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Plan B and Double Effect

The most recent issue of The Hastings Center Report has a very interesting article on emergency contraception, so-called Plan B. The author, Rebecca Stangl, argues that even if opponents of Plan B are right that emergency contraception works, at least sometimes, by making the uterus inhospitable to a fertilized egg, it does not follow that there is no moral difference between Plan B and abortion. Her analysis of the case in relation to the principle of double effect is worth reading. Registration is required, by registered users can read the article here.

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Her difficulty is that, according to the principle of double effect, the intended good must be proportional to the foreseen-but-unintended negative consequence. She works hard to get around or overcome that objection, but I guess I'm just not convinced by her reasoning. Contracepting is not proportional to aborting - I'd think there would be widespread agreement on that.Also, at several points in the article, she seems to be assuming something - that the chance of Plan B acting as an abortifacient in a given situation is minuscule - that, as of our last discussion of this, hasn't been demonstrated. Istm the cautious position to take on that question is that we don't know with certainty the extent to which Plan B acts as an abortifacient. Also, she goes right to the extreme/hard cases - 'suppose a young girl becomes pregnant'.

It is known for certain that Plan B prevents ovulation as its primary mechanism as a contraceptive. It is unknown, according to the article, whether it prevents implantation, and apparently if it does, it is in a very small number of cases. It seems to me that -- assuming there is a morally good reason for preventing conception (as in the case of rape) -- the theoretically possible but unknown actions of taking Plan B are, if they even exist, unwanted side effects.If you listen to drug commercials on television, some of them have lists of side effects that are alarming and include death. Abilify and Advair are two (and that's just the A's!). It is not immoral to take them for their intended purpose even if there is a risk of death. This is a particularly interesting point:

The bodily changes brought about by hormonal forms of emergency contraception can be and are brought about in other ways. It appears, for example, that breastfeeding causes changes in the endometrium that are similar to the changes brought about by the use of emergency contraception. If such changes can have an abortifacient effect in the former case, then there is no reason to think they cannot also have an abortifacient effect in the latter. But no one takes this to be a reason not to breastfeed.

I am not 100% clear on this, but isn't it licit for a Catholic woman to breast feed for a reasonable time not merely to feed the baby but also to avoid a second pregnancy from following too quickly upon the first? It would seem to me that if Plan B is forbidden on the grounds that it might possibly result in prevention of implantation, then breast feeding would be forbidden, too, at least if used to delay another pregnancy.It seems to me that the opposition to Plan B in true emergency situations is another example of "sheer moral sentimentality which turns the fetus into a fetish." A drug may not be used to prevent a rape victim from conceiving on the unverified belief that there is a mere possibility that a fertilized egg may be prevented from implantation. The potential good is knowable, the possible harm is unknown and merely theoretical, and yet some want to go to any length to preserve a theoretically possible life and allow a rape victim to bear her rapist's child.

Istm the cautious position to take on that question is that we dont know with certainty the extent to which Plan B acts as an abortifacient.Jim,According to the article, it is unknown whether Plan B acts as an abortifacient at all. It seems to me in order to consider something morally impermissible, you have to have some idea if it occurs, and after that, you have to have some idea of how often it occurs. Would it be wrong to use Plan B if its likelihood of acting as an abortifacient was 1 in 10 million? Or 1 in a million? If the possibility is miniscule, then certainly it could be considered an unwanted side effect. Her difficulty is that, according to the principle of double effect, the intended good must be proportional to the foreseen-but-unintended negative consequence.The foreseen-but-unintended negative consequence here is the prevention of implantation. It is the small risk (or possibly theoretical risk) of the prevention of implantation. That would seem to make an enormous difference. I may go for a Sunday drive, for pure pleasure, even if there is a small (and even predictable) risk that I am going to kill a pedestrian. If the risk is 50-50, though, that makes a big difference.

If in doing the proportional analysis it was 'abortion' (that is, direct killing) vs. the other good then, yes, the other good could never be enough to outweigh the intentional direct killing of a person. However, this is not what Plan B (even theoretically) does. If it does have abortifacient qualities, then it is much more like a refusal to sustain someone with one's body (the embryo is refused implantation into the uterus)...which, because it is not the direct intentional killing of a person, could in theory be taken for a proportionate reason. I can think of virtually no case that did not involve non-consensual sex or health issues where this was the case,however. In an interesting overlap with social ethics (and proving yet again that the distinction between 'life' ethics and 'social' ethics is way overdetermined), in most cases one could and should point to the special duty one has to sustain a life for whose need one is responsible.

