Readers generally would have thought the original article to be about
early
embryo loss and NFP. The Response of 12th June seem to have moved on
somewhat from this.
Rather than keeping to early embryo loss, Bovens now provides figures
giving
overall observed and estimated embryo losses; and not so much in
observational studies of healthy...
Readers generally would have thought the original article to be about
early
embryo loss and NFP. The Response of 12th June seem to have moved on
somewhat from this.
Rather than keeping to early embryo loss, Bovens now provides figures
giving
overall observed and estimated embryo losses; and not so much in
observational studies of healthy natural human conception, but in IVF
studies,
human studies giving sub-groups with medical problems, animal AI studies,
and human and animal studies where ovulation or fertilisation were
manipulated to varying extents, and from which there is 'extrapolation'
and
'guess'.
In healthy human populations conceiving naturally, the decreased survival
rates related to delayed implantation rather than "ageing" gametes.
Atypical
cycles – a very vague term – deserve investigation rather than quotation
as
the norm, and cycle variations provide no problem to modern NFP.
The opening section shoehorns modern NFP in with a calculation-based
approach that no-one has advocated for 40 years, and later on Bovens
equates or identifies NFP with contraception in any form.
Whatever the disagreements about percentages and extrapolations, the
ethics
of natural conception cannot be decided on their basis.
In his later paragraphs on ethics, Bovens seems effectively to equate
early or
late foetal loss with induced abortion. This is compounded by his
suggesting
that foetal loss be regarded as a side effect of intercourse, if this is
in any way
"targeted". "Fanciful thought experimentation" follows, in which
particular
conditions are imposed on any double-effect consideration.
Conjecture is of use if it leads to clarification; but the only end result
here is a
construct whose practical meaning is to try to strip natural human
conceiving, if in any way informed, of any innocence or presumption of
good.
Comments to the paper of L Bovens “The rhythm method and embryonic
death“,
J. Med. Ethics 2006; 32:355-356
Dear Editor,
There is no evidence that a conceptus has reduced survival chances if
conception occurred on the fringes of the fertile period looking into data
concerning the first 6 weeks of pregnancy (see also (Raith, E, Frank, P.
et al. 1999; Freundl, G, Gnoth, C. et al. 2001; Frank, P., Freundl,...
Comments to the paper of L Bovens “The rhythm method and embryonic
death“,
J. Med. Ethics 2006; 32:355-356
Dear Editor,
There is no evidence that a conceptus has reduced survival chances if
conception occurred on the fringes of the fertile period looking into data
concerning the first 6 weeks of pregnancy (see also (Raith, E, Frank, P.
et al. 1999; Freundl, G, Gnoth, C. et al. 2001; Frank, P., Freundl, G. et
al. 1985). Also no association was found between aged spermatozoa and
early pregnancy loss (Wilcox, A. J., Weinberg, C. R. et al. 1998). In the
late 1980s, the issue of aging gametes and pregnancy outcomes was
thoroughly investigated, although the author does not seem to be aware of
this literature (Simpson, J. L., Gray, R. H. et al. 1988;Simpson, J. L.,
Gray, R. H. et al. 1997).
Bovens fails to make the necessary moral distinction between natural loss
of an embryo and loss caused by deliberate human intervention. Natural
Family Planning does not cause loss of the embryo, and is not intended to
do so. On the other hand, the oral contraceptive pill, the morning-after
pill, Norplant, and the IUD all may cause abortions because one of their
mechanisms of action is to impede implantation of the embryo in the
uterine endometrium.
Alcom (in the reference listed cited as Alcorn!!), who was cited in the
paper (Alcom, R 2005;Alcom, R and Larimore, WL 2006), stated that
regardless of the likelihood of implantation failure under such
circumstances, any such failure is spontaneous, not induced, and thus, for
Alcorn, is a miscarriage, which he does not consider ethically
problematic.
It is only at the very end of his paper that Bovens admits to the
possibility that his probabilistic arguments about the likelihood of
implantation failure can potentially be addressed by making the
distinction between artificially inducing an environment "in utero"
inhospitable to implantation vs. its natural occurrence as part of the
ovulatory cycle. But he fails to admit that Alcom makes this distinction
all along.
Boven’s first assumption that 50% of natural human conceptions are
lost is an often-repeated figure based on problematic research in 1956
using histological analysis of hysterectomies where intercourse was
encouraged prior to surgery. The higher figure of 78% often quoted rests
on a 1975 analysis of a hypothesis based on a series of weak assumptions.
In summary, we think that concerning the Natural Ethics of Harris
(see references in the article) the article fails to acknowledge the
distinction between natural loss and loss caused by deliberate human
intervention; common sense and every criminal law system recognises the
importance of knowledge and intent in human responsibility. In particular,
the fact that accidental deaths happen does not justify causing similar
deaths. Bovens adopts Harris’ perspective, that the knowledge that some
embryos will not naturally survive, amounts to convicting any couple then
continuing to conceive naturally of “destruction” of embryos.
Philosophically however it is even more problematic to think that people
cannot have a say by controlling their reproductive life. Technically we
can spend our whole life in bed trying to have babies, since every moment
that passes is an opportunity 'lost'. Indeed this in itself is a reductio
ad absurdum of Boven's argument.
Finally, I am concerned as such an article in a well known ethical
journal obviously influences various publications (Catholic News Service,
6/2006 and catholic news, 7 Jun 2006) to statements as such “…using
natural family planning to have only one or a maximum of two children is
nothing other than a kind of series of brief parentheses within an entire
conjugal life willingly made sterile". Bovens did not write it directly,
but his article paves the way for rejecting NFP as a method of family
planning for religious people as well. Is that what we want?
Reference List
1. Alcom,R. (2005) Does the birth control pill cause abortions?
Gresham, OR: Eternal Perspective Ministries, 50-73.
2. Alcom,R. and Larimore,W. (2006) Does the birth controll pill
cause abortions? The growing debate about the abortifacient effect of the
birth controll pill and the principle of the double effect. Ethics in
Medicine, in review.
3. Frank,P., Freundl,G., and Gray,R.H. (1985) [Natural family
planning. Introduction and epidemiologic studies] Gynakologe., 18, 224-
230.
4. Freundl,G., Gnoth,C., and Frank-Herrmann P. (2001) Freundl,G.
(ed), Kinderwunsch - Neue Wege zum Wunschkind. Gräfe und Unzer, München, 1
-289.
5. Raith,E., Frank,P., and Freundl,G. (1999) Raith-Paula,E., Frank-
Herrmann P., and Freundl,G. (eds), Natürliche Familineplanung heute mit
ausführlicher Darstellung der Zykluscomputer. Springer, Berlin, 1-273.
6. Simpson,J.L., Gray,R.H., Perez,A. et al (1997) Pregnancy outcome
in natural family planning users: cohort and case-control studies
evaluating safety. Adv.Contracept., 13, 201-214.
7. Simpson,J.L., Gray,R.H., Queenan,J.T. et al (1988) Pregnancy
outcome associated with natural family planning (NFP): scientific basis
and experimental design for an international cohort study.
Adv.Contracept., 4, 247-264.
