Denial of Antipregnancy Prophylaxis to a Rape Victim

A 20-year-old woman is brought to St. Agnes Hospital emergency department after being raped. Medical treatment, begun immediately by emergency department personnel, includes psychological support, a general physical examination, and the standard me­dicolegal rape examination. No significant physical injury is found, and the patient is discharged on antibiotics to prevent possible venereal disease, with instructions to follow up with the rape crisis counselor.

The physician on duty neither offers nor prescribes hormonal prophylaxis to prevent pregnancy (the "morning after pill"), since hospital policy (based on Catholic Church doctrine), forbids physicians from prescribing postrape hormonal prophylaxis on the grounds that the medications induce abortions. Postrape hormonal prophylaxis is standard therapy at nonCatholic hospitals across the country, however.


Should this physician impose her or the Catholic Church's moral code on patients presenting for emergency care? Should this patient be advised that specific antipregnancy care is available but not at this facility? Should this facility and this specific physician refer all rape patients to other emergency departments for care?

Comment: This case was adapted from a letter to the editor of the New England Journal of Medicine by John M. Goldenring. Dr. Goldenring advocates, among other things, that "caring professionals and women's groups should ... urge local and national organ­izations to demand that all rape victims have immediate access to estrogen prescriptions," and that they should "warn malpractice-insurance carriers that the failure of certain hospital emergency rooms to practice according to community standards in rape care may be engendering a serious danger of major malpractice suits."

Commentary

Were a Catholic hospital a private institution entirely supported by the Catholic Church and dedicated to caring only for Catholic patients, complaints about the treat­ment of this woman would be illegitimate. But this is not the case. Catholic hospitals are not funded by the Catholic Church alone — they also receive support from federal and state governments. And they serve the public at large, not just Catholics. In most instances, in fact, a Catholic hospital is best described as "a pluralistic community health care facility operated under Catholic auspices ... with multiple social and moral accountability."

SHOULD THE TREATMENT BE PROVIDED?


Does this mean that a Catholic hospital, as a general health care institution, should perform those medical procedures that are considered to be standard forms of treatment in other hospitals, even if they are contrary to the most fundamental moral values of the Church? Should the hospital, for instance, be required to offer abortions to anyone who wants one?

The answer is a most definite no. Our society rightly places great importance on the freedom to choose among a plurality of values. This freedom includes not only the recognition of a competent patient's right to refuse lifesaving medical treatment but also the conscientious refusal by physicians to do something that they believe is wrong. Individual physicians are, in general, free to choose what procedures they will perform.


A hospital that offers abortions, for instance, may not force a physician to perform one if it is against his beliefs. Similarly, this freedom of conscience extends also to institutions. This is especially true in relation to procedures like abortion, which still provoke a considerable amount of controversy within society at large.

The case of the rape victim, however, differs from most abortion cases in several important ways. First, abortions usually are not performed on an emergency basis. The "morning after pill," on the other hand, must be provided immediately or, at least, within 72 hours of the rape — which in some instances may be when the woman finally arrives in the emergency department. Second, women who seek abortions usually choose their own health care providers.

The rape victim, on the other hand, was brought to this particular emergency department after having undergone a traumatic rape. No doubt she was unaware that she would be treated differently elsewhere — and, within the time limitations given, she may not discover this until it is too late. Third, the existence of abortion procedures is common knowledge. This is not true of antipregnancy estrogen treatments, however, and it is likely that if the rape victim does not receive that med­ication at this emergency department, she will not know enough to seek it elsewhere.


Fourth, abortions are invasive procedures, requiring physicians to be actively engaged in the processes and requiring special hospital equipment. To prescribe an antipregnancy hormonal treatment, on the other hand, a physician need only fill out a sheet of paper, and this requires considerably less involvement on the part of the physician or the hospital.

Finally, there is a very high probability that an abortion — especially a first trimester abortion — will kill the conceptus. But it is more likely than not that the rape victim is not pregnant, in which case the antipregnancy care will ease the woman's mind but will probably not destroy any conceptus.

It could be argued that these distinguishing features of the rape situation are significant enough to warrant the conclusion that although Catholic hospitals are not morally required to offer abortions, they are required to offer hormonal treatment to prevent possible pregnancy in cases of rape. But this conclusion would be too hasty.