How interesting that only the "voices" of men are appearing here (so far)...

If the embryo before implantation is not an actual human person, but only a potential one, there would seem to be a difference, between preventing implantation and aborting after implantation.

How interesting that only the voices of men are appearing here (so far)Michael,It is true that men write much more frequently about these kinds of issues, and much more passionately (at least on Catholic blogs). But this seems to be a "technical" argument, so I am wondering if women would bring a different perspective. I am hoping to hear Cathy Kaveny's reaction,not because she is a woman, but because she is well versed in this type of argument. One of the most important issues, it seem to me, is how to determine if a particular action of a drug is a side effect. When you take the antihistamine Benadryl (which is diphenhydramine), the fact that it makes you sleepy is a side effect. When you take Sominex (which is also diphenhydramine) you are taking it because it makes you sleepy. So it seems that unwanted side effects are a matter of what your intent is in taking a drug, and not something inherent in the drug itself.

One more thought on this: I wonder if it would be more accurate, in the case of Plan B, to refer to a "Principle of Double Cause" rather than a "Principle of Double Effect". The intention of taking Plan B, presumably, is, "remain not-pregnant". And Plan B provides (allegedly) two means to that end: a contraceptive means, and (allegedly) an abortive means.

One more thought on this: I wonder if it would be more accurate, in the case of Plan B, to refer to a Principle of Double Cause rather than a Principle of Double Effect.Jim,The only problem is that there is no such thing as the Principle of Double Cause. Since the author bases her argument on the principle of double effect, if that principle cannot be applied to this situation, it means she has no argument. Her analogy to morphine seems a good one. If you are in terrible pain, you can take morphine at such doses that it can possibly hasten your death. If I understand your reasoning, you could say the intention in such a case was "to escape pain." Morphine can allow you to escape pain in one of two ways -- by affecting the nervous system in such a way that your pain is lessened, or by killing you. By defining the intention of using Plan B as "to remain not-pregnant," you are implying that whichever way the drug works, a woman is willing the death of a possible embryo, and therefore you think it is objectionable. In the case of morphine, by your reasoning, someone who takes high doses "to escape pain" is willing for the drug either to dull pain or to kill. It seems quite probable to me that someone in extreme pain might be quite willing to die rather than continue to suffer. People in such excruciating pain that they would prefer to die rather than keep on living in such pain, ironically (and cruelly), would have to limit morphine so as not to risk death.

Hi, David, yes, one of the most interesting things about the article is the author's analogies. The morphine, the nursing mom, the driver who strikes a pedestrian while driving to the grocery store - they're all food for thought, at least they were for me.I agree with you that the intention of taking morphine is "to escape pain". I expect that most patients would concatenate an implied "... while continuing to live", so that having the morphine kill them isn't really their intention. Perhaps a more likely outcome would be that they would become dependent on/addicted to morphine. That would seem to be a classic principle of double effect situation.You touch on the heart of what I've been thinking about when you write, "By defining the intention of using Plan B as to remain not-pregnant, you are implying that whichever way the drug works, a woman is willing the death of a possible embryo, and therefore you think it is objectionable."In reply, I guess I would say that (a) I don't claim to be able to read the hearts and minds of women who take Plan B, so I don't know what their intentions are, but I suspect that at least some of them (perhaps a significant %) are willing to bring about the destruction of a fertilized egg in order to remain not-pregnant (is there a word for the condition of not being pregnant?). (b) I admit I'm not entirely sure what to think of these Plan B scenarios. I've ended up in more or less the same place I was at the last time we discussed Plan B here: if the chances of aborting a fetus by taking Plan B really are 1 in a million, then maybe it is so close to zero as to be a reasonable risk. But that way of thinking about it isn't the same as applying the Principle of Double Effect. Because of the proportionate requirement, I think that the only way the PDE can be applicable would be if the contraceptive effect could be shown to be proportionate to the (alleged) abortive effect - which I don't believe the author has succeeded in showing. Perhaps if there are medical situations (and I don't know if such exist) where the very fact of being pregnant would pose a grave risk to the mother's life, that would be a proportionate risk. Then the mom could intend to preserve her own life by taking Plan B, and the unintended outcome would be the (possible?) desctruction of a fertilized egg.

