technological blind spot between a positive ovulation test and a positive pregnancy test is one of the factors on which the bishops based their decision. The other, which I think is shakier, is their conclusion that there are "serious doubts" about exactly how Plan B drugs work.

William,Given your first point, of which I wasn't aware, I find this news somewhat more concerning. If I understand you correctly, there is no way of testing whether there is a fertilized, unimplanted egg--a state of affairs which I would call "pregnancy."

Is it possible/legal for Catholic hospitals to inform rape victims that a pregnancy test will not detect an unimplanted embryo?In that case, regardless of the bishops' statement, wouldn't any woman in any hospital, Catholic or otherwise, have the right to insist that she NOT be given Plan B after a rape until it could be established that she is pregnant?Why do responses to this story automatically assume that destruction of unimplanted embryos among rape victims treated in Catholic hospitals will result from this policy change?

Is the Plan B pill in this instance being used as a birth control pill based on the sperm being and unjust agressor toward the woman. I think this argument was used in protecting nuns from rape. If this is true, when else could the sperm be considered an unjust agressor?

Kathy--I'm not a physician, so if there is an Ob/Gyn reading this blog, and he/she is inclined to add expertise to the discussion, please do so.Here's my lay understanding of ovulation testing and pregnancy testing. A human ovum (unfertilized egg) is one of the largest cells in the body, yet it is barely visible to the naked eye and is about the size of the period at the end of this sentence. Approximately 24 to 36 hours before ovulation occurs, the pituitary gland in the brain (the pituitary is the body's "master gland") releases a hormone known as "luteinizing hormone" (LH) in a large quantity into the bloodstream. It is the release of LH that triggers ovulation in an ovary (monthly ovulation usually involves one ovary only), and it is LH that is measured during an ovulation test. Some women use home ovulation tests to try to identify their most fertile time period for conceiving. An elevated LH indicates ovulation will soon occur and or that it occurred a short while ago. It indicates nothing about whether the ovulated ovum has been fertilized. The ovum travels down one of the woman's fallopian tubes. Most fertilization takes place in the fallopian tube. The fertilized egg is still extremely small, and it ordinarily does not give off any chemical signals, or chemical signals in adequate quantities, that can be chemically detected in the blood or urine by tests are currently available. (Perhaps there will be such tests one day.) In normal circumstances, the fertilized egg continues on to the uterus, where if the environment is properly prepared, it will implant approximately 6 or 7 days after conception. (Once ovulation took place, the ruptured area on the ovary began to fill in with a substance known as corpus luteum, which produces hormones that begin to initiate physiological changes in the lining of the uterus to make it more receptive to the fertilized egg.) Occasionally, the trip down the fallopian tube by the fertilized egg can go horribly wrong, and the fertilized egg implants in the fallopian tube itself. This is known as an ectopic pregnancy and can become a medical emergency.Assuming uterine implantation occurs, the fertilized egg/embryo begins to nest in the lining of the uterus. The hormonal changes initiated by the corpus luteum make the lining spongier, and they increase blood flow to the area. The embryo's chorion in effect merges with the lining, and the placenta begins to develop. Not only a living anchor for the developing embryo and fetus, the placenta is the conduit through which sustenance passes to the embryo or fetus (e.g., oxygen, nutrients), and through which waste (e.g., carbon dioxide and harmful metabolites) pass in the other direction. As the chorion grows, and especially as the placenta develops, increasing quantities of human chorionic gonadotrophin (HCG) are produced by these structures. The levels of HCG increase almost exponentially at first, and they are detectable in a pregnant woman's urine several days to a week after implantation. As I mentioned earlier, it is HCG that is measured by the pregnancy tests now in use. To answer your last question directly, after my logorrhea about ovulation, etc., I don't know of any test, chemical or microscopic or otherwise, that allows detection of the presence of a fertilized egg that has not implanted. If I remember correctly, there are instances when non-implanted fertilized eggs give off detectable amounts of HCG before implantation occurs, but those instances are very rare.

