BY: RONALD P. HAMEL, PhD, and MICHAEL R. PANICOLA, PhD
Dr. Hamel is senior director, ethics, the Catholic Health Association,
St. Louis. Dr. Panicola is corporate vice president, ethics, SSM Health
Care, St. Louis.
Sexual assault is an egregiously violent act that inflicts
unspeakable trauma upon the person assaulted. This trauma is
exacerbated for women, particularly those of reproductive age,
who may become pregnant as a result of the assault. In the face
of such violence and because of their fundamental commitments,
Catholic health care providers should offer compassionate and
understanding care focused on the person's physiological, psychosocial,
and spiritual well-being; collect forensic evidence for police
support and possible identification of the assailant; and, when
the person is a woman, provide every moral means of preventing
conception from this unjust attack for which she is in no way
responsible. Although it is never permissible for Catholic health
care providers to terminate an established pregnancy or administer
medications that "have as their purpose or direct effect the
removal, destruction, or interference with the implantation
of the fertilized ovum," Catholic teaching allows for the administration
of emergency contraception* within certain moral limits. Measures
taken to prevent conception in such cases fall outside the general
prohibition against contraception because the assailant's act
is a violation of justice, and any semen within the woman's
body is considered a continuation of the unjust aggression against
which she may licitly defend herself.1 Directive
36 of the Ethical and Religious Directives for Catholic Health
Care Services (ERDs) supports this position and provides
further guidance on the matter:
(* For purposes of this article, "emergency contraception" refers to the
Yuzpe regimen containing ethinyl estradiol plus a progestin and progestin-only
regimen containing levonorgestrel. Some authors include mifepristone, which
is a progesterone antagonist and known abortifacient, in their definitions
of "emergency contraception." All data presented on emergency contraception
refer to the former regimens and not mifepristone, which is actually unavailable
at this time to women in the United States for emergency contraception.)
A female who has been raped should be able to defend herself
against a potential conception from the sexual assault. If,
after appropriate testing, there is no evidence that conception
has occurred already, she may be treated with medications
that would prevent ovulation, sperm capacitation, or fertilization.2
Though the directive specifies when and for what purposes
emergency contraceptive medications can be administered, it
does not spell out precisely what constitutes "appropriate testing"
and "evidence that conception has occurred." Consequently, some
variability exists among Catholic health care providers (as
well as ethicists and theologians) as to how these phrases are
interpreted.3 Two general approaches to treating
women who have been sexually assaulted have thus emerged in
Catholic health care. The first might be referred to as the
"ovulation approach" and the second as the "pregnancy approach."
The ovulation approach seems to be gaining ascendancy within some Catholic
circles, where it is sometimes heralded as the only morally acceptable approach
for Catholic health care providers, short of directly transferring the woman
to another facility or doing nothing at all. Evidence of this can be found in
the positions taken by some bishops and theologians in support of the ovulation
approach as well as in the increasing number of Catholic hospitals espousing
some version of the approach. This article calls into question the belief that
the ovulation approach is the preferable or only permissible moral approach
to preventing conception in women who have been sexually assaulted. It argues
instead that the pregnancy approach is morally justified and shows how this
approach is in keeping with the Catholic moral tradition as well as reflective
of the scientific literature and what is considered by most clinicians to be
good medical practice.
This article is divided into three sections. The first describes
the general tenets of the ovulation approach and illustrates
how it is applied in what has become known as "the Peoria Protocol."
The second identifies concerns with the ovulation approach.
The third provides the moral grounding or justification for
the pregnancy approach. We limit our examination to the ovulation
and pregnancy approaches, recognizing the existence of another
school of thought, which claims that emergency contraception
maynever be administered to women who have been sexually assaulted,
regardless of where they are in their menstrual cycle, for fear
of harming a conceptus. Because that third approach does not
fall within the reasoning and spirit of Catholic teaching and
Directive 36, we do not address it in this article.
