C.

Thompson

Dr. Hazel Markwell

THO 2315

2 November 2023

Uncertainty in Medicine: Emergency Post-Rape Contraception

Moral problems tend to come in one of two varieties: either unintuitive situations in

which it is not obvious how more general moral axioms should be applied, or a situation where

some crucial information is missing but one must still make a moral decision in its absence. The

latter kind of quandary is especially prominent in medicine because of both the uncertainty that

comes with empirical, scientific investigation as well as the practical unknowns that accompany

ordinary healthcare. One can find these kinds of medical uncertainty in all sorts of everyday

healthcare situations, but they become particularly thorny when a given medical procedure, like

emergency contraception after rape, potentially risks someone’s life (in this case, a possible

unborn child of the victim). If emergency contraception is not abortifacient, and if a given rape

victim is pregnant, then knowingly administering EC is harmless – but those “if’s” are uncertain,

and therein lies the rub. What degree of uncertainty should we be willing to allow before the

risks become to great to permit? I aver that we can allow some uncertainty, but that the amount

of uncertainty we tolerate depends on the kind of uncertainty in question, the precise nature of

the medical operation, and the applicability of the doctrine of double effect.

Before we can decide how much uncertainty to allow in the case of EC as well as any

other medical problem involving uncertainty, it bears examining in further detail scientific

uncertainty, moral uncertainty, and what makes them different. The modus operandi of the
natural sciences is, ultimately, sense-experience, since the object of the natural sciences is the

physical world, which is properly known through the senses. It is because the natural sciences

depend on the senses that they are uncertain, for the senses can be easily mislead in questions of

great precision and detail, and the sensible evidence of some physical thing can prove obscure or

indetectable without the aid of special technologies (that may or may not exist). Moreover, as

Sulmasy explains in his article, “Science, particularly biomedical science, is inherently

probabilistic and fraught with irreducible uncertainty…much of what medicine claims to know is

provisional; and much of that is statistical—knowing that something is the case 1 percent or 10

percent or 99 percent of the time” (308). There is no universal or purely objective way to decide

whether the probability of X leading to Y is significant enough to prove a causal link between X

and Y; instead, scientists attempt to reach a consensus in their respective fields about which

probabilities are important and which are negligible. Moral uncertainty is very similar to

scientific uncertainty, as in many situations the limitations of sense-experience prevent us from

knowing whether our actions will yield certain desirable or undesirable effects.

Now, the uncertainty in the use of emergency contraceptives after rape is twofold. First,

as Sulmasy explains, there is some scientific uncertainty in the workings of emergency

contraception drugs, namely, whether and to what extent they prevent pregnancy by “prevention

of sperm capacitation, decreased sperm motility, sperm trapping, changes in cervical mucus,

prevention of chemical attraction of the sperm by the unfertilized egg,…the prevention of

ovulation” (which, being merely contraceptive, is permitted by the consensus of orthodox

Catholic theologians in the case of rape), or “by preventing implantation” (thereby being

abortifacient, and making the prescription of EC the commission of murder) (309). Note, as

Sulmasy takes pains to emphasize, that these mechanisms are not mutually exclusive; rather,
most drugs operate through several different mechanisms acting simultaneously (309). Based on

his review of the medical literature on EC, Sulmasy believes that there is an extremely small but

non-zero chance that EC drugs are abortifacient (310). Secondly, there is the physician’s

“practical uncertainty” (that is, moral uncertainty) of whether a given rape victim is pregnant,

and of what probability there is that the EC drugs will induce abortion in the potentially pregnant

woman; pregnancy tests, and to a much lesser extent, ovulation tests (which have their own small

risk of inducing abortion), mitigate this uncertainty to various degrees, but they are limited to

testing for indirect indications of conception (e.g., implantation) and are not absolutely effective

(310). Sulmasy estimates, using Bayesian inference and based off of relevant medical statistics,

that there is around a 1 in 2500 to 4 in 2500 chance that EC drugs will induce abortion following

the “pregnancy method” (testing for pregnancy, then administering EC should the test turn out

negative), and at the very least a 1 in 25,000 to 4 in 25,000 chance that they will induce abortion

following the “ovulation method” (testing for pregnancy and ovulation, then administering EC if

both tests are negative) (311-312). From these figures, there seems to be decidedly little

uncertainty in the use of emergency contraception. The scientific consensus on EC is that there is

next to no evidence that EC drugs are abortifacient (310), and Sulmasy says that the 1 in 2500

chance of a physician inducing abortion in a rape victim through the use of EC drugs would be

widely recognized by doctors and medical scientists to be “clinically unimportant” (318-319).

To what degree, however, can we allow even so little uncertainty in questions of life or

death, as in the use of EC drugs where there remains the small possibility that an unborn child

might be killed? One could always say that no act, no matter how well-intentioned, can be

committed which could even possibly endanger a human life. This is absurd, however, because

countless acts which could possibly, and do frequently, end in unintended human death are
tolerated and even commended. Driving, for instance, is one of the deadliest killers in the world

– and inevitably so: the high speeds of cars, their mass, the impossibility for a driver to be aware

of all his surroundings at once, the many other drivers, pedestrians, and cyclists who share the

road, the slowness of human reflexes, and the frequent poor driving conditions brought on by the

weather mean drivers will be irreducibly uncertain, in Sulmasy’s terms, as to whether or not their

commute will end in someone’s death. Similarly, soldiers risk killing their fellows in the

confusion of the battlefield where it becomes difficult to tell friend apart from enemy. Yet most

would say that the soldier is still justified in fighting despite his uncertainty.