Andrew--This is just my opinion, of course, and we'll have to see if the CT bishops make any clarifications in the days to come, but I don't think they based their decision on "unjust aggressor" analysis. They are basically saying two things: (1) There is no reliable test at this point in time for detecting conception before a fertilized egg implants in the uterus and sends out a measurable chemical signal that a pregnancy has taken place; and (2) It is not clear how Plan B drugs work. As to # 2, I think the bishops mean that it is not clear that in the absence of a positive pregnancy test--the key factor for them--that conception has occurred. The bottom line or the CT bishops: Offer a pregnancy test to the rape victim. If it comes back negative, it is o.k. to offer the victim a Plan B drug. The bishops' caveat: If a test becomes available in the future that can reliably detect conception at an earlier physiological stage, or if medical authorities show that Plan B is an abortofacient even in the absence of a positive pregnancy test, then the bishops will reevaluate their decision.Just a short comment about the unjust aggressor rationale. I hope that this does not come off as trite or unsympathetic to rape victims--that is the last impression I want to make--but even if a sperm can be an unjust aggressor, how would that characterization be applicable to a fertilized egg, which is neither a sperm nor an ovum but a new entity and life with its own intrinsic nature and rights?

Just to bring this thread back around a bit, two things stand out:One, whatever one argues here about the Plan B pill, the point is that the bishops of CT held its use as incompatible with Catholic teaching. Now they don't. That seems to be the problem, at least for me. Even in their statement they don't explain why they changed their minds--I have to believe Catholic teaching didn't change. Second point is that to better understand the arguments against the Plan B pill I would like to see the arguments the bishops were making before their recent "evolution."I haven't found those yet, but will try to do so. Also, I'm sure the bishops Pro-Life Office must have materials on the pill.

The bishops are clearly looking to give help to rape victims. I applaud them for that and for their good will. I will not deflate that by absurd casusistry.

Two points:1. It is my very humble opinion that the church should not only not go out of its way to find instances of conflict with ordinary treatment provided to people, especially vulnerable people, but that it should try mightily to figure out an ethical approach if the treatment raises ethical issues. 2. I am not an ob-gyn, but I do understand the hormones and the tests involved, and the above post accurately explained the physiology of the process. There is no test for detecting fertilization prior to implantation -- if there were fertility specialists would know about and would be using it because it would be extremely useful. They probably would have invented one if they could. However, I really don't understand all this reference to Beta HCG testing. It takes, minimally, about seven days before even the most sensitive pregnancy test would detect an implanted zygote at a meaningful laboratory value. Plan B is generally deemed effective only if a woman presents herself within 72 hours after being raped (though it might be longer under certain conditions), but in any event, it probably wouldn't work more than 72 hours after fertilization. In other words, it's unlikely that a pregnancy that can be detected within 72 hours of a rape is the result of that rape -- or that Plan B would do anything to thwart it (it might have some impact, but if Plan B was reliable for that purpose, it too would have been discovered and would be in use as we speak). As for ovulation tests, let me just say that if a woman who has been raped has a positive ovulation test, basically, she will ovulate somewhere within the next 12 to 36 hours and she's the person who really, really, needs Plan B to prevent pregnancy. I've read studies of how Plan B is thought to work, and based on the fact that it works much better the earlier it is given, it is thought that its primary effect is on ovulation/fertilization, not implantation.

William, Thanks for Your reply. My only question is: if you can use a Plan B pill after a pregnancy test in a rape case, and if you throw out the 'unjust agressor theory', why can't you use the Plan B pill in other cases as long as you use a pregnancy test beforehand?

"Nonetheless to administer Plan B pills in Catholic hospitals to victims of rape a pregnancy test to determinethat the woman has not conceived is sufficient." -- Connecticut Bishops' StatementSo a woman can be given Plan B if the pregnancy test proves she is not pregnant. However, Plan B has no effect on pregnancy (see http://www.go2planb.com), so there is no consequence from either withholding or giving Plan B pills after a positive pregnancy test. So what is the point of a pregnancy test?Could it be the bishops are confused about the meaning of the word pregnancy? I hope not. But I do think it is crucial for people on both sides of debates like these to take care to use accurate terminology. Pregnancy commences with implantation. That is not a matter of debate. It's a matter of definition. Also, abortion is the termination of a pregnancy, so abortion cannot take place before implantation. An abortifacient is a drug that induces an abortion. The drug RU-486 is a true abortifacient, but if Plan B prevents implantation (and it's apparently not clear that it does), it is NOT an abortifacient. Of course, since it is the Catholic position that life begins at conception, it is impermissible to use a drug to prevent implantation. It may be considered morally the equivalent of an abortion, but it is not an abortion.

I too am confused about the rationale for offering a pregnancy test and the only thing I can think of is that it might reassure the woman that if she is pregnant it was not the result of the rape when it might not otherwise be obvious to her.