The Ovulation Approach
The ovulation approach tests for a pre-existing pregnancy (i.e.,
a pregnancy that existed before the sexual assault) and assesses
whether the woman is at or near the time of ovulation in order
to determine the possibility of conception resulting from the
sexual assault. Typically, this is done by inquiring about the
woman's menstrual history and/or administering one or more tests
to screen for ovulation. The underlying rationale is that a
pregnancy test will not be positive from a recent sexual assault
and, as such, ovulation is the only clinical indicator capable
of providing evidence that the conditions are such that conception
could occur. Under this approach, emergency contraceptive medications
are offered to the woman if her pregnancy test is negative and
personal and/or empirical data indicate she is not at or
near the time of ovulation. This approach seeks a high degree
of certainty that the medications will prevent conception only
by inhibiting ovulation. If the woman is about to ovulate or
has ovulated recently, contraceptive medications are not
offered because it is presumed they may (or can only) have
an abortifacient effect.* In other words, if the woman is at
a point in her cycle where the medications "would not be effective
in preventing ovulation," then they would not be administered
because "given the slight chance that conception could have
occurred, a possibly abortifacient result might follow."4
* We use the phrase "may (or can only)" because some proponents of the ovulation
approach believe that emergency contraception may have an abortifacient
effect, whereas others believe that when administered after ovulation, these
medications can only have an abortifacient effect.
The popular version of the ovulation approach is known as
the Peoria Protocol, which was first developed in 1995 at Saint
Francis Medical Center in Peoria, IL. Like other versions of
this approach, the Peoria Protocol rests on the premise that
the occurrence of ovulation suggests conception may have
taken place, and that this possibility is sufficient to cause
caregivers to refrain from offering emergency contraception,
which may (or can only) have an abortifacient effect if administered
after ovulation. Where the Peoria Protocol goes further than
other versions of the ovulation approach is in the assessment
of ovulation. In addition to testing for a pre-existing pregnancy
unrelated to the recent assault and asking the woman about her
menstrual history to ascertain where she is in her cycle, the
Peoria Protocol also requires caregivers to conduct (1) a urine
dip-stick test to determine luteinizing hormone (LH) surge,
which is believed to be a reliable guide to the prediction of
ovulation; and (2) a blood test to determine the woman's progesterone
level, which is another indicator of ovulation and helps to
categorize the timing of the woman's ovulatory cycle. Depending
on the results of these tests, the Peoria Protocol directs different
courses of action5:
- If the woman who has been sexually assaulted is determined
to be in the pre-ovulatory phase of her cycle, emergency
contraception may be administered if her menstrual
history and findings of a physical exam are consistent with
the pre-ovulatory phase, the LH urine test is negative, and
the woman's progesterone level is less than 1.5 ng/mL. In
this situation, the first dose of the emergency contraceptive
should be given immediately and the second dose 12 hours later.
If the first dose is not administered immediately, the risk
that the medication could have an abortifacient effect increases.
- On the other hand, the woman is determined to be in her
midcycle LH surge phase or her early post-ovulatory
phase if her LH urine test is positive or her LH urine
test is negative but her progesterone level is greater
than or equal to 1.5 ng/ml or less than or equal to 5.9 ng/mland
her menstrual history is consistent with midcycle and
early post-ovulatory phases (menstruation is expected in more
than seven days). In these situations, emergency contraception
should not be given.
- The woman is determined to be past the early post-ovulatory
phase of her cycle if the LH urine test is negative and
her progesterone level is greater than or equal to 6 ng/ml
In this situation, the timing of the sexual assault could
not have coincided with the presence of an ovum. Hence, it
is morally permissible to administer an emergency contraceptive
for the victim's psychological benefit.
- Finally, the woman is determined to be in the late post-ovulatory
phase if the LH urine test is negative, her progesterone
level is less than 6 ng/ml, and she anticipates menstruation
in less than seven days. Here, too, it is morally permissible
to administer a contraceptive medication.
Concerns with the Ovulation Approach
The merit of the ovulation approach is that it seeks to prevent conception
resulting from a sexual assault while at the same time seeking to prevent the
destruction of human life if conception has already occurred. Despite the considerable
merit of this approach, we find several aspects of the approach to be of concern
and, when taken as a whole, these concerns suggest to us that the pregnancy
approach might be morally and practically preferable.
The first concern is that the ovulation approach limits Directive 36. Nowhere
in the directive does it state that Catholic health care providers must refrain
from administering emergency contraception to women who are about to ovulate
or who have ovulated recently. In fact, Directive 36 explicitly affirms that
medications can be administered to prevent fertilization, which occurs after
ovulation. By limiting the administration of emergency contraception to situations
in which the woman has not yet ovulated or is past the early post-ovulatory
phase of her menstrual cycle, the ovulation approach unnecessarily restricts
the moral options available to women who are at or near the time of ovulation
and wish to prevent a potential conception.
In actual fact, the window of opportunity to administer emergency contraceptive
medications is physically or biologically wider than the ovulation approach
seems to acknowledge. Conception does not occur immediately after the ovum is
expelled from the ovary; it can only be achieved after fertilization is complete.
