DIFFICULT MORAL QUESTIONS
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Question 67: May a physician prescribe contraceptives?
I am a Catholic physician working under contract for a health maintenance organization (HMO) and providing primary care to some patients enrolled in it. Some are Catholic; many are not.
In principle, primary care includes family planning. But I am not expected to fit diaphragms, do sterilizations, or perform abortions; women who want those services can and do go directly to a gynecologist. I offer natural family planning (NFP) to all my patients who need help with birth regulation, and some accept it. But many do not, and they often ask me to prescribe birth control pills. Up to now, I have done so only infrequently and quite reluctantly for non-Catholic patients. Should I be refusing all contraceptive aid except NFP, regardless of the patient’s personal convictions? Does it make a difference if the patient is a Catholic who does not accept the Church’s teaching?
I have gotten different answers from the several priests with whom I have discussed this matter. All said that opinions among theologians vary, and one told me some bishops do not think contraception is wrong. But I realize that theologians and even bishops who disagree with the pope cannot change the Church’s teaching. I would like to forget about the problem, but it continues to worry me.
I have another question, less urgent but related. The pill has certain therapeutic benefits distinct from its contraceptive effect, and these sometimes make it appropriate to prescribe it. As you probably are aware, its primary action is to suppress ovulation, but there is a significant chance of breakthrough ovulation, so that the pill achieves its high rate of effectiveness by acting as an abortifacient perhaps one time in fifty (or more often, depending on which version of the pill is used). Should this secondary action of the pill be taken into account in prescribing it for noncontraceptive purposes?
Finally, in some cases it is hard to decide whether using the pill would be contraceptive. For example, one patient, over forty, has had seven deliveries, five by caesarean section. According to the gynecologist who saw her, this patient’s uterus is not fit for another pregnancy. He said if he were in private practice, he would do a hysterectomy; but the HMO’s policy is to minimize surgery, and so he prescribed the pill. Now, in a case like this, where the pill is used as the alternative to hysterectomy, it seems to be therapeutic. But is it also contraceptive?
Analysis:
The questioner asks three distinct questions, which can be dealt with in reverse order. The third concerns the application of the norm excluding contraception. Though pregnancy avoidance is therapeutic for the patient, the hysterectomy’s purpose would be to sterilize her; so, using the pill as an alternative to hysterectomy is contraceptive. The second concerns the acceptability of side effects. When the pill is used for genuinely therapeutic purposes, the risk that it will act as an abortifacient is an unintended side effect, which perhaps can be rightly accepted, but only if that will be fair to any embryonic individual whose life may be lost. The first concerns formal and material cooperation. Respect for others’ consciences never calls on one to set aside one’s responsibility for one’s own actions. Prescribing the pill as a contraceptive generally is formal cooperation in contraception. In my judgment, even when it is only material and is reluctant, it is wrong.
The reply could be along the following lines:
While I do not doubt your account of what priests told you about varying opinions of theologians and even dissent by some bishops, this conflict and confusion in no way undercut the truth of the Church’s constant and most firm teaching. It remains precisely what it always has been: Contracepting is always gravely evil (see LCL, 506–19, 634–36). Catholics who, like you, wish to be faithful to their commitment to live in the light of the moral truth taught by the Church should follow without compromise that teaching excluding contraception.
Laws, such as the former requirement that Catholics abstain from meat on Friday, do not apply to everyone, but only to people subject to the authority that enacted them. Hence, in dealing with people, one must take into account whether a law applies to them or not. For example, in years gone by it would have been wrong to encourage a Catholic to eat meat on Friday, but one might rightly have encouraged some non-Catholics to do so. By contrast, negative, exceptionless moral norms, such as the norm excluding contraception, identify actions at odds with every person’s human fulfillment, and so apply to everyone, though some people, being ignorant of them, violate them guiltlessly. Thus, the Church’s teaching that contraception is wrong is not a law, binding Catholics only. It is a moral norm, true for all people, though not everyone recognizes its truth.
Respect for others’ consciences can require that one neither prevent them from doing what they believe they should nor urge them to do what they believe they should not, and generally requires that one not coerce them into doing what they believe wrong (see DH 2). But respect for others’ consciences never calls on one to set aside one’s responsibility for one’s own actions. So, in every case you are responsible for your own actions, and you may never do anything you believe wrong. Therefore, in judging what you yourself may and may not do—with respect to contraception and every other moral question—it makes no difference whether your patient is a Catholic whose conscience is formed by the Church’s teaching or someone, Catholic or not, who thinks an action Catholic teaching rejects as immoral would be permissible or even obligatory for himself or herself, or for you.
Someone might object that the preceding paragraph is at odds with the patient’s right to choose among ways of handling medical problems.242 But while physicians always should respect patients’ freedom to choose among possibilities that are both morally acceptable and technically feasible, neither a physician nor a patient who differ in their sincere moral judgments may act contrary to conscience, and neither should expect the other to do so. Refusal to cooperate with patients’ use of contraceptives, therefore, is entirely consistent with a general policy of informing patients about morally acceptable and technically feasible options and respecting their preferences.
