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!)

Human Shields.

I think that many of the moral problems that confound the average person have at their core a confusion between innocence and in culpability. Inculpability is not innocence; one can do wrong and not be deserving of punishment for it.

For there to be culpability there must be an evil act of the will(intent) or evil act; that is, a person's deserts are dependent on their acts An evil act in the absence of an evil will may render that person inculpable of desert evens though not innocent of the act. When we say a person "meant well", it usually means that they did something wrong but that their intent was good. In many cases it is as defence for actions which in themselves were deserving of punishment.

Consider a human shield. How do we evaluate the actions of a such a person even though they may be involuntary? Clearly a human shield is shielding a combatant, the human shield is performing a function even though it may not have been deliberately chosen. In the case of a terrorist advancing behind a human shield, the shield is "protecting" the terrorist and hence is complicit in evil albeit involuntarily. The shield is not innocent, it is inculpable. Armchair moralists please take note.

Now suppose a person is being coerced into an action which is morally wrong, what is the right course of action to take, given that failing to take that action will cost them their life? Traditional moralists have argued that we must not do wrong even at the expense of our careers or our life, we must love the good more than we love life. The proper action of a person finding himself as a human shield is to oppose being one, even if it costs them their life. Now I'm not saying that this is what I would have the courage to do, rather it is what should be done.

From the point of view of the person defending themselves from an attacker hiding behind a human shield, it would appear to be morally permissible to defend oneself from the attacker even though it may injure the human shield. In fact it would appear to be justified to directly attack the human shield in order to get to the attacker. The shield is an involuntary accomplice.
The problem of course is that in attacking the shield, we may be inflicting grievous injury on one that is undeserving and that in itself is an evil.

In choosing the correct course of action we must return back to the principles of double effect. Namely :
1) That our action(defence) is just.
2) That on balance the action will result in more good than evil.

Number (2) of course is the fly in the ointment as it is a prudential judgement and hence open to a wide variety of opinion. Sometimes there are no clear answers and we have to make the best of a bad choice in the fog of war.

The innocence of evil.

Several months ago there was a case over here which raised profoundly disturbing questions.

A local convenience store attendant was attacked by a knife wielding schizophrenic. The attacker was in a psychotic state and proceeded to grab the man in a headlock, soon a hostage type of situation ensued. Local bystanders called the police who arrived quickly. Upon their arrival the attacker became more agitated and started to stab the attendant in the neck, the police yelled at him to stop, which he did not do. At risk to themselves from the knife and under pressure to act immediately, the police shot the schizophrenic man who died at the scene. The attendant survived.

How does one morally evaluate the actions of the policemen and the schizophrenic man?

The schizophrenic man was clearly causing evil, He was actuating it. If innocence or guilt refers to responsibility of causation, then the man was guilty. But clearly the man's mind was diseased, so doesn't it offend reason to say that this poor fellow was as guilty of evil in the same sense that a murderer is? Many people would say that the schizophrenic man was an innocent victim. I would disagree.

Traditional morality would have separated guilt from desert. That is, it recognised that a person may not have been totally free to choose the action taken. Traditional moralists would have argued that while the person was guilty of evil he was inculpable. While he did cause harm, he did not know what he was doing, and therefore this person did not deserve to be shot. Causing death to an undeserving man is evil.

The police on the the other hand had an obligation to protect the life of the service station attendant and their own with the practical means available. They were trying to stop the schizophrenic man from stabbing the attendant, their intent was good. Furthermore one is morally justified in using deadly force if the circumstances permit. This was such a circumstance so the actions the police took were morally justifiable. The police performed a good moral action which had a double effect. It saved the life of an innocent service station attendant while it caused the death of an inculpable schizophrenic.

The bottom line is that situations can arise in which we are forced to do good, but that good may result in evil effects to undeserving people. More on this in the next post.

Blessed are the Engineers.

Not many people know who this man is.


His name is David Salonimer, an engineer who worked at the U.S army's Redstone proving ground. He is the father of the modern laser guided bomb. You have probably never heard of him.

His idea, with the collaboration of others has probably done more to reduce human suffering in warfare than any of the peace treaties or political gestures at disarmament since the Second World War. By improving the accuracy of weapons by several orders of magnitude he has spared countless people from becoming collateral damage. He has also probably spared many soldiers and airmen from death and massively increased the military power of his country. In this age of military barbarism he has probably done the most to lessen the miseries of war.

Part of the reason that that area bombing was implemented was because the accuracy of bombing was so low that an inordinate number of large high explosive bombs had to be dropped on a target in order to achieve a probable hit. Given that pinpoint precision is now a real ability of armed forces, military forces have now begun to use the weapon of David, albeit in a smart form. The smart rock.

This guy is an all out legend, yet no one knows of him. As far as I understand it he has won a few engineering awards but that is it. Al Gore gets to win the Nobel peace prize for being an environmental windbag while the man who actually save lives gets passed over. I personally feel he comes second to Henry Dunant in reducing the suffering in war. The world honours its sinners and passes over its saints.