Is emergency contraception abortion?

Emergency contraception (EC) — the “morning-after pill” — is taken by a woman after an episode of unprotected intercourse in order to try to prevent pregnancy.  It contains a hormone that acts to prevent pregnancy by preventing ovulation (the release of an egg from the ovary). However, theoretically, if ovulation has already occurred, EC might prevent pregnancy by preventing implantation, the attaching of an already-fertilized egg to the lining of the uterus. This second, conjectural mechanism raises ethical problems for those of us who consider that life begins at the moment of conception, since preventing the implantation of a fertilized egg could be viewed as inducing an abortion. Should we oppose EC because it might in theory cause an abortion?

The authors of a review article in the Fall 2012 issue of Ethics & Medicine address just this question. They review the best available scientific evidence and conclude that  there is “sufficient motivation” to believe that EC does not prevent implantation, and therefore does not cause abortion. (p. 116)

Good ethics begins with good facts. But our understanding of scientific facts is constantly changing; so even though we use the same moral reasoning (“It is wrong to deliberately take a human life, so one should not use a medication to cause an abortion”), our ethical conclusions may change as our understanding of the facts progresses  (i.e., if the facts indicate that EC causes abortion, we should not advocate its use; on the other hand, if the best data indicates that EC does not cause abortion, it may be ethically justifiable to use in certain circumstances ).

In a fallen world, our knowledge of the truth will always be imperfect; but it is the best we have to work with. Given the current state of knowledge, it appears that EC is not tantamount to abortion, and that I should not use “It might cause an abortion” as a reason not to prescribe it in certain circumstances (such as rape). I am open to changing this stance as knowledge grows and changes; what I am not willing to change is my commitment to not deliberately take a human life.

(See my post here for more on this topic.)

Professionalism vs. commercialism in medicine (or, Yet another Black Friday special!!!)

Some thoughts on medicine and commercialism on this, the high holy day of the gods of commercialism:

The understanding of medicine as the satisfaction of consumer wants is corrosive to the practice of medicine as a profession.

“The practice of medicine is not a business and can never be one . . . Our fellow creatures cannot be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations.” (Sir William Osler, 1903)

A profession involves the freedom if its practitioners from the simple market reduction of the work to that of the tradesman. It is fundamentally an ethical and moral endeavor. It entails independence of judgment, a degree of self-regulation, a covenantal commitment to patients, the bearing of a characteristic set of responsibilities, and adherence to a distinctive ethical code.

*  *  *

From a hypothetical ad in today’s paper:

“Yes, you heard right, it’s our Black Friday special!! Have we in medical practice got a deal for you! Come over to St. Exorbitant’s where today, we’re offering one MRI for the price of two! (Actually, we’ll charge as high a rate as we can and take whatever your insurance company will allow!) Plus, we’ve got all the most-requested procedures of dubious benefit and unnecessary tests for your enjoyment!! (Unnecessary for your care, that is, but they might help finance that new atrium we’re building on to the hospital, which has really helped us attract patients away from our competition!)

“And if you don’t like our Hippocratic™ – brand selection, come on over to our other showroom, where you can peruse some of our less-traditional items! So, you’re not interested in our time-honored offerings of compassion, presence, and comfort? Well, we have a special discount today on Physican-Assisted Suicide (at such a bargain, too — at least, for our medical system which can finally stop paying for all those pharmaceuticals you’re taking!)! Looking for the perfect child? Sorry, we don’t have that yet, but we can test the one you’re carrying to see if she meets your specifications and tolerances! Now how much would you pay? But wait, there’s more! Our technicians can abort, ah, that is, terminate the child you’re carrying if we find something wrong, or for any other reason, or for no reason at all! We’re eager to serve — YOU! Here, the patient is King and Queen! We will do anything — anything — within our power (and your ability to pay) that you want, and if it isn’t within our power yet, don’t worry, we’re experimenting on your embryos to find ways to serve you better!  (We accept many insurances, cash, and all major credit cards!)”