8. Wilcox,A.J., Weinberg,C.R., and Baird,D.D. (1998) Post-ovulatory
ageing of the human oocyte and embryo failure. Hum.Reprod., 13, 394-397.
Luc Bovens’s assumption that intercourse on the fringes of the
fertile phase of the menstrual cycle by users of rhythm will result in
increased embryo loss is not based on convincing evidence (J Med Ethics,
2006;32:355-356). In fact, some scientific evidence points to the
opposite conclusion. Researchers at the US National Institutes of Health
Science reported they found no evidence for this associa...
Luc Bovens’s assumption that intercourse on the fringes of the
fertile phase of the menstrual cycle by users of rhythm will result in
increased embryo loss is not based on convincing evidence (J Med Ethics,
2006;32:355-356). In fact, some scientific evidence points to the
opposite conclusion. Researchers at the US National Institutes of Health
Science reported they found no evidence for this association based on
single acts of intercourse during the fertile window.(1) In a subsequent
study they did find a significant increase in pregnancy loss from acts of
intercourse on the estimated day of ovulation, but the study had severe
limitations due to imprecise timing of intercourse and in estimating what
acts of intercourse actually caused the pregnancy.(2) But neither of
these studies involved couples using rhythm or what is commonly known as
natural family planning (NFP).
Researchers from Johns Hopkins and Georgetown University conducted a
prospective study that included 373 unplanned and 367 planned pregnancies
which occurred from women who were taught natural family planning (NFP) at
5 centers worldwide. The researchers found no significant differences in
adverse pregnancy outcomes including spontaneous abortion rates between
the two groups of women.(3) Although these same researchers found some
evidence of poor pregnancy outcomes from unintended pregnancy compared to
NFP couples who intended pregnancy, the poor pregnancy outcomes were only
from couples who had a history of early pregnancy loss.(4) The largest
study to test the hypothesis that users of NFP with unintended pregnancies
have different pregnancy outcomes than couples that practice spontaneous
intercourse resulted in no difference in pregnancy outcomes.(5)
Bovens’s assertion about ageing gametes with use of rhythm and
resulting spontaneous embryo wastage is not new. In fact moral
theologians postulated this possibility in the 1970s.(6) Back then, their
assertions were based on poorly designed research studies and
circumstantial evidence. One of the studies was a thesis that involved a
retrospective assessment of parents of mentally handicapped children from
one Dutch village who were asked, up to 10 years later, to recall when the
conception intercourse occurred. These couples practiced a calendar-based
system of NFP, not the more modern methods that rely on biological markers
of fertility. The same researcher also provided circumstantial evidence
of an increase of Downs Syndrome by young Catholic mothers using NFP.(7)
Guerrero and Rojas tested the ageing gamete theory and seemed to show an
increase in the spontaneous abortion rate and possibly malformations based
on the recordings of the basal body temperature thermal shift and timing
of artificial insemination.(8) However, we now know that the thermal
shift is a very imprecise method of estimating the fertile phase, and
conclusions based on this biological marker are fraught with error. Poor
scientific studies result in poor outcomes and false conclusions.
Physiological mechanisms in the human being facilitate fresh gametes
for the process of fertilization. During the fertile phase of the cycle,
estrogen stimulated cervical mucus serves the purpose of filtering out
defective sperm. Only the most robust succeed in reaching the ovum.
Furthermore, the ovum is viable only about 12 – 24 hours. Approximately 50
-75% of spontaneous abortions are a result of chromosomal abnormalities of
the embryo, and most of these occur by chance.(9) How much of this
chromosomal damage is due to ageing gametes from intercourses on the
fringes of the fertile phase has not been documented. Other factors
contributing to early embryonic loss include uterine abnormalities,
immunologic disorders, bleeding disorders, endocrine disorders,
infections, and environmental factors such as smoking. The more
troublesome ageing factor is oocytes from older women, especially when
they have intercourse with older men. Women in modern developed countries
tend to delay (largely by use of hormonal contraception) having children
until later in life, often at an age when their fertility is in decline
and their oocytes are diminished and genetically old.(9,10)
In fact, it could be postulated that couples using hormonal
contraception will contribute to higher spontaneous abortion rates and
poorer pregnancy outcomes than couples using other forms of family
planning. Many couples who are on hormonal contraception will eventually
discontinue the contraceptive pill to achieve a pregnancy. (Please note
that couples do not stop using NFP when they want to achieve a pregnancy –
in fact, NFP helps couples to target the fertile phase). Couples who
discontinue hormonal contraception often experience irregular menstrual
cycles, delayed ovulation, longer follicular phases, and shortened luteal
phases.(11) Longer follicular phases and shortened luteal phases have
been cited as factors that could contribute to oocyte ageing and early
spontaneous embryo loss.(12) Millions of women discontinue hormonal
contraception each year to achieve a pregnancy. Should we ask them to
avoid achieving a pregnancy until their cycles normalize?
The highest probabilities of pregnancy from an act of intercourse
during the fertile window are the two days before the day of
ovulation.(13) We do know that there are factors that decrease this
probability such as poor quality cervical mucus, the age of the woman and
the man (not the age of the gametes), and smoking.(14,15) If you accept
absolute numbers of natural preimplantation losses of 50%, then it is
likely that these will occur much more (in absolute terms) with
intercourse during the days of highest fertility. That is, if 50% of all
zygotes fail to implant, since there are many more zygotes formed at days
of peak fertility, there will be many more failed implantations during the
high fertile time. This is true even if the percentage of failed
implantations on the extreme margins of the fertile period were to be
slightly higher (say 1% or 5% more) - a possibility that we can't entirely
exclude.
From an ethical standpoint, even if you hold to the assertion that
fertilization on the margins of the fertile time results in embryos loss,
that doesn’t mean NFP use is causing embryo deaths in any morally relevant
sense. Thisis the case for at least two reasons, first, intercourse at
these times is not unique to NFP users. Where is the evidence that NFP
users have intercourse on the edges of the fertile phase significantly
more than the general population? Research has indicated couples have
intercourse more frequentl on the weekend when there is more time and less
stress.(16) Weekend intercourse will result in intercourse anytime during
the fertile phase, including the fringes. Second, having intercourse at
these times does not equal doing anything (either “action” or "omission")
to the woman or the embryo to cause the embryo’s death – as is the case
when a woman uses an abortifacient drug or device. The parallel Bovens
tries to draw between the two cases just doesn’t work. The point is
basically the same as one would make in distinguishing between [non-
abortifacient methods of] contraception and NFP. They both avoid
fertilization, but contraception does so by doing something to the act of
intercourse – either an "action" or [in the case of withdrawal] an
"omission" – that takes away as much as possible of the fertility it would
otherwise have. NFP does nothing of the sort.