This is important if one recalls that fertilization is not a moment but rather
a process that unfolds over at least a 24-hour period, with the possible
result being a conceptus. Thus, in truly keeping with Directive 36, emergency
contraception could always be administered morally to women who have been sexually
assaulted, even if they are near ovulation or have ovulated recently, as long
as they come to the emergency department within at least 24 hours of ovulating.
In such a scenario, the medications would act by way of preventing fertilization
from ultimately occurring — which is permissible according to the directive — not
by destroying a conceptus because fertilization could not possibly have been
completed, if indeed it had actually begun. Proponents of the ovulation approach,
however, do not concur because they assume that contraceptive medications may
(or can only) have an abortifacient effect if given immediately before or after
ovulation has occurred. We will address this assumption below.
The second concern is that the ovulation approach gives too
much weight to ovulation in setting the moral limits of treatment.
Ovulation does not provide evidence that conception has occurred
but only that it may occur. Yet even this may be overstating
the matter. A well-known study on the relationship between the
timing of intercourse and ovulation that involved 221 healthy
women trying to conceive demonstrated that "[e]ven with daily
intercourse, most ovulatory menstrual cycles (an estimated 63
percent in our study) may be incapable of producing a conception."6
Coupled with the fact that the rape-related pregnancy rate is
approximately less than 1 percent to 5 percent,7
the results of this study indicate it is highly improbable that
emergency contraception would contribute to the demise of a
conceptus, even if the woman had ovulated recently and the medications
had an abortifacient effect. This consideration is not meant
in any way to diminish the seriousness of the loss of even one
conceptus, should that occur. It is simply meant to underscore
the improbability of that occurring. Furthermore, it must be
considered in conjunction with the next concern.
The third concern is that the ovulation approach leans too
heavily on the presumption that emergency contraception acts
in some instances (or only) as an abortifacient once ovulation
has occurred by inhibiting implantation or interrupting an early
pregnancy after implantation. Although it is possible
that emergency contraceptive medications may cause histologic
changes in the endometrium that inhibit the implantation of
a conceptus or have a post-implantation effect, conclusive evidence
supporting this position has not surfaced.8 Even
studies hypothesizing that emergency contraception acts as an
abortifacient have difficulty finding definitive evidence to
substantiate this hypothesis and thus ultimately proffer tentative
conclusions about post-fertilization effects.9 Of
interest is a recent review article by Anna Glasier in which
she reports that "the group with the greatest expertise and
track record in research on the endometrium was unable to demonstrate
any effect which might be associated with the inhibition
of implantation."10 The fact is, the scientific literature
suggests that emergency contraceptive medications act primarily
by inhibiting ovulation or disrupting fertilization and have
only relatively minor and secondary, if any, post-fertilization
effects. Rivera and colleagues11 describe this well:
[E]ven though the precise mechanism of action of modern contraceptives is
not yet fully known, scientific evidence suggests the main mechanism of action
for each method. Inhibition of ovulation and effects on the cervical mucus
are the primary mechanisms of the contraceptive action of hormonal methods.
. . . All these methods, directly or indirectly, have effects on the endometrium
that might prevent implantation of a fertilized ovum. However, so far, no
scientific evidence has been published supporting this possibility. No scientific
evidence supports an abortifacient effect.
That emergency contraception prevents conception and is most
likely not abortifacient is also supported by recent studies
showing that the medications are "most effective when administered
within 24 hours of unprotected sex" and decrease in effectiveness
substantially and progressively when "administered in the 24-48
hour and 48-72 hour intervals."12 As Croxatto et
al point out, "this fact alone does not allow for discriminating
between possible modes of action, [however] it does lend support
to a significant role of pre-fertilization mechanisms
in their contraceptive effectiveness."13 If emergency
contraceptive medications truly had post-fertilization effects,
then "the same level of effectiveness "should continue beyond
24 hours, possibly even until implantation is established."14
The fact that emergency contraception is most efficacious early
on before fertilization could possibly be completed, if indeed
it had actually started, suggests that the medications act primarily
by suppressing ovulation or disrupting fertilization and have
only relatively minor and secondary, if any, post-fertilization
effects.
