Pharmaceutical Morality

Just off the phone with your doctor, you head straight for the pharmacy to pick up a dose of the not so felicitously named “morning after” pill. (Better: “Emergency Contraceptive Pills.”) Within earshot of just about everybody in the store, you are told that your new pharmacist’s conscience prohibits him from honoring your physician’s request.

Since the morning after pill has a 72-hour window of effectiveness, at most, what do you do now? Throw a fit? Leave the store with a paper bag over your head? Call your doctor in a panic and ask him to ring up another pharmacy? Confess to your minister what you and your partner been doing all this time in secret?

This particular pharmacist’s dubious moral stance rests upon the medically disputed notion that ECPs cause the uterus to contract and expel an implanted egg after the fashion of the abortion pill Mifeprex (also known as RU 486.) What makes his position dubious is that ECPs act only to delay ovulation and fertilization, or to block the implantation of a fertilized egg in the wall of the uterus. Since, according to the American College of Obstetricians and Gynecologists, a woman is considered pregnant only after implantation (the conceptus cannot develop and thrive without it), blocking the implantation serves only the purpose of contraception, not of abortion.

What went wrong at your pharmacy, therefore, is that on private moral grounds, your pharmacist made a medical decision (not to fill your prescription) that runs counter to prevailing medical opinion. There is nothing heroic about this action. Pharmacists have no business deciding moral issues for their customers in advance, in this case by finessing medical science altogether. Basically, they need to get out of the way while the rest of us, from both moral and medical communities, keep on talking.

So, let’s talk. One thing that does indeed make it difficult to assess whether people have a moral right to use ECPs is that we cannot be sure whether in any particular case, a feared conception has in fact occurred. Morally rather than medically speaking, preventing ovulation or fertilization is a quite different issue from that of preventing implantation of what has in fact been fertilized, but we cannot know for sure in particular cases whether it is the first or the second kind of prevention that an ingesting of the medication in question accomplishes. Does this make erring on the side of caution more defensible?

Perhaps, but this possibility leads straightaway to a second difficulty: we have no consensus in our society about when a human life (or, expressed more theologically, “ensoulment”) properly begins. By way of examples, for some it begins only with the first movement or with viability, in utero; for still others it begins only with the first breath after delivery. But if it does indeed begin with fertilization, then our misguided but conscience-driven pharmacist may still have a point. Upon this assumption, ECPs that block implantation (but not ovulation or fertilization) would indeed have lethal consequences for an actual and not merely potential human life, the view of the medical establishment to the contrary notwithstanding.

Even granting this latter assumption, however, will not dissolve the complexity of this issue. For another moral consideration is surely the circumstances under which conception may have occurred. For example, was it the outcome of a long-standing pattern of indifference to any serious thinking about the consequences of sexual behavior at all? Here, going for the ECPs would seem only to reinforce a continuing opting out of responsibility for ensuring that one’s actions bring no harm to others. One reason that sex isn’t for kids is that fooling around with it only makes for more kids, not intimacy, no matter how mature the bigger kids may think they are.

Perhaps, though, the conception --- if it occurred at all --- resulted from a single lustful act of two faithful lovers whose momentary passion swept away their usual cautions and preparations. Or from a simple forgetfulness to take THE pill. Or from a faulty condom. Or, more horrifically, from rape or incest. Do considerations like these add weight to the old adage that circumstances alter cases? I think so. If not in all cases, at least in some of them. With this qualification, though, the question still remains: from a moral perspective, are there any circumstances that might allow us to interfere with preserving human life?

Unfortunately, the pharmacist who is the subject of this meditation would like to decide all of these thorny issues for everyone by decree, and refuse access to ECPs altogether. Hopefully, instead of trying to undermine much needed dialogue on this very difficult moral issue, he and his fellow true believers will quit preaching and meddling long enough to join us in it.