Counter-conservatives, civil resistance and professional boycott (about RU-486)
Gonzalo Herranz. department of Bioethics, University of Navarra
lecture at the workshop on Professional activism in favor of life.
Pamplona, Saturday, June 22, 1991
RU-486 as an abortifacient agent
Could RU-486 be used as a contraceptive?
Psychological and social aspects of RU-486
The deliberate confusion of the terminology
The trivialization of abortion
III. The civil resistance of pro-lifers
We all already know a lot about the RU-486 compound, about pharmacological abortion, and about the strong, irreconcilable division of opinion that has arisen around the problems raised by this drug.
Anyone who wants to find out what motivates the promoters of the RU can do a very simple thing: inform themselves directly from them. At the end of 1989, Etienne Emile Baulieu was awarded the award and the Lasker Medal, a highly esteemed American distinction, which rewards great scientific merit. As was customary, Baulieu had to deliver, at the submission event of the award, a lecture, which is published in JAMA and Science, in which, along with the biochemical and clinical aspects of RU-486, he spoke of the ethical and social projects to be achieved by means of countergenetics. I point this out, since these lectures by Baulieu contain much of the information that I am going to transmit (Baulieu EE. RU-486 as an antiprogesterone steroid. From receptor to contragestion and beyond. JAMA 1989;262:1808-14. Baulieu EE. Contragestion and other clinical applications of RU-486, an antiprogesterone at the receptor site. Science 1989;245:1351-7).
But just as it has been applauded by the major players in international neo-Malthusianism, RU-486 has come in for sharp criticism from the defenders of prenatal human life.
I will first summarize the medical information on RU-486, and then deal with its ethical aspects. Finally, I will have to talk about how to substantiate and put on internship that very special form of civil resistance that is the professional boycott.
1. The compound RU-486 is the first "abortion pill". Its use raises very serious problems, both moral and social, as well as medical and scientific. The product was developed in the laboratories of the French signature Roussel Uclaf (hence the name RU). The scientific designation of the molecule is mifepristone. In France, it is marketed under the trade name Mifégyne.
2. RU-486 is a synthetic steroid with very unique anti-hormonal (anti-progestin) properties. It binds with high affinity to the receptor for progesterone present in the tissues on which progesterone acts, including the endometrium, thereby nullifying the actions of progesterone. As its name indicates, progesterone is necessary for gestation. The continued action of progesterone - produced, in the first weeks of pregnancy, by the ovary and, later and in large quantities, by the placenta - is necessary for the maintenance of gestation, particularly during the first trimester. If its action is nullified by the administration of RU-486 in adequate quantity, it causes early abortion. This is the most studied and best known action of RU-486, but not the only one.
3. RU-486 has other effects. Administered from agreement with certain guidelines, it can act as a contraceptive. It also has, when used in large doses, an anti-glucocorticoid effect, which gives it a certain potential, not yet fully confirmed, in the treatment of certain diseases. These medical applications of RU-486, other than early abortion, are now the subject of very intense programs of study , which will be discussed later.
RU-486 as an abortifacient agent
4. The main use of RU-486 so far, and its most studied effect, is as an inducer of early abortion. When RU-486 is administered alone, the success rate is not very good, because abortions are incomplete in 15% of women when administered within 5 weeks of amenorrhea. The failure rate rises to over 60% when abortion is induced at 9 weeks of amenorrhea.
5. But this difficulty can be overcome to some extent by combining RU-486 with other drugs. RU-486 causes an increase in the sensitivity of the uterus to other abortion-inducing agents: certain prostaglandins. When RU-486 and a suitable prostaglandin are used in combination, the efficacy increases markedly: a single 600 mg dose of RU-486, followed a day and a half to two days later by a 0.25 mg injection of sulprostone or a 1 mg vaginal suppository of gemeprost, achieves complete abortion in almost all women. However, this treatment is accompanied by side effects of varying importance: pain, which requires analgesia, during expulsion of the fetus; hemorrhage, which averages 80 ml and lasts one to two weeks. New combinations of RU-486 with prostaglandins are under study and in the clinical essay phase, in order to attenuate these undesirable effects.