 

Oh, wait — you say you can’t pay? No insurance? Well, well, funny how those market forces work, isn’t it? I’m sorry, we won’t be able to help you today. Why don’t you try the internet? I hear there’s very good care to be had there!

 

Rape, God’s sovereignty, and the value of human life

I live in Indiana, and most of the time I think that is a good thing. This election season I am not so sure. The race for our Senate seat has been one of the ugliest I can remember. It has been so bad I am seriously considering not voting for either candidate. Now a statement made in a recent debate between the two candidates has made the national news and reflects on Christian bioethics. When asked whether abortion should be allowed in cases of rape or incest, Richard Mourdock said during the debate, “I struggled with it myself for a long time, but I came to realize that life is that gift from God. And, I think, even when life begins in that horrible situation of rape, that it is something that God intended to happen.”

Mourdock has been attacked by those who say that if a Christian is opposed to abortion in cases of rape they are saying that God has intended the rape to happen. Christians are divided over whether abortion is permissible in cases of rape. Balancing the value of an unborn human life and caring for the victim of such horrific wrong who is also of great value is a difficult thing to do. Those who address this need to be much more careful than most political candidates in what they say and how they say it.

It can be reasonable from a Christian perspective to take the position that the value of the life of the innocent fetus whose life was begun as a result of rape is such that the life of the innocent fetus should be preserved no matter what his or her origin was. Those who take that position are not saying that rape is not a horrible evil. Rape is evil and the scripture clearly identifies it as evil. Scripture also emphasizes God’s compassion on those are victims of violence and we should have that same compassion. Expressing how we reconcile God’s love and his sovereignty with the evil in the world is something that theologians have struggled with for centuries. From a Christian perspective it is clear that God is not the author of evil, but he is able to use the evil done by human beings in ways that produce something that is good. Even though he did not say it well, that may be the Christian truth behind what Richard Mourdock was trying to say. Rape is evil and God is not the cause of such evil, but God can take something as evil as rape and from it bring an innocent human life that is good. It is when we see the good of the life that came out of what was an evil act that we can see why we should think that such an innocent life should be protected even though his or her origin was in something evil.

Eugenics and the genetic testing of embryos and fetuses

In a recent article in the Australian media Julian Savulescu, a noted Oxford ethicist who is a visiting professor at Monash University in Melbourne, makes the contention that selecting which babies are born by doing genetic testing on embryos or fetuses and only allowing those that are desired to live to birth in the way that it is allowed in Australia shares the moral problems of past eugenics programs that we have rejected. His point is that the current practice in Australia allows selection of embryos by preimplantation genetic diagnosis and fetal testing with selective abortion only for diseases and not for sex selection or other non-disease characteristics. By allowing selection based only on diseases the society is saying that “lives with disability are less deserving of respect, or have lower moral status.” That is why we rejected the eugenics programs of the past.

Savulescu points out that “If either the embryo or the fetus has a moral status – then it would be wrong to kill either, whether or not a disability is present. If the embryo or fetus does not have a moral status, it should be permissible to destroy an embryo or abort a fetus for any reason. In this way, paradoxically, allowing testing for diseases, but not for other genes, is eugenic in objectionable ways.”

It would be easy to go from there to saying that genetic testing of embryos and fetuses for the purpose of selecting who will be allowed to be born should not be done based on the principle of the value of all human lives underlies our rejection of eugenics, but he does not go that direction. Instead he moves toward the permissibility of all embryonic and fetal testing by saying that lifting the restrictions on personal liberty imposed by limiting genetic testing of embryos and fetuses to testing for disease would resolve the moral objection that the current policy involves morally impermissible eugenics. He gets there by saying that since most people already accept the testing of embryos and fetuses for diseases, we should not say that all such selective testing is wrong based on the moral status of embryos and fetuses and the way to validate people’s acceptance of testing for diseases is to allow testing for non-disease characteristics.

