Sunday, August 23, 2009

Sunday Exercise: The Hastings Center Makes Waste

I have a question, which I'll offer after giving, briefly, the appropriate background.

In a recent Hastings Center Report (you may have to register to get the complete article), a Rebecca Stangl puts up a thing entitled "Plan B and the Doctrine of Double Effect." Plan B is an "emergency contraceptive" that sometimes has an abortifacient effect, preventing implantation of an embryo in its mother's womb. It may also prevent pregnancy by inhibiting ovulation or fertilization. (How it does this is not well understood.) Assuming that intentionally procuring an abortion is always wrong, the first of these three mechanisms is the one that concerns us. She asks: "Suppose that emergency contraception works exactly as its opponents claim. Would it follow that taking emergency contraception is morally equivalent to intentionally procuring an abortion?"

She answers: "Perhaps surprisingly" [actually, Rebecca, it doesn't surprise me at all], "I shall argue that it would not. If one accepts the doctrine of double effect, there would be circumstances in which the former is permissible even if the latter is never permissible."

She defines double effect as follows:

The doctrine makes a crucial distinction between harm that a person merely foresees will be the result of her action, and harm that she intends either as a means or as an end. According to the doctrine of double effect, it may be morally justifiable to perform an action that one foresees will result in some harm even if it would be unacceptable to aim at that very same harm, either as an end or as a means. Whether this is so in any particular case depends on whether the good to be achieved is proportional to the harm that is foreseen. I will argue that taking hormonal contraception can be justified by the doctrine of double effect even if it is true both that it can have an abortifacient effect, and that one may never intentionally obtain an abortion.

She attempts to "prove" her thesis as follows:

Someone who obtains a first trimester surgical abortion directly intends to secure the death of the fetus, either as an end or as a means to some other end. But someone who uses emergency contraception need not intend the death of any particular fetus...She may believe that, under exceptional circumstances, the contraception will fail to prevent the conception of a fetus. And in a proportion of these cases, the changes in her body brought about by the use of emergency contraception may mean that the fetus will not be able to implant itself in the womb. But she need not intend for that to happen...Not every effect of a person’s action need be intended.

She employs an analogy:

An example from another area of bioethics may help here. Opponents of euthanasia generally concede that we may give dying patients high doses of morphine even if we know that such treatment may hasten death. What we may not do, they claim, is directly intend the death of the patient and administer the morphine as a means to that end. So the same action—administering morphine—has a different moral status depending on the structure of our intentions. Because this one action has two different effects, it is possible to directly intend one of the effects and merely to foresee the other. If we take the morally good end (the relief of suffering) as the object of our intention, the action may be permissible. But if we take the morally bad end (the death of the patient) as the object of our intention, the action will be impermissible...if this distinction works in the end-of-life case, it seems to me that it must also work in the case of emergency contraception...We can then agree that directly intending the death of any particular fetus, either as a means or as an end, is impermissible, while allowing that if our intention is merely the morally good end—the prevention of a pregnancy—then the action may be permissible...Indeed, it seems to me that opponents of emergency contraception must accept something like the intend/foresee distinction.

She employs another analogy:

It appears, for example, that breastfeeding causes changes in the endometrium that are similar to the changes brought about by the use of emergency contraception. If such changes can have an abortifacient effect in the former case, then there is no reason to think they cannot also have an abortifacient effect in the latter. But no one takes this to be a reason not to breastfeed...A breastfeeding woman does not intend the death of any particular fetus by breastfeeding. Even if there is an extremely rare risk of this occurring, it will occur only as a wholly unwanted side effect of her action...

She then deals, in conclusion, with the problem of proportionality:

One might object that such a good [preventing pregnancy], while important, could never be proportional to the foreseeable possibility of the harm of the possible abortifacient effect. If the embryo really is a person with moral rights, perhaps only the risk of the mother’s death would be proportional to the foreseeable possibility of the death of the embryo. But this doesn’t seem right. Even on the interpretation of the empirical facts most favorable to opponents of emergency contraception, the chance that it will result in the death of an embryo, in any particular case, is very small.

In essence, "I claim that women who use emergency contraception need only intend the contraceptive effect of the medication, and not any possible abortifacient effect it may have."

My question is: what's wrong with her argument?


Peony Moss said...

Let me guess: merely "intending" isn't enough. My good intention of scaring off a stray cat isn't enough to allow me to start shooting a BB gun out my back window. "But officer, I didn't intend to hit my neighbor -- I just wanted to scare the cat."

Maybe I'm just getting too bogged down in that science stuff. But granting her (erroneous) premise that contraception in the sense of preventing fertilization is okay (as opposed to the abortifacient effect of suppressing the endometrium) -- she doesn't point out that in order to be certain that Plan B is being as a contraceptive, one would have to know whether or not ovulation has already taken place.

If ovulation has not taken place, then Plan B suppresses the release of the ovum, and thus no conception. But if ovulation has not taken place -- or if one doesn't know if ovulation has taken place -- then one is taking the risk of killing a baby. And mere "intention" isn't enough. "I just intended to scare the cat -- I didn't intend to hit that particular neighbor."

William Luse said...

"she doesn't point out that in order to be certain that Plan B is being [used] as a contraceptive, one would have to know whether or not ovulation has already taken place."

She deals with this in a part of the article I didn't include, for the reason that I think she can be defeated without it.

I think you're on the right track with regard to "intention", but I'm going to see first if others comment.

I'm surprised you didn't say anything about her breastfeeding analogy. :~)

William Luse said...

Oh, btw, Peony, you would need to show that "intending" with plan B is different than the 'intending' in the other examples she gives.

Lydia McGrew said...

She ought to be willing to get into probabilities. The "may hasten" w.r.t. morphine is weasel stuff. Is it going to kill the person, or isn't it? What do you know? Some people using that analogy man up and say, "You know that it _will bring about the person's death_." Well, okay then, you're sunk. That's too high a dose of morphine. Driving on the highway "may" cause somebody's death, but obviously, I don't have reason to believe that it _will_. But with the morphine, they want to use enough to kill somebody.

But I don't have time to read the article, so I don't know if she tries to say how likely it is that the use _will_ cause implantation failure. As Peony points out, that's going to depend in no small measure on where the woman is in her cycle.