Jim,It seems to me you are evaluating the Plan B situation as if it were a certainty that an egg will be fertilized and die. Sticking only with the situation of rape, you are weighing the good of preventing a pregnancy against the evil of killing an embryo as if the death of the embryo were certain. It seems to me the appropriate approach is to weigh the good of preventing the pregnancy against the risk (which we are not even sure exists) of an embryo being prevented from implanting.You are placing such an extremely high value on the life of a possible embryo that you want there to be no risk at all, or maybe a 1 in a million risk, but in everyday life we don't come anywhere near such a high standard. For example, we all have a 1 in 38 risk of dying from an infection acquired in a hospital. That does not mean that if you catch an infection in the hospital, you have a 1 in 38 risk of dying from it. It means that right now, 1 in 38 of us will catch an infection in the hospital and die of it. (It is a shocking statistic, and a lot more should be done about it.) You also seem to me to be dismissing all too easily the possibility that someone in severe pain might be willing to die if that's what it would take for relief. But you seem to be quite ready to believe that a woman taking Plan B actively wills a death.

Hi, David, we're really not connecting today ... I don't assume that it's a certainty that an egg will be fertilized and die - that is an uncertainty in any instance of sex between a fertile man and fertile woman. Nor do I see why we should stick with the situation of rape - the author of the article didn't stay within those constraints, and Plan B isn't limited to rape victims.I'm inviting us to think about things like 1 in a million vs. 1 in 38 vs. 1 in 3. Does the likelihood of something happening change the moral analysis? If so, what is the magic ratio that would switch "shouldn't" to "may"? Of course, it seems to be premature to engage in that kind of analysis in the case of Plan B, as I don't think anyone knows whether it is 1 in 38 or 1 in 3 for aborting human life.That 1 in 38 of us die from an infection caught in a hospital is a bad thing; but what is the alternative for a patient who requires hospitalization? Presumably, there are few or no other alternatives. Is that the case for Plan B - are there any alternatives?

Does the likelihood of something happening change the moral analysis?Jim,I would say absolutely it does. Virtually any activity at all comes with a small risk. As I said before, going for a Sunday drive purely for pleasure carries with it a small but finite risk of a fatal crash or the killing of a pedestrian. If the degree of risk doesn't matter, there could be no justification at all for taking a Sunday drive. I think you would agree that if the risk of death from a Sunday drive was 1 in 2, it would be foolish and immoral to take a Sunday drive. I would say the same if it were 1 in 10, 1 in 100, or even 1 in 1000. But if it's 1 in 10,000,000, certainly no one would say it was immoral to take a Sunday drive. Nor do I see why we should stick with the situation of rape the author of the article didnt stay within those constraints, and Plan B isnt limited to rape victims.I am sticking to rape cases because if Plan B works by all the mechanisms described but does not prevent implantation after fertilization, it is still a contraceptive, and Catholics are usually not permitted to use contraceptives. However, the use of a non-abortifacient contraceptive in the case of rape is not merely permitted, but (I hope we can all agree) a moral good. I think there is a problem with the way the author argued her case. She says,

According to the doctrine of double effect, it may be morally justifiable to perform an action that one foresees will result in some harm even if it would be unacceptable to aim at that very same harm, either as an end or as a means. Whether this is so in any particular case depends on whether the good to be achieved is proportional to the harm that is foreseen.

In the classic examples of the principle of double effect, such as the case of a pregnant woman having a cancerous uterus removed, what is foreseen but not intended is the death of the fetus, not the risk of its death. In the case of Plan B, what is foreseen (and, the author argues, unintended) is a risk that if the drug fails to prevent ovulation (or if it has already occurred), and if the drug then fails to work by some other mechanism, and if conception takes place, the drug will prevent implantation of the fertilized egg. What is foreseen in this case is not an unintended effect, but rather the risk of an unintended effect. I am not sure one even needs to invoke the principle of double effect to justify the use of Plan B in case of rape. I think all one needs to do is to determine if the positive result of preventing a woman from having to bear her rapist's baby is enough to justify the risk. And if the risk is hypothetical (as it currently seems to be) or if it is determined to be small, I think it is clearly justifiable to use Plan B.

Hi, Jim, to refocus your analysis: it isn't just the likelihood of the risk -- in this case, it is completely unknowable whether, if ever, that risk materializes. There is no way to verify the existence of a "just fertilized" conceptus prior to implantation. Thus, in order to find Plan B morally objectionable on those grounds, you would, in essence, be saying, "even the speculative possibility of the existence of a zygote trumps a woman's right to use this form of birth control."