Savulescu’s means of getting to his conclusion is an interesting and commonly used one to justify things that have previously been understood to be wrong. Rather than giving arguments for why we should believe that a human embryo or fetus does or does not have full moral status, he says we have already accepted a limited practice that would otherwise have been considered immoral, so we should accept a broader version of the same sort of practice. This is the process by which immoral behavior takes over a society, and also the process by which an individual falls into immorality. First justify a very limited violation of morality, and then once that is accepted use that to justify further immorality.
That is why we need to stand firm on basic moral values such as the dignity and value of every human life. Defending the moral status of the weakest and most defenseless human beings is essential to avoid the acceptance of things like aborting fetuses because they are female that currently seem obviously wrong, but may become accepted by a gradual breakdown of moral values.

Eugenics in Our Day

Researchers have now developed a technique for doing genetic testing of a fetus by using cells circulating in maternal blood, avoiding the more invasive and dangerous technique of amniocentesis.   These new technical capabilities hail the dawn of a new age of eugenics, or the pursuit of “good (eu) genes.”  With these new technical achievements, physicians can gain knowledge of the child’s genetic makeup as early as 7 weeks after conception.  This can mean a new opportunity for interventions earlier in the pregnancy for the sake of the health of the child or it may provide doctors with more information to inform a decision to abort the child.

Arthur Caplan helped develop guidelines for organ transplants in the 1980s and has for some time pressed for similar oversight of the “wild west” of reproductive medicine, largely because of its eugenics implications.  He is very aware that genetic testing could be used for selecting athletic ability, eye color, or gender.  Sex selection using abortion is already something practiced in countries like India and China, and genetic testing using maternal blood would only make it easier.  However, Caplan is firmly pro-choice, saying that there are good and bad reasons for an abortion.  As Caplan puts it,“Sexism is not a good reason for ending a pregnancy.”

What is missing in this discussion is our response to those with diseases and abnormalities.  To many, a chromosomal defect like Down Syndrome or a physical abnormality like malformed limbs is a good reason for ending a pregnancy.   Too often our attitude to those with abnormalities and diseases is to consider them as unfortunate mistakes rather than opportunities to live in fellowship with another human being.  We think getting rid of the mistake solves the problem, especially when it involves fetal tissue out of our line of sight.  If our drive for perfection bumps into human autonomy, we back off.  If it does not, we proceed in getting rid of the patient if we can’t get rid of the disease.  This is a serious misunderstanding of the ethos of medicine.  An improvement in our ethical strategies will not come from a new set of protocols to use in the clinic.  It will only come about if physicians adopt a new value system concerning the purpose of medicine and develop their character accordingly.

Henri Nouwen, well-known for living in the L’Arche community for adults with disabilities, articulated  a vision of such an ethic when he said, “When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.”

Click here for a video of Art Caplan discussing gender selection.

Wrongful birth, the next expression of a life unworthy of living

Last week I wrote about how the idea that we can judge that there are some lives that are unworthy of living underlies the practice of aborting fetuses who have major abnormalities. I suggested that we need to remember the serious consequences that followed the acceptance of the idea the there are lives unworthy of living in Germany in the first half of the twentieth century.

This week the news reminds us that once an ethical barrier is broken we human beings tend to pursue the breach as far as we can. Aborting a fetus with some type of disability violates the basic moral principle that all human lives have great value. The violation of that principle is justified by saying that some disorders can make a person’s life not worth living. That is claimed to make the abortion permissible. But what if the abortion is not done because the parents don’t know that the child has the abnormality until after the baby is born? Some are taking the next step to say that it is not only permissible to do an abortion when a fetus is known to have an abnormality but that parents have a right to know about any and all abnormalities of their unborn children so that they can abort them. Violation of that assumed right has resulted in physicians being sued for the harm of allowing a wrongful life. It is in the news because several states, including Kansas and New Jersey, have proposed laws to ban such lawsuits.

Those who support the laws banning wrongful life suits go back to the moral principle that every human life has value even if the person has significant disability. They say no suit should be based on saying that a child’s life is not worth living. They may understand that doing so puts us back in the moral climate of pre-Hitler Germany.

Life unworthy of living

Sometimes we need to remember the past. Of course that is what historians try to teach us. The recent translation into Italian of the 1920 German book Allowing the Destruction of Life Unworthy of Living by Karl Binding and Alfred Hoche prompted a reminder by Italian historian Lucetta Scaraffia about how the central idea of the book played out over the next few decades in Germany (see Washington Post article).