Lydia McGrew said...

Btw, I believe the mechanism whereby this would prevent ovulation (if it did) is actually pretty well understood. Ovulation requires a highly precise hormonal cascade, in which each step depends on the previous step. Introducing large amounts of hormones, particularly progesterone, into the body prior to ovulation interrupts this cascade by, in effect, confusing the ovaries so that they don't produce the hormones they are supposed to produce in the precise order necessary. If the ovaries are sufficiently confused they temporarily shut down, and the LH surge does not occur, so no egg is extruded.

Another thing that probably has never been well studied is whether, once ovulation has occurred, taking the rather high doses involved in Plan B would actually have the claimed effect on the endometrium. Ovulation itself sets in motion a further series of hormonal events which rapidly produces a receptive endometrium. The question then arises whether the effects of the estrogen, in particular, in the Plan B would be such as to make the endometrium hostile despite the effects already set off by ovulation itself. It seems possible that it would, but my suspicion is that they simply don't know. It may be that a failure of the conjectured anti-implantation effect may account for the fact that Plan B actually doesn't "work" very well, in the sense of preventing detectable pregnancies.

William Luse said...

"Driving on the highway "may" cause somebody's death, but obviously, I don't have reason to believe that it _will_."

She actually uses this analogy too, but I didn't include it because it struck me as absurd.

The "may hasten" w.r.t. morphine is weasel stuff.

Yes 'tis.

"But I don't have time to read the article..."

Any chance that might change?

"so I don't know if she tries to say how likely it is that the use _will_ cause implantation failure."

Let's say it's not as common as the other two effects, just for the sake of argument. Stengl seems to think it's rare, but gives no inkling how she could possibly know.

Re ovulation she says:

"At one point, Catholic hospitals lobbied to be excused from a bill that required all hospitals to provide emergency contraception to victims of rape. The Catholic hospitals were in favor of providing emergency contraception to victims of rape, but only following a negative test for ovulation. The worry seemed to be that, if ovulation had already occurred, then the effect of Plan B could not be contraceptive. This is important to my argument because I have focused on the intentions of the person taking Plan B. If one knows that Plan B cannot function as a contraceptive, then one cannot take it with the intention that it will. So one might think I am committed to defending the position defended by the Catholic hospitals. But a positive ovulation test would *not* show that it is impossible for Plan B to function as a contraceptive. We know it can inhibit ovulation. Failing this, it might either interfere with fertilization or impair implantation. Because interfering with fertilization is also a contraceptive effect, one could still take it with the contraceptive effect as one’s goal, even if one has a positive test for ovulation."

Did I miss something, or did you fail to tell me what's wrong with her argument, other than that she ignores probabilities?

William Luse said...

Also, could any female out there tell me if her breastfeeding analogy is at all related to fact? I find it hard to swallow. Umm, no wordplay intended.

Lydia McGrew said...

Nobody knows _for sure_ if breastfeeding could cause implantation failure. I doubt there have ever been any tests on it, and such tests would be very difficult to do. It is "related to fact" just in the sense that long-term, on-demand breastfeeding, especially when it stops a woman's periods, does result in thinning of the endometrium, sometimes rather dramatic thinning, which is similar to the thinning that takes place when a woman takes regular contraceptive pills over a period of several months. The question then is whether, if breakthrough ovulation took place, the hormonal events that permitted ovulation would also result in a receptive endometrium despite its previous thinness. Indeed, every single month a woman's endometrium goes from thin (immediately after her period) to receptive, and this thickening and softening is caused by the very series of events that causes ovulation and by ovulation itself. So it seems plausible that if a woman ovulates the endometrium would become receptive. But that argument would then at least plausibly apply to long-term thinning caused by OCs as well. The only extra question regarding Plan B is whether taking the especially high doses of estrogen post-ovulation (Plan B involves higher doses than ordinary OCs and is often given without regard to whether ovulation has already taken place) would work quickly to make the endometrium hostile despite the previous ovulation. In other words, is Plan B worse in terms of the possibility of implantation failure than either on-demand breastfeeding or lower-dose OCs?

If her argument ignores probabilities, that is a huge problem, IMO. After all, if it were 99.99% likely that breastfeeding over a period of months combined with normal marital intercourse caused implantation failure, that would be a big deal. We judge recklessness and the morality of actions based on rough judgments of probability. Driving in nice weather when you're a good driver is fine; driving when you're seriously impaired by drinking is criminally reckless.

I think what you quote from her concerning inhibiting fertilization is dubious, because it assumes that the thickening of the cervical mucous (which is what would inhibit fertilization) would take place _so fast_ after giving dose #1 as to make a serious difference to the likelihood of fertilization. Given that intercourse has already taken place some time prior to giving the drugs, and given that the sperm move into the uterus over a period of just six hours anyway, the probable relevant effectiveness there is questionable. If it's already been several of those hours before she even gets the pills, and if her cervical mucus was highly receptive prior to getting them, it's doubtful that its quality would change virtually instantaneously upon taking the pills. Moreover, the female egg is only likely to be able to be fertilized for about one day after ovulation, so if you have reason to believe ovulation took place more than 24 hours ago, then the "preventing fertilization" claim is a complete sham.

I think she's pushing the science a bit to make her own claims fly. It would be a lot more defensible for her to take the position that the hospitals may morally give the pills up to about Day 10-11 of a woman's cycle, after which the probability of ovulation within the population is sufficiently high that the claim of an intent to prevent ovulation/fertilization becomes dishonest. Unless a woman can show them by charts or convince them by her past charting (which will hardly ever happen) that she never ovulates before a much later day--Day 21, for example, for a woman with a 35-day cycle.

Lydia McGrew said...

By the way, in all these discussions I think people often assume that pills do whatever they do to its fullest extent instantly, which is certainly not always true.

Marie said...

Can the amateur hour chime in?

Way back in high school I was conned with a "quick change" operation -- where you take logic and give it a tweak and wind up walking in with twenty dollars, asking for change, and walking out with forty?