6. In France (data May 1990), abortions induced with the combination of RU-486 and prostaglandin amounted to 45,000. In 1990, about 1000 per week are performed, which means that this technique is applied in one out of every three or four abortions. Only cases in which gestation is less than 7 weeks are accepted. Women are required to consent to surgical abortion in the event of treatment failure or significant bleeding. Abortion with RU-486 is subject to fairly stringent regulation management assistant and epidemiology. Recently, following the death of a woman as a result of a pharmacological abortion, the French Ministry of Health has ordered that women who smoke and are over 35 years of age be excluded from this abortion subject . This decision, of dubious scientific basis, was taken to reassure public opinion.
7. It is not easy to make a weighted assessment of the data concerning the complications associated with RU-486-mediated abortion, as these data are presented with a certain bias. We cannot forget that there is a strong polarization of opinion among gynecologists and a lively discussion that pits proponents of pharmacologic abortion against advocates of surgical abortion. A little over a year ago, the former claimed that there were only 2 cases of serious complications among 30,000 abortions induced by RU-486; others put the number of serious complications at 5 per 1000 cases. Significant hemorrhage occurs in 10% of women treated, of whom one in a hundred requires transfusion. Between 5 and 20 % of the cases present retention of the fetus, necessitating surgical evacuation.
8. The experience gained in the trials carried out to date requires that early abortion with RU-486 should always be performed under the control of a physician, since it is necessary to attend to the frequent complications. These have so far prevented the free marketing of RU-486 and, with it, the possibility of "home abortion". The same complications, the need for ultrasound monitoring after the intervention to verify that the abortion has been complete, are the reason why RU-486 cannot be used in countries with scarce human medical resources, contrary to the wishes of some who saw in it the ideal method for abortion in the Third World.
9. As noted above, in 7, there is a clash between the proponents of surgical abortion and those of pharmacological abortion, which is not exclusively about providing "better service" to women seeking abortions, but has to do with the struggle for supremacy in the abortion industry. Proponents of surgical abortion have said that RU-486 represents a dubious technical advance in a area where there was no need for it. Complications of RU-486 abortion cause women to miss conference work and go to the hospital. From the economic point of view, even discounting the cost of RU-486, pharmacological abortion does not seem to have advantages over surgical abortion.
10. Interestingly, a multicenter international project , sponsored by the World Health Organization, has come up with an eclectic solution. It has studied how to combine RU-486 with surgical abortion and has shown that RU-486 provides good cervical preparation for internship aspiration abortion. On the other hand, pretreatment with RU-486 facilitates second-trimester abortion induced by extra-amniotic infusion of prostaglandins, thereby achieving a marked reduction in both the induction-to-abortion interval and the total amount of prostaglandin used.
Could RU-486 be used as a contraceptive?
11. For the time being, the use of RU-486 as a contraceptive remains in the realm of speculation. The clinical experiments necessary to test and comparatively evaluate its possible capacity as a contraceptive have not yet been carried out.
12. It seems that the systematic use of RU-486 as a "postcoital contraceptive", or, from agreement with the less traumatic designation, as a "period inducer" or "single-dose monthly contraceptive (next month's pill)", should be ruled out, since it shows a priori insufficient theoretical efficacy (4% of calculated failures). In reality, the mechanism of action of RU-486, which would be taken in the last four days of the cycle, would, in these circumstances, not be contraceptive, but rather anti-implantation or very early abortifacient. To act as an efficient monthly contraceptive (abortifacient) pill, RU-486 would have to be combined with an anti-gonadotropin-releasing hormone or an oral prostaglandin.
13. It would be possible to induce luteal contraception by administration of RU-486 during the postovulatory phase of the cycle. The alteration of the secretory activity and vascular changes of the endometrium caused by RU-486 would make embryo nidation impossible.