NFP helps couples to monitor, understand, and live with their
fertility. Contraception works to block, suppress, or destroy fertility --
actions that are contra fertility and, at times contra life. Fertility
for many couples is a precious and awesome gift. Human life is precious
and at the most vulnerable during the passage from the fallopian tubes to
the womb. The assumption that intercourse on the edges of the fertile
phase leads to the utilization of aged gametes and increased embryonic
destruction is plausible, but there is scant evidence of this among human
beings. The assumption that practicing NFP results in the use of aged
gametes and increased embryonic death has no good evidence and in fact
some good evidence to the contrary. The use of NFP is not an action or
omission against embryonic human life anymore than normal human living and
loving. Taking Bovens’s notion to the extreme would mean that couples
should not have intercourse at all – since, it might result in a
spontaneous abortion. Perhaps the real absurdity is the thinking that
what is natural is bad and what is destructive of fertility is good.
Separating sexuality from fertility is a dualistic system counter to
the natural intent of the sexual act. It only works in a fantasy world
with a false sense of sexual freedom by use of condoms, hormonal
contraception, emergency contraception, abortion as a backup, IVF when a
perfect child is wanted, and sterilization when fertility is no longer
desired. This dualism creates a false representation of human being, human
relations, human boding, and the transmission of human life.
References
1. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse
in relation to ovulation, effects on the probability of conception,
survival of the pregnancy, and sex of the baby. N Engl J Med,
1995;333:1517-1521.
2. Wilcox AJ, Weinberg CR, Baird DD. Post-ovulatory aging of the
human oocyte and loss of pregnancy. Hum Reprod, 1998;13:394-397.
3. Bitto A, Gray RH, Simpson JL, Queenan JT, Kambic RT, Perez A,
Mena P, Barbato M, Li C, Jennings V. Adverse outcomes of planned and
unplanned pregnancies among users of natural family planning: a
prospective study. Am J Public Health, 1997 Mar;87(3):338-43.
4. Gray RH, Simpson JL, Kambic RT, Queenan JT, Mena P, Perez A,
Barbato M. Timing of conception and the risk of spontaneous abortion
among pregnancies occurring during the use of natural family planning. Am
J Obstet Gynecol, 1995 May;172(5):1567-72.
5. Barbato M, Bitto A, Gray RH, Simpson JL, Queenan JT, Kambic RT,
Perez A, Mena P, Pardo F, Stevenson W, Tagliabue G, Jennings V, Li C.
Effects of timing of conception on birth weight and preterm delivery of
natural family planning users. Adv Contracept, 1997;13:215-28.
6. Haring B. New dimension of responsible parenthood. Theological
Studies, 1976:37:120-132.
7. Jongbloet PH. The ageing gamete in relation to birth control
failures and Down syndrome. Eur J Pediatr, 1985 Nov;144(4):343-7.
8. Guerrero R, Rojas OI. Spontaneous abortion and aging of human
ova and spermatozoa. N Engl J Med, 1975;293:573-575.
9. Speroff L, Fritz MA. Recurrent early pregnancy loss. Chapter in
Clinical Gynecology Endocrinology and Infertility. Phildelphia:
Lippincott Williams & Wilkins, 2005:1069-1101.
10. ESHRE Capri Workshop Group. Fertilty and ageing. Human Reprod
Update, 2005;11:261-267
11. Gnoth C, Frank-Hermann P, Schmoll A et al. Cycle characteristics
after discontinuation of oral contraceptives. Gynecological
Endocrinology, 2002;16:307-317.
12. Tarin JJ, Pérez-Albala S, Cano A. Consequences on offspring of
abnormal function in ageing gametes. Hum Reprod Updates, 2000;6:532-549.
13. Wilcox AJ, Dunson D, Baird DD. The timing of the "fertile
window" in the menstrual cycle: day specific estimates from a prospective
study. BMJ, 2000 Nov 18;321(7271):1259-62.
14. Dunson DB, Colombo B, Baird DD. Changes with age in the level
and duration of fertility in the menstrual cycle. Hum Reprod, 2002
May;17(5):1399-403.
15. Scarpa B, Dunson DB, Colombo B. Cervical mucus secretions on the
day of intercourse: an accurate marker of highly fertile days. Eur J
Obstet Gynecol Reprod Biol, 2006 Mar 1;125(1):72-8.
16. Wilcox AJ, Barid DD, Dunson DB, McConnaughey DR, Desner JS,
Weinberg DR. On the frequency of intercourse around ovulation: evidence
for biological influences. Hum Reprod, 2004;19:1539-1543.
Acknowledgements: I wish to thank Joseph Sanford, MD and Professor
Kevin Miller for ideas included in my response.
Combining children and gene therapy has the potential to precipitate
quite an
ethically volatile mix. Consent may be impossible to obtain from a child.
Yet,
if we require valid consent from all research subjects, then will there
not be
large groups of people, children included, in need of the benefits of
research
who will never get them? Thus we arrive at the conclusion that through
any
number...
Combining children and gene therapy has the potential to precipitate
quite an
ethically volatile mix. Consent may be impossible to obtain from a child.
Yet,
if we require valid consent from all research subjects, then will there
not be
large groups of people, children included, in need of the benefits of
research
who will never get them? Thus we arrive at the conclusion that through
any
number of philosophical arguments parents are able to consent for their
children. However, consent is only a small part of the picture.
Clinical equipoise must be satisfied for a trial to be ethical, and I
am not so
sure that it would be satisfied in a trial involving cystic fibrosis, gene
therapy,
and children. The authors mention that several other children who
underwent retroviral gene therapy for a different ailment developed
leukaemia. These children had life-threatening illnesses, but the
development of leukaemia seems to be quite relevant. It seems that the
onus
to prove, if possible, the children did not develop leukaemia as a result
of
retroviral gene therapy lies with the potential investigator of any
retroviral
gene therapy trial involving children.
The authors’ survey is interesting, because they themselves claim
there may
be significant risks associated with a gene therapy trial but make no
mention
of any risks in the survey. How can such a survey accurately reflect a
person’s attitudes towards gene therapy? Surely, if the risks were
clearly
explained on a consent form people would react quite differently.
While it is probably correct to claim that the research questions at
hand
cannot be answered in any other way that realization alone must not give
us a
scintilla of motivation for commencing retroviral gene therapy trials on
children with cystic fibrosis. Only after more evidence, be it indirect,
has
been gathered to demonstrate the safety of such a procedure should
clinical
trials begin. However, in the absence of the availability of such
evidence the
trials may be ethical.
For simplicity, I will assume (as I actually believe) that all human
embryos are
persons, since Bovens is trying to argue that granting this assumption,
the
use of rhythm or Natural Family Planning (NFP) is if anything more morally
problematic than the use of hormonal contraception, at least in respect of
embryonic death. Let me grant Bovens' empirical assumptions, though they
do not seem based...
For simplicity, I will assume (as I actually believe) that all human
embryos are
persons, since Bovens is trying to argue that granting this assumption,
the
use of rhythm or Natural Family Planning (NFP) is if anything more morally
problematic than the use of hormonal contraception, at least in respect of
embryonic death. Let me grant Bovens' empirical assumptions, though they
do not seem based on sufficient empirical data.
Now, there is nothing morally problematic about conceiving someone
who
will die. Otherwise, every case of human conception would be morally
problematic simply because human beings are mortal. When a conscientious
couple deliberately conceives a child, they presumably believe that it is
better
to conceive a child who will live and die than not to conceive a child at
all.
