Cura personalis

Hey guys.  I haven't written in eons, but I had a conversation quite recently that has sent me racing back to my little blog, anxious to share my indignation with anyone who will listen.

This was what transpired:  I had a patient last week, a nice, older male, armed with a full set of nice, older male "family values."  Towards the end of our encounter, he told me happily of a story he had heard on the news.  To be brief, the story centered around a young pregnant woman with cancer, who forewent chemotherapy in order to deliver a healthy baby.  Due to the delay in treatment, she died soon after giving birth, a decision my patient lauded and defended.  Lest I doubt his thoughts on the matter, he added:  "Isn't that just great?  So many women would be selfish and put themselves first, and so many would even throw their babies away and have an abortion!"

http://www.turnbacktogod.com/virgin-mary-pictures-06/

Now, who knows what particular instance this man was referencing.  There are countless instances of pregnant women choosing to put the well-being of their fetuses above their own.  Choosing being the operative word.  All well and good.  Yet once this decision becomes expected of women, once we as a society make the Rick Santorum-approved assumption that a woman - endowed with hopes, dreams, life experiences, the abilities to enjoy life an to contemplate death - is worth less than the fetus she is carrying, we have come to a dangerous conclusion.

There is already a disturbing history of Catholic hospitals (which, by the way, comprise 13% of healthcare providers in the U.S.) denying life-saving care to pregnant women.  It is the Church's official policy not to provide therapeutic abortions even in cases of ectopic pregnancy.  Under the auspices of the so-called "Protect Life Act," these hospitals could continue to withhold treatment while still receiving federal dollars!  Catholic hospitals which do perform such procedures may face loss of funding, excommunication, and general Catholic self-righteousness.

Fittingly, just as I had this issue on the brain, I interviewed this morning at Georgetown's (Catholic) School of Medicine.  After a long speech about Georgetown's philosophy of "cura personalis," the "respect for the individual humanity of every patient," we sat in on a class on, of all things, complications of pregnancy.  The descriptions of ectopic and molar pregnancy were not followed by mention of treatment, in good Catholic form.  Question:  Could I really attend this school?

Answer:  Even if I don't, society's views on motherhood and the rights of women extend, alas, far beyond the nunnery walls.

The Rosaries in the Ovaries

In spite of the Catholic Church's continued and unwavering stance against birth control, it turns out that most American Catholics are, not surprisingly, hypocrites.  According to the National Survey of Family Growth, about 98% have used a form of contraception banned by the Vatican at some point in their lives, and 40% identify as pro-choice.  No word yet on whether these sins come up during Confession.

http://puzzledponderer.wordpress.com/2010/04/28/most-ridiculous-catholic-clothing-ever/

Yet in the developing world, particularly in Latin America and Africa, the Pope's anti-birth control, anti-condom opinions are taken more seriously.  In Catholic nations such as the DR Congo, Peru, and Haiti, rates of birth control use are negligible, and are inversely correlated with rates of HIV infection and unwanted pregnancy.  In Kenya, there have even been widely-reported instances of condom-burnings at the behest of Catholic bishops.

Now, even Pope Paul VI, composer of the treatise Humanae Vitae, acknowledged that couples might "decide not to have additional children" after giving due consideration to "physical, economic, psychological, and social conditions."  And so, to "keep up with the times," ta-da! - thus was born the Catholic institution of Natural Family Planning.  NFP is a complicated system of tracking fertility by taking one's temperature, recording daily levels of cervical mucus secretions, and filling out charts.  This enables a Catholic couple to attempt to avoid pregnancy by abstaining from sex on likely fertile days, while not "perverting the purpose of the marital act."

http://www.learkentfool.com/?p=1678

First, let's be honest:  NFP is birth control.  It's just complicated and ineffective birth control.  Second, Catholicism seems to be very arbitrary with its endorsement of all things "natural:" naturalness is something to be embraced in contraception, but to be shunned when keeping PVS patients alive for decades via ventilators and feeding tubes.

Third, I don't see how this birth control method stands up even to Catholic logic.  The line of reasoning seems to go:  "Sex that isn't open to procreation is wrong.  If I use a condom then God will be displeased, because I'm trying to prevent pregnancy.  But if I have sex according to an intricately-designed calendar, God won't be able to see through my intention.  God wants me to have babies whenever he chooses.  God can do anything.  But he can't surmount a latex barrier even when he really, really wants to."

http://babymakingmachine.blogspot.com/2009/04/natural-family-planning-techinique.html

Sure gets me all hot and bothered.