Obviously, there is one error that you are looking for here and I don't think I can find it. But what I find "wrong" with this argument is as follows:

1. The Pill, or this pill, is not a medicine. A medicine works to correct or mitigate the bad effects of a human bodily system that has gone wrong -- replace insulin in a kid who's pancreas doesn't make it any more, mitigate pain when the nervous system continues to give someone a "high alert" for a situation that can't be remedied or already has been. Contraceptive chemicals work by taking a healthy function of the human body -- ovulation and building of the endometrium -- and altering it. It is not a medicine designed (well or poorly) to fix a problem, it is an engineering tool designed to change nature for an external reason. For this reason, it is hard to find secondary effects acceptable when the primary effects are so unnatural. Also, this goes to the breastfeeding argument -- breastfeeding being natural, healthful, and holding a purpose for human individuals and society and the use of the morning after mixes being unnatural and contrary to nature, unhealthy, and holding a purpose only readable as useful if you read it in the light of a particular sociological dogma.

2. The breastfeeding argument is, moreover, very like a doctor I heard of that said he no longer beieves abortion is wrong because he has seen the stats on natural spontaneous abortion and, essentially, if God can abort it must be o.k. for him too, also. Following this logic, since God lets people die in car accidents I'm free to cut brake lines, since God lets folks die in war I can shoot away. . .

4. Her argument about proportion is not comparing proportions solely, it is multiplying risk by effect and putting those two quantities on a balance scale. But you can't multiply by zero or by infinity, and life is infinity. So what she should be comparing for proportion is the potential results of the action of taking or not taking this chemical mix for any one individual woman. The down side of taking the pills? Nine months of pregnancy, a condition millions of women have bourne without permanent physical or psychological maiming. The down side of taking the pill? You kill an innocent human. There's your proportion.

As for the comparisons with morphine use, I'd argue probability works against her here. If I pump heavy doses of morphine into someone to relieve pain I pretty much know for sure that I am hastening death as a secondary effect. That is what makes it secondary -- it is regrettable, it is a burden I bear in order to get what I need, it is on the far side of the ledger sheet. But if I take a morning after pill hoping to prevent ovulation, and figure that I may be, perhaps, sort of, taking a chance on creating a hostile endometrium for a fetus instead, I'm not deciding to bear the loss in order to win the gain. It is, in fact, not a loss to me. It is the same practical end -- no baby any more -- arrived at through a different means. I may vaguely regret the means, but I am not bearing that risk, I am blinking at it. In giving morphine to a suffering patient, there are two different practical ends -- a patient no longer suffering and a patient no longer alive. Especially if you accept a Christian POV, there is no guarantee that the dead patient is no longer suffering.

Well, that's a ramble. Thanks for letting me play, and I'll be eagerly watching for the ten thousand dollar answer.

Lydia McGrew said...

Again, if we knew **for a fact** that if you breastfed your baby for six months while carrying on normal relations with your husband, this would _definitely cause_ implantation failure, then you should either bottle feed or abstain from sexual relations. But there is no good reason to think that this is the case. Frankly, I think the "natural" vs. "unnatural" thing gets overpushed. If doing something "natural" that you could avoid doing _definitely kills_ somebody innocent, we need to find a way around that. The evidence that it does, however, is pretty darned weak, and I don't think any breastfeeding mother needs to get worried. In all probability, if you have breakthrough ovulation while you are breastfeeding, the endometrium will become receptive as a result of the ovulation. However, I have to say this: My approach here does mean that you can't just say, "Any risk is unacceptable." That's just not true. We all take risks of accidentally causing deaths all the time. The evidence regarding how risky something is is relevant.

alaiyo said...

Just a quick comment on the breastfeeding analogy she uses -- I spent a number of years when every time I ovulated I was in severe pain for a couple of days -- severe as in I could barely function and nearly passed out in front of my classes more than once, could barely make myself walk because each step sent stabbing pain through my entire body, etc.

When I was breastfeeding exclusively -- no pain. For the first months, with exclusive breastfeeding, the act suppresses ovulation altogether -- it's a natural way that the body spaces babies. After that, I have trouble believing it is abortifacient, given that my first two children are 17 months apart, and I got pregnant, it seemed, the day I gave the first one his first bite of solid food. :) If babies are naturally miscarried during breastfeeding, it's probably the same causes that occur any other time.

I was on the pill for a time -- the old evil high-dosage ones -- because that higher dosage of hormones actually does suppress ovulation: evidence -- the lack of pain. I wouldn't even consider the lower-dosage pills because, first, of the almost certain abortifacient effect, and second, my purpose was to avoid pain, which they of course didn't do for me. So my own experiences make that analogy just seem silly to me.

I'll see if I have the time tonight to look at the rest of the argument and try to see where it fails overall. I was struck in the last quote you give by this: "But this doesn’t seem right." She makes a long convoluted argument about intentionality and proportionality and so on, but in the end, her argument seems to simply be, "I feel like it's okay so it must be."

Well, whatever, as the kids say. If I'd for one instant thought that the pills I was on could have killed a baby, however remote the possibility, I'd have endured the pain without hesitation.

[p.s. to my Catholic friends -- although I'm very close to your ideas about contraception, I don't yet buy them entirely; also, I had to support my family by myself, and to do so had to function physically in a regular job. Don't worry, we've done a pretty good job of populating the earth -- 5 kids, and 14 grandkids and counting. :)]

William Luse said...

Marie, it's all right if you play, because I'm an amateur too. Lydia's the only one so far I'd call a pro. There's probably no ten thousand dollar answer, because her probability argument is gaining sway with me, as in "after which the probability of ovulation within the population is sufficiently high that the claim of an intent to prevent ovulation/fertilization becomes dishonest." Even so, I'm not sure that taking such a risk is permissible because, as you say, the cost can be a human life.

But we do take risks with human life. That's the purpose of her other analogies. The risk involved in driving a car I considered ridiculous, because no one gets behind the wheel thinking, "I might kill someone today, but that's a risk I'll have to take." People don't drive with any intention whatsoever of killing anybody, except a few like that lady up North who ran over her husband several times in a circular driveway just to prove she really meant it. (Besides, other drivers on the road have consented to the same risk, which cannot be said of an innocent baby.) Now, drunk drivers might have been a more appropriate analogy, because they can be prosecuted for their risk-taking, and I'll bet the chances of a drunk driver killing someone are more akin to the odds that "emergency contraception" will kill a baby, and we consider those chances unacceptable. My problem with the doctor giving painkillers to a patient is that he, too, has no intention of killing the patient. The drugs might hasten death without themselves being the cause of it, that being laid to an underlying, terminal condition. A conscientious doctor will try to insure that this is what happens. But emergency contraception is not meant to ameliorate an underlying condtion, but in fact to bring about the condition that will cause death.