Clearly nobody has been wronged.
At the same time, it would be deeply morally problematic to conceive
a child
and to perform an additional act, before or after the conception, that
causes
the conceived human being's death. Consider a couple who to conceive a
child and deliberately inject the embryo or ovum with a time-delay toxin
that
would cause the child to die at some specified future point. It does not
matter whether the specified future point is in fourteen days, fourteen
years,
forty years or eighty years. The couple is directly responsible for the
death of
the human being, and as long as the death occurred at a time at which the
law accounted the child a person, the couple would presumably be legally
responsible at least for manslaughter. Someone is also clearly wronged
here:
Were the couple not to have injected the toxin, their child at least might
have
lived longer.
Likewise in a case where use of hormonal contraception has made the
uterus
inhospitable to implantation, the use of the hormonal contraception is an
act
additional to conception by which the woman has brought it about that the
child would be unable to survive more than about two weeks. Thus, the
woman is directly responsible for the inhospitable conditions that would
render implantation impossible or less likely.
Moreover, it seems at least possible that someone is wronged by this
act. It
seems possible that the child who was conceived at time A might have been
conceived at time A even had the contraception not been used, but would
then have been better able to implant.
Now in a case where uncontracepted sexual intercourse at a given time
leads
to a failure of implantation, a single act--intercourse--causes a human
being
to exist and to exist under conditions that make it impossible for the
human
being to survive more than about two weeks. But there is only one action
here, and a fairly direct result of this action is conception. It is
simply that
the conceived child is, we assume, certain to die within about two weeks.
The
couple is not directly responsible for the death, since the couple did not
create the conditions inhospitable to implantation.
Furthermore, nobody is wronged by this act. For the child conceived
at this
point in time, call the time A, would not have come into existence had the
couple abstained from the intercourse. Of course, if the couple engaged
in
intercourse at a different time, call it B, then perhaps the child
conceived then
would have lived longer. But that would have been a different child. By
having intercourse at time A rather than at B, the couple is not wronging
the
child they are conceiving, since that child is not worse off for being
conceived
and living for two weeks than for not being conceived at all. Nor are
they
wronging the child they would have conceived at time B, since one cannot
wrong someone who never exists. Moreover, there is no action the couple
could have done to give the child who actually comes to exist a chance to
live
a longer life. No one has been wronged.
A crucial assumption in my argument is that it is not worse to live
for two
weeks and die than not to live at all. A lot of pro-life people think
that a
human life, no matter its quality or length, is better than no life at
all, and
Bovens' argument was addressed to pro-life readers. But I can argue for
my
assumption even without regard for this controversial (though I think
correct)
pro-life position. For there are several things that are bad about the
typical
death of an adult human being. A typical list might be: (a) The human
being
is deprived of a future like ours, (b) various communities, friends and
family
are deprived of this human being's life, (c) the human being's plans and
desires are interrupted, (d) the human being suffers pain in dying (spiritual,
emotional and/or physical) and (e) friends, family and others suffer.
Now, when the human being who dies is an embryo, the bads are like
(a) and
(b), as well as like (e), but not like (c) and (d), since the embryo does
not seem
to have plans, desires or pains. The bads in (a) and (b) are indeed
serious.
However, they are not bads relevant to the question whether it would be
better to live for only two weeks or not to have lived at all. For (a)
and (b) are
deprivations of goods. And the goods in question, namely a future like
ours
and connection with various social networks, are lacking on both the
scenario
where the child lives for only two weeks after fertilization and on the
scenario
where no conception occurs. Thus the only relevant badness in the NFP
scenario is that in (e). But that is suffering that at most happens to
the
couple, and an informed and competent individual is the best judge whether
an instance of her suffering is worthwhile or not. Moreover, in practice,
the
couple does not know about the death of the embryo, and so the death does
not cause specific pain, though knowing that deaths might occur could
cause
a moderate amount of psychological pain over time.
Thus, there is nothing wrong with conceiving someone who will live
for only
two weeks after fertilization, as long as one had no way of conceiving her
in
such a way that she would have lived longer.
The pro-life objection to hormonal contraception is not to embryonic
death
per se, but to the causing of conditions inhospitable to embryos, embryos
that quite possibly (very difficult questions about identity are relevant
here)
could have lived longer were it not for these conditions.
I am very grateful to Professor Bovens for a number of enlightening
discussions.
Some of my critics draw a distinction between the rhythm method and
natural family planning (NFP). I take the rhythm method to be any method
that relies on abstinence around the time of ovulation. Of course there
are various ways to determine when ovulation occurs, including the
calendar method (Ogino Knauss), examining mucus (Billings) or checking
basal temperature (STM). I do not take this metho...
Some of my critics draw a distinction between the rhythm method and
natural family planning (NFP). I take the rhythm method to be any method
that relies on abstinence around the time of ovulation. Of course there
are various ways to determine when ovulation occurs, including the
calendar method (Ogino Knauss), examining mucus (Billings) or checking
basal temperature (STM). I do not take this method to cover the use of
barrier methods during the fertile period, as some definitions of both
‘NFP’ and ‘the rhythm method’ seem to permit. I find reports on success
rates for this method between 75% as the lowest number for typical use and
99.3% as the highest number for perfect use. Should one use numbers for
perfect use or for typical use in moral arguments? On the one hand, one
could say that a proponent of a method of contraception should not have to
take responsibility for people failing to follow proper instructions. But
on the other hand, recommendations are for real people and real people are
not perfect users. To postulate a 90% success rate does not seem to be
out of line with the available evidence. It is probably somewhat too low
for perfect use and somewhat too high for typical use.
If the method fails, then how does it fail? If the purpose is to
avoid having sex around the time of ovulation, then the following seem to
be reasonable answers. (1) The last time of having sex before the period
of abstinence was too close to ovulation. (2) The first time of having
sex after the period of abstinence was too close to ovulation. (3)
Ovulation was atypically early or late during some cycle and though the
users checked the markers for ovulation, they failed to determine its
occurrence accurately. Or a combination of (1) and (3) or of (1) and (2)
are also reasonable. Since we are talking about typical use, such
failures could be due to self-deception and wishful thinking. (1) raises
the problem of ageing sperm, (2) raises the problem of an ageing ovum and
(3) raises the problem of an atypical cycle.
Now comes the main empirical point of contention. For my argument to
work, it must be the case that the probability of viability given that a
conception occurs with ageing sperm or ovum or during an atypical cycle is
lower than the probability of viability given that a conception occurs
with fresh sperm and a fresh ovum and during a typical cycle. Both Mark
Witty and Anne Williams phrase the objection to this assumption very well.
"There is no evidence that there is any variability of viability of the
conceptus with time of fertilisation within this narrow window," writes
Williams. “Any conception is as viable as the next, barring a fatal
genetic or developmental defect; there is no truth to the 'old sperm' or
'old ovum' speculation...," writes Witty. So let us turn to the relevant
empirical literature.
Tarin et al. (2000) review a fifty-year literature not only on the
effect of ageing gametes on pre-menstruation embryonic loss, but also on
fertilization, spontaneous abortions and the pathology of the offspring.
