A lot has already been written on the emergency contraceptive pill (ECP) and the reason I wish to contribute is not really to put forward another opinion but to argue that what we have here is not a conflict (of values) but a dispute that can be resolved by proper dialogue and evaluation of recent studies.
We all have a responsibility not to try to deceive people in any way. By emergency contraception I take it that we are not in any way trying to bring in abortion through the window. We have a law not merely prohibiting abortion but protecting an embryo.
The discussion is not about avoiding a pregnancy but about recognising the value of conception. What we mean is that emergency contraception ought to be available to allow doctors to help women to prevent fertilisation of an egg and not to prevent implantation.
A conflict is said to exist if there is a difference of value. Otherwise we are simply speaking of a dispute. If we accept that we are not discussing the prevention of the implantation of a fertilised egg, then we are agreeing on the value of life.
The first dispute here is whether it is morally right to do something that prevents fertilisation of an egg. The British bishops had stated that a woman (they took, for obvious reasons, the case of a woman who was raped) has a right to prevent conception and accepted that ECP can be given to delay ovulation.
Now doctors can already give emergency contraception by using a normal contraceptive pill and giving an equivalent dose – a practice referred to as ‘off-label’ use. This incurs certain medico-legal risks when it comes to the process of informed consent as one needs to explain what this means in practice – in a situation in which the woman is presumably under a lot of anxiety. Having a preparation of the ECP will give doctors the proper tool to prevent conception and not have to resort to off-label preparations.
As to the fact that one can actually use ECP even to prevent implantation of an already fertilised egg, this can still be done using the same off-label drugs mentioned. So basically we will not be shifting our current position. We will only be legitimately recognising the practice of delaying ovulation.
But to come to the second more contentious issue of preventing implantation, should ECP be used only to delay ovulation? The WHO has reported pregnancy rates of 0.5 per cent after 12 hours from intercourse, 2.6 per cent at 48 hours and 4.1 per cent at 72 hours. If the chances of having a fertilised egg are high then we ought to favour the embryo; but what is the duty of a doctor when the chances are remote and how do we assess remote? Will the law still apply? Do doctors still have a right to a moral objection? If women are allowed to carry this pill with them to take it immediately then the chances of fertilisation go much further down.
Doctors should have the tool of the emergency contraception pill
The balance is therefore between the right of women and a remote chance of having a conceptus, not between the right of women and the right of an existent fertilised egg. This has to be balanced by duties to care and an obligation not to pass judgement on patients.
I would say that doctors should have the tool of the ECP rather than have to resort to off-label use of drugs. After all, when we prohibited the use of the coil it was for the same reasons. But we accepted Mirena, a coil that is combined with hormones which lower the chance of conception. But the coil is still there to prevent implantation. It is all based on the chances of having a fertilised egg – which with Mirena are much less than with other coils.
Science is not absolute, as many make it out to be. Resorting to so-called scientific advice that many base their arguments on can also be tantamount to deception if you choose the arguments that suit you.
It is a fact that life does begin at fertilisation. The issue with many is when we ought to put a moral value on it. I do not think it is naïve to say that this has been solved for us by the Embryo Protection Act, and in my opinion it is not under attack. The reasoning is parallel to the reasoning used for coils and Mirena.
At the end of the day it is very likely that once someone has been prejudiced for or against something it is very difficult to change their mind. But medical positions may change with new evidence and I feel it our duty to continue evaluating the fields and to foster credibility by balancing evidence.
These drugs were marketed as an abortifacient without any evidence simply because that was the intended market. But the American Congress of Obstetricians and Gynaecologists and the Baby Center for Global Reproductive Health of the University of California are both mounting a challenge, saying that there is very little evidence pointing to the prevention of implantation.
In one study, pregnancy rates for those who had received EC when ovulation had occurred were compared with an identical group that did not receive EC under the same circumstances: pregnancy rates were the same.
Although there is literature to the contrary, more recent studies and reviews of published literature are showing that existing methods of EC act mainly by inhibiting ovulation or preventing fertilisation. Also, Levonorgestrel and Ulipristal do not impair the endometrial receptivity or embryo implantation.
For an informed decision about this I suggest that the Bioethics Consultative Committee evaluate the evidence for double-blind controlled studies and invite professionals to produce evidence-based reports, including the Malta Medicines Authority’s position (which, of course, would be backed by the European Medicines Authority) and then review our position based on evidence.
We owe this to patients while we have respect for the Embryo Protection Act which was, in turn, based on a normative moral position.
pierre.mallia@um.edu.mt
Prof. Pierre Mallia is coordinator of the University’s Bioethics Research Programme and chairman of the Medicine and Law Programme. He chairs the Health Ethics Committee of the Department of Health.