Now I shall deal with your three questions, but in reverse order.
Your final question, about prescribing the pill to a woman whose uterus has been severely damaged, actually involves no special problem. In this case, the hysterectomy’s immediate purpose would be to sterilize the woman. One can easily see the point by asking oneself: If the patient were no longer fertile or were not sexually active—for example, if she were now past menopause or a chaste widow—would the gynecologist have considered a hysterectomy or prescribed the pill? Obviously not. So, while an important medical indication makes it reasonable for this woman to avoid any future pregnancy, the intention of the gynecologist in prescribing the pill plainly was to prevent future conception. And even though avoiding pregnancy would serve a therapeutic purpose in this case, using contraception as a means to prevent pregnancy cannot be justified by that good end or any other.
Your second question, about prescribing one of the pills for therapeutic benefits independent of its contraceptive effect, poses a real and special problem that confronts many physicians. If the patient is known to be sterile or does not engage in sexual intercourse, prescribing one of these drugs involves no moral questions other than those raised in prescribing any other medication. But if the patient does engage in sexual intercourse and is reasonably presumed to be fertile, the possibility of unfairness to embryonic individuals who might be killed must be taken into account.
The possible bad side effects that argue against prescribing many drugs in various other cases almost always are far less significant than risk to a third party’s life. So, if a presumably fertile patient engages in intercourse, the reasons for therapeutic use of one of the pills must be serious indeed to warrant it. When the condition being treated is relatively minor or you could use adequate alternative therapy with less serious side effects, prescribing the pill plainly would unfairly risk abortion. In less clear cases, the Golden Rule must be applied carefully, taking fully into account the personhood of the embryonic human individual even at the very earliest stage of his or her life. On this basis, a risk of the abortifacient side effect would be justified if, for example, the therapy would forestall an even greater risk to the mother’s life.
But what about cases falling between these extremes? One rule of thumb might be this: Do not prescribe one of the pills for its therapeutic benefits when you are confident that not prescribing it would not be considered malpractice by omission. Most of your professional colleagues whose judgments constitute the standard of good practice clearly do not share your concern about possible abortifacient effects of prescribing the pill. So, if not prescribing it meets even their standard of practice, it surely should meet yours.
However, their standard plainly is not a sufficient criterion of fairness toward the embryonic persons whose lives are at risk. In cases of persistent and serious pathology, if surgery would be considered an acceptable option by your specialist colleagues, you might recommend that approach.243 Again, you sometimes might be able to prescribe a type of medication that would minimize the potential abortifacient side effect; that very small risk could then be fairly accepted for the sake of significant and highly probable benefits to the woman’s health. Or, if you can estimate the probable time of breakthrough ovulation, you could minimize the risk of abortion with patients who practice NFP by instructing them to abstain during the relevant stretch.
What about a case in which the HMO’s policies and an uncooperative patient leave you with no workable alternative to prescribing the pill as therapy, and with a risk of abortion that you judge, prescinding from consequences to yourself, to be unfair and, therefore, unacceptable? In such a case, you may take into account the likely consequences to yourself—say, of giving up your contract with the HMO or accepting a risk of being sued for malpractice—and reconsider the fairness of accepting the possibly abortifacient side effect. But this will not, by itself, solve the problem. As with other difficult fairness questions, you must consider all the facts from the point of view of every person involved—including, of course, the embryonic individual whose life may be at risk—apply the Golden Rule, and judge as honestly as you can what you may and should do.
As to the first of your three questions: Physicians prescribing the pill for contraception ordinarily thereby advise and direct patients to use it. When they write the prescription, “Take one pill each day . . .,” they normally intend that it be followed. They therefore share, and sometimes even induce, the patient’s choice to contracept. Regardless of patients’ beliefs or opinions, conscientious or not, that is wrong, because a physician is responsible, not only for the patient’s action, but for his or her own. Intending the contraceptive to be used, the physician who realizes that contraception is wrong yet prescribes it not only has the contralife will characteristic of contraception but unjustifiably accepts the abortifacient risk of using any of the contraceptive pills.
You say you prescribe the pill only reluctantly and when asked to do so by a patient. Further, perhaps you urge the patient to reconsider, explain the pill’s bad side effects, including the risk of abortion, point out the advantages of NFP, conduct a careful examination to try to find some medical contraindication ruling out the pill, and so on; and only if the patient persists in her request after all this do you at last give in and write the prescription. Can someone who cooperates only with such reluctance be said in any real sense to intend the contraceptive use of the pill? Yes, just as a victim of blackmail who reluctantly commits treason really does intend to help the enemy. Moreover, in writing the prescription and instructing the patient, even a physician proceeding in that manner ordinarily hopes the patient will use the pill effectively, not encounter side effects that will interfere with doing so, not make mistakes and experience an accidental pregnancy (which might end in abortion), and so on. Such hopes are indications of the contraceptive intention involved in even reluctantly prescribing the pill.
