The morning-after pill and informed consent
_{(Medical ethics and the morning-after pill, II)}

Gonzalo Herranz.
department of Humanities Biomedicas, University of Navarra.
article published in Diario Médico, 30-IV-2001.

In this second article, the author stresses the importance of full information when prescribing this product and the doctor's deontological obligation to respect the patient's convictions, on whom he cannot impose his opinion.

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Although it is highly questionable whether the morning-after pill (dpd) can be considered as a conventional medicine, for the time being, in Spain it has to be prescribed and dispensed as a genuine medicine. The pharmacist can only dispense it when it has been prescribed by a doctor.

The question therefore arises as to which ethical rules are particularly relevant to the case. Two articles of the current Code of Medical Ethics and Deontology seem to me to contain them.

article 25 of the Code of Medical Ethics and Deontology

This article states that "the physician shall provide relevant information at subject on human reproduction in order to enable the persons who have requested it to decide with sufficient knowledge and responsibility".

The Code declares that information on human reproduction is a special, privileged area . In our case, it imposes on doctors, especially gynaecologists and general practitioners, the duty to provide information about hrp, not in a routine way, but in a qualified way, because the information they give to those who ask them about it must help them to make decisions with knowledge sufficient and with sufficient responsibility. Such information must be objective, intelligible and adequate.

Partial, obscure or biased data cannot lead to responsible decisions. It is generally accepted that the patient's consent would not be genuine, i.e., neither free nor informed, if the physician withheld information that the patient considered ethically significant. With respect to pdd, it is for the woman herself to judge. article subject of human reproduction, which, in today's ethical pluralism, admits different versions: for some, it is about exercising a wonderful cooperation with God's creative power; for others, it is about expressing the centrality that human reproduction occupies in their life plan staff; for others, finally, it is about exercising the right to transmit to the child, through genetic material, the image of one's own identity.

Physicians must recognise that those who believe that the life of a human being begins at fertilisation are acting with full rationality when they refuse treatment that would destroy a nascent human life, even if the absolute frequency of such an event were leave. It is true that, in the process of informed consent, the physician is not obliged to refer to very rare risks, but this rule ceases when there are reasonable indications that the rare possibility is regarded by the patient as important, very important. Such indications are obtained by informing and asking. Failure to do so would be tantamount to vitiating consent, which would no longer be informed. Negative psychological effects - feelings of deception, guilt or sadness, reactions of anger or depression - have been known to occur in women who believe that human life begins with fertilisation and who later learn that pdd may have eliminated one of those lives, without being informed and given an opportunity to express their will. Lack of consent in such a case can expose the physician to unpleasant deontological and judicial consequences.

The article 8 of the Code

This article states that "in the exercise of his profession, a physician shall respect the convictions of his patients and refrain from imposing his own convictions on them". To respect people is to respect their convictions. Of course, the convictions that physicians cannot impose are not only political, ideological or religious. They are also technical and scientific. The doctor must express his opinions and recommendations as appropriate, but he must do so without abusing his position of power. If the doctor thinks that the human embryo is respectable only after implantation or even later, that is his opinion, but he cannot impose it on those who regard fertilisation as the beginning of human existence. The doctor cannot forget that many people find unacceptable those forms of reproductive regulation that allow fertilisation and then cause the embryo to be lost.

In his or her relationship with the individual patient, the physician cannot apply the criteria assigned, by sociological surveys, to majorities. Opinion polls may say that the prevailing view is that unwanted or unexpected pregnancy has its most appropriate destination in abortion, or that pdd is the option to be offered without further enquiry to those seeking urgent contraception. But that may well not be the view of many others. It may even contradict other statistics. For example, among adolescents, who constitute the most vulnerable group , the circumstances (social, cultural, religious, familial) involved in the decision to abort or to continue a pregnancy are highly complex and unpredictable, and require individual and unbiased attention. In any case, the most justified prejudice would be the pro-life prejudice. Indeed, data for the approximately one million teenagers who become pregnant annually in the United States tends to show B consistently that only one-third of them (35%) decide to have an abortion, while the other two-thirds (65%) continue the pregnancy, although one-seventh of the total (14%) end in miscarriage.

The physician cannot assume that the person in front of him or her holds the same ethical convictions as he or she does. Still less can he or she assume that the person in front of him or her would prefer to ignore or disregard the moral or religious implications of the use of dpd. And, given that there is evidence that pdd has an antinidatory effect and that it is impossible for the physician to know in advance whether or not the woman who enquiry will object to his employment, it cannot be argued that it is good medical internship to deprive the woman of the information necessary for her to give her consent. Failure to provide such information would be both a deception and an abuse, expropriating the woman of her autonomy.

The status defined as emergency contraception does not exempt from this unique and unbiased dialogue between the doctor and the woman. The prescription of pdd does not belong to the small issue of situations of extreme urgency in which informed consent can be dispensed with. In the case of the presumed prescription of pdd, there can be no dispensing with an intelligent, informative, ethically respectful relationship with the woman that takes into account her beliefs and values.

The authorisation to market pdd brings to the forefront those two basic aspects of the professional ethics of medicine: respect for the patient's convictions and the communication of the truth. Those that have not been addressed here can be left for another occasion.