A range of studies is reviewed of in vivo and in vitro fertilizations with
ageing gametes, involving humans, non-human mammalians, and non-mammalians. These studies are not always univocal. Furthermore, we often
have to extrapolate from non-human animal populations, in vitro contexts,
and patients with a history of infertility to what might be happening in
human populations of normal fertility in in vivo contexts. Sometimes the
best we can do is to guess what would provide the best explanation for
experimental results. Nonetheless, I do think that there is a trend
present which supports the idea that viability given conception may vary
with the age of the ovum, the age of the sperm and whether the cycle is or
is not typical.
As to ageing ova, I quote: "It appears that ... post-ovulatory ageing
of oocytes is associated with: (i) decreased potential of oocytes for
fertilization and pre- and / or post-implantation embryo/fetus development."
(Tarin et al., 2000: 544) Table 1 (Tarin et al., 2000: 533) contains a
range of studies documenting the effect of the ageing of the ovum on
embryo/fetus development and mortality. To pick one example, Wilcox et
al. (1998) study ovulation, hCG levels and intercourse patterns of a
cohort of women attempting pregnancy and find an increase in post-
implantation embryonic loss for intercourse on the day of ovulation in
human populations. Considering the time-lag between intercourse and
fertilisation, these data support the hypothesis that post-ovulatory
ageing of ova compromises embryonic survival. (I should add that Wilcox
et al. (1998) do not record any conceptions from intercourse after the day
of ovulation.) Wilcox et al. (1999) compare late implantations and early
implantations. Late implantations have levels of embryonic loss that are
radically higher (82% after day 11) than early implantations (13% up to
day 9) . However, it is not known what causes these late implantations.
As to old spermatozoa, I quote from Tarin et al., 2000: 544:
"Likewise the ageing of spermatozoa in ... the female reproductive tract ...
is associated with decreased ... potential for fertilization and pre- and/or
post-implantation embryo/fetus development." Table 2 contains entries
with articles documenting the effect of in vivo ageing of spermatozoa in
the female genital tract and increased embryo/fetal mortality with ageing
spermatozoa. Tarin et al. (2000: 542) write: "This notion is supported by
the high mortality rate observed in embryos/fetuses derived from sperm
aged in stagnant environments, e.g in ... the] female reproductive tract."
Parkening and Soderwall, in a study of golden hamsters, write that their
data "indicate that inseminated spermatozoa are capable of penetrating the
zona pellucida and fertilizing some ova after residing 14 to 16 h within
the female reproductive tract, but that the viability of ova fertilized in
this manner is greatly reduced." (1975: 627-8) There are supporting
results about golden hamsters in Bell and Shaver (1982). Vishwanath and
Shannon find that after storage, bull sperm may retain its "oocyte
penetrating ability", yet "mitochondrial DNA damage and chromosomal
abnormalities" could "compromise the viability of the resulting
conceptus." (1997: 321-32)
One might conjecture that if there is a higher rate of early
embryonic loss in conceptions involving ageing gametes, then there would
also be a higher rate of spontaneous abortions. Gray et al. (1995: 1568)
cite a number of studies that confirm this finding. However, in his own
study, he does not find a difference in the spontaneous abortion rate for
conceptions resulting from intercourse on the day before or on the day of
ovulation on the one hand and from intercourse outside this narrow window
on the other hand within the total population. There is however a
significant difference in the spontaneous abortion rate in the
subpopulation of women who have had spontaneous abortions before. There
is no conclusive interpretation of these results.
Let us now turn to atypical cycles. There are many open questions
here and much of my evidence comes from consulting with researchers in the
field. Implantation rates are dependent on the nature of the embryo and
the development of the endometrium. In IVF (in vitro fertilisation),
ovulation is timed carefully by adjusting drug dosages so that it comes
neither too early nor too late. This might indicate that the quality of
the ovum could be a function of ovulation time and since we can control
for fertilisation in IVF, the concern is a concern about the viability of
the embryo. In IUI (in utero insemination), some doctors will refrain
from inseminating in case of an early ovulation. This might indicate that
the quality of the ovum is compromised when there is early ovulation or
that a short follicular phase may compromise the development of the
endometrium. Early ovulation is believed to correlate with higher rates
of oocyte aneuploidy leading to more pre- and post-implantation embryonic
loss due to chromosal abnormalities. About late ovulations, Tarin et al.
(2000: 535) write that "...under particular circumstances, including long
follicular phases ... fully grown GV oocytes may undergo pre-ovulatory
ageing before the occurrence of the endogenous LH surge ..." (2000: 535) He
also presents a list of studies documenting the effect of pre-ovulatory
ageing on fertilization, the development of the embryo and the offspring.
(2000: 534)
Whitty objects to my use of the figure of 50% of embryonic loss,
claims that such high figures are based on old and questionable studies
(from 1956 and 1975), and that animal studies give single-digit
percentages. A standard source for embryonic mortality is Edmonds (1982).
Edmonds assesses embryonic loss by the appearance and disappearance of hCG
in the urine at the time of implantation and presents a figure of 62%.
This underestimates the actual percentage since it does not count pre-implantation loss. In Wilcox et al.'s study (1999) the pre-menstruation
embryonic loss plus miscarriages is at 33%. Why is there this
discrepancy? The only explanation that I can see is that Edmonds samples
from a normal population, whereas Wilcox restricts his population to
couples without previous fertility problems. In any case, considering
that this does not measure pre-implantation loss, a figure of 50% for
normal populations does not seem outlandish in the face of these data.
So far I have tried to defend the assumptions that come into the
model. But of course, it is another thing to check whether the
predictions of the model hold true in the real world. Clearly we know too
little to fill in the values of all the parameters. It may be the case
that, say, the viability given conception is variable, but this
variability is not sufficiently great to obtain meaningful differences
between embryonic death rates for condom users and NFP users. Or there
can be hidden variables that are not included in the model. In principle,
it is possible to do the following empirical test. One could compare post
-implantation embryonic loss rates between condom users and NFP users by
checking for hCG in urine tests. However, in practice, this would require
quite a large number of subjects, because in any given cycle, there would
only be a relatively small number of conceptions. This would be one step
forward, but it would still not yield information about pre-implantation
embryonic loss, because hCG does not register in the woman’s blood or
urine before implantation.
Let us turn to the philosophical objections. My critics claim that
even if I were right about the empirical data, there would still be a
moral divide between NFP and contraceptive pills, because the embryonic
deaths occurring on NFP would be "natural deaths" whereas the deaths
occurring on contraceptive pills would be "induced deaths", in Ira
Winter’s words. Justin and Sue Fryer talk about "letting nature take its
way" versus "deliberately taking action by swallowing a pill, or other
means, to end the life of an embryo". And Mark Whitty points to the
relevance of the doctrine of double effect.
