EMERGENCY CONTRACEPTION

POSITION STATEMENT

"A community can believe that abortions are not happening in their cities if no abortion clinic is present, but if Plan B is sold in pharmacies, then abortions are in fact happening every day."  

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WE AFFIRM THIS ECP STATEMENT...

PHYSICIANS

Adam Coombs

MD

Mihaela Missel

DO

Tim Flowers

MD

Brett Jeter

MD, FACP

Richard Randolph

MD

Coleman Boyd

Rowlen Dennis

MD

Hugh Muse

MD

Seth Brown

DO

PHARMACISTS

Kenny Willoughby

RPh

Richard Wakefield

Pharm.D.

Tyler Jeter

PharmD

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Emergency Contraception: A Position Statement

Biblical Ethics of Life

For a culture, city, or state to truly value life, the protection of pre-born children must extend beyond abortion clinics to hospitals, outpatient facilities, and pharmacies. We assert that human life begins at conception, or fertilization. We believe that God is actively creating all human life within a mother’s womb (Psalm 139:13). We also believe that human life has intrinsic value, since we are created in the image of God (Genesis 1:27). Therefore, life at all stages is to be valued and protected at all costs. From a Christian worldview, abortion and abortive medications end valuable human lives that have been created by God and in God’s image. 

Since life indeed begins at conception, it behooves medical professionals to protect this life. The Hippocratic Oath, which is still widely revered by physicians today, states “I will do no harm or injustice” (North, 2002). The American Nurses Association (ANA) states that, “the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA, 2015, p. v). The American Pharmacists Association (APhA) oath states, “I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients” (APhA, 2016). Physicians, nurses, and pharmacists are committed to the safety and ethical treatment of all human life. This includes life at all stages. Therefore, any drug or procedure that could potentially end the life of a fertilized egg should not be available in stores, clinics, or hospitals. 

The Science of Pregnancy and Emergency Contraception

Emergency contraception is a class of medications or interventions that seeks to prevent pregnancy after sexual intercourse. Pregnancy depends on a physiologic balance of hormones, two of which are estrogen and progesterone. These hormones are the main targets of emergency contraception pills. In the late 1960s, high-dose estrogens such as diethylstilbestrol were the primary means of emergency contraception. This treatment was replaced in the 1970s by combination high dose progestin/estrogens like ethinyl estradiol/levonorgestrel. Further options like copper intra-uterine devices (IUDs) in the 1970s and mifepristone in the 1980s became available. These latter interventions are considered by the wider medical community to be abortive in nature. However, recently progestin-only pills like Plan B and a selective progesterone receptor modulator (SPRM) called Ella have been approved for use in emergency contraception. Whereas copper IUD’s and mifepristone are seen as abortive, the potentially abortive nature of Ella and Plan B have been subject to much debate. 

To review the mechanism of action, Copper IUD’s create a local inflammatory reaction in the uterus that is intended to prevent sperm from fertilizing an egg. However, it can also prevent implantation of a fertilized egg due to the inflammation created by this local reaction. Mifepristone is a progesterone antagonist that acts by inhibiting the growth of the endometrium, thus preventing implantation. In the case of mifepristone, it can cause degeneration of the existing endometrium and induce abortion of the implanted embryo. Therefore, mifepristone is used in combination with misoprostol for chemical abortions. Ella works in similar fashion by competitively blocking progesterone action – albeit in smaller dosages. Thus, Ella is abortive in nature. 

Plan B works by a different mechanism with the stated intention of preventing fertilization and thickening the cervical mucus. Plan B does this by giving larger doses of levonorgestrel, which is the same drug present in smaller doses in birth control pills. However, on further review – there seem to be other downstream effects. This was noted in the FDA labeling on the mechanism of action for Plan B to be primarily to inhibit ovulation or fertilization but also that “it may inhibit implantation (by altering the endometrium)” ("Plan B One-Step: Highlights of prescribing information," 2009, p. 4). In a recent Princeton review article describing the mechanism of action of emergency contraceptives the writers state: “it must have a mechanism of action other than delaying or preventing ovulation” (Trussell, Raymond, & Hu, 2014, p. 5). This potential mechanism is problematic and vital for understanding Christian opposition to emergency contraception.