14. One application, in which the promoters of RU-486 have high hopes, would be the use of low doses (10 to 25 mg) of RU-486 on the days of the late, pre-ovulatory, follicular phase to cause suppression of ovulation. Apparently, progesterone plays an important role in determining the timing and intensity of the luteinizing hormone peak, decisive for ovulation induction in the normal cycle, a role that could be overridden by RU-486. In such a status, RU-486 would act, unlike in previous situations, as an anovulatory contraceptive.
Psychological and social aspects of RU-486
15. Some psychological aspects involved in the employment of RU-486 are mentioned below, when dealing with questions of nomenclature and definition. Some others are mentioned here accredited specialization .
16. The advertisement of the 'abortion pill' has been greeted with jubilation by the pro-abortion movements, by international birth control agencies and by feminist movements. It is seen as a solution, or at least a promise of a solution, to many psychological and social problems.
17. For pro-abortion groups in advanced countries, where surgical abortion is safe, cheap and quick, RU-486 would guarantee greater choice. These groups claimed, with excessive and unfounded optimism, that RU-486, or the drugs that follow it, would offer the opportunity to procure abortion in privacy. These groups postulate that, if pharmacologic abortion were to reach the desideratum of 100 percent efficacy and 0 percent complications, it would become the dominant form of abortion because it is endowed with substantial advantages: private, domestic, non-medicalized, and inexpensive.
18. With purely voluntarist arguments, international population control agencies claim that the 'abortion pill' will make abortion more accessible and safe in developing countries development, and, therefore, much more sought after. It would thus contribute to selectively curb population growth in these countries, while avoiding a large part of the alleged 100,000 to 200,000 deaths that these countries pay annually for unsafe surgical or clandestine abortions. But, for the time being, RU-486 abortion needs as much or more medical support than surgical abortion, which dashes the illusions of RU-486 as an easy means of population control.
19. Many groups in the feminist movement see RU-486 as the first step towards women becoming the de facto masters of their reproductive capacity and herald the advent of true reproductive freedom. This will come when a safe abortion pill becomes available, which pharmacists will dispense without a prescription. Ideally, this pill, taken as a 'menstrual inducer' or 'monthly pill', would remove the guilt feelings associated with abortion. In effect, the woman would no longer have to worry about whether or not she has conceived. Each month she would proceed to chemically cleanse her uterus. Baulieu himself has put it this way: "My purpose is to make the word abortion disappear, because this word is as traumatic as the fact of abortion itself". In November 1988, the then French Minister of Health, Claude Evian, in ordering Roussel Uclaf to resume distribution of RU-486, suspended a few days earlier, stated that he was doing so "in the interest of public health and in support of women's rights". In this, Evian was merely transcribing the idea expressed in a letter signed by more than 1000 gynecologists attending a congress in Rio de Janeiro, who had been encouraged to declare that the withdrawal of RU-486 was "a blow to women's rights".
20. It is, however, doubtful that abortion - even early and deliberately inadvertent abortion - can be free of psychological trauma. Although its emotional impact may be less severe than that caused by surgical abortion, which is burdened with the constraints of going to a clinic, undergoing anesthesia and undergoing a major invasive procedure, 'home' pharmacological abortion is not free of stress and anxieties. De-medicalized abortion leaves the woman left to herself and in the uncomfortable company of fear, pain and fear of hemorrhage. The abortion pill favors the woman's privacy and secrecy, but condemns her to loneliness.
21. Those interested in the commercialization of RU-486 know that, from the point of view of social psychology, it is important to find other clinical applications for the molecule that will redeem it from the "bad reputation" inherent in its status as an abortifacient. This is both a symbolic and a practical problem. If RU-486 were to obtain, thanks to these clinical applications, a worthy place among the drugs, opposing its use in situations that have nothing to do with abortion and contraception would be irresponsible and malevolent behavior, since it would deprive many patients of the benefits that RU-486 can provide them. In order to explore the therapeutic possibilities of RU-486, new aspects of its interactions with different tissues and functions are being studied in some basic research laboratories.