These are difficult issues that require a much more careful analysis
than what I can offer at this point. Let us clearly bracket the empirical
issues from the philosophical issues. My critics say that even if I were
right about the empirical details, then we could still invoke the
action/omission doctrine or the doctrine of double effect to draw a
distinction between NFP and contraceptive pills. So let us not quibble
about empirical data from here on and suppose—to make things simple—that a
particular implementation of NFP and a particular contraceptive pill,
would lead to the same number n of conceptions, lead to the same number of
embryonic deaths d, and lead to the same number of live births m. And let
us suppose that condoms lead to the same number m of live births but with
fewer conceptions and hence fewer embryonic deaths. A final alternative
is abstinence with carefully targeted pregnancies, leading to m life
births with even fewer conceptions and even fewer embryonic deaths.
Let us do the following admittedly fanciful thought experiment.
Suppose that conceptions always lead to live births. However, all these
contraceptive techniques would have the same mechanisms and consequences
as they now have, substituting neonatal death for embryonic death. So a
contraceptive pill user would have n conceptions, n live births, but d
deaths of newborns and hence only m children that survive for longer than,
say, one week. Similarly for NFP, condom usage and abstinence with
targeted pregnancies. Would there not be an outcry about any method that
would have an excessive neonatal death rate? Could we defend NFP on
grounds that the deaths of these newborns is just nature’s way or on
grounds that these deaths are not intended? I don’t think so. If embryos
have the same moral status as newborns, then why would we think that we
can put up such defences for NFP involving embryonic death?
Now I am a friend of the action/omission doctrine and the doctrine of
double effect. For example, as to the action/omission doctrine, I do
agree that one has to have better reasons—i.e. the prognosis has to be
worse—before one is justified to withdraw treatment (action) rather than
withhold treatment (omission). As to the doctrine of double effect,
suppose that I can advance the war effort to the same extent by target
bombing, say, by bombing a depot, while expecting to kill n innocent
civilians living around the depot as collateral damage, as by terror
bombing, say, by bombing a neighbourhood with the intention of killing n
innocent civilians. I do agree that terror bombing is worse than target
bombing. But just to say that bad effects did not come about due to
direct agency or were not intended is not sufficient to make a practice
permissible on the action/omission doctrine or on the doctrine of double
effect. The bad effects also have to be outweighed by the good effects
and furthermore, there must be no other practice (in which the bad effects
do not come about due to direct agency or were not intended) that achieves
the same good effects while incurring fewer bad effects.
Further to the action/omission doctrine: There is a continuum between
agency (say, a direct killing of an embryo) and an omission (say, not
providing a drug that would prevent a miscarriage). Now one might argue
that, on this continuum, "taking a pill so that fertilisation is unlikely
to occur or so that the endometrium is inhospitable for incoming embryos"
is more on the action side than "organizing your sex life so that
fertilisation is unlikely to occur or so that embryos are either non-viable or come in at times when the endometrium is not hospitable". But
is the distance on this continuum sufficiently great to make the former
qualify as a grave sin and the latter as a morally permissible method of
birth control? I am not convinced. Maybe it is worse to remove edible
plants and animals from an island to make it inhospitable and then to drop
off someone on it than to carefully pick a time of the year to drop off
someone when you know the island not to be hospitable for human
habitation. But really, is it that much worse? And furthermore, even if,
given our assumptions about the numbers, contraceptive pills are worse
than NFP on action/omission grounds, then would one not want to reverse
this judgment if embryonic death rates for NFP would come to exceed
embryonic death rates for contraceptive pills to a sufficient degree?
Clearly we carry some responsibility for the consequences of our
omissions. If embryonic deaths are a bad thing, then should we not try to
minimize them? Indeed, we should take due care, also in our omissions.
And, given my assumptions, there are alternatives available, viz. condoms
and abstinence with targeted conceptions, that come at a lower embryonic
death rate.
I have two concerns with invoking the doctrine of double effect.
Clearly it is not enough to say that an NFP user does not intend the
embryonic death. This would get a pill user off the hook. She could just
say that she only intends to block ovulation by taking this pill and
furthermore she intends this as a means not to become pregnant. A
proponent of the doctrine of double effect would just say to the pill user
that if embryonic death were not to occur she would shoot short of her
target – there would simply be more pregnancies. Embryonic death is
integral to reaching her goal while, say, the deaths of innocent civilians
in target bombing are not. But the same response holds for the NFP users.
Without the embryonic deaths, there would be more pregnancies.
Secondly, target bombing would be no longer permissible if there were
another way to gain the same military advantages at a lower cost in the
lives of innocent civilians. But is this not what we are facing in the
case of NFP? There are alternative ways to gain the same advantages at a
lower cost of embryonic deaths, e.g. by condom use. Now I realize that
there may be independent grounds for opposing condom use as a malum in se,
but then there is the possibility of abstinence with targeted conceptions.
Granted, the gains of sex are lost in abstinence, but do they weigh up
against embryonic deaths?
Clearly there are many open questions in this area. And I have not
even touched on questions about the status of the embryo. These are not
only questions in the context of the pro-life versus pro-choice debate.
For instance, some critics have pointed out that many of my embryonic
deaths are deaths of defective embryos and defective embryos are not
possible persons. Other critics have claimed that embryonic deaths as
such are not a bad thing, but that killing an embryo is nonetheless a
wrong action. Many such questions remain unexplored.
My intention here was to point out that an appeal to the
action/omission doctrine or the doctrine of double effect does not
straightforwardly block the argument. Maybe it can be blocked. To make
headway on this issue will require some serious thinking and constructive
dialogue.
Let me take this occasion to thank my critics in JME, e-mail
correspondents and bloggers for their thoughtful comments. I am also
grateful for helpful (e-)conversations with Roger Gosden, Kathy Hoeger,
Kathy King, Michael Otsuka, Alexander Pruss, Danny Schust, Alan Thornhill,
and Alex Voorhoeve.
References
Bell, C.L. and Shaver E.L. (1982) Analysis of preimplantation golden
hamster conceptuses resulting from spermatozoa aged in utero. Gamete Res.,
6: 199-207.
Edmonds, D.K., Lindsay, K.S., Miller, J.F. Williamson, E. and Wood,
P.J. (1982) Early embryonic mortality in women. Fertil. Steril., 38, 447-
53.
Gray, R.H., Simpson, J.L., Kambic, R.T., Queenan, J.T., Mena, P.,
Perez, A. and Barbato, M. (1995) Timing of conception and the risk of
spontaneous abortions occurring during the use of natural family planning.
Am. J. Obstet. Gynecol., 172, 1567-72.
Parkening, T.A. and Soderwall, A.L. (1975) Delayed fertilization and
preimplantation loss in senescent golden hamsters. Biol. Reprod., 12, 618-
31.
Tarin, J.J., Perez-Albala, S. and Cano, A. (2000) Consequences on
offspring of abnormal function in ageing gametes. Hum. Reprod. Update, 6,
532-49.
Vishwanath, R. and Shannon, P. (1997) Do sperm cells age? A review of
the physiological changes in sperm during storage at ambient temperature.
Reproduction, Fertility and Development, 9, 321-32.
Wilcox, A.J., Weinberg, C.R. and Baird, D.D. (1998) Post-ovulatory
ageing of the human oocyte and embryo failure. Human. Reprod., 13, 394-7.
Wilcox, A.J., Baird, D.D. and Weinberg C.R. (1999) Time of
implantation of the conceptus and loss of pregnancy. N. Engl. J. Med.,
340, 1796-99.