The doctrine of double effect (which, incidentally, Sulmasy invokes at one point in his

article) makes sense of our moral intuition that many acts are permissible even though they cause

death or other evils. As it is usually formulated, the doctrine of double effect states that it is

permissible to commit an act which has a foreseen undesirable side effect for the sake of a good

effect, so long as the act is itself either good or neutral, and so long as the evil side effect is

unintended but reluctantly permitted by the agent, proportionate to the good attained, and merely

incidental to the act rather than the means through which the good end is accomplished

(McIntyre). The classic example of this is self-defence: it is perfectly legitimate, or indeed

positively good, to prevent someone from maiming or killing oneself by striking at them, even if,

as an unintended consequence of one’s purely defensive blow, the assailant should die, so long as

one’s own blow was proportionate to the attacks of the assailant (McIntyre). In this respect, not

only are acts where it is uncertain whether or not the act will result in someone’s death justified

so long as the conditions of the doctrine of double effect are met, but even in cases where death

is foreseeable with minimal uncertainty the DDE still justifies acting. For example, it is widely

accepted (to my knowledge) among Catholic theologians and bioethicists that, in the event of an
ectopic pregnancy where the embryo has implanted in the fallopian tube, it is permissible to

perfume a salpingectomy (the removal in whole or in part of the affected fallopian tube) since its

imminent rupture poses a threat to the mother, with the consequent death of the unborn child

being justified under the DDE since the surgeon has not performed a direct abortion and removed

the child’s remains but has instead performed a legitimate operation on the fallopian tube which

had the unintended side effect of killing the child (Anderson et al., 18). The use of emergency

contraception would seem to be justifiable on a similar basis, since it too is an otherwise

legitimate medical procedure which protects the patient from an immense harm (in this case, the

violation of the woman rather than her death), but which has the regrettable but unintended and

proportionate consequence of causing an unborn child’s death – save, of course, the fact that the

child’s death is far from guaranteed in the case of EC drugs, whereas it is inescapable in the case

of salpingectomy.

However, the crucial difference between EC and salpingectomy, as well as all the other

examples of the DDE correctly applied, is that while in the latter cases it is evident that the

unintended effect is not the means by which the intended effect is caused (that is, it is not more

“causally close” than the intended side effect), the same is not obvious of EC. Like all drugs,

there is some uncertainty about the exact mechanism by which emergency contraception acts,

whereas there is no uncertainty about whether salpingectomy acts through removal of the

fallopian tube or direct abortion. Notice, though, that this is a scientific uncertainty rather than a

moral uncertainty. If it can be established that EC drugs do not prevent pregnancy through

abortion, then practical uncertainty is irrelevant because the DDE would justify prescribing EC

since a physician could then reasonably act under the assumption that any death that results is

less “causally close” then the drug’s ordinary mechanism. Since the proper arbiters of scientific
uncertainty are scientists, as Sulmasy rightly notes (118), especially because, lacking any purely

objective measure of the significance of scientific uncertainty, the collective experience and

convention of scientists in a given field is the best way to judge uncertainty in that field, it would

follow that we ought to base our judgement of the workings of EC drugs on the relevant

scientific research, critically appraised on its merits. Granting this, since Sulmasy’s review of the

relevant literature shows that there is little to no evidence to believe that EC drugs are

abortifacient, the DDE would hold, and the prescription of EC drugs would be justified. If the

scientific uncertainty approached the level of significance which experts in the relevant field

commonly accept as being statistically or clinically important, however, the above argument

would no longer hold true and it would be better to refrain from acting (in this case,

administering EC). In cases with greater moral or practical uncertainty, the arguments above

would still apply so long as the practical uncertainty is not so great that the results of one’s

actions cease being reasonably foreseeable: that is, so long as moral uncertainty was at most

lower than 50%.

In short, the amount of uncertainty we can tolerate in medicine depends on the kind of

uncertainty involved. Scientific uncertainty ought to be no more than what the relevant scientific

field has decided is significant or important. The consensus, conventions, and experience of

scientists in there respective field on what is significant and what is not is the best standard we

can hope for, since there is no universal or objective way of determining statistical importance.

More practical or moral uncertainty can be tolerated than scientific uncertainty, though, so long

as a physician can still reasonably foresee the results of his actions.

 Works Cited

Anderson, Marie A., et al. "Ectopic Pregnancy and Catholic Morality: A Response to Recent

Arguments in Favor of Salpingostomy and Methotrexate." National Catholic Bioethics

Quarterly 11.1 (2011): 65-82.

McIntyre, Alison. "Doctrine of Double Effect." Stanford Encyclopedia of Philosophy. Ed.

Edward N. Zalta and Uri Nodelman. 21 September 2023. 5 November 2023.

<https://plato.stanford.edu/archives/fall2023/entries/double-effect/>.

Sulmasy, Daniel O. "Emergency Contraception for Women Who Have Been Raped: Must

Catholics Test for Ovulation, or Is Testing for Pregnancy Morally Sufficient?" Kennedy

Institute of Ethics Journal 16.4 (2006): 305-331.