Anyway.  Couples hoping to marry in a Catholic church are now required to attend four-month classes in Natural Family Planning, to learn the ins and outs of cervical mucus charting and the evils of secular methods of birth control.  For those unable to attend a class, the marriage requirement can be fulfilled with a "home study" class for just $161.  Nevertheless, NFP use is not very common in the developed world, even among Catholic women.  In fact, only about 3.6% of Catholics practice NFP.  Still, for the very high and holy, Natural Family Planning is the one and only way to go.

Given that the Catholic stance against birth control is so often criticized for the plight of starving, HIV-ravaged third world countries, I was curious to see whether NFP had made its way to Latin America and Africa.  Surely, since the Church acknowledges that everyone might not want to procreate constantly, and since it is so concerned with preserving human life, it would try to promote its one approved method of birth control in the third world.  I discovered, however, that NFP courses are available - in English and Spanish only - in all of fifteen nations worldwide.  The majority of these nations (the US, Canada, Great Britain, Ireland, Argentina, Spain, South Africa, and inexplicably, China) are already highly developed.  NFP classes are taught in just six countries total in Africa and Latin America.  Furthermore, according to Natural Family Planning International, current efforts are focused on bringing NFP to the Czech Republic, a country with a fertility rate of 1.24 births per woman, whose people have suffered from "secularism and immorality."  In third-world majority Catholic nations, however, I suppose that the "suffering" has not been so great.

One rare instance I could find of Catholics promoting NFP in the third world comes from my very own Jesuit Georgetown.  A cohort of Jesuits affiliated with the Institute for Reproductive Health is attempting to dispense "cycle beads," rosaries for counting days of the menstrual cycle instead of Hail Marys, in Rwanda, Guatamala, and the DR Congo.  The sad fact is, though, that in the DR Congo, the so-called "rape capital of the world," where girls are often married off at puberty, even a woman's husband is unlikely to respect her wishes to abstain from intercourse during a fertile period.

If Catholic couples truly want to practice Natural Family Planning, then of course that is their right and their choice.  What I'd like to see, however, is some admission that this form of birth control is an elitist luxury, akin to buying organic food or running in Nike Nakeds.  For reasons logistical, economic, and societal, NFP is available almost exclusively in the developed world, while those without easy access are still told that condoms and other forms of "artificial" contraception will drag them down into the depths of Hell.  Yet even faced with these criticisms, the Vatican is as determined as ever not to waver in its resolve.  Pope Benedict XVI, speaking in 2008 on the 40th anniversary of Humanae Vitae, firmly supported his predecessor's treatise, and reminded the world's one billion Catholics that the Church's stance against birth control is "so crucial for humanity's future."

And I would have to agree with him there.

Dividing Cells, Splitting Hairs

In his 1968 encyclical Humanae Vitae, a treatise condemning the use of contraceptives, Pope Paul VI famously established the Catholic church's official stance on all matters procreative.  In the 40-odd years since the publication of Humanae Vitae, the Church has not budged it its contra-contraception position, and Pope Paul VI's treatise has been lauded as "prophetic"for how it anticipated today's issues of reproductive ethics.  These aren't just echoes of the "be fruitful and multiply" argument, however.  Supporters of the Church claim that the Pope's views on birth control are even more relevant given that chemical contraception is "known" to induce abortions through preventing implantation of a fertilized embryo.  Thus contraception is not a lesser, separate evil, but is tantamount to abortion itself.

http://stemcells.nih.gov/info/scireport/appendixa.asp

A life begins... OR WILL IT????

It's not just the Catholics who have voiced this condemnation of the "abortifacient" properties of birth control.  The Evangelicals who fill the ranks of the pro-choice movement are similarly quick to criticize any use of "unnatural" hormonal contraceptives.  There is the outstanding example of the Duggar family, who believe that their use of the Pill caused the miscarriage of one of their pregnancies back in the '80s, and have spent the past two decades atoning for this crime by pushing the limits of human reproductive capacity.  Just a quick Google search will yield a bevy of emotionally-charged, poorly-researched, and often blatantly deceptive websites devoted to defaming all birth control use and equating contraceptives with murder.  (Notable examples including Birth Control is a Sin, Birth Control Causes Abortions, AbortionFacts.com, and perhaps most horrifying, PoisonedByThePill).  A common thread throughout these websites is that of deliberate deception at the hands of doctors and pharmacists.   Readers are urged to "read the fine print" and "wake up" - as if the entire medical profession were aligned in some giant conspiracy to kill Evangelical embryos for the good of Science and Atheism and Richard Dawkins.