Bovens' argument is clever, but it misrepresents Alcorn, and pro-lifers in general, as being concerned about the absolute number of embryonic deaths without distinction as to the cause. But even a cursory reading of Alcorn (e.g.
http://www.epm.org/articles/bcp5400.html) makes it clear that Alcorn's concern is not embr...
Bovens' argument is clever, but it misrepresents Alcorn, and pro-lifers in general, as being concerned about the absolute number of embryonic deaths without distinction as to the cause. But even a cursory reading of Alcorn (e.g.
http://www.epm.org/articles/bcp5400.html) makes it clear that Alcorn's concern is not embryonic death in general, but induced embryonic death: Alcorn merely applies the customary ethical distinction between induced abortion and miscarriage to the situation of a fertilized embryo facing implantation.
Alcorn argues that the use of forms of contraception that create an environment "in utero" inhospitable to implantation (IUD, pill) in so doing induces the death of the embryo (which cannot survive long without implantation), making it ethically comparable to induced abortion. In response, Bovens argues that implantation failures can also conceivably occur when periodic abstinence is being used to avoid pregnancy. However, the convoluted probabilistic arguments Bovens uses to estimate how likely implantation failure might occur, arguments that make up the bulk of the paper, are quite beside the point: regardless of the likelihood of implantation failure under such circumstances, any such failure is spontaneous, not induced, and thus, for Alcorn, is a miscarriage, which he does not consider ethically culpable.
It is only at the very end of his paper that Bovens admits to the possibility that his probabilistic arguments about the likelihood of implantation failure can potentially be addressed by making the distinction between artificially inducing an environment "in utero" inhospitable to implantation, vs. its natural occurrence as part of the ovulatory cycle. But he fails to admit that Alcorn makes this distinction all along; Bovens merely states that he thinks the distinction asks "more from the action/omission doctrine than it can deliver", and leaves it at that. But if Bovens is serious about addressing Alcorn, it is here that his paper should start, not end.
I have two comments to make with regard to the article about the
rhythm
method. It is not true that the Catholic Church only approves the
“rhythm”
method of family planning. It approves all natural methods and especially
the
Billings Ovulation Method of natural fertility regulation that has a
better than
99% effectiveness rate, as shown in numerous recent published studies.
(www.woomb.org)...
I have two comments to make with regard to the article about the
rhythm
method. It is not true that the Catholic Church only approves the
“rhythm”
method of family planning. It approves all natural methods and especially
the
Billings Ovulation Method of natural fertility regulation that has a
better than
99% effectiveness rate, as shown in numerous recent published studies.
(www.woomb.org)
On a philosophical level L. Bovens’ argument is flawed in trying to
equate
natural miscarriages with induced abortion of a healthy embryo. A ten
year
old child would be able to see the moral distinction between nature taking
its
course as in the case of a miscarriage and deliberately taking action by
swallowing a pill, or other means, to end the life of an embryo.
This article on Reproductive Ethics is unfortunate in a number of
respects,
and while I would not identify with the pro-life movement of the article,
I feel
it necessary to respond from the standpoint of a proponent of the modern
Billings Ovulation Method of Natural Family Planning (NFP).
NFP Methods Bovens seems to choose to reduce all NFP to one approach, the
defi...
This article on Reproductive Ethics is unfortunate in a number of
respects,
and while I would not identify with the pro-life movement of the article,
I feel
it necessary to respond from the standpoint of a proponent of the modern
Billings Ovulation Method of Natural Family Planning (NFP).
NFP Methods Bovens seems to choose to reduce all NFP to one approach, the
definitively
obsolete Rhythm Method. This alone renders the basis of the article’s
moral
extrapolations to all NFP at best inappropriate, and signals that the
“plausible
empirical assumptions” on which much else in the article is based are
inapplicable to current NFP use.
Boven’s second assumption is correct only in the sense that the obsolete
rhythm method was a statistical calculation, and intercourse on days
adjacent
to the required abstinence phase’s limits could in a minority of cases
result in
conception, because that method failed to recognise the natural variation
of
cycles, which almost all current NFP methods do. It is not correct,
however, as
a basis for what follows in the article.
Physiology Boven’s first assumption that 50% of natural human conceptions are
lost is an
often-repeated figure based on problematic research in 1956 (1) using
histological anaysis of hysterectomies where intercourse was encouraged
prior to surgery. The higher figure of 78% often quoted rests on a 1975
analysis (2) of an hypothesis based on a series of weak assumptions.
Animal
studies commonly give percentages in single figures.
Boven’s third assumption is wholly invalid in the light of current
knowledge of
human reproductive physiology. The ovum lasts for about 12 hours, 24 at
most; sperm may last up to 3-5 days with the support of both the
appropriate types of cervical mucus and of the activity of the cervical
crypts.
Any conception is as viable as the next, barring a fatal genetic or
developmental defect; there is no truth to the old “old sperm” or “old
ovum”
speculation, or its “twice as likely to be viable”, “lack resilience” and
“reduced
survival chances” assumption.
Neither is there any truth in the “heightened fertility (HF)” and ‘tail-
end
fertility” idea, with or without further speculative assumptions about
extrapolated comparative embryonic viability based on this innacuracy. A
luteal phase of less than 11 days may be insufficient to sustain a natural
conception, but this is a case for medical intervention. So all that
follows
based on the HF and other assumptions is invalid.
His fourth point of counter-argument depends on the idea that natural
conception could be timed in NFP use for when the endometrium is
inhospitable to an embryo; this is physiological nonsense. The symphony of
ovulation-related events ensures that the endometrium is ready for
implantation until when either the corpus lutem expires or ßHCG is
produced.
It is a complete fallacy to assert, even in regard to the obsolete rhythm
method, that any NFP methods “depend for their successes on massive
embryonic death”.
Natural Ethics, Harris The article fails to acknowledge the distinction between natural loss
and loss
caused by deliberate human intervention; common sense and every criminal
law system recognise the importance of knowledge and intent in human
responsibility; in particular, the fact that accidental deaths happen does
not
justify causing similar deaths.
Bovens adopts Harris’ perspective, that the knowledge that some embryos
will not naturally survive, amounts to convicting any couple then
continuing
to conceive naturally of “destruction” (3) of embryos. This is a thesis
open to
redutio ad absurdum, and rests on Harris’ having dismissed to his
satisfaction the double effect principle patently used universally in
daily life
and medical practice.
Probability Calculus Any mathematical model’s results based on inaccuracies and guesses
are
misleading; the comparative scale of embyonic loss is baseless because the
fundamental assumption in regard to NFP and embryo survival is
unsupported by the evidence.
Alcorn The article’s use of Alcorn is open to question. He proposed an
“infinitesmal”
small proportion (0.01%) of pill-use cycles resulting in a conception lost
due
to pill use, to provide a minimum statistic for purposes of illustration
and
contrast. Bovens takes Alcorn’s minimal estimate and uses it as if it were
fact
in regard to embryo loss on the combined oral contraceptive pill, so that
his
supposed “loss” with use of the rhythm method seems huge by comparison.