I had thought that Stengl, based on double-effect and her analysis of intention, might have tried a wartime analogy, such as that of a pilot who needs to bomb a target and worries that he might kill some innocents in the process. He ought to be very scrupulous about it, and if he knows in fact that he can't take out the target without killing the civilians, then he shouldn't do it because the supposedly unwanted evil effect has now become a thing that he directly intends. Let's say, though, that he doesn't know it in fact, and that this is an accurate analogy to the woman taking emergency contraception (hereafter EC).

Except that it isn't. The pilot can at least lay responsibility for the presence of any civilians near a bombing target to the callous disregard of the perfidious enemy he is trying to defeat. The woman using EC cannot. If a baby is conceived, it is there because of her own actions, not someone else's (save in case of, e.g., rape, in which instance the target for extermination should be the rapist, who is the enemy, not the child).

Bottom line, I don't think any of the analogies work because of the circumstances peculiar to pregnancy, or perhaps I should say conception, because I think a woman who takes EC is not only trying to prevent pregnancy, but is demonstrating a willingness to prevent it even if it means killing a baby. In other words, this willingness (intention) is embodied in the act of taking the drug, which cannot be said of the other examples.

Furthermore, if the risk is between preventing ovulation/fertilization and killing a baby, I'm not sure we are allowed to use double-effect to protect our option to commit an intrinsic evil. (Of course, we Catlicks, some of us, think the former an intrinsic evil as well, but I'm leaving that aside.) I'm having trouble seeing how the fact that the intrinsic evil is only possible and not certain allows us to flip a coin since, as I've already said, the coin was flipped, and your willingness to kill made manifest, when you opened your mouth and took the pill. (continued..)

William Luse said...

Also (and related to Lydia's last and very fine comment) - and upon which I don't have time to expound right now - all this murkiness about how EC actually works does not, in my opinion, work in Stengl's favor. We have an obligation to know the probabilities before we undertake risky behavior. If a woman taking EC really doesn't want to kill a baby, then she needs to know a lot more.

Re breastfeeding: in my male ignorance I'd always assumed that it inhibited ovulation, with a consequent effect on the endometrium. I have trouble believing God created the female anatomy to slough off babies while she's nourishing another. Stengl's fuzzy about it, and since the pro-contracepters and aborters are always looking to analogize the unnatural to the natural, I feel justified for the time being in getting sick to my stomach at the very thought of it.

Marie said...

I've never heard the endometrial line about breastfeeding, but even if a breastfeeding mother risks losing a viable fetus because her endometrium is thin, I believe breastfeeding is a moral choice while using EC is not. This does hinge on the "natural" angle, but only because I believe in God, and therefore believe that those things that are truly a function of the natural process of a healthy body and healthy population are there for a reason that was designed by one who does not do evil.

This doesn't mean we have to cooperate with everything because it is natural -- sometimes it is our place not to. It is natural for bacteria to kill and completely moral to fight them with antibiotics. But if I lived during the Middle Ages and my child died from the black death because we lived in a harbor town, I would not be culpable -- that would be part of the risk of living in a fallen world.

If, however, I worked in a lab and created a super-potion that could turn rocks into bling but every two-thousandth time killed my lab parter, I'd be culpable for that even if the die rolled such that no one ever actually did die.

Let's not forget, too, that in breastfeeding we are doing a good for an other. If we are prevented from having that good be a perfect good because we ain't in Eden any more, that doesn't remove the good. If our motive for nursing was solely to keep an ample bosom and we found that a side effect of that was a fetus might be killed, that would be a different story.

Lydia McGrew said...

"in my male ignorance I'd always assumed that it inhibited ovulation, with a consequent effect on the endometrium."

That's more or less what I said. But...I hate to be the one to point this out: Regular, daily, oral contraceptives probably have the effect they do upon the endometrium for the very same reason--that is, because they inhibit ovulation and, even more relevantly, the pre-ovulatory estrogen surge (which itself is necessary and usually sufficient to trigger ovulation) that initially produces a thick endometrium. It is at least plausible that if ovulation is _not_ inhibited in either case, then the endometrium will be sufficiently receptive that implantation failure, if it happens, happens for some totally independent reason (e.g., the absence of a sufficient amount of a binding protein in the embryo).

Also--and I hope this isn't too annoying, Bill--_if_ the probability of causing the death of an innocent is low, the driving analogy seems to be a good one. Remember that there are plenty of babies in the cars on the highway, too, who didn't consent to be there. Their parents brought them there, but that's because their parents had reason to assume that they wouldn't get killed. It's legitimate for you, as a non-impaired, good driver, to assume that too, which is why it's moral to drive. But that's because the probability is low. If the probability is equally low in the case of taking ECs, then the analogy seems to me as though it could be okay.

_But_, Stengl said "assume it works the way its opponents say it does." Now, I take it that the opponents _don't_ think the probability is that low. Maybe they haven't thought about it in those terms, but tacitly, I'm guessing they don't.

My impression from the quotes you gave is that she thinks double effect can do all the work for her without her actually discussing how big of a risk we're talking about. My contention would be that there are cases where the licitness of applying double effect depends crucially on how big the risk really is. The morphine case seems like a good example. The ethical doctor should be careful about the dose, in my opinion, so that he doesn't actually believe that the dose he is giving will cause death. If he really believes it will cause death, then double effect, IMO, doesn't get him off the hook. If he reasonably believes it won't, but knows merely that there is a small risk that it will (e.g., if the patient responds atypically), giving it could be legitimate.

William Luse said...

"oral contraceptives probably have the effect they do upon the endometrium for the very same reason"

Yes, as long as we ignore the relevant circumstances, such as why she is doing one thing as opposed to the other. Do breastfeeding women really sit around thinking, "Wow, what a great contraceptive this is. I can still have sex and any conceptions will either be blocked or miscarried. Whoopee." I suppose it's possible, but I hope not.

