Article May 1, 2014

The confusion about contraceptives

The Hobby Lobby case has brought to the fore the current state of confusion regarding how contraceptives work. One of the problems is lack of clarity on the question of whether some—or any—contraceptives can cause an abortion.

Why is there so much uncertainty? Doesn’t the name contra (against) conception say it all?

A Change in Definition

Well, actually, the answer is no. And to understand why, we need to go back about fifty years, when Albert Rosenfeld realized that the newly available oral contraceptive pill (OCP) might not only prevent the sperm from fertilizing the egg (the classic definition of ‘conception’) but might also terminate embryonic human life by inhibiting implantation in the womb (which occurs about a week later). Since such interference would occur after conception, he realized that some people would say this represented an abortion (or was abortifacient). He recommended a ‘solution’ to this problem: “Equate conception with the time of implantation rather than the time of fertilization—a difference of only a few days.” That is, he got around the fact that these drugs might cause the termination of a pregnancy by changing the definition of when a pregnancy started—because if there were no pregnancy, you couldn’t say you were causing an abortion. (Whether this abortive mechanism does actually operate for the pill is still not clear, as we see below.)

Following Rosenfeld’s logic, the subsequent printing of the American College of Obstetricians and Gynecologist’s terminology text in 1972 saw a deliberate change of the definition of ‘conception.’ The accepted scientific view that conception was the result of the process of fertilization was altered to define ‘conception’ as implantation. As a result, the link between fertilization and conception was broken. Pregnancy was still defined as “the state of a female after conception and until termination of the gestation,” but the text now dated a pregnancy (and by implication a human life) from the time of the implantation of the embryo into the wall of the mother’s uterus. Under the new definition, any device that prevented the embryo from implanting in the uterus could be marketed as a contraceptive. 

Note that those who made this definitional change had no authority to do so—they weren’t embryologists. Despite medical textbooks adopting the new definition, respected embryology textbooks still mark conception (and the beginning of human life) at fertilization.

Two Classes of Contraceptives

This change of definition means there are two classes of contraceptives: those that work before fertilization, the classic definition, and prevent the sperm from joining with the egg; and those that cause an early abortion by acting after fertilization. We can work out which category any given contraceptive method falls into by considering how it works. This isn’t as easy as you might think—but some guidelines are available for those whose conscience prevents them from putting an early human embryo at risk.

If you want to avoid fertilization from occurring, you need to stop the egg and sperm from meeting. The methods in this group will include barrier contraceptives, such as condoms or diaphragms, where a physical obstruction is placed between the sperm and the egg. You could achieve the same effect by limiting the availability of one or the other. Preventing the production of eggs would make fertilization impossible (this is usually done with hormones). Similarly, the withdrawal method and natural family planning (also called fertility awareness methods) will work by keeping the sperm out of the way. Natural family planning works by avoiding intercourse during the woman’s fertile period, so that no sperm is around when there’s an egg present. The withdrawal method aims to keep sperm out, period.

We also have information to put some methods in the other camp—those that work after fertilization and so run the risk of causing an early abortion. We know that some hormonal implants, ormeloxifene, IUDs, and ‘abortion’ pills such as RU486 can definitely work after fertilization, and so would be ethically unacceptable for those who value life from fertilization.

However, we are left with a grey area—those methods whose mechanism is not fully understood. Because they are so widely used, the most important ones in this category are the oral contraceptive pill and some other hormonal contraceptives. Debate about whether the pill is an abortifacient has raged for years, with some dodgy research muddying the waters for the non-scientifically-minded. 

Here’s a brief explanation. There are three known actions by which the pill prevents pregnancy: 

1.    The pill suppresses ovulation (egg production); 
2.    the pill makes it difficult for the sperm to move through the cervix; and 
3.    the pill makes the lining of the womb thinner and hostile to the embryo implanting. 

The first two actions are not controversial, as they obviously just stop egg and sperm from getting together and so are acting before fertilization. The concern is the third effect. Some Christians have argued that if the first and second mechanisms fail, so that an egg is produced and sperm do get through the cervix, then an embryo could form. If this was the case and the womb was not prepared for the embryo to implant and develop, it would put the pill into the second contraceptive category of abortifacients. 

However, I think there is better evidence that if the first and second mechanisms fail and an embryo is formed, then we would also expect the third mechanism to fail (as they come as a package—all or none) and you would not have an abortion, but an unplanned pregnancy. There are disagreements about the reliability of the evidence both sides claim to support their arguments. The definitive research needed to decide the issue once and for all has not, and probably will never be, done. 

To make it all a little more confusing, some contraceptives, such as the pill, can be prescribed for non-contraceptive purposes, such as hormonal disturbances in the woman. If the required action of the method for the effect you want does not involve prevention of pregnancy, you can argue this is a permissible use even for those who oppose abortion. 

Obviously this is a complex area, and putting aside the legal implications of the decision, it doesn’t help to just lump all contraceptives into one basket when we are debating the morality involved. 

We need to remember, then, that the Hobby Lobby case is not about all contraceptives, but only those that challenge the ethical values of those that value human life from the time of fertilization. It’s good to debate these issues in our community, but let’s make sure we base our arguments on the facts.

(Editor’s Note: Megan Best, MD, is a medical ethicist and author of Fearfully and Wonderfully Made: Christian Ethics and the Beginning of Human Life. In the book she discusses these issues in depth. Further information about contraceptives can be found in Chapter 6. Appendix 1 explains in detail the debate about whether the pill causes abortions.)

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