From this movement has grown a plethora of misconceptions and taboos about the "Morning After Pill" and oral contraceptives.  Many women worldwide are misinformed about emergency contraception and its mechanism of action:  some actually mistake the Plan B pill with RU486, the "abortion pill."  Pro-life lobbying on this issue has also spawned “the Pharmacist’s Conscience Clause,” a provision which allows a pharmacist to withhold oral contraceptives and the "morning after pill” on moral grounds. A recent study estimated that 6% of American pharmacists actually withhold contraception - which probably makes it pretty difficult to purchase birth control in Kansas.  This poor understanding of emergency contraception deters many genuinely well-meaning women and couples from choosing Plan B following unprotected intercourse - which, of course, is the intended effect of the religious fear-mongering. 

Now, Pope Paul VI was not a doctor or a biologist, so I was interested in how he arrived at his understanding of the mechanism of action of birth control pills and emergency contraception.  So I popped on over to PubMed to see what relevant (and unbiased) information medical researchers had discovered on the topic.

But first, a little background on early embryonic development: the human embryo typically implants in the uterine wall at the blastocyst stage, approximately one week after fertilization, when it consists of 32 cells.  To prevent a subsequent pregnancy, the ovaries begin secreting progesterone, a hormone which inhibits further ovulation.  Progesterone also inhibits the process of sperm capacitation, which enables a sperm to fertilize an egg.  In addition, this hormone thins the lining of the endometrium - just like it does during the luteal phase, i.e. a menstrual period.

Both oral contraceptives and older versions of the Plan B pill (which is essentially a higher dose of the same thing) rely on progestrin, a synthetic form of progesterone, essentially to trick the body into believing that it is already pregnant.  Thus, ovulation and sperm capacitation do not occur, and the endometrial lining thins.  It is this capacity of progesterone which has conservatives jumping down throats and splitting hairs about what constitutes prevention vs. termination of pregnancy, and losing sleep over the fate of the human blastocyst.

http://www.glowm.com/?p=glowm.cml/section_view&articleid=2&SESSID=evpji2lnn7ah65gbjah4bgnc40

So let's see what a few decades of medical research have to say on the matter.  First, newer Levonorgestrel-based contraceptives (such as Plan B One-Step) can apparently only prevent ovulation, and cannot prevent pregnancy once ovulation has occurred.  No studies indicate that Levonorgestrel has any "abortifacient" capabilities.  Thus, Levonorgestrel is only 80% effective at preventing pregnancy.  The results of studies on progesterone-based pills are a little bit hazier:  some report "with mild confidence" that progesterone prevents implantation, while others deny this to be the case.  Most review articles state that the prevention of implantation is "possible in theory," but do not provide relevant statistics.  In contrast, the post-coital insertion of an IUD has been shown to prevent implantation of an embryo; Mifepristone, the "abortion pill," can be taken in small doses to produce the same effect.

The general medical consensus:  certain forms of emergency contraception (Mifepristone and IUDs) have the secondary effect of preventing embryonic implantation.  However, the most commonly-used form of emergency contraception (Levonorgestrel), does not act in this way.  In regards to the Pill, it is possible in theory that these contraceptives prevent the implantation of a fertilized embryo, but no study to date has strongly indicated that this is the case.  I speculate that the findings of such studies are complicated by the fact that, even in the absence of birth control, at least half of fertilized human ova do not successfully implant.  Here's a little graph I threw together about the prevalence possible fetal fates in the U.S.:

Needless to say, these stats are going to make Georgia Rep. Bobby Franklin's job very difficult if he in fact intends to investigate and press charges for every miscarriage that occurs in his state.  The majority of fertilized oocytes to not make it to be full-fledged humans, even without medical or chemical interventions.  Ultimately, it is difficult to determine how often emergency contraception prevents an embryo from implanting when God Himself is already doing such a good job of it.