I hope I am not contributing to any additional "absurd casusistry" [sic]. :)However, in the effort to understand and fully evaluate the CT bishops' statement, it seems important to be clear about the terminology they used. With that goal in mind, I offer the following about the "Plan B pills" referenced in the statement.1. Plan B is the trade name for an emergency contraceptive marketed by Duramed Pharmaceuticals. The biochemical name for Plan B is "levonorgesterol." 2. Plan B is not the same as the RU-486 pill (biochemical name: mifepristone), which has been documented clearly as an abortofacient and is in fact used in conjunction with another drug to induce abortions up until the 6th or 7th week of pregnancy. In low doses, RU-486 can prevent ovulation; in higher doses, it has been shown to prevent implantation. The biological mechanism by which RU-486 works is still not completely known. Once again, however, RU-486 is beyond the scope of the bishops' statement, and the use of the drug as an emergency contraceptive is not a treatment the bishops would likely condone.3. Plan B, on the other hand, is not effective if the fertilized egg has already implanted, i.e., if pregnancy is already underway. The biological mechanism behind Plan B is also not completely understood. It is thought to prevent ovulation or fertilization, though there is some speculation that it "may" inhibit implantation. (Barbara alluded to these effects earlier in this thread.) By my (several) readings of the bishops' statement, it is the uncertainty about how and when Plan B interrupts the reproductive process that provided the bishops with one of the rationales for their statement.Andrew--Perhaps by limiting their statement to the circumstance of rape, the bishops were implicitly relying on some sort of unjust aggressor analysis. But I think you'll agree (I hope I'm not being presumptuous) that if there were currently diagnostic tests that could pinpoint the moment of fertilization with certainty, the bishops would have objected to the administration of any medicine that would have impaired a fertilized egg in its journey into the uterus and hoped-for implantation there. Unjust aggressor analysis would have had no persuasive effect on them if such diagnostic tests were now in existence.

Sorry, I meant to comment also on the good points David and Barbara make. As to Plan B not affecting implantation, perhaps the bishops (and their expert advisers) believe that this issue is also uncertain, and that a positive pregnancy test is the best method now available for demarcating when Plan B pills should not be given. The bishops say the following in their statement: that there is "doubt about how Plan B pills and similar drugs work." Perhaps the unspecified "similar drugs" can interrupt implantation (I'm just speculating), and, again, a positive pregnancy test provides the only bright line test now available. By focusing on a positive pregnancy test as the trigger for when Plan B cannot be given, I don't think the bishops are limiting themselves to considerations about abortion only. As David notes, they are opposed to any chemical or mechanical (e.g., the IUD) method that prevents implantation. I speculating again, but I think they would be strenuously opposed to the use of an IUD in a rape victim, but because the best science now available reveals that Plan B likely works by prohibiting ovulation or fertilization, the drug does not have the moral onus that an implantation-blocker or implantation-terminator would have.

I'd just like to remark that the fact that this is now the law of the State of Connecticut is also pertinent. As I understand it, before it became law, the State's bishops opposed its passage. But once it became law, it seems that the burden of proof was put on those who counsel that the law be disobeyed or contested in some way. My interpretation of the bishops' statement is that those who believe the law to be unjust couldn't make a strong enough case to persuade the bishops that they must oppose the civil authorities. Perhaps laws, at least in the US, are assumed to be just unless it can be demonstrated otherwise.

Yes, I agree that is probably a big factor. Plus, given the state of scientific knowledge, to argue that the law was unjust and therefore should not be obeyed would put them in the unenviable position of having to argue that even the teensiest bit of contrary evidence meant that they were justified in giving the complete benefit of the doubt to a rapist's potential offspring. Can you say backlash?

It's interesting to me that this is a concrete instance of a limit being put on the church's disapproval of contraception. I can't help wondering if there is an underlying principle here that could be applied to, for example, the use of condoms in at least some circumstances in places where HIV is endemic?

I do not know exactly where Im going with this, but I wonder if, in discussing the church's position on this and other points of law and medicine, did I forget the most important question. What would Jesus do if he met the rape victim? As I recall, we have the woman at the well and the woman who was to be stoned and probably other examples that I don't recall. Somebody once taught (Bob Fox) that we get so involved with the institution that sometimes we forget to ask the first question: " what would Jesus do"

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About the Author

David Gibson is a national reporter for Religion News Service and author of The Coming Catholic Church (HarperOne) and The Rule of Benedict (HarperOne). He blogs at dotCommonweal.