We must remember that according to the Catholic view the zygote is as morally significant as you or I. Accordingly, to provide medication which changes the uterine wall so that the zygote cannot implant is tantamount, according to the Catholic view, to killing an innocent human being. Hence writing a prescription — which the druggist then fills and the woman follows — would be like conspiring to murder. We also must remember that this is not a peculiarly Catholic view.

Many nonCatholics in our society hold similar views regarding the moral status of the conceptus and the wrongfulness of abortion, views which they insist apply even to cases of rape. One of the difficulties here, then, is that we are dealing with a subject that society as a whole is not comfortable with and that raises serious moral questions for a significant proportion of the population.


With the enormous controversy surrounding the moral status of the zygote, plus the high value our society has placed on respecting self-determination and pluralism, would it be fair to require Catholic hospitals and physicians to compromise their most fundamental moral convictions by requiring them to provide the "morning after pill?" The answer, I think, depends in large part on the question of the medical necessity of the medication.

"MORNING AFTER PILL" AS APPROPRIATE MEDICAL CARE


Rape is a horrible ordeal, causing in many cases severe physical and mental harm. Proper medical treatment attends to both present and future impairments; so in this case, the woman's immediate needs were cared for, and she was also referred to a rape crisis counselor and given antibiotics to prevent venereal disease. She was not, however, given medication to prevent pregnancy.

The result may be that she will worry — or fret, or fear, or obsess — that her attacker has impregnated her. Not only must she bear the horror of remembering the rape, but she also must bear the disgust of the possibility of carrying her attacker's child. That the chances of her being pregnant are small is irrelevant; her concern and anguish over the possibility is an important enough reason to give her the option of taking the hormonal treatment to prevent pregnancy.


Although hormonal treatment as a prophylactic against pregnancy is standard therapy at most hospitals, it is therapy that should be offered but not insisted upon as the uncontroversially medically indicated treatment in all cases of rape. There are good reasons for not taking the drug if offered it. Some of these reasons are moral — a woman might believe, for instance, that it is not the zygote's fault that it was brought into being and that therefore she has no right to destroy it.

But most of the reasons for not taking the morning after pill are practical: (a) the morning after pill is not always effective; (b) if the woman is already pregnant, it may cause serious abnormalities to her fetus; (c) some women cannot take it without harming themselves (those with cardiovascular or liver diseases, among other conditions); and (d) it induces severe nausea and vomiting in most women who take it. Further, and perhaps more importantly, there are other options available to a woman who does not want to be pregnant.


A woman might decide, for instance, that she would rather wait until her next menses to discover if she is pregnant and then have an abortion if she is. But she need not wait that long. An extremely reliable, noninvasive test is available to determine pregnancy within ten days of conception. Using urine or blood samples, technicians can test for pregnancy (even ectopic pregnancy) by checking the beta subunit HCG.

These medical factors militate against requiring hospitals and physicians to pre­scribe the drug, quite independently of concerns about the moral status of the conceptus. A woman would suffer from the uncertainty of not knowing if she were pregnant for only ten days (if she had the beta subunit HCG tested), or, at most, for a couple of months (if she waited until the standard pregnancy test can reliably indicate her status). This burden, while significant, does not seem significant enough to outweigh the freedom of conscience of the Catholic physician or hospital.

DUTY TO REVEAL OPTIONS


This does not mean, however, that the physician in this case is not without fault. She may have been justified in not prescribing the estrogen treatment to prevent preg­nancy, but she was wrong not to tell the rape victim that the treatment is available elsewhere.

The peculiar circumstances of this situation, especially the fact that the treatment must be taken immediately and the fact that its existence is not common knowledge, in addition to the facts that this emergency department serves the entire population and that this patient had no choice over which emergency department she was brought to, mandate that the information not be withheld from the patient.


Further, the hospital must recognize that abortion is legal in this country (without exception during the first trimester) and that this patient has the legal right to take the hormonal prophylaxis if she so desires. Therefore, although the hospital and the physician are not required to provide the treatment themselves, they should be required to facilitate the patient's receiving it elsewhere — perhaps by transporting her to another facility or by having a physician on call who will write the prescription.

This seems like a fair accomodation to mutually opposing interests. Although the Catholic hospital and physician are expected to compromise their views a bit — insofar as they are asked in a sense to collude in a type of abortion — they at least are not required actually to give the antipregnancy treatment, and hence their responsibility for the outcome is lessened.

And although the rape victim is further troubled by having to get her prescription elsewhere, the inconvenience could be kept to a minimum and does not seem to be unduly burdensome.

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