22. In fact, some clinical applications of RU-486 are now known. It has been found to be useful in some diseases: in Cushing's syndrome, in the treatment of certain cases of breast cancer, in the treatment of some inoperable meningiomas containing progestin receptors, as financial aid for delivery in cases of insufficient cervical dilatation, or as a facilitator of surgical abortion during the second and third trimester.
23. The possible usefulness of RU-486 in other clinical situations has been suggested, but only on such a tenuous objective instructions that one sometimes has the impression that these suggestions are based on wishful thinking rather than on firm data . Here is a list of potential indications for RU-486: non-surgical treatment of ectopic pregnancy, treatment of endometriosis, of certain tumors, in the modulation of the biological response to certain virus infections, in the local treatment (eye drops) of glaucoma, and finally, as mentioned above, as a contraceptive.
So far, the clinical application of the RU-486 pill has been authorized only in France. At the end of 1987, the National Advisory Ethics Committee for Life and Health Sciences ( committee ) issued an opinion in favor of the limited and closely monitored use of RU-486, from agreement in accordance with the current French abortion law. The World Health Organization (WHO) is impatiently awaiting the time to rely on RU 486 as a means of controlling births. According to Nature magazine, Roussel Uclaf has signed a contract with WHO to provide the product at cost price. Naturally, the multinational abortion and contraception organizations (the International Planned Parenthood Federation, the United States Agency for International Development, the Pathfinder, Ford and Rockefeller Foundations) have a vested interest in this matter. There are reports that RU-486 is being used in the People's Republic of China, which has not adhered to the international conventions on patents. A few months ago, the use of RU-486 was authorized in Austria. The process of introducing the product in Sweden, the United Kingdom, Holland and other Scandinavian countries is said to be at an advanced stage. In Spain, the issue was discussed at the congress de los Diputados, in the autumn of 1990: the proposal to authorize the use of RU-486 made by the group of Izquierda Unida was defeated by the joint civil service examination of the Socialist, Popular, Catalan and Centrist groups.
This brings us to the
Obviously, the fact that the abortion is obtained by means of a surgical procedure or chemical agent does not substantially modify the moral gravity of the action. Consequently, the ethical and moral condemnation of abortion falls, in its entirety and without extenuating circumstances, on abortion induced by RU-486 or by any other chemical compound that, with abortifacient action and with the appearance of a drug, may be applied in the future with the purpose of causing abortion. But it is worth questioning the effects that the acceptance and generalization of pharmacological abortion may have from the point of view of medical ethics.
The deliberate confusion of the terminology
26. It is well known that the introduction of customs or notions that clash with social tradition requires the manipulation of ideas, which necessarily requires the tricky use of the words that designate them. The skilful adulteration of language and definitions allows the introduction of new atraumatic expressions that give the appearance of dignity, make fashionable or establish as necessary certain behaviors that until then were considered repugnant or immoral.
27. The entrance and diffusion of surgical abortion in society has been possible not only thanks to permissive legislation, but also to the advertising technology of socially persuasive formulas, of syntagms that dignify it, of expressions that tarnish those who oppose it. The evil, sinful nature of abortion is nullified when the fact of destroying a human life is hidden under the veil of new and innocent expressions, which are at the same time scientific, progressive, technical and tolerant, such as "microaspiration", "menstrual extraction", "voluntary interruption of gestation" or simply "interruption", "menstrual regulation", "interception", "monthly pill", and others.