What is known is that older formulations of the pill allowed breakthrough
ovulation in 2-10% , (4,5) or 4.7% (6) of cycles, and about 27 cycles per
100
women per year in later studies (7). Progesterone preparations have higher
ovulation rates, and the IUD still higher. Recording or calculating a
‘conception and loss rate’ for these cycles is another matter.
Condom use statistic Any manufacturer would be delighted to be able to claim a 95% use-effectiveness for his condom. 88% is more usually quoted as an average
figure.
“can this argument be blocked?” The first point is in fact valid; the article’s embyonic death
proposition is
untenable, being based on ignorance and error in physiology – sadly not
unique to Bovens.
The second point seems to call abortion an action but the use of an IUD a
form of omission; ensuring that implantation will not occur (to put it
graphically) is not “not providing the right environment for embryonic
growth”.
The third point conflates OCP use and NFP use from a moral standpoint in
continuing the incorrect assumption that NFP is a “mixed” contraceptive
approach involving the loss of embryos.
The fourth point involves the physiological fallacy that a natural
conception
could be timed for when the endometrium would be unsupportive of its
implantation, and a repetition of the mis-application of “the
action/omission
doctrine”.
The conclusion This article is anything but a reductio ad absurdum of anybody’s
cornerstone.
In regard to factual accuracy (8) and undestanding of its bases in NFP and
physiology, it is itself unfortunately based on the absurdum.
Dr Mark Whitty, MSc; Dublin, Ireland.
References
(1) Hertig AT, Rock J, et al: A description of 34 human ova within
the first 17
days of development. AJAnat 98; 435-493, 1956.
(2) Roberts CJ, Lowe CR: Where have all the conceptions gone? Lancet
1;
498-499, March 1 1975.
(3) Harris J: Stem cells, sex and procreation. Camb Q Healthc Eth12,
353-371,
2003; (page 364).
(4) Peel J, Potts M: Textbook of Contraceptive Practice, Cambridge UP
1969.
(6) Van der Vange N: Ovarian activity during low dose oral
contraceptives. In
Chamberlain G ed: Contemporary Obstetrics and Gynaecology, Butterworths
London 1988 pp 315-326.
(7) Grimes DA, Goodwin AJ et al: Ovulation and follicular development
associated with the low-dose oral contraceptive; a randomised controlled
trial. Obstet Gynae 1994 83 1; 29-34.
(8) For information on physiology and NFP, the best single source is
the
website www.woomb.org . Articles such as “Correlating the Signs and
Symptoms of Fertility at the Vulva and Vagina” and “The Continuum” provide
good summaries of decades of collaborative research. There are several
summaries of effectiveness studies on the site.
I'd like to respond to the article by L Bowens you printed in 2006,
Vol. 32:355-56.
1. The rhythm method has been out of date for decades.
2. The rhythm method was not a form of contraceptive. It was based on
abstinence during fertile periods. (Admittedly its method for calculating
those was flawed, hence point 1). Nevertheless pregnancy does not result
from abstinence.
I'd like to respond to the article by L Bowens you printed in 2006,
Vol. 32:355-56.
1. The rhythm method has been out of date for decades.
2. The rhythm method was not a form of contraceptive. It was based on
abstinence during fertile periods. (Admittedly its method for calculating
those was flawed, hence point 1). Nevertheless pregnancy does not result
from abstinence.
3. Users of NFP only differentiate between fertile and infertile days.
There is nothing half way, such as less fertile days. Couples engaging in
sex during fertile days know to expect a pregnancy. Assumptions that they
hope for or expect embryonic death (by engaging in sex on so called less
fertile days surrounding high fertile days) are absurd.
4. The author does not differentiate between natural death and induced
death.
Dear Editor,
A response to Bovens' reply to his critics.
Readers generally would have thought the original article to be about early embryo loss and NFP. The Response of 12th June seem to have moved on somewhat from this.
Rather than keeping to early embryo loss, Bovens now provides figures giving overall observed and estimated embryo losses; and not so much in observational studies of healthy...
Comments to the paper of L Bovens “The rhythm method and embryonic death“, J. Med. Ethics 2006; 32:355-356
Dear Editor,
There is no evidence that a conceptus has reduced survival chances if conception occurred on the fringes of the fertile period looking into data concerning the first 6 weeks of pregnancy (see also (Raith, E, Frank, P. et al. 1999; Freundl, G, Gnoth, C. et al. 2001; Frank, P., Freundl,...
Dear Editor,
Luc Bovens’s assumption that intercourse on the fringes of the fertile phase of the menstrual cycle by users of rhythm will result in increased embryo loss is not based on convincing evidence (J Med Ethics, 2006;32:355-356). In fact, some scientific evidence points to the opposite conclusion. Researchers at the US National Institutes of Health Science reported they found no evidence for this associa...
Dear Editor,
Combining children and gene therapy has the potential to precipitate quite an ethically volatile mix. Consent may be impossible to obtain from a child. Yet, if we require valid consent from all research subjects, then will there not be large groups of people, children included, in need of the benefits of research who will never get them? Thus we arrive at the conclusion that through any number...
Dear Editor,
For simplicity, I will assume (as I actually believe) that all human embryos are persons, since Bovens is trying to argue that granting this assumption, the use of rhythm or Natural Family Planning (NFP) is if anything more morally problematic than the use of hormonal contraception, at least in respect of embryonic death. Let me grant Bovens' empirical assumptions, though they do not seem based...
Dear Editor,
Some of my critics draw a distinction between the rhythm method and natural family planning (NFP). I take the rhythm method to be any method that relies on abstinence around the time of ovulation. Of course there are various ways to determine when ovulation occurs, including the calendar method (Ogino Knauss), examining mucus (Billings) or checking basal temperature (STM). I do not take this metho...
Dear Editor,
Bovens' argument is clever, but it misrepresents Alcorn, and pro-lifers in general, as being concerned about the absolute number of embryonic deaths without distinction as to the cause. But even a cursory reading of Alcorn (e.g. http://www.epm.org/articles/bcp5400.html) makes it clear that Alcorn's concern is not embr...
Dear Editor,
I have two comments to make with regard to the article about the rhythm method. It is not true that the Catholic Church only approves the “rhythm” method of family planning. It approves all natural methods and especially the Billings Ovulation Method of natural fertility regulation that has a better than 99% effectiveness rate, as shown in numerous recent published studies. (www.woomb.org)...
Dear Editor,
This article on Reproductive Ethics is unfortunate in a number of respects, and while I would not identify with the pro-life movement of the article, I feel it necessary to respond from the standpoint of a proponent of the modern Billings Ovulation Method of Natural Family Planning (NFP).
NFP Methods
Bovens seems to choose to reduce all NFP to one approach, the defi...
Dear Editor,
I'd like to respond to the article by L Bowens you printed in 2006, Vol. 32:355-56.
1. The rhythm method has been out of date for decades.
2. The rhythm method was not a form of contraceptive. It was based on abstinence during fertile periods. (Admittedly its method for calculating those was flawed, hence point 1). Nevertheless pregnancy does not result from abstinence.
3....
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