Thursday, October 24, 2013

Some More Thoughts on the Pill.



On the other hand, the Church does not consider at all illicit the use of those therapeutic means necessary to cure bodily diseases, even if a foreseeable impediment to procreation should result there from—provided such impediment is not directly intended for any motive whatsoever.
 Humanae Vitae.

The oral contraceptive pill is used for a wide variety of reasons. In my practice, its use as a contraceptive comes about fourth on the list of reasons why I prescribe it. I mainly prescribe the pill for the treatment of endometriosis, dysmenorrhea and acne in that order.  Paradoxically, and to my surprise, when used for the treatment of endometriosis it may, in fact, protect fertility! (Go figure!). Now, Catholic moral theology permits the use of the pill for medical reasons where the intention is to use the pill as a therapeutic agent and not as a contraceptive.  The moral logic which permits the pill's use in such circumstances is the principle of double effect.

The doctrine of double effect has come about due to the recognition of the fact that sometimes a good action may have unintended bad effects.  The classic case being the legitimacy of removing a bleeding fallopian tube in the instance of an ectopic pregnancy, and thereby causing  the loss of life of the fetus.

Cynics, looking at the doctrine of double effect, have claimed that it is possible to justify anything  by appeal to this doctrine. To protect against such abuse, in order for an action to be considered morally good, it must satisfy the following criteria:
  1. The nature-of-the-act condition. The action must be either morally good or indifferent.
  2. The means-end condition. The bad effect must not be the means by which one achieves the good effect.
  3. The right-intention condition. The intention must be the achieving of only the good effect, with the bad effect being only an unintended side effect.
  4. The proportionality condition. The good effect must be at least equivalent in importance to the bad effect.
Now,when I prescribe the pill for an issue such as endometriosis what I'm aiming to do is give a woman a pill to take to treat her medical condition. Taking pills is not morally illict so condition 1 is satisfied. As far as we are aware, the direct action of the hormones on the endometrial tissue modulates the expression of the endometriosis, so condition 2 is satisfied. My intention in these circumstances is to treat the endometriosis with no reference to contraception whatsoever, so condition 3 is satisfied. But where I get stuck is on how to satisfy the proportionality clause: condition 4.

How do I weigh a woman's fertility in relation to a condition like endometriosis? Or acne for the matter? Is suppressing a woman's fertility of the same order of gravity as making her go blind or is it the same order of gravity as an appendectomy?

If, as Humane Vitae asserts, the suppression of fertility is associated with grave sin, then must endometriosis be really-really bad before I can prescribe the pill? How bad is really-really bad?  Or make things even more complicated, sometimes the symptoms can be out of all proportion the degree of disease on imaging or laparoscopy? Is badness a measure of the patients discomfort  or the actual objective disease load? Where the dividing line is I don't know.

The problem with Humane Vitae lays in its evaluation that the the suppression of fertility is a very grave matter. This has practical implications on the treatment of medical conditions if one is to follow the full letter of the law and thereby be consistent with the principle of double effect. In order to satisfy condition no 4, the only way I could legitimately use the pill, as a therapeutic agent, is if the patient's medical condition is grave. Therefore the pill could only be justified in extreme cases. This, of course, would be a terrible outcome, since the pill is a very effective way to treat many medical conditions with minimal side effects compared to the alternatives.  Menorrhagia, a condition which affects many women, would have to be treated with other agents which are less effective and have more complications than the pill. Humanae vitae, strictly applied, effectively removes a whole class of therapeutic agents except for extreme circumstances.

As far as I can see, when it comes to its application, Humanae Vitae is asymmetric in its understanding. When it comes to sexual matters, the suppression of fertility is a grave matter, when it comes to the treatment of medical conditions it is not.

(Note. One of the weirdest things I ever had to do was put a Nun on the Pill for endometriosis!)

14 comments:

GK Chesterton said...

There is a Western desire to have the answer to everything and I think you express that with (4). Not all answers are easily available. I'm happy that (4) allows for judgement.

Given too that endometriosis can cause infertility isn't that de facto equivalence? Acne though, I can't see proscribing a carcinogen for acne. It just doesn't seem worth it.

The Social Pathologist said...

@GK

The aim is not to have an answer for everything but a desire to avoid evil.
Too many people don't understand double effect and either apply it too strictly or too liberally.

Given too that endometriosis can cause infertility isn't that de facto equivalence?

It's not necessarily a defacto equivalence. Endometriosis may cause infertility, pill use will suppress fertility, the balance of probabilities weight heavily in favour of the suppression over the protective effect, and thereby shouldn't be licit by a strict reading of HV and the application of the principles of double effect.

Acne though, I can't see proscribing a carcinogen for acne. It just doesn't seem worth it.

Once again, interesting topic. The is no definitive proof that the pill causes breast cancer. There may be some increased risk with cervical cancer, but factors such as the co-involvement with papilloma virus make this difficult to evaluate. The pill definitely decreases the risk of endometrial cancer and ovarian cancer.

