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ss triple helix - autumn 1999,  Postcoital contraception

Postcoital contraception

GP registrar Mandi Fry shares some of John Holden's concerns but takes a different line in practice

The rate of unwanted teenage pregnancies in the UK is one of the highest in Europe at 8.2 per 1000, and one of the 'Health of the Nation' targets is to decrease this by 50% by the year 2000[1]. Effective contraceptive services are one way in which the government is seeking to achieve this[2], hence the increased focus on the availability of postcoital, or 'emergency', contraception. However, as pointed out by John Holden in the last issue of Triple Helix[3], prescribing postcoital contraception is not without its own ethical considerations.

The sanctity of life argument

Even non-Christians tend to agree that the taking of another human life is wrong and the Bible could not be more clear cut on the issue[4]. However when it comes to abortion, arguments begin to centre upon the definition of when life actually begins. Opinions vary from fertilisation to implantation, to viability, or even to birth itself. Each viewpoint has biblical and ethical frameworks to back it up.

The mode of action of emergency contraception by the Yuzpe (or 'morning after pill') method depends upon its timing in relation to ovulation. Used relatively early in the cycle it may prevent or postpone ovulation, and it also renders the genital tract mucus and uterine fluid hostile to the sperm or blastocyst. Used later in the cycle however, its method relies primarily upon blocking implantation[5]. Consequently for those individuals who see fertilisation as the commencement of life it could indeed be considered abortifacient, despite the Faculty of Family Planning's clear statement to the contrary in its guide-lines on emergency contraception[6].

However, if the Yuzpe method is abortifacient then so is the intra-uterine contraceptive device (even when not inserted as emergency contraception) and so, more controversially, is the progestogen-only pill. Both these methods involve an effect on implantation[5], although it is not their primary mode of action, and so logically should not be endorsed by those ethically opposed to postcoital contraception on the grounds of abortion.

Personally I subscribe to John Guillebaud's view[5] of conception as a continuum, commencing with fusion of sperm and ovum but not complete until successful implantation. I admit that, to an extent, this is a pragmatic view which neatly sidesteps some of the issues, but I cannot sustain a position that sees God himself effectively throwing away life when you consider how many unimplanted embryos are lost each month.

The Christian ideal of marriage

Emergency contraception in general is used primarily by those outside a loving, mutually supportive relationship. The majority of requests that I have received have been from teenagers or women involved in extramarital affairs. (There are of course exceptions, such as sexual assault, but these come with their own host of ethical dilemmas and I do not propose to consider them further here.)

The biblical ideal is of one man and one woman, committed to one another for life in matrimony[7]. Society's accepted norm is one of serial monogamy. As Christian healthcare professionals we have an obligation towards educating the public as to the meaning of sex, not as a throwaway gift but as an important, self sacrificing act of love. Even those non-Christian patients who do not uphold biblical principles in this or other aspects of their lives can be encouraged to think about the consequences of their actions.

Some may even go so far as to withhold contraception from the unmarried and whilst I do not endorse this viewpoint personally, I do try to encourage some degree of sexual morality from my patients.

The role of the health professional - advance prescriptions and OTC sales

Recently the British Pregnancy Advisory Service has advocated the prescription of PC4 (the hormone combination) in advance, particularly over the millennium period, in light of the fact that its efficacy is related to the duration of time elapsed since the act of unprotected intercourse[8]. In general this idea has received positive media coverage[9] but raises some interesting questions. For example, can an 'emergency' be foreseen? And if so, should we not be promoting alternative, more efficacious contraceptives particularly if, as seems likely, there may well be several acts of intercourse within the same menstrual cycle? Also the prescription of medication for an event which may happen does not fail within a GP's terms of service[10] (like ciprofloxacin for travellers' diarrhoea), and should thus generate a private prescription. That would naturally incur a charge, perhaps denying access to the very individuals who are most at risk.

Some also see it as the first step towards 'over the counter' sales of emergency contraception as occurs in some other European countries. Certainly PC4 is safer 11 than many of the other medications already available without a prescription in the UK, and OTC sales would certainly solve the availability problem to a large extent. However it would simply shift the ethical and practical considerations (such as potential failure and ongoing contraceptive needs) from one group of healthcare professionals to another; from GPs and other doctors to pharmacists who may not have the time, inclination or training to fulfil this role adequately. It would however be a very public statement of intent from a government publicly committed to reducing the burgeoning teenage pregnancy rate.

Wanting the best - Yuzpe or progestogen-only?

As healthcare professionals and as Christians we should all want the best for our patients. In practice this is often a balance between the most efficacious and the safest treatment options. Where postcoital contraception is concerned there is the added dimension that treatment failure may well, although by no means inevitably, result in abortion of the unwanted pregnancy.

In the UK at present the only licensed hormonal method of post-coital contraception is the Yuzpe regime (Schering PC4). However, there is a growing body of evidence that progestogen-only regimes are more efficacious, and potentially safer, in pre-venting pregnancy[12]. This has led to some doctors prescribing this option, outside of the product licence on an individual basis. This is being done particularly by those involved in dispensing contraceptive services who are able to obtain single dose 750ug levonorgestrel preparations [13]. For the rest of us, explaining to a woman that she must take 50 Microval tablets has often deterred us from offering the most reliable evidence-based treatment. Perhaps therefore we should be involved in campaigning for the licensing of a suitable preparation 14 in order to achieve the best for our patients.

Conclusion

Any Christian who views postcoital contraception as just another prescription, without any thought of the ethical considerations involved, is like an ostrich with their head in the sand. We owe it to our Lord and Saviour to consider carefully the issues involved so that, when challenged by non-Christian colleagues, we can offer a rational, carefully considered response. The beginning of life is just like the end, fraught with moral dilemmas that are best thought of in advance rather than in the emotional heat of the moment with the patient in front of us.

References
  1. The Health of the Nation: a strategy for health in England. Secretary of State for Health. HMSO, London. 1992
  2. Callaghan D. GPs get clearer guidance on cutting teenage pregnancy. Pulse, 26 June 1999
  3. Holden J. Postcoital 'contraception'. Triple Helix, Summer 1999
  4. Exodus 20: 13, Deuteronomy 5: 17, Matthew 5: 21, Romans 13: 9
  5. Guillebaud J. Contraception: Your Questions Answered. Churchill Livingstone. 1993
  6. Kubba A, Wilkinson C. Faculty of Family Planning and Reproductive Health Care. Recommendations for clinical practice: emergency contraception. 1998
  7. Matthew 19: 6, 1 Corinthians 6: 13b-16, Genesis 2: 24
  8. Trussell J, Rodriguez G, Ellerton C. New estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception, 1998; 57: 363-369
  9. Advance prescriptions for emergency Pill welcomed. GP, 16 July 1999
  10. GP Terms of Service: The 'Red Book'
  11. Vasilakis C et al. The risk of venous thromboembolism in users of postcoital contraceptive pills. Contraception, 1999; 59:79-83
  12. World Health Organisation Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. The Lancet, 1998;352: 428-433
  13. Kubba A, Wilkinson C. Faculty of Family Planning and Reproductive Healthcare. Guidance, 3 November 1998
  14. Mashta O. Call for UK launch of OTC contraceptive. Doctor, July 1999
  15. (See also Readers' Letters)
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