***EDIT: It seems I was slightly mistaken concerning the effect of estrogen on ovulation. From reader Kevin and consultation with my trusty physiology book, the effect of estrogen would seemingly have opposing effects depending upon what part of the menstrual cycle the woman was in at the time it was administered. There is a large estradiol surge preceding the leutenizing hormone surge responsible for ovulation. Presumably, a large estrogen dose could actually cause ovulation if she were at this point in her cycle. It turns out that estradiol has a negative feedback effect on LH during the follicular and luteal phases, but a positive feedback effect near the time of ovulation. Given this, it seems that high dose estrogen would probably be a bad idea as it could aid in bringing about pregnancy. Perhaps Dr. Paul was just trying to simplify the issue by naming a hormone everyone would recognize? Perhaps I’m still missing something… /EDIT

I posted the other day about Ron Paul and his views on law in relation to those of St. Thomas Aquinas. In the comments, RP’s views on abortion were brought up so I thought it might be good to address it here. Luckily, we now have plenty of fodder after Dr. Paul’s interview on Piers Morgan Tonight. Here’s the relevant clip:

What can be clearly stated from the above is that he believes that life begins at conception. This is stated with little room for doubt. Where I find his resolve, or at a minimum his coherency, lacking is when Piers delves deeper with the special case of rape. As stated in the interview, rape resulting in pregnancy is an exceedingly rare phenomenon (about 5% of rape victims of child bearing age) and should not be used as the exception to justify the rule. Having said that, let us take a look at rape and morally sound methods of dealing with its sequelae.

First, we must define what rape is so that we might know what means we are morally able to resort to in order to deal with its possible effects (namely pregnancy). Quoting Germain Grisez:

Rape is the imposition of intimate, bodily union upon someone without her or his consent, and anyone who is raped rightly resists so far as possible.

The key, and obviously so, to understand is that rape is an act of violent imposition upon another who has not freely given consent to the sexual act. In this case, the person being raped has every right to protect herself (we’ll just stick to the feminine from here on out…) from bodily harm. This includes protecting her eggs from the “assault” or violation of the rapist’s sperm. Perhaps at some later point we’ll have a conversation about the ethical implications of contraception, but suffice it to say that when a person contracepts the object is to impede the beginning of a new human life that one reasonably forsees may come from freely chosen acts. In the case of rape, this is certainly not the case. One may legitimately turn to the use of mechanical devices or high dose contraceptives (so long as they are not abortifacient) in order to prevent conception. Note that the object is different from the case of someone freely choosing to contracept during consensual genital acts. The object in this case is not to impede the beginning of a new life but rather to protect herself from further bodily and personal violation by a rapist! The woman has absolutely no obligation to permit the rapist’s sperm to penetrate and fertilize her ovum since she has not consented to this act. Again to quote Grisez:

It can scarcely be doubted that someone who cannot prevent the initiation of this intimacy is morally justified in resisting its continuation; for example, if a woman who awakes and finds herself being penetrated by a rapist need not premit her attacker to ejaculate in her vagina if she can make him withdraw. On the same basis, if they cannot prevent the wrongful intimacy itself, women who are victims (or potential victims) of rape and those trying to help them are morally justified in trying to prevent conception insofar as it is the fullness of sexual union. The measures taken in this case are a defense of the woman’s ovum (insofar as it is a part of her person) against the rapist’s sperms (insofar as they are parts of his person). By contrast, if the intimate, bodily union of intercourse is not imposed on the woman but sought willingly or willingly permitted, neither she nor anyone who permits the union can intend at the same time that it not occur. Hence, rape apart, contraceptive measures are chosen to prevent conception not insofar as it is the ultimate completion of intimate bodily union but insofar as it is the beginning of a new and unwanted person. (The Way of the Lord Jesus, Vol. 2, Living a Christian Life, p. 512).

Again, the moral object of the act is not the prevention of the formation of new life, but rather the protection of her body-person from further violation by the rapist’s body-person. Thus, the US Conference of Catholic Bishops in 1994 stated succinctly in directive 36 of the Ethical and Religious Directives for Catholic Health Care Facilities:

Compassionate and understanding care should be given to a person who is the victim of sexual assault. Health care providers should cooperate with law enforcement officials and offer the person psychological and spiritual support as well as accurate medical information. A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.