"implantation failure, if it happens, happens for some totally independent reason"

Let's hope so, but that doesn't let the EC woman off the hook, and if it happens often to a breastfeeding woman because she's breastfeeding (and she knows it), then she should heed your admonishment to abstain from sex.

"there are plenty of babies in the cars on the highway, too, who didn't consent to be there."

This is true, but the mother who puts her kid in the car and the one who takes EC are doing so for different reasons. One's putting him in a car seat to keep him safe. What is the other doing to keep the child safe? Oh, it's not a child yet, just a possible child. Well, should that child come about, what will she do to keep it safe? What least little thing, even if it's ineffective?

"If the probability is equally low in the case of taking ECs, then the analogy seems to me as though it could be okay."

Maybe, if probability is all that counts. I guess when I said it the first time it didn't make much of an impression: a woman who takes EC is not trying only to prevent pregnancy, but is demonstrating a willingness to prevent it *even if* it means killing a baby. This willingness is implicit in the act. The mother driving the car might even be able to take evasive action on behalf of her child should she see the accident coming. I'm trying to imagine what similar evasive action the EC woman could take, as though, after swallowing the pill, she can call it off or take an antidote if it looks like the embryo won't implant. She can't take the pill and then say to herself, a la Stengl, "There's a small chance it won't implant, but I don't really want that to happen; I don't intend it." She doesn't get to split her intentions into those she likes and those she doesn't, when her chosen behavior not merely includes but *approves* both possibilities. And thus, imo, Stengl's claim that "...women who use emergency contraception need only intend the contraceptive effect of the medication, and not any possible abortifacient effect it may have" is an attempt to teach people how to lie to themselves.

Same goes for the morphine doctor who, if he "knows merely that there is a small risk that it will [cause death] (e.g., if the patient responds atypically), giving it could be legitimate." *That* death would be an accident. The death of the embryo who fails to implant because of EC is no accident. It was an acceptable result from the outset, whether the possibility was low or not.

Thus, a woman who truly thinks that intentionally procuring an abortion is evil should use a contraceptive only in the complete certainty that it *never* acts as an abortifacient.

Lydia McGrew said...

The doctor can't do anything to take back the morphine once he gives it.

Lydia McGrew said...

I guess I would say that probabilities are related to the question of whether one is treating the undesired outcome as an "acceptable" result. For example, you can't be _certain_ that if you go hunting there will never be an accident where you will shoot some hiker. And hunting is a purely recreational sport. We'll imagine the person doesn't have to do it to live or something. It's a pretty low priority in life, all things considered. So it might be a perfect case where we would say that you shouldn't go hunting if you can't be _certain_ (by which I assume you mean morally certain, not mathematically certain) that you'll never shoot anybody accidentally. But it seems to me that it's sufficient for you to be _very, very sure_--which is pretty highly confident, though one might not designate it as "certain"==that you will never have a hunting accident. You could do this by going to places where you know hikers don't go, by having training to know the difference between the way people move in brush from the way deer move, or whatever, even though once you pull the trigger, you can't take back the bullet. I would not say that all hunters consider it an "acceptable" result that they might accidentally shoot somebody, even though they are hunting despite knowing it's _possible_ that they might shoot someone, and they are (obviously) going ahead and taking that risk. I would base my evaluation of whether they are being reckless and treating a hunting accident as "acceptable" on what precautions they take, how careful they are.

So, for example, in the EC scenario, the doctor who gives EC to a woman who tells him she normally has regular 28-day cycles and is now at day 17 is being reckless, because, as Stengl herself nearly acknowledges, there is no way for the pills to work other than by preventing implantation. They may not work that way, but he can't intend to prevent ovulation, because very likely the woman has already ovulated and may plausibly have already conceived. But the doctor who gives it to a woman who is at day 8 in her cycle is not being reckless (at least not about implantation failure; I'm leaving out the side effects to the woman here); hence, he's like the hunter who goes to the places where the hikers don't go or the doctor who carefully calibrates his dose of morphine.

Marie said...

But don't you downplay the benefits to the recreational hunter?
I would assume that someone who hunts recreationally is not doing so just for "pleasure" -- there are ways to find entertainment that do not require so much hard work. The hunter does so because it is a productive and creative endeavor that makes him a better person, more the person God wants him to be. Now, you can argue with that assumption, but a hunter who goes out and takes the chance that he will get killed, shot and wounded, fall in a hole and break a leg, or even just get into a car accident on the way to the campsite is not balancing those risks against mere enjoyment. He feels hunting is a good thing to do.

We agree with him. We are not offended, generally, by the proposition that he risks shooting someone in the course of hunting, as long as he takes the precautions you mention. But if someone playing a video game somehow was taking a similar chance, we would insist that game never be played (I would hope). Same with the soldier risking shooting an innocent, even if you don't agree with his goals you agree that he has goals that, if attainable and if he were right about their good, would justify risking lives. Same with the doctor administering morphine to relieve pain.

Contrast that with the woman using EC, or the doctor helping her. What creative endeavor are they embarking on? What good are they pursuing? I imagine there could be some situations in which the balance is worth weighing -- let's say a woman is raped, she's on day 3 of her cycle so can have near certainty the effect is on ovulation, she is a widow with three young children and lives in a society where her children will be removed from her home if she is publicly seen as pregnant -- absurd extreme, but I can see then the attempt to balance the very big chance that her kids will gain by her staying with them against the incredibly small chance that another kid will be killed. There may be real life situations that do the same.

But for most situations, it seems to me that the small risk to an infinite good placed on one side of the scales simply can't be balanced by even a great gain of things that are, in themselves, not goods at all.

Thing is, this all springs from a point of view that says all things claimed as benefits aren't so. The woman who feels an uninterrupted college career is worth the small risk to human life has my sympathy, but not my agreement. Being able to complete college unimpeded by a pregnancy and birth may be a good or may not -- it is not automatically so, in my world view. If you come from a world view where it is, maybe it's o.k. to pull the scales out. But I think the author is trying to persuade folks who think like me.

Lydia McGrew said...