The Controversy

Does pregnancy begin at fertilization or does pregnancy begin at implantation? This is the key question. Language and definitions are vital. The definition of abortion depends on the definition of pregnancy and thus informs which medication is potentially abortive or not. This is where organizations like the American College of Obstetricians and Gynecology (ACOG) and the FDA make mistakes in their recommendations and literature. In the above Princeton article, the writers mention that “ECP’s (emergency contraceptive pills) do not interrupt an established pregnancy, defined by medical authorities such as the FDA/NIH (National Institute of Health) and ACOG as beginning with implantation. Therefore, ECPs are not abortifacient” (Trussell et al., 2014, p. 8). 

This is the fatal error. These organizations do not believe life begins at fertilization and therefore misunderstand pro-life criticisms. In ACOG and the FDA’s view, drugs are abortifacient only if they act post implantation. This is contrary to science and the Christian worldview; drugs that inhibit implantation are abortifacient. In ACOG’s website under FAQ’s for emergency contraception, they state copper IUDs and contraception pills are valid options for emergency contraception. Further, they state that Ella is the most effective of the pills for emergency contraception compared to progestin-only or combination pills (ACOG, 2019). Ella was marketed by the FDA as contraception, but in its release in 2010 it mentioned, “it is possible that ella may also work by preventing attachment to the uterus” ("Ella: Patient information leaflet," 2015, p. 11).

We know that copper IUDs are abortive, and the same can be said for Ella. Why would ACOG and the FDA place copper IUDs, Ella, and Plan B in the same category as contraceptive and not abortive unless there was confusion on when life begins? The answer lies in the definition of pregnancy.  Plan B has a potential mechanism of preventing implantation and thus must be considered abortive just like Ella and copper IUDs. If a pharmacy or clinic would not sell Ella, why would they sell Plan B? 

Appraisal of Medical Literature

In recent years, primarily due to pressure from the pro-life community in relation to the potentially abortive nature of emergency contraception, there have been several new studies evaluating this mechanism in particular. Synthesizing the results of this research led ACOG in their clinical practice guidelines to state that the “review of evidence suggests that emergency contraception is unlikely to prevent implantation of a fertilized egg” ("Practice Bulletin No. 152: Emergency Contraception," 2015, p. 2). Unlikely to prevent implantation is dramatically different than doesn’t prevent implantation. If one fertilized egg is prevented from implantation, then the medicine is abortive. The use of the word “unlikely” devalues life and underscores that Plan B regularly causes abortions.

Further, these studies had small sample sizes and were variable in their structure. One of these studies looked at endometrial markers of receptivity with emergency contraceptive use and another study looked at ovulation rates on emergency contraception (Durand et al., 2001; Raymond et al., 2000). Neither study can definitively prove that implantation is not affected. Thus, this recommendation from ACOG and other media outlets is founded on subpar evidence as well as confusion on when life begins. 

Furthermore, opposite conclusions have been reached by reputable organizations such as the Catholic Medical Association (CMA) and the American Associations of Pro Life Obstetricians and Gynecologists (AAPLOG). The CMA is the largest association of catholic medical professionals and they synthesized the available evidence in a position paper in August 2015 where they examined the Peoria protocol (a protocol for using Plan B in Catholic Hospitals): “the research findings appear to show clearly that these criteria are not met when Plan B is given…or when any other FDA approved emergency contraceptives are administered…. To administer (emergency) contraceptives is to choose evil…” (Raviele et al., 2015, p. 6). In Linacare Quarterly 2/2015, Kahlenborn, Peck, and Severs (2015) summarize the available data and state: “Many doctors and researchers claim that it has either no—or at most—an extremely small chance of working via abortion. However, the latest scientific and medical evidence now demonstrates that Plan B emergency contraception theoretically works via abortion quite often” (p. 18). 