The fourth concern is that the ovulation approach, especially more rigorous
versions such as the Peoria Protocol, seems to seek a degree of certainty more
akin to absolute rather than to moral (no reasonable fear of error). It does
so by insisting that emergency contraceptive medications cannot be administered
if the woman is about to ovulate or has ovulated recently because conception
is then a possibility and the medications would not be capable of inhibiting
ovulation but instead might harm or destroy a conceptus. However, the risk that
a conceptus will be destroyed seems to be extremely small, if it exists at all,
given the facts that most ovulatory menstrual cycles do not result in conception,
that the rape-related pregnancy rate is extremely small, and that emergency
contraception most likely acts by preventing conception, not inhibiting implantation.
Even this small or nonexistent risk, however, seems to be too great for proponents
of the ovulation approach. We shall return to the matter of moral certainty
and risk later.
The final concern is that proponents of the ovulation approach do not accurately
characterize the moral object when contraceptive medications are administered
either immediately before or after ovulation has occurred. They view the moral
object in such circumstances as the destruction of a conceptus (in other words,
the act is viewed morally as an abortion) because they presume that emergency
contraceptive medications may (or can only) have an abortifacient effect if
administered at these times. However, as previously noted, the evidence does
not seem to support this assumption.
The Pregnancy Approach and Its Moral Justification
Given these concerns with the ovulation approach, we believe that it is not
the preferable or only permissible moral approach to treating women who have
been sexually assaulted. Rather, we find the pregnancy approach to be both morally
permissible as well as morally preferable. As the name suggests, the pregnancy
approach tests only for a pre-existing pregnancy. The underlying rationale is
that no tests presently available or personal information supplied by the woman
can provide evidence of conception from a recent sexual assault, and this being
the case, the most that can be done is to rule out a prior pregnancy unrelated
to the recent assault. Under this approach, emergency contraceptive medications
are offered to the woman if her pregnancy test is negative.
We believe the pregnancy approach is morally justified for several reasons
when taken together as a whole. First, prior pregnancy is always ruled out,
and once this occurs, nothing is done that would directly harm a developing
embryo or terminate a pre-existing pregnancy. This is assuming, of course, that
emergency contraception actually has a teratogenic or abortifacient effect on
a developing embryo or fetus, neither of which has ever been proven convincingly.
Second, once a prior pregnancy is ruled out, moral certainty exists sufficient
to justify administering emergency contraceptive medications to the woman upon
her request, even if she has ovulated recently. This moral certainty is rooted
in a constellation of factors that coalesce to support this action. First, the
risk of pregnancy resulting from a sexual assault is very small (less than 1
percent to 5 percent). Second, the scientific literature indicates that emergency
contraceptive medications most likely act by preventing ovulation or fertilization
and do not have post-fertilization effects sufficient to prevent implantation.
Third, given these two considerations, the probable direct effect (or moral
object) of administering the medications is prevention of a conception from
an act of unjust sexual aggression rather than bringing about the demise of
a conceptus.* Fourth, the intention in administering emergency contraception
is to prevent conception and not to inhibit implantation. If a conceptus is
present, but fails to be implanted and ultimately is destroyed, this would be
an unintended and even an unforeseen effect, given the extremely low likelihood
of conception occurring as a result of the sexual assault and the lack of evidence
supporting abortifacient effects of the medications. Finally, a proportionate
reason exists for administering emergency contraceptive medications, namely,
the prevention of pregnancy resulting from the sexual assault and its subsequent
impact on the overall well-being of the woman.
* It may seem as though we are invoking the principle of double effect here.
However, we are not convinced that the principle applies in its classic form
because the action of administering emergency contraception to women who have
been sexually assaulted does not really have a "double" effect — one good and
intended (prevention of conception) and the other bad and foreseen but unintended
(inhibition of implantation). First, no evidence to date definitively supports
the claim that emergency contraceptive medications in fact produce the unwanted
effect, so it is not certain that a bad effect actually results from the action.
Second, even if the administration of the medications results in a bad effect,
this obviously cannot occur at the same time as the good effect. Either the
medications will work as a contraceptive or as an abortifacient but
not as both. For a further discussion of the appropriateness of the principle
of double effect to this situation, see Cataldo and Moraczewski, p. 11/14.
Some might argue that the tradition requires taking the safer,
even tutioristic, course in situations of doubt when a value
of great importance (e.g., innocent human life) is at stake.
In such situations, not even a slight risk can be taken that
might lead to undermining the value. One of the examples frequently
offered to make the point is the hunter in the woods. A hunter
is in the forest and notices movement behind a bush. However,
the hunter is unsure whether what is behind the bush is a deer
or a human being, possibly another hunter. In the face of this
doubt, may the hunter shoot? The tradition answers in the negative.