I would think that the question of what good is being pursued would take us away from the idea that Bill is "setting aside" or "waiving" the issue of whether the contraceptive effect is itself wrong, unworth pursuing, etc. In other words, once we start saying that intending contraception is itself wrong because unjustified, etc., it doesn't seem we're setting that aside anymore. I would take it that in setting that aside we are granting if only for the sake of the argument that the intent and attempt to prevent ovulation and fertilization (but not implantation) are legitimate intents. Whether that's because we're imagining a case of rape, imagining the woman in desperate circumstances, or whatever, doesn't seem to matter.

I want to emphasize (for Bill) that what I said about abstaining from sexual relations while breastfeeding was in the absurd hypothetical case that you had 99.99% probability that combining breastfeeding with normal marital relations would cause implantation failure. Of course, I don't think that's the case at all. Many women _do_ use breastfeeding as a form of natural child-spacing. I think they are justified in doing so, and I think they can have their minds at rest knowing that the mechanism whereby it does so is by inhibiting ovulation. And, yes, they may very well deliberately continue on-demand feeding or delay giving solid foods in part as part of an overall child-spacing strategy. As long as the child is getting the nutrition he needs, I see no problem with this, even if the mother is thinking, "I'm not ready to get pregnant again, so I'll continue this breastfeeding for a while." Can she be _certain_ of the mechanism? It depends, I guess, on what you mean by "certain." I don't think she can be as sure of it as she is sure that she has two hands or that the entire external world is real rather than an hallucination. It's an empirical conclusion, and if she knows about the long-term endometrial thinning, that could part of her evidence, too, as could be information about how the endometrium is thickened by the same events that produce ovulation. I think she can be _very rationally confident_ of it. Could a woman who takes EC or ordinary oral contraceptives be in a similar position vis a vis rational confidence that she is not causing implantation failure? I see no reason why that should be impossible, depending on the evidence and also depending on the precautions taken, such as the time of month when the woman begins taking the pills, past charting of her own ovulation pattern, and so forth.

But I get the strong impression that Stengl doesn't want to get into that messiness.

Marie said...

I understood that the question of Catholic morality and artificial contraception shouldn't be a factor here, yes -- that the whole "theology of the body" or "recreational and procreative" stuff can get set aside. I'm willing to take it from the POV that it doesn't really matter why the woman is pregnant or how she came to have not not conceived.

I guess what I think should still be in the mix is the world view that says birth and life are intrinsically good. If you consider life intrinsically good, and you do not have a positive assertion that any one particular human experience would be improved by the absence of any one life, then the weights always have to drop on the side of the potential (even very potential) fetus. If you think children sometimes are and sometimes aren't good for a mother, and that we can predict fairly accurately based on circumstances whether for any one mom and any one possible child it will be good or bad, then you can put on one side of the scales chances of killing fetus X importance of human life <=> improvement in quality of life without child.

So I guess what I'm saying is that if you refuse to make a call on whether children are or are not sometimes a burden that outweighs their good (e.g. if there are some children in existence today that we, with all good will, wish were not because the good they brought is less than the trouble they've caused) you either can't evaluate this author's proposition, or you have to go with societal defaults (kids sometimes shouldn't exist) and concede her point is reasonable.

I imagine there are lots of pro-life folks that do believe a child coming into existence at certain times is a tragedy. But I think there are fewer of them than those on the other side of the question would believe.

Lydia McGrew said...

Well, I have to say that if preventing the union of egg and sperm following rape (which I gather is supposed to be the hypothetical situation for EC) is not granted to be at least as legitimate a thing to try to do as the enjoyment, exercise, manliness, "becoming what God wants you to be," etc., of deer hunting, then _some_ sort of strong and purely anti-contraceptive assumption does seem to be imported into the discussion.

William Luse said...

"The doctor can't do anything to take back the morphine once he gives it."

I'm assuming you read the part where I said he's giving it for a different reason, which is connected to...

"I guess I would say that probabilities are related to the question of whether one is treating the undesired outcome as an 'acceptable' result."

This is of the essence (seems to me) because, first, the death by morphine would not be acceptable in the sense that, though he accepts the risk, he is not assenting to the 'atypical result' in the same way as the woman who takes EC; and second, deriving from the first, that the former death would be accidental and the latter not so.

"But the doctor who gives it to a woman who is at day 8 in her cycle is not being reckless."

I will concede that if it can be calibrated this precisely, i.e., to a moral certainty, that you're probably right. But, as you say, "Stengl doesn't want to get into that messiness." She says only that the probability is low, which isn't improbable enough for me to concede that double effect lets her off the hook or that it even applies based on a meretricious parsing of her intention (and which is the true basis of Stengl's position).

Re the hunter, like the morphine doctor, even should his bullet hit a human, he will not find the result acceptable nor is an assent to the perishing of another human being built into the behavior of firing a bullet.

Assuming I understand it correctly, I appreciate Marie's general approach as a course of wisdom, though I sense you and she are coming at this from somewhat different angles, as witness "I would take it that in setting that aside [that contraception is wrong] we are granting if only for the sake of the argument that the intent and attempt to prevent ovulation and fertilization (but not implantation) are legitimate intents."

Yes, and I guess my essential point is that -under the general circumstances described by Stengl, not the more precise ones described by you - the woman taking EC cannot separate her legitimate contraceptive intent from her homicidal one. That's why it's called "emergency" contraception. The circumstances under which she's taking it are rather relevant to *why* she's taking it.

"I think they [breastfeeding women] can have their minds at rest knowing that the mechanism whereby it does so is by inhibiting ovulation."

I sure hope so.

Marie said...

Naw, I'm not being clear (no surprise, I'm often not).

O.k., here's the best I can do.

My understanding of the original premise is that you are not allowed to do a wrong in order to gain a good. However, IF you intend to do a good and you know that one effect of the action you take to do the good may very well be to do harm, you may still be permitted to take that action provided certain conditions pertain (proportionality, etc.).

So, here's what I'm thinking.

Saving the life of a woman is a good. If in operating on a woman to save her life an unintended side effect is the risk of the death of a fetus, it may still be acceptable to have the operation.

Feeding your family, maintaining a connection between humans and their food supply, etc. are good things. If in hunting an unwanted side effect is the risk of shooting your partner, it may still be acceptable to hunt.