The AAPLOG states in a letter to the FDA that “Plan B’s labeling does not give adequate notice to a potential user that Plan B may prevent implantation of a human embryo as one potential mechanism of action” (Shadigian, 2005). Further, Dr. Gene Rudd, an OBGYN and associate director of the Christian Medical and Dental Association (the largest Protestant Christian Medical Association), stated that “no credible expert disputes that emergency contraception must have post-fertilization effects to be effective” and “current packaging violates informed consent” (LifeSiteNews.com, 2006). Taking all of these statements into consideration, the weight of evidence is in favor of the abortive nature of emergency contraception – including Plan B. Not only does emergency contraception cause abortion, but packaging misleads the consumer, pharmacy and community into false assurance. A community can believe that abortions are not happening in their cities if no abortion clinic is present, but if Plan B is sold in pharmacies, then abortions are in fact happening every day. 

Conclusion

By understanding biblical ethics, the physiology of pregnancy, and emergency contraception, and synthesizing the medical literature and appraising relevant Christian societies, it is clear that Christians cannot support usage of emergency contraceptives. These medications potentially take human life and therefore should be expelled from society in order to protect the most vulnerable among us. Ethically, Christians should abstain from using these medications, but civic leaders should also call on pharmacies and clinics not to provide these medications in order to protect all life in their jurisdiction. In order to be comprehensively pro-life, civic leaders should disallow all medications or interventions that could harm life, which includes medications like Plan B. 

 

Brett Jeter, MD, FACP

Jacob Crouch, BSN, RN-BC

References

  1. ACOG. (2019). Frequently asked questions: Contraception. Retrieved from https://www.acog.org/Patients/FAQs/Emergency-Contraception

  2. ANA. (2015). Code of ethics for nurses: With interpretive statements (L. Badzek Ed.). Silver Spring, Maryland: American Nurses Association.

  3. APhA. (2016). Pharmacists’ impact on patient safety (A. Cassano Ed.): American Pharmacists Association.

  4. Durand, M., del Carmen Cravioto, M., Raymond, E. G., Durán-Sánchez, O., De la Luz Cruz-Hinojosa, M., Castell-Rodrı́guez, A., . . . Larrea, F. (2001). On the mechanisms of action of short-term levonorgestrel administration in emergency contraception. Contraception, 64(4), 227-234. doi:https://doi.org/10.1016/S0010-7824(01)00250-5

  5. Ella: Patient information leaflet. (2015). In L. H. Pharma (Ed.). Osny, France.

  6. Kahlenborn, C., Peck, R., & Severs, W. B. (2015). Mechanism of action of levonorgestrel emergency contraception. The Linacre quarterly, 82(1), 18-33. doi:10.1179/2050854914Y.0000000026

  7. LifeSiteNews.com. (2006). CMA doctors: FDA move to allow ‘Plan B’ without a prescription is unsafe and unwise. Retrieved from https://www.lifesitenews.com/news/cma-doctors-fda-move-to-allow-plan-b-without-a-prescription-is-unsafe-and-u

  8. North, M. (2002). Hippocratic Oath. Retrieved from https://www.nlm.nih.gov/hmd/greek/greek_oath.html

  9. Plan B One-Step: Highlights of prescribing information. (2009). In D. Pharmaceuticals (Ed.). Pomona, NY.

  10. Practice Bulletin No. 152: Emergency Contraception. (2015). Obstetrics & Gynecology, 126(3), e1-e11. doi:10.1097/aog.0000000000001047

  11. Raviele, K., Kahlenborn, C., Peck, R., Ruppersberger, L., Yeung, P., Tham, J., & Gutowski, M. (2015). Statement on emergency contraception in cases of rape. Retrieved from https://www.cathmed.org/wp-content/uploads/2015/09/Statement-on-Emergency-Contraception-in-Cases-of-Rape.pdf

  12. Raymond, E. G., Lovely, L. P., Chen-Mok, M., Seppälä, M., Kurman, R. J., & Lessey, B. A. (2000). Effect of the Yuzpe regimen of emergency contraception on markers of endometrial receptivity. Human Reproduction, 15(11), 2351-2355. doi:10.1093/humrep/15.11.2351

  13. Shadigian, E. (2005). Letter to the FDA regarding over-the-counter status for Plan B. Retrieved from https://aaplog.org/letter-to-the-fda-regarding-over-the-counter-status-for-plan-b/

  14. Trussell, J., Raymond, E., & Hu, H. (2014). Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy. Contemporary Readings in Law and Social Justice, 6. 

 
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