Hi, Barbara, I suppose it is completely unknowable *given the current state of pregnancy tests*, yes? i.e. if pregnancy could be detected earlier, we would know.Staying focused on the article, it just seemed to me that the author more or less waved away the odds of an egg being fertilized as being exceedingly small. It's helpful for her analysis that it be exceedingly small, but afaik, we don't really know. Nobody knows.I'm not as interested in law and policy as I am in the moral analysis, and from that point of view, it's far from clear that a woman (or a man) has a moral right to take Plan B or any other form of birth control.Btw, I assume that opponents of Plan B didn't invent their objection out of thin air - there must be some clinical and/or theoretical basis for supposing that it acts as an abortifacient.

It's theoretical. As I said above, it's unknowable because, per the FDA, the existence of a pregnancy begins at implantation -- it's the only means of detecting whether a fertilized conceptus exists: at the time it implants it triggers the secretion of the hormone, HCG, the existence of which is what is measured by a pregnancy test. From women undergoing IVF, the earliest point at which this, in turn, occurs even with the most sensitive tests is 5-6 days after insertion of the embryo into the uterus, which is, in turn, no earlier than three days after the process by which the embryo has been fertilized. That means no earlier than 8 days after what would start a natural pregnancy (and often, later). Plan B works within 12-72 hours of intercourse -- the earlier it is taken, the more effective it is (which itself suggests that its main operative principle is preventing fertilization).

There's another technical point here, however. In classic double effect theory, in my understanding, there are 4 criteria, one of which is this:the good effect must not be brought about by means of the bad effect. Consider two scenarios in which pain relief is sought for a patient in terrible pain. Opiate drugs relieve pain and at the same causal remove from the initial action (giving the drug,) inhibit respiration in a way that might endanger the patient's life. Using a shotgun will also reliably relievethe patient's pain, but it does so by means of the anticipated evil effect, the deathof the patient, so it's illlicit. Here, it seems to me that the good effect, remaining non-pregnant, occurs by means of the evil effect, the death of the embryo. The analogy of breastfeeding (interesting in Stangl's piece!) doesn't hold, if the end is defined not as remaining non-pregnant, but nourishing the infant. The slipperiness of double effect reasoning, as can be seen from my disallowing of the breastfeeding parallel, was the impetus for the development of proportionalism as a modality for moral reasoning. Proportionalist thought that in the end, double effect boiled down to proportionality. I think this case, as folks have noted above, also devolves to proportionality, and here those who believe in the possible personhood of the early embryo will remain utterly opposed to those who do not. Too bad--I was rooting for Stangl to present a new way out of a vexing situation.

Hi Lisa. Quick question: how is the death of the embryo the means by which a woman who takes Plan B in order to get pregnant achieves her end? This is no more the case than the death of the person I could have saved with a 20 dollar donation to Catholic Relief Services is the means by which I instead buy myself dinner at Olive Garden tonight.This really is a way out...at least, in my view, for situations of non-consensual sex and serious health situations.

Hi Charles,Hmmm, perhaps I jotted too quickly. No, I think I definitely jotted too quickly. (Had just gotten off a red-eye from West coast to East...but still...) If you define her act as "Take Plan B," then it clearly passes Double-effect muster, granted proportionality. If her act is (and this is where I think I was going,) "to avoid becoming pregnant by taking Plan B," this is structually parallel to "control severe pain by using opiates." Two effects: ovulation is blocked, and endometrium is rendered inhospitable to any ambryo. The second is bad in Catholic thought, and is the mechanism of ac tion of the IUD. But I was still wrong--blocking ovulation is unrelated to the endometrial effects.Yup--I blew it. Thanks for the correction. I agree this holds unproblematically for cases of non-consensual sex. For serious health reasons, then I think we're back at the Humanae vitae drawing board, though. Unless, I suppose, for some reason (too much to drink at the office Christmas party?) a woman for whom pregnancy would be a big risk, who usually is a scrupulous practitioner of NFP, has sex at an unwise time of the month. So yes, non-consensual or otherwise "unintentional" sex. Why would this hold only for serious health reasons, though? Why not the list of reasons given (by, was it Pius XII addressing the midwives?,) for licitly spacing out births?

Hey Lisa...this is a good point...I think we are probably right back where we started with HV when talking about the health issue...but only with regard to the contraceptive aspect of Plan B and perhaps not its (possible) abortifacient aspect. This is where the fact that this aspect chances of happening are either zero or vanishingly small...and thus the good of not becoming pregnant (if one accepts it is a good at all, of course) could be chosen giving a proportional analysis. This thread looks to be buried sometime soon...so please feel free to continue this conversation via e-mail: camosy@fordham.edu.