28. Baulieu has specifically coined the term contragestation to replace that of RU-486 induced abortion. He justifies the need for the term: "Many methods of fertility control are not contraceptive in the common and accepted sense of the term. This is the case with intrauterine devices, hormonal contraception based on gestagens, and postcoital contraception. In fact, post-fertilization termination, which should be considered abortifacient, is available at agenda, it is the norm. In addition, practically all women have had or will have some (spontaneous) abortion, even if they are not aware of it.... The concept of abortion includes a violent and controversial connotation, as if, collectively, consciously or not, we were only concerned about whether or not fertilization has taken place, and forget about the multitude of stages that must take place for a human being to develop. Considered in its entirety and continuity the process of generating life, and the natural selection mechanisms that determine its existence, the employment, when dealing with abortion, of terms such as "murder" or "killing" simply serves to obscure the real terms of a problem that has to do only with health. For that reason, we have proposed the term "counter-management," a contraction of "counter-gestation," to include most methods of fertility control, a term which, hopefully, will serve to prevent the discussion from getting out of hand."
29. The intention to amortize the transmission of human life, to reduce it to pure biology, to disconnect it from all moral responsibility, is evident. Chemical abortion must be separated from all moral implications. It must certainly be subjected to the civil laws that regulate abortion internship , to the norms of good health internship and to population control programs. The preoccupation of pro-life activists with fertilization must be condemned as obsessive, and the use of expressions - murder, killing - endowed with moral content must be declared perverse, or at least intentionally obscuring. The new term of contragestion, which is "tricked" contraction to steal semiological meaning from the original contragestion, not only frees from possible traumas, but also serves to anesthetize the moral conscience. It should no longer awaken a association of ideas with the process of transmitting life and with the role that women play in it, but only with the general administration of affairs.
30. It is worth noting for a moment the total imperviousness to arguments in ethical confrontations with the authors of RU-486. They have not only created and exploited the field of counter-management: they claim for themselves the exclusive right to the ethical analysis of the problems connected with it. An example: when someone reproached Baulieu for the laughable nature of his ethical assessment of chemical abortion, pointing out that changing terminology does not change the moral substance of actions, that it is abusive to call fertility control what it is to evict a human being from the womb, Baulieu, in a very typical way, reproached his opponent for using language designed, by means of a deeply unscientific semantic manipulation, to provoke an a priori rejection of the facts and ideas involved in the idea of counter-management. I believe that the status is very well described in the Spanish proverb: "Dijo la sartén al cazo: apártate que me manchas". Any comment is superfluous.
The trivialization of abortion
31. A few years ago, I described the threat of the trivialization of abortion that the use of RU-486 can bring with it. "The significance of this abortion subject is extremely important: to establish as a socially admitted fact the notion that the human embryo is a mere waste product. Not only is the embryo reified, stripped of its human value: it is reduced to the negative condition of an excreta. Just as a laxative is capable of exonerating the lazy colon of its fecal contents, the new pill allows the pregnant uterus to be freed from the embryo growing in it. Disconnected from the mother by means of a precise mechanism of molecular competitiveness between anti-hormones and hormones, and catapulted towards the sewer network by the action of specific stimulators of the uterine myocyte, the embryo ends its existence without pain or glory. The transmission of human life, the supreme capacity of man to create men, that participation in the creative power of God, is thus converted into a function of the same physiological, psychological and moral rank as urination or defecation".
III. The civil resistance of pro-lifers
32. Any attempt to enlighten, from a perspective of respect for life, the conscience of the public, to clarify the pharmacological and moral characteristics of RU, its mode of action, or to denounce the manipulation underlying the language of contraception, will be violently and elegantly rejected by the scientific "establishment" and by the very powerful organizations of population control. Whoever speaks out publicly against the UK, runs the risk of being discredited and reduced to silence. In the scientific press, whether on the news and commentary pages or within the articles of research, any moral criticism of RU is rejected as an "aggressive threat, a manifestation of fanaticism, result of a retrograde mentality that wants to intimidate researchers from investigating the myriad potential uses of RU as a drug". Groups opposed to RU are said to be using slander and anonymous threats to destroy the family life of employees of the Roussel Uclaf company, an attitude that was described as scandalous and vile by Minister Evian. Those who set up a professional boycott plan against Roussel Uclaf and the super-powerful Hoechst to stop producing the RU are put on bread, while the threat made by a thousand gynecologists, gathered at a congress in Rio de Janeiro, to boycott Roussel Uclaf if it stops manufacturing the abortion pill is highlighted as a wonderful act of moral courage.