Two links you might find interesting:

Cancer Mortality amongst Nuns

There may be a moral case for putting Nuns on the pill. ( No jokes in bad taste please!) and:

Oral Contraceptive use and Cancer

The Social Pathologist said...

@Gk.

Sorry, that last study has a final update, six years later. It's probably the best study out there.

Oral contraceptive use and cancer: final report from the Oxford–Family Planning Association contraceptive study

dalrock said...

Speaking of breast cancer studies, do you have any thoughts on the possible link between divorce (as a stressful event) and increased breast cancer risk? I recall seeing one study which seemed to suggest a strong relationship, but looking at a number of sources like WebMD the conventional wisdom seems to be that there isn't anything here. Do you think that this is a case of one study getting a one off result, or buckling to PC pressure?

The Social Pathologist said...

@Dalrock

Mild stress can positively stimulate the immune response and severe stress can negatively modulate it. Cue herpes.

I'm not aware of any studies, but my oncology friends have talked to me about "cancer personalities". I.e they seem to have noticed a link between anxiety and cancer but it is anecdotal.

unwobblingpivot said...

Your exposition of #2 is off the mark. You do satisfy #2, but not for the reason you gave. The reason is that the suppression of fertility is not what brings about the improvement in the patient's health. The best way to test the validity of what I'm saying is to ask, 'Would the same effect be achieved by avoiding pregnancy via abstinence?' You provide my answer by stating that this therapy expects to successfully treat a presumed celibate nun for the same condition. Which, rather than striking me as weird, strikes me as useful for clarifying the very principle of double effect under consideration.

Jason Lee said...

There is a Western desire to have the answer to everything and I think you express that with (4). Not all answers are easily available.

Are you implying that non-Westerners are lazy?

Kathy Farrelly said...

I think that SP (please correct me if I have misunderstood SP)is implying that non Westerners question less, and take things more on faith, Jason.

Inane Rambler said...

"Are you implying that non-Westerners are lazy?"

No, he's implying that Westerners are addicted to data and think they can't make a decision or a statement without having every last shred.

mdavid said...

SP, ...the only way I could legitimately use the pill, as a therapeutic agent, is if the patient's medical condition is grave. Therefore the pill could only be justified in extreme cases.

You sound full of angst here, as if there is something wrong with something. Sounds fine to me.

It's pretty simple: co-creation of a soul is a unearned gift given in love. To reject said gift is an extreme act, and thus would require an extreme situation. Personally, I like HV's word "grave". Exactly.

Of course, what is "grave" must be decided by each woman. And this is so, so beautiful. God is clever but never malicious. All these poor, uneducated women keep making the choice for God and children, never quite grasping the clever parsing the rich Western women are wont to do. These poor women want love...and they reach for it. Rich women? They reach for the pill. For death.

So why worry about what exactly constitutes "grave". On one side lies definitions, logic, parsing, cleverness. On the other, pure love. I nearly tear up at how clever God is. The Church, rigid with fear at such a grave matter, shudders and tries to warn, to teach, to persuade. Yet the modern woman's head (along with her male lackey's) nearly explodes in frustration. It's so sad. But so right.

It's also like watching a slow train wreck, one of those terrible sins with delayed but sure punishment, like starting to use drugs: first the high of the good life, then the women growing old, missing their fertility window, and slowly watching their family dying off, outliving their men, wallowing in regret, often witnessing the death of their whole community, one family at a time. Two women sit side by side: one fades to winter, hope and love slowly choked by self, while another gives and suffers willingly, thus creating an eternal spring, growing old with her grandchildren hugging her to return the pure, unparsed love love she once gave so willingly.

I repeat: I remain in awe at God's cleverness regarding HV. His Truth on children must be the absolute tops. Hell, as a hard-bitten middle-aged man I nearly tear up thinking about it. It makes me terrified of ever parsing natural law in any form ever again.

ThinkChastity said...

One aspect not discussed in the article is that the birth control pill prevents birth some of the time by preventing implantation, that is, performing an early abortion. I have seen estimates of this being the effective mechanism range from 10 to 40 percent of the time for various pills. This mechanism is an established fact and is frequently described in the insert paperwork under clinical pharmacology. As a result, I could not see using the pill to treat an illness unless the patient was refraining from sexual activity.

The Social Pathologist said...

@ThinkChastity.

Previous post dispels those thoughts.

Anthony said...

Duration of effect is a consideration in judging proportionality. If a woman who is taking birth control pills for endometriosis (or other conditions) wants to restore her fertility, she can, merely by ceasing to take the pill. Since the suppression of her fertility is temporary and reversible, the harm of suppressing fertility isn't that great, compared to the benefit. Especially if by temporarily suppressing her fertility one is preserving or enhancing it for the future.

The Social Pathologist said...

@Anthony

Thanks for your comment.

The church teaches the directly suppressing fertility is an intrinsic evil, therefore direct suppression of fertility is not permitted. Indirect suppression is accepted as a unintended consequence of treatment.

The question is how do you "weight," in calculations of proportion, the evil of suppression of fertility? It may be easy in the case of endometriosis, but what about acne, or mood disturbance or menorrhagia? It's not easy.

The Devil is in the detail.