The hunter must first resolve the doubt and, if this is not
possible, refrain from shooting.
Like Cataldo and Moraczewski,15 we do not believe
that the example is applicable in the case of sexual assault.
In this classic example, the doubt is about the nature of what
is behind the bush (a deer or a human). There is definitely
something behind the bush; the hunter is simply not sure what
it is. In the case of sexual assault, however, the doubt is
about whether there is anything (i.e., a conceptus) there at
all. And the probability is that there is not. Furthermore (and
here we go beyond Cataldo and Moraczewski), in the example,
the hunter's intention is presumably to kill what is behind
the bush and the assumption is that the shot will be lethal.
Neither of these conditions applies to administering emergency
contraception in cases of sexual assault. As we have already
noted, the intention is certainly not to destroy a conceptus,
and it is unlikely that contraceptive medications have an abortifacient
effect.
One final point should be made here. The Catholic tradition does not insist
on the "safest" course even when actual human life is at stake, let alone
when the presence of human life is seriously doubtful, as in the case of sexual
assault. For example, the tradition permits the administration of opioid analgesics
for patients in severe pain even though the possibility exists this action might
hasten or even cause the patient's death. The tradition also justifies bombing
military targets even when the possibility exists or it is likely that civilians
will be killed in the attacks. From these examples, it is clear that the tradition
is willing to allow certain actions that may result indirectly in the loss of
human life for a proportionate reason. It would seem to follow that the tradition
would also be willing to permit the administration of emergency contraceptive
medications, which have not been proven to be destructive, when the fact of
conception is so seriously in doubt. Although the destruction of a conceptus
cannot be absolutely ruled out, it is highly unlikely to occur as best we can
determine given the current state of medical knowledge. If it should occur,
as we have previously stated, it would be an unintended and even an unforeseen
tragic consequence.
For all these reasons taken together, we believe that the pregnancy approach
is morally justifiable. We also believe that it is morally preferable for two
reasons. First, Directive 36 is contained in the professional-patient relationship
section of the ERDs and not in the beginning of life section. This suggests
that treating a woman who has been sexually assaulted is primarily an issue
of caring for a vulnerable patient in the context of the therapeutic relationship,
allowing for some degree of discretion on the part of the professional and patient
within moral limits. The decision about whether to use emergency contraception
is one that is rightly made between the woman and her physician, taking into
account medically and morally significant considerations. Some women will choose
to accept emergency contraception solely on the basis of the exclusion of a
prior pregnancy. Others may prefer a "safer" course. However, routinely subjecting
the victim of sexual assault to added testing for ovulation, delays in treatment,
and increased anxiety, especially when the most the tests can offer is verification
that conception is a remote possibility, seems to add to the woman's trauma
and humiliation and to impose an unnecessary burden upon her. Turning away a
woman who has been so traumatized and victimized on the basis that she is likely
to ovulate soon or has ovulated recently and on the unproven assumption that
emergency contraceptive medications are abortifacient only seems to add further
to the harm already done her.
Second, implementing versions of the ovulation approach that require screening
for ovulation (such as the Peoria Protocol) places an added burden on some Catholic
hospitals and an excessive burden on others. This approach requires having ovulation
screening kits on hand, health professionals available who are trained in administering
the test, laboratory technicians on call at all times to interpret the tests,
or easy access to an external lab. The consequences of adhering to this type
of protocol could lead Catholic hospitals to forgo providing care to women who
have been sexually assaulted because of the expense and/or the practical difficulty
or impossibility of fulfilling the requirements of the protocol.
The pregnancy approach is responsive to the needs of the woman who has suffered
untold trauma from being sexually assaulted and is consistent with the Catholic
moral tradition generally and Catholic teaching on this matter particularly.
Among other reasons, the improbability that the woman has conceived as a result
of the assault and the unlikely abortifacient effects of emergency contraception
provide moral certainty sufficient to justify the administration of the medications,
even if the woman is about to ovulate or has ovulated recently. In these tragic
situations, Catholic health care providers have a unique opportunity to reveal
God's healing presence by responding with compassion and sensitivity to the
vulnerable woman in need of care. We believe the best way to do this is by using
the pregnancy approach, which allows Catholic health care providers to stay
true to fundamental values while at the same time showing profound concern for
the woman.
NOTES
- For a discussion of the theological justification of preventing
conception in cases of sexual assault, see Edwin F. Healy,
Medical Ethics, Loyola University Press, Chicago, 1956,
pp. 275-78.