She suggests that the history of that idea is relevant to current bioethical issues. Some of those have been discussed recently on this blog. A few days ago Joe Gibes wrote about decisions to abort fetuses found to have major abnormalities such as Down syndrome. Back in December Jon Holmlund wrote about the use of PGD to diagnose embryos with major genetic disorders so that parents at risk for having a child with such a disorder could choose to give birth to a child without the disorder and not bring embryos with the disorder to birth.

Both the practice of aborting fetuses with a major disorder and doing PGD to choose which embryos should be brought to birth to avoid giving birth to a child with a genetic disorder involve the concept of a life unworthy of living that Binding and Hoche wrote about. If we make a decision to abort a fetus with Down syndrome or even one with a more serious disorder we are making a decision that the life of the person who that fetus will be is not worth living. If we choose to create multiple embryos and choose to implant those who do not have a serious genetic disorder so that they can live, but choose not to implant those who have the disorder so that they will not live we are saying that the lives that would be lived by those embryos who are discarded are not worth living. Whether one believes that and embryo or a fetus has full moral status or not they are unique individuals who have live that they would live if they are allowed to. Not allowing them to live those lives due to the presence of a disorder is saying that those lives are not worth living.

Remembering what happened in Germany helps us remember what a serious thing it is to say that a person’s life is not worth living. The idea that Binding and Hoche wrote about began as a philosophical concept, but it was embraced by the German government under Hitler as a reason for German physicians to put to death mentally deficient children whose lives were thought to be not worth living. Later that was expanded to large numbers of Jews and others whose lives were not thought to be worth living. The experience in Germany helps us to see that the idea that there are people whose lives are not worth living depends on a negation of the fundamental idea that every human life has inherent value. As Christians we understand that this value is due to our being created in the image of God. Even for those who do not have that understanding the inherent value of every human being underlies the concept of universal human rights that has become the foundation for global justice.

The German experience reminds us that there are some lines that we must not cross. One of those is saying that another human being has a life that is not worth living and using that as the justification for ending the life of an embryo or fetus.

The myth of non-directive genetic counseling

An article and its accompanying editorial in this month’s American Journal of Obstetrics & Gynecology report on a study comparing the practices and attitudes of two types of specialists regarding prenatally diagnosed fetal abnormalities: maternal-fetal medicine (MFM) specialists, who are obstetricians; and fetal care pediatric (FCP) specialists, who are (as the name suggests) pediatricians. The article is titled, “Prenatally diagnosed fetal conditions in the age of fetal care: does who counsels matter?”

The answer to the question posed in the title is decidedly yes. For instance, compared to the pediatricians, the MFM obstetricians reported  more than twice the pregnancy termination rate among patients carrying a fetus with Downs Syndrome. They were more likely than the pediatricians to “somewhat or strongly support” a decision to abort a fetus with Downs Syndrome. The discussion section of the article notes that pediatric and obstetrician specialists may “hold contrasting perceptions of life with disabilities . . . We cannot explain why, after multivariate analysis, our reported termination rates differed between specialties for Downs Syndrome.”

Two observations: First, those who deny that prenatal genetic testing is eugenic claim that the counseling given around such testing is non-directive, that is, that it does not influence a woman whose fetus tests positive for some condition to have an abortion. They say that the counseling gives just the facts: “Your fetus has Downs Syndrome,” not,”You should abort this fetus because it has Downs Syndrome.” If the results of this study are true, it exposes that claim for the wishful thinking — or insidious deception —  that it is. As the study authors write, ” …our study supports concerns that prenatal decisions and outcomes may sometimes reflect provider attitudes.”

Second, isn’t it interesting that between obstetricians (who typically do not care for Downs Syndrome patients) and pediatricians, it is the specialists who actually care for patients who have Downs Syndrome, who actually know something about how the syndrome affects people and families, and who are far more familiar with the details of living with the syndrome, who are the ones less likely to recommend that a woman abort a fetus who is suspected of having it?