So was Dr. Paul on morally sound ground stating that he would give high dose estrogen to a woman who presents herself at the ED after a sexual assault? Well, now we must delve a bit into the science! Firstly, I must say that I’ve not seen much in the literature about high dose estrogen alone as a post-rape treatment. The most popular medical drug used is levonorgestrel, colloquially known as Plan B, and it is a progesterone agonist. In the past, combined estrogen-progestin pills like Ovral were used for the same purposes.

First, we’ll tackle Dr. Paul’s proposal – high dose estrogen. It has been a while since I’ve studied this physiology, so if I make a mistake, please correct me. Estrogen only (as advocated by Ron Paul, although he may have just been trying to simplify the answer for the audience) would likely prevent ovulation (release of an egg) if it had not occurred, and would, in fact, likely increase the chances of implantation if an embryo had already formed as an estrogen spike during the luteal phase of the menstrual cycle is necessary to increase the vascularity and secretory activity of the endometrium to prepare for the receipt of the fertilized egg. If this is the actual mechanism of action of high dose estrogen (prevention of ovulation) and it does not interfere with the implantation of the embryo, then it is morally licit. Thus, Piers Morgan’s follow up question, “So you would allow them to abort the baby?” assumes something which is not necessarily true, namely that a baby exists! Unfortunately, Dr. Paul did not address this but rather dodged saying, “It is absolutely in limbo… you don’t know if you’re taking a life.” What concerns me about this answer is that he basically states that we don’t know whether there is a human life there or not, yet we can take actions which would (under the parameters assumed, which are unlikely to correlate with reality), in effect, cause its death. This is the most concerning part of this interview for me and I would like to see some follow up concerning this view – was it a simple case of misspeaking? This is the exact reasoning the Supreme Court resorted to when formulating the infamous Roe vs. Wade decision – a lack of certitude means we can act as if there were no human life present. A terrible mistake indeed.

Getting back to the science, I’ll also touch on two other methods commonly employed – levonorgestrel and mifepristone. The first is, as mentioned above, known as Plan B and is the most often used drug today for cases of “emergency contraception.” This is a progesterone agonist (mimics the effects of progesterone) which would primarily inhibit ovulation. There is controversy in the literature over whether or not Plan B has any effects on post-fertilization events despite the package insert stating that it can prevent implantation. For a brief overview of the scientific literature see Fr. Nicanor Austriaco’s article in the winter 2007 edition of the National Catholic Bioethics Quarterly (Is Plan B an Abortifacient? A Critical Look at the Scientific Evidence, pp. 703-707). My own reading of the literature leaves little doubt in my mind that levonorgestrel has little or no effect on post-fertilization events. Physiologically, it doesn’t make sense for progestin to prevent implantation, as it, like estrogen, is required to maintain a pregnancy. Quoting Fr. Austriaco:

The evidence also addresses what until now has been a nagging, unanswerable question for pharmacologists: Why would levonorgestrel, a progesterone agonist that mimics the effect of progesterone, prevent implantation, when progesterone produced from the corpus luteum immediately after ovulation actually promotes implantation by converting the endometrium to decidua? Answer: It does not.

It would seem that, much like estrogen, the use of this hormone would actually aid in the implantation of an embryo rather than hinder it. Besides these effects, there are also reports that state that Plan B has effects on sperm which hinder their mobility and ability to penetrate the ovum – these would be morally licit means to prevent pregnancy in the case of rape.

Finally, there is a third drug commonly used known as mifepristone or RU-486. This is a progesterone antagonist, which is to say that it inhibits the action of progesterone. There is no doubt whatsoever that this drug prevents implantation and can even cause termination of well established pregnancies – it is commonly used in first trimester pregnacies to induce a “medical abortion.” Because this drug is clearly an abortafacient, it is not morally permissible to use even in the case of rape. The fact that this drug and levonorgestrel have opposite mechanisms of action further strengthens the hypothesis that levonorgestrel does not prevent implantation. It wouldn’t make sense for a progesterone agonist and a progesterone antagonist to both prevent implantation!