- United States Conference of Catholic Bishops, The Ethical
and Religious Directives for Catholic Health Care Services,
4th ed., USCCB, Washington, DC, 2001, p. 21.
- See, for instance, Steven S. Smugar, Bernadette J. Spina,
and Jon F. Merz, "Informed Consent for Emergency Contraception:
Variability in Hospital Care of Rape Victims," American
Journal of Public Health, vol. 90, September 2000, pp.
1372-76.
- Joseph J. Piccione, "Rape and the Peoria Protocol," Ethics
and Medics, vol. 22, September 1997, p. 2.
- St. Francis Medical Center, Interim Protocol, Sexual
Assault: Contraceptive Treatment Component, Peoria, IL,
October, 1995.
- Allen J. Wilcox, Clarice R. Weinberg, and Donna D. Baird,
"Timing of Sexual Intercourse in Relation to Ovulation — Effects
on the Probability of Conception, Survival of the Pregnancy,
and the Sex of the Baby," New England Journal of Medicine,
vol. 333, no. 7, December 1995, p. 1520.
- Melisa M. Holmes, Heidi S. Resnick, Dean G. Kilpatrick,
and Connie L. Best, "Rape-Related Pregnancy: Estimates and
Descriptive Characteristics from a National Sample of Women,"
American Journal of Obstetrics and Gynecology, vol.
175, August 1996, p. 320. Interestingly, proponents of the
ovulation approach contend that the rape-related pregnancy
rate may be lower than studies suggest because the studies
tend to rely on data from the general population rather than
on data generated from women who have been sexually assaulted.
Were the latter group of women studied, the thinking is the
rape-related pregnancy rate would be lower because sexual
offenders experience a high degree of sexual dysfunction and
many women who are assaulted are not at risk of pregnancy
because they are taking contraceptive medications, have been
sterilized, or are not of reproductive age. For further discussion
on this point, see Eugene F. Diamond, "Ovral in Rape Protocols,"
Ethics & Medics,vol. 21, October 1996, p. 2; and
Julie A. Mickelson, "Pregnancy Prevention After Sexual Assault,"
in Catholic Health Care Ethics: A Manual for Ethics Committees
Peter J. Cataldo and Albert S. Moraczewski, editors, National
Catholic Bioethics Center, Boston, 2001, p. 11/10.
- Anna Glasier, "Drug Therapy: Emergency Postcoital Contraception,"
New England Journal of Medicine, vol. 337, October
9, 1997, p. 1060. See also Horacio B. Croxatto, Luigi Devoto,
Marta Durand, et al, "Mechanism of Action or Hormonal Preparations
Used for Emergency Contraception: A Review of the Literature,"
Contraception, vol. 63, 2001, p. 117, and Melissa Sanders
Wanner and Rachel L. Couchenour, "Hormonal Emergency Contraception,"
Pharmacotherapy, vol. 22, 2002, p. 44.
- See, for instance, Walter L. Larimore and Joseph B. Sanford,
"Post-Fertilization Effects of Oral Contraceptives and Their
Relationship to Informed Consent," Archives of Family Medicine,
vol. 9, February 2000, pp. 126-133.
- Anna Glasier, "Emergency Contraception," British Medical
Bulletin, vol. 56, 2000, pp. 733-734. Emphasis added.
- See Roberto Rivera, Irene Yacobson, and David Grimes, "The
Mechanism of Action of Hormonal Contraceptives and Intrauterine
Contraceptive Devices," American Journal of Obstetrics
and Gynecology, vol. 181, November 1999, p. 1267. See
also Peter J. Cataldo and Albert Moraczewski, who note that
"the chance of an abortifacient effect in a sexual assault
survivor should be 1.2% or less (even less under the restrictions
of the St. Francis Medical Center Protocol)," in "A Moral
Analysis of Pregnancy Prevention after Sexual Assault," Catholic
Health Care Ethics: A Manual for Ethics Committees, Peter
J. Cataldo and Albert S. Moraczewski, editors, National Catholic
Bioethics Center, Boston, 2001, p. 11/14.
- Rivera, Yacobson, and Grimes, p. 1266.
- Croxatto, p. 117
- Rivera, Yacobson, and Grimes, p. 1266.
- Cataldo and Moraczewski, p. 11/16.
The authors of this article and the editorial staff of Health
Progress invite readers to continue this important discussion
of emergency contraception in the case of sexual assault. We
welcome response to this moral analysis in the form of Letters
to the Editor. Send them to HP Editor
or:
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