The morning-after pill and ignorance
_{(Medical ethics and the morning-after pill, I)}

Gonzalo Herranz.
department of Humanities Biomedicas, University of Navarra.
Published in Diario Médico, 3-IV-2001.

The author refers to the mechanism of action of the so-called morning-after pill and is astonished by the cloud of ignorance surrounding its anti-inflammatory effect, precisely at the time of evidence-based medicine. In another article to be published tomorrow in the rules and regulations section, Professor Gonzalo Herranz will analyse informed consent in the prescription of this product.

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The recent approval by the Spanish Medicines Agency of the marketing of levonorgestrel in the pharmaceutical form of the morning-after pill (dpd) is a matter that raises ethical-medical and deontological issues that are not trivial and worthy of comment.

The mechanism of action of pdd includes a component of strong ethical significance: it prevents the nesting and thus the development of the human embryo. We know that it does this, but we do not know how often it does it. Consequently, whether the doctor prescribes or the woman takes the dpd are actions with a strong burden of responsibility, in which factors of two orders play a very relevant role. One could be assigned to area of biological ethics; the other to professional ethics. The biological-ethical factor consists of knowing what is happening in the woman's organism when she uses dpd: only by knowing this, we will be able to act rationally and rationally, and we will be able to act with knowledge . The ethical-professional factor consists of analysing, in the light of the principles and norms of medical ethics, what requirements - of unbiased information, of respect for people and their moral convictions - should be required for a doctor to be able to prescribe pdd.

Mechanism of action in the penumbra

What do we know about pdd? Here, the question is not primarily about its efficacy and safety, its interactions: we know enough about those. It is about its mechanism of action, which we need to know and talk more about.

It is almost routine to say that pdd exerts a diverse and multifactorial effect, depending on the time relationship between ingestion of the product and the day of the menstrual cycle or the time elapsed since intercourse. The official version of the facts is that pdd can inhibit ovulation or, through subtle disturbances in the function of the hypothalamus-pituitary-ovary axis, delay ovulation; that it can change the texture of cervical mucus and make it impractical for sperm; that it can slow down tubal motility and with it the transport of gametes; that it can weaken the vitality of sperm and oocyte and reduce their ability to fertilise; or that, finally, it can alter the endometrium and make it refractory or less receptive to the implantation of a fertilised egg. In other words, some changes are contraceptive because they inhibit fertilisation; others, on the other hand, operate after fertilisation and must be considered as interceptive or very early abortifacients.

What part each of these factors, and particularly that last and decisive anti-natal effect of pdd, plays in the final net result of fewer children being born, no one has set out to elucidate. The issue, important as it is, remains shrouded in a stubborn cloud of ignorance. It is surprising that such a thing should happen in the age of evidence-based medicine, a time when, in clinical pharmacology, clinical pharmacology is finely tuned and ignorance and indeterminacy are frowned upon. We have only indirect, though relatively reliable, estimates which allow us to conclude that, even if given in time, pdd does not always inhibit ovulation; that, despite the changes it induces in the cervical mucus, pdd does not prevent sperm from passing into the tube in a reduced but sufficient quantity; and that the endometrial antinidating effect plays a decisive, though unquantified, role in the efficacy of the treatment.

Clarities and ambiguities

Such a status forces one to act in doubt, with less data than necessary, which creates conflicts. Those who have a deep respect for all human beings without exception rightly believe that no human being should ever be exposed to the risk of being destroyed, even if this risk is not quantified. It is enough that pdd is in fact capable of depriving a human embryo of the opportunity to live for pdd to be condemnable. Those who do not profess such respect prefer to deny the ethical problem by means of certain changes in language. For them, changing the name of actions transmutes their morality. A publishing house in the New England Journal of Medicine states: "...even if emergency contraception acted exclusively by preventing zygote implantation, it would not be abortifacient". But we are not told what it is. Breaking the life of a human being, however miniscule the victim, is something that deserves to be called something. Preventing the implantation of the human embryo is an act of B ethical importance that cannot be volatilised by the easy transcript of leaving it nameless. Its moral substance does not disappear, even if we resort to the redefinition of gestation and conception agreed upon years ago by the WHO, ACOG, FIGO and the birth control multinationals. But such a redefinition is not from receipt: it has been resisted year after year, with sensible tenacity, by many men and women of good will, by successive editions of general and medical dictionaries, and by books on human embryology.

In any case, even in the midst of concealment and indeterminacy, there is no shortage of those who, overcoming all ethical scruples about abortion and hard contraception, speak out with sincere frankness. A couple of examples: in the Spanish version, but curiously not in the English version, on the Population Council's website, we read: "what emergency contraceptive pills and emergency mini-pills do is mainly to modify the endometrium (the mucous layer lining the uterus) in order to inhibit the implantation of a fertilised egg". And Émile Etienne Baulieu coined the concept of contraceptives to group together with RU-486, the abortion pill he had designed, fertility control methods that are very early abortifacients, including intrauterine devices, hormonal contraception based on gestagens and postcoital contraception. In fact," he said in his speech on receiving the Lasker Medal, "post-fertilisation termination, which should be considered abortifacient, is something that is available at agenda [...] For this reason, we have proposed the term 'contragestation', a contraction of 'contra-gestation', to include most methods of fertility control.

That is straight talking and straightforward. The historical evolution of contraception has followed a well-defined trajectory: from anovulation to interception, from ovary to endometrium, from pre-fertilisation to post-fertilisation. How, where and when it works has changed over the last 45 years. But people still talk about contraception, as if nothing had happened.

A doctor who has a deep respect for life and who is not unaware of the anti-natal effect of ddp will refuse to prescribe it, for which, in view of the terms of the recent authorisation of levonorgestrel, there is no need, in view of the terms of the recent authorisation of levonorgestrel, for conscientious objection. However, if pdd were one day to be included among the benefits of private insurance companies or the national health system, the doctor could raise a conscientious objection to its prescription, just as he or she does to the abortion of embryos and older foetuses.