Being pro-life: abortion prevention revisited

 

I have missed my usual Friday posting to this blog twice in the last month. We have had as a guest at our home since January a little 18-month-old girl, and while she is a wonderful delight, caring for her has consumed much of the time and energy that I normally spend  preparing for and writing this blog.

We are caring for this girl as a part of a volunteer network called Safe Families, which provides temporary homes for children of families that find themselves in a variety of difficult circumstances, whether it be temporary homelessness, a stint in the hospital or drug rehab, or time in prison. It is a good alternative to DCFS and other dangerously overloaded components of the social safety net.

I see working with Safe Families as part of being a pro-life physician. In particular, I see it as a part of trying to address abortion by providing support to those women and families who do choose to carry their babies to term rather than abort them. I am not holding myself up as a paradigm in this area; there is much more I could and should be doing. But anyone who identifies as pro-life must ask oneself, “What am I doing to be part of the solution to this problem of which abortion is a symptom?” Too often we look to the government to take care of the problem of abortion. We think our part in the solution is simply voting for the right candidate or sending money to the right lobbying group. Now those are not bad things; but if that is all we do — if we are looking solely to the government to fix the problem — we are abdicating our responsibility and opportunity to make a difference in the lives around us with the love of Christ.

It’s far more trouble to reach into the troubled lives around us with Christ’s love than it is to vote for a particular candidate. For our family it has meant disrupted schedules, re-ordered priorities, deferred schooling, missed blog entries. But it has also meant the joy of seeing a little girl flourish, of serving Christ, and of making a little difference in a little corner of the world where someone could very easily say, “In my situation, I can’t have this baby, I don’t have the support I need, and abortion is my best option.” Reaching out to those around us will of course look different for different people in different circumstances; by no means do I think that everyone can or should take children into their homes! But just think what a difference it would make in turning a culture of death into a culture of life if it became known that this people, the followers of Christ, were radically committed to helping and promoting the life and welfare of the mothers and children among whom we live.

Abortion, breast cancer, and truth

 

Eric Zorn wrote a provocative column for the Chicago Tribune last week maligning the various bills in various state legislatures that require a woman to be notified, before undergoing an abortion, that there may be a risk of breast cancer associated with abortion. In the column, Zorn argues that there is unequivocally no such risk, pointing to authorities such as the American Congress of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) that have come out with statements denying a connection between abortion and breast cancer.

Intrigued, I searched the web and came up with differing opinions on the topic. Unsurprisingly, pro-life websites tended to assert a connection between abortion and breast cancer, while pro-choice websites tended to deny that there was any association between the two.

Still intrigued but unsatisfied, I did my own search of the primary scientific literature. Using a medical journal database called Ovid to which I have access through my hospital, I found over 2000 articles in medical journals. I did not read through every one, but after several pages of abstracts and articles I found multiple studies that showed a correlation, and multiple studies that showed none. I could not of course check for ideological bias in each study, but certainly some of the articles did not reach an ideologically pre-determined conclusion; for instance, one would expect that in China, the bias would be towards showing the safety of abortion, but a recent study from that country showed a correlation between abortion and breast cancer.

I think that we in the pro-life camp must be very careful about how we approach this topic. We must not, by ignoring or dismissing the studies that do not reflect our views, pretend that there is a consensus in the scientific literature where in fact none exists; ACOG, WHO, and Eric Zorn may use such subterfuge, but we should not resort to those tactics. We must be careful how we interpret even the studies that do show a correlation, remembering that they demonstrate only a correlation between abortion and breast cancer; and we know that correlation does not imply causation. If we are to be completely truthful, we must not pretend that the studies say what they in fact cannot say.

And finally, I don’t think we should spend too much energy on what is ultimately a side issue. I understand that one of the ways to show that abortion is wrong is to bring to light the ways that it hurts women; however, we should not put more weight on the connection with breast cancer than it can scientifically bear, else we run the risk of having our position undermined by something that is incidental to our main argument. Abortion would be wrong even if it lowered the risk of breast cancer, and we had best not rest our arguments against abortion on shaky science that very well might be disproved some day.