Are there any situations in which a physician could avoid intending the pill’s use as a contraceptive while prescribing it for someone who meant to use it in that way? The answer depends on what is meant by prescribe. Suppose someone who wanted to use the pill as a contraceptive put a gun to a physician’s head and said, “Write a prescription for the pill or I’ll kill you.” Under such a threat, the physician, without intending the contraceptive use, could write the prescription; his or her intention would be to avoid being killed, and the use of the pill and its contraceptive and potentially abortifacient effects could be accepted as a side effect. Moreover, it seems to me that in this case the physician could plausibly and honestly apply the Golden Rule and say: “It is fair enough for me to write this prescription.” Then too, writing it would not be likely to lead the physician to share the contraceptive intention or to tempt others to contracept. In other words, the physician not only could write the prescription without intending the drug’s use but writing it could be justifiable. Yet even in this case a physician not impeded by other responsibilities from laying down his or her life might rightly consider himself or herself called to bear witness to the moral truth about contraception by refusing to write the prescription.
Coercion by less serious threats—for example, the threat of the loss of one’s job with an HMO or one’s share in a group practice—also could bring it about that writing a prescription for a patient who demanded the pill would not involve intending that the drug be used. The patient, having already determined to use the pill as a contraceptive, would regard the prescription she sought, not as a directive, but only as a legally required means of obtaining the pill from a pharmacy. In such a case, the physician, anticipating that the patient would have no trouble obtaining the necessary prescription from some other physician and intending to avoid threatened harms, could write the prescription, regarding it solely as a certificate that no recognized medical indication precluded the patient’s use of the pill. Under these conditions, the physician’s reluctant cooperation would not involve a contralife will.
But can such cooperation be morally acceptable? I think not. In the first place, writing such prescriptions, however reluctantly, is almost certain to be understood by patients and others as approval of the pill’s use. That perception of approval—especially approval by a physician who, like you, usually tries to follow the Church’s teaching—will reinforce the self-deception and rationalization involved in the dissenting opinions you described. By contrast, taking a clear stand and refusing to have anything to do with the pill’s contraceptive use offers a necessary witness and example for patients and other physicians. Second, in the ongoing physician-patient relationship, a physician’s prescribing the pill, together with his or her concern for the patient’s well-being, is all too likely to lead to intending the drug’s effective use. Third, using the pill involves risking the lives of embryonic persons, a risk that becomes a certainty when the pill is used not briefly by a single patient but for long stretches by many. So, unless all the patients would obtain the prescription elsewhere if not from you, prescribing the pill is virtually certain to result in the death of some embryonic persons who otherwise would survive. That side effect, in my judgment, cannot be fairly accepted merely to avoid economic hardship, even of a severe sort. Fourth, and finally, if in the absence of extreme pressure you prescribe drugs without intending their effective use, you cease being a responsible professional and become a mere functionary who makes a living by giving people what they want.
In sum, you should not prescribe the pill as a contraceptive to any of your patients. Insofar as you have been doing that, you should stop at once, and not just try to work out some way of stopping or wait until your contract with the HMO expires, so that you can decide whether to renew it. If the contract does not clearly require you to prescribe contraceptives, you should resist any pressure either to do so or to give up your position. Giving in to such pressure would set a bad example and weaken the position of others who follow the Church’s teaching with upright consciences. If, however, your contract does clearly require you to prescribe contraceptives, that provision does not morally bind you, since nobody has an obligation to keep a promise to do something wrong. Perhaps you will be able to negotiate a contract amendment that will exempt you from prescribing the pill. Still, very likely you will not be able to continue working for the HMO while avoiding doing what you have contracted to do, and so will have to terminate your relationship with it. In that case, unless you have some compelling reason for going quietly, you should object strenuously to the unjust coercion, in the hope that objecting will serve as witness to the truth of the Church’s teaching, a good example to other physicians and patients, and a contribution to the struggle to protect all health care professionals against coercion to participate in contralife activities, beginning with contraception but extending to abortion and euthanasia.
You do not explain why you raise these questions only now, when you already are working under contract with an HMO. Perhaps until recently you were misled about the Church’s teaching concerning contraception or failed to take it seriously, and only now are coming to see and accept its implications for your practice. But if no such development has occurred, you should have considered what the work would involve before contracting to do it. I realize that this advice is of no help to you with your present problems. But you should examine your conscience about what you have done and failed to do until now and, if necessary, make a good confession.
Finally, if doing what you must reduces your income or results in legal problems, regard those unfortunate consequences as a small price to pay for the everlasting life promised Christians who are faithful until death. In rectifying your practice you are joining the small but splendid band of Catholic physicians who courageously and consistently have said no to contraception, sterilization, and abortion. Their witness is especially valuable because it is being given despite theological dissent and clerical confusion. And it is a witness to the truth about not only the good of human life and the sins against it but the heavenly kingdom. People without hope do not willingly accept so much loss and suffering.