Freeing people from oppression is good. If the war to do that has an unintended side effect of risking killing an innocent, it may still be acceptable under certain conditions to wage war.

Mitigating pain is a good. If in giving pain killers you run the unintended risk of hastening a death, it may still be acceptable to give morphine.

Now let's go with this. Preventing the existence of a human being is a good. If in the process of preventing the existence of a human you unintentionally risk killing a human being, it may still be acceptable to proceed with that process under certain conditions.

Now, you may argue with my way of presenting that, that's fair. But that's what I'm saying, is that I'm not taking as my starting point that contracepting is wrong, I'm taking from my starting point that it is never a moral *good* to prevent life. It may certainly be a moral neutral. It may certainly be practical, or useful, or ease life in some ways. As such, you may decide to substitute one of those into my formula above ("It is good to make life easier for a woman who has just been raped, therefore. . . .") but I think that would be cheating just a little bit, because it assumes a step (that preventing ovulation chemically--while risking a chemical miscarriage with all the additional trauma and hormonal suffering that brings--would in fact make life easier for a rape victim) which not everyone would ascribe to (while most of us would agree that giving morphine does reduce pain).

So, if you accept the premise that preventing a human existence can be a moral good (not just a moral neutrality),or are willing to substitute second-step premises using assumptions not everybody shares, then the author's argument is persuasive. If you aren't, it's not. I don't think that's about your stance on egg plus sperm, although I'll concede those points of view usually go together so maybe I'm cloudy on the issue.

Marie said...

I'll also confess, on rereading the above, that my assumptions about EC are not that it will be or is used nearly exclusively in the case of rape. It should not affect my view of the argument, since if even one woman is using EC after a rape and the author's line of reasoning is sound then that woman deserves to have that reasoning communicated to her for her use and alleviation of any unfounded guilt. However, my assumption may prejudice my view of the author's argument altogether.

Lydia McGrew said...

I'm really trying to wrap my mind around this thing about "finding the result acceptable." Are you saying that the woman "finds the result of implantation failure acceptable" if she knowingly takes the EC pills late in the month (say, day 18 in an apparently normal cycle when she usually ovulates on day 14) when it's quite plausible that she has already ovulated and conceived? I think I would agree with you there, but that's because there really is no plausible way anymore that it can have a purely contraceptive result. It's too late in the cycle for that. So it looks like she must be taking them for some other reason. Is that what you're getting at?

Btw, I realized my previous comment was confusing. I actually do realize that EC is being marketed as "back-up" for promiscuity, not only for the true, unexpected emergency of rape. That comment sounded like I don't know that. Sorry about that.

Marie said...

You know, take out my last big comment if you can. Mr. Luse restating the paragraph on the premise of this comment thread makes me realize that I've gone off track.

If we are starting from the assumption that preventing ovulation is a good act, period, then I have thrown a wrench in. Seems like an impossible "given" to me, but if that is the "given" the rest of the argument certainly makes sense, in that it logically follows -- but not in that it draws a correct conclusion.

Thanks for letting me play, guys, I'll just listen in, now.

Lydia McGrew said...

Just for the record (and I'm not really saying anything turns on this, but it's relevant to one of Marie's comments), implantation failure causes no trauma to the mother. In fact, it's silent and unknown. She doesn't even know it has happened. That's one reason it's so hard to get studies about it, because we can only conjecture how often and under what circumstances it happens, much less what causes it.

Marie said...

O.k., I imagine I was thinking of early miscarriages, I can't think of any way a body would know an embryo failed to implant, so that makes perfect sense.

William Luse said...

Godalmighty. I go mow the daughter's yard, drink a bunch of beer, and come back to all these comments. I'll try to sound semi-rational.

I'm not editing or deleting Marie's "last big comment" because I like it.

Are you saying that the woman "finds the result of implantation failure acceptable" if she knowingly takes the EC pills late in the month (say, day 18 in an apparently normal cycle when she usually ovulates on day 14) when it's quite plausible that she has already ovulated and conceived?

Those are your stipulations, not Stengl's. She's not nearly so scrupulous. Refer back to my earlier quoting of her on Catholic hospitals: "But a positive ovulation test would *not* show that it is impossible for Plan B to function as a contraceptive. We know it can inhibit ovulation. Failing this, it might either interfere with fertilization or impair implantation. Because interfering with fertilization is also a contraceptive effect, one could still take it with the contraceptive effect as one’s goal, even if one has a positive test for ovulation."

She's essentially lobbying for the moral licety of taking Plan B under any circumstances whatsoever, even after a positive test for ovulation, on the grounds that if there is some chance that the drug will have a contraceptive effect, the woman can remain nonculpable on the basis that she intended only the contraceptive effect. My position is that, in the nature of the act, she is embracing both and will "find either result acceptable," and which is what I meant earlier by saying that "her chosen behavior not merely includes but *approves* both possibilities."

Even so, I'm getting the impression that you would allow her more leeway with playing the odds than I would. My reason is that I have a gut discomfort with rolling the dice on an intrinsic evil, under the assumption that the contraceptive intent is not intrinsic, but the anti-implantation intent is. This discomfort would be valid only if I am also correct that both intentions are built into the act. I am interested in what she does, not what she says.

E.g., not to beat it to death, but it is extremely unlikely that a single dose of morphine carefully given is going to result in death. Such palliative care happens over a period of time, and I'd think the risk increases with it. The EC gal doesn't have that kind of wiggle room. If EC required 6 (or even 2) doses to be fully effective, and if, after taking the first dose, she was found to have ovulated, and then refused to take the second dose, I'd believe her that she found abortion abhorrent. But just one pill, which does either this okay thing or that bad one...nope.

Lydia McGrew said...

"She's essentially lobbying for the moral licety of taking Plan B under any circumstances whatsoever, "

In that case, she's a scientific idiot, because a couple of days after ovulation it _cannot_ prevent fertilization.

Actually, I believe EC is indeed taken over a period of two days, if not three. I'd have to check that out. That's one of its problems for the woman. We're talking big doses here, repeatedly. They throw up and stuff, I gather. Miserable stuff.