So there you have it! It would seem that Ron Paul was on the right track and not duplicitous in any way when stating that life certainly begins at conception, yet allowing for the use of contraceptives for the prevention of pregnancy in the case of rape. Concerning was his assertion that a lack of clarity about whether an embryo was present or not made no difference, morally speaking.

Turning now, briefly, to Dr. Paul’s legislative record concerning abortion, I would like you to watch this clip from the recent debate in South Carolina:

Ron Paul sees abortion primarily as a moral problem, not a legislative problem. In his eyes, the law reflects the fundamental moral failure of the people under the law! The true solution to the abortion problem is to change the hearts of the people and have that reflected in the law. I agree that this is absolutely the case, but as the Angelic Doctor says, “…since some are found to be depraved, and prone to vice, and not easily amenable to words, it was necessary for such to be restrained from evil by force and fear, in order that, at least, they might desist from evil-doing, and leave others in peace, and that they themselves, by being habituated in this way, might be brought to do willingly what hitherto they did from fear, and thus become virtuous.” Law does have a corrective component, as discussed in my previous post.

There is little doubt that Ron Paul is pro-life based upon what he has said, for example, concerning ob/gyn being a “two patient specialty” and his statements in this evening’s interview with Piers Morgan. I think where he differs from someone like Rick Santorum is in the legislative practicalities. Murder, theft, and other similar crimes are not handled at the level of the federal government, and it seems Ron Paul doesn’t think abortion should be either. I tend to disagree with him in this matter as it is in the interest of the federal government to protect the life of human beings – in keeping with the principle of subsidiarity, if states fail to protect human life, then the federal government should. Having said that, I think his approach is actually more practical than waiting for all three branches of the federal government to align their views on abortion in order to have Roe v. Wade overturned (which would then just send the matter to the states anyway) and a personhood amendment ratified in its place. Ron Paul simply wants the federal government taken out of the picture all together to allow states to decide. In this case probably 3/4 of the states would outlaw abortion and we’d have limited this evil to a great extent. Many states already have pro-life laws enacted which would become enforceable upon the removal of federal jurisdiction. Practically, it would seem to me that we would have far fewer abortions far more quickly under the plan Ron Paul proposes. Is it perfect? No. Is it practical? Probably more so than the other politicians who wish to protect life. Even having said all that, the president really has little say in the matter unless the legislators in Congress manage to pass any pro-life laws, in which case the president has the power to veto. I doubt Ron Paul would ever veto a pro-life bill if it were to land on his desk in the Oval Office.

Furthermore, some fact checking reveals Rick Santorum was incorrect about the 50% agreement with NRLC – over his entire voting career it is 75% and from 2009-2011 it is 100%. Looking through some of the votes, it seems he gets points taken off for disagreeing with the NRLC on things like the “Medicare Prescription Drug Price Negotiation Act” and the “Medicare Modernization Act.” Very few of the disagreements with NRLC actually stem from disagreements over abortion and even those that do are more about the practicalities and limits of the federal government. For example, he disagreed with NRLC about the Unborn Victims of Violence Act because he felt the federal government was overstepping its constitutional bounds by enacting it even though he recognized it as “laudable goal of protecting unborn children from assault and murder.”

The concluding quote from his commentary sums up his position pretty well it seems: “Protection of life (born or unborn) against initiations of violence is of vital importance. So vitally important, in fact, it must be left to the States’ criminal justice systems. We have seen what a legal, constitutional, and philosophical mess results from attempts to federalize such an issue. Numerous States have adequately protected the unborn against assault and murder and done so prior to the Federal Government’s unconstitutional sanctioning of violence in the Roe v. Wade decision.”

After all this, I have little doubt in my mind that Ron Paul is resolved to undo the disorder brought about by the Roe vs. Wade decision and to protect the life of the unborn in the United States. You can certainly bet that he would not be supplying any funding to agencies that provide abortions as that’s clearly not a constitutional function of the federal government. How about you? Do you still doubt Ron Paul’s pro-life resolve?