33. For health professionals who respect human life, the use of RU for abortifacient purposes is an extraordinary moral evil, from which not only they must abstain, but they must see to it that no one else can use it. This provides the specific elements for civil resistance, i.e., for the application of actions taken only in extraordinary cases. As a rule, health professionals should not practice discriminatory policies against any provider of materials or services, if their services, all other things considered, are of similar quality and price to those offered by other competitors. Therefore, it is not morally justified to discriminate against a laboratory that produces effective drugs that meet the standards of good internship, especially if they offer some advantages (access, economic, quality) over other similar products: patients have the right to these advantages. Health professionals who are in favor of life must also be in favor of justice, must lead a peaceful life, know that a good end can never justify the application of morally evil means and are convinced that violence can become as monstrous as the evil they wish to combat.
34. A boycott action against a pharmaceutical laboratory seeks to change the policy of this laboratory on the basis that the economic damage caused by the decision of many not to prescribe their drugs will be much more burdensome than that resulting from fail the manufacture or marketing of the product that provoked the boycott. The elements of the boycott are very simple: although other people (patients, journalists, other pro-life activists) can participate in it, the action is fundamentally aimed at health professionals who wish to collaborate (doctors, pharmacists, pharmaceutical distribution centers, nurses). They are to be provided with a card, which is circulated by the pro-life professional group(s) promoting the boycott, indicating their address and telephone number. On one side of the card is written a concise explanation of the reasons for the boycott and an invitation to collaborate personally and to invite other colleagues to join the boycott. The reason for the boycott is given and a description is given of the coordinated actions that should be taken at internship: write to laboratory requesting the withdrawal of these products, refrain from prescribing or dispensing the other drugs produced by laboratory . To this end, a list of equivalent products is provided on the other side of the card , indicating the brand names or generic products that can replace the various drugs of the boycotted company. It is very easy, with a good drug vademecum or with the current year's prescription guide , to make this table of equivalents.
35. It is important to keep in mind that the boycott action is part of a very broad way of life: that of changing the opinion of many indifferent people in favor of life, making them see that it is not a passing eruption, but a profound and permanent movement. There should not be "one" promoter, but many, very many, who spread the message. And they must do it in a positive, cheerful, encouraging, modern way, ordinary people. Even the appearance of connection of the boycott with political, cultural or religious groups is not wise: they must have an open professional character. Sometimes an ill-advised gesture can be used by journalists to discredit the whole action in the eyes of public opinion. It is essential that, at all times, pro-life activists be courteous, kind; that it be seen that, although suffering, they are not bitter; that they are confident that they will eventually appear reasonable and noble in their aims; that, although combative, they are not aggressive or violent. If they demonstrate in public, they will do so peacefully, with humor, carrying a kind and positive message. If they write letters, or make a campaign of telephone calls to the central laboratory or to their local representatives, they must give their name, their professional degree scroll , and communicate with simplicity and in very different ways the message that, in essence, consists of expressing their pain for seeing that a laboratory that produces high quality drugs and that one has been prescribing or dispensing for a long time, or whose research one was proud of, has diverted its action in favor of health and life towards the destruction of innocent human beings. Add that one will boycott, for as long as the anomalous status lasts, their products, but that one hopes that this will be short-lived, as one expects a reasonable reaction.
In a hospital, a list of signatures can be opened to request the withdrawal of the product. Lists of shareholders and managers can be obtained from the relevant yearbooks and should be written to politely but clearly.
It is up to the promoters to work seriously in the preparation of the boycott and of the satellite actions, so that at the moment of launching the operation all the immediate collaborators can be sufficiently endowed with moral reasons, with the capacity to attract new adhesions, to develop initiatives, to have access to the means of opinion. A boycott operation is short-lived, but it must be very intense.