A single dose of morphine can cause death if it _isn't_ carefully calibrated, and one of the problems I've had with the morphine crowd is that they sometimes talk very loosely about double effect. One really gets the impression that they have no problem with _causing_ death so long as they can say they "intended" to stop pain. And even when it requires a continuous morphine drip over a longer period, the truth is they _don't_ stop. I have known one man who was, I believe, killed a bit sooner than his time by such tactics, when my husband was racing to see him a last time. Yes, the man was dying of cancer, no question, but they got a morphine drip on him, and he went down fast, fast, became unable to communicate, and died when he'd been chatting on the phone just three days before, as I recall. It looked suspicious.

Just to really curl your hair, a young doctor wrote to me about how he was told to increase the dosage on a patient every hour "until the patient expires." His supervisor said, "If you're not comfortable doing it, I will." The young resident said the family was very grateful afterwards for the supervisor's concern to alleviate their relative's pain.

William Luse said...

"Actually, I believe EC is indeed taken over a period of two days, if not three. I'd have to check that out. That's one of its problems for the woman."

If true, she'd have an obligation to take an ovulatory test so that she could stop if necessary. Probably before taking the first dose, actually.

The two morphine cases you mention are scary because I imagine that when someone is being ravaged by a terminal illness, it's very easy to kill him while making it look like all you're doing is alleviating pain, and to fool yourself into thinking that that's all you're doing. It's as though the presence of the disease induces a carelessness that would not be practiced if the disease were merely painful but not fatal. I also wonder how routine a practice it is.

Lydia McGrew said...

I shd. mention that the only ovulation test I know works for only a few days a month. It won't tell you a week later that you ovulated last week. The one I know of tests for the LH surge while it's happening.

I'm afraid the morphine cases are pretty common. That's an impression. But I read on a watchdog site for hospice that a nurse once said to somebody or other (sorry to be so vague, but this is all I remember), "I'm just like Dr. Kevorkian, only I do it with morphine." It has always seemed to me that there is something ominous about the way that it became so common about 10-15 years ago for living wills to contain statements that the person wants pain medication even if it may hasten death and also that ethicists, including Christian and even Catholic ethicists, started saying the sorts of things Stengl picks up on. There was a big movement to make doctors not liable for death from morphine overdose because of a perhaps legitimate concern that people weren't getting enough pain management out of doctors' fear of prosecution. But at this point I scarcely ever hear of anybody being prosecuted for killing somebody by morphine overdose, even though I know it does happen. The only case I've heard of in recent years was an organ donation case where the donation doctor was improperly involved in the patient's care and kept sending nurses for more and more morphine. That was so blatant that they prosecuted, though he was acquitted. But when a doctor is really the treating doctor and the person has a painful disease, never anymore, as far as I can tell. This really does lead to the conclusion that they can basically give you as much morphine as they want under the rubric of pain management, and even kill you with it, and they will believe themselves justified and will face no legal sanctions.

Tim came back from the situation I told you about and earnestly told me, "If I'm ever dying, keep the guys with the morphine drip away from me."

Lydia McGrew said...

What you say about my being more comfortable with someone's "playing the odds" than you would be is interesting and complicated by the contraception issue. I have lots of problems with EC, a major one being that no one should be trying to use contraception _after the fact_ of willing sex. The only case I can think of where I sympathize with the woman and think the whole situation might be legitimate is careful use (such as I've described) following rape. But if one is concerned about implantation failure, then the most obvious thing to do with contraception is either to use a barrier method or else to use _regular_ OCs, not EC, starting within one week of the beginning of the woman's menstrual period, and taking the pill as rigidly as possible at the same time every day. That is a _far_ more reliable way to prevent ovulation and hence to avoid the possibility of implantation failure. Far more reliable, that is, than taking EC after sex with little or no regard to the time of month. EC is from every perspective, even the amoral one, a ridiculously poor "method." It makes the woman ill because of the high doses, it could be dangerous to her to use repeatedly, and it has a lousy effectiveness rate precisely because it often does not prevent ovulation and hence pregnancy. From the moral perspective of considering sex outside of marriage to be wrong, EC is being marketed for use after willing sex in a way that encourages fornication.

But of course everything I have just said is without taking into account the Catholic view on the intrinsic illicitness of contraception.

William Luse said...

What Tim's saying is that he'd rather suffer than fall painlessly asleep (forever) if the latter means being the victim of murder. It actually takes some guts to say it (and mean it, which I've no doubt he does) since a whole lot of people these days can't understand it. After all, you're going to die anyway, so wouldn't you rather fall asleep?

"I have lots of problems with EC, a major one being that no one should be trying to use contraception _after the fact_ of willing sex."

Yes, that's probably why I see the willingness to kill as being built into the act. It's sort of fascinating how much a woman has to know about her ovulatory cycle and reproductive biology in general if she is truly to be conscientious about implantation. I wonder how many of them actually know what you know, or even care to know it.

I'm hoping more Protestants continue to move in the Catholic direction on contraception. It might actually make a difference in the health care atmosphere. But then there's another problem: getting Catholics to move in the Catholic direction.

Lydia McGrew said...

I think probably more patients would be willing to suffer at least _some_ pain and remain conscious than is generally thought. For one thing, I think people like to be able to be aware of their loved ones at the end.

wl said...

Yes. Leastwise that's what I've always hoped for myself. Maybe I'll get lucky.

I miss Zippy at times like this. Can't help thinking he'd have had something useful to say.

Lydia McGrew said...

No doubt. Then again...I might have refused to talk.

wl said...

Nah. You're too inquisitive, argumentative, passionate and obstinate. That's a compliment, btw.

Adam Smith said...

"I'm hoping more Protestants continue to move in the Catholic direction on contraception"

Frank Cavelli, our senior pastor at St. Pauls Presbyterian wrote an article for the congregation concerning this double-effect of birth control. As a result my wife and I have moved over to charting her temperature as a means of predicting ovulation. It's been a year - so far so "good." The Protestants are on the move!

Marie - "...since God lets people die in car accidents I'm free to cut brake lines..."

Not to take away from the seriouness of the topic, but the image I got of a defendant using that in court threw me into a serious fit of laughter.

wl said...

It's been a year - so far so "good."

And I wish you many more of such good years.