Wednesday, December 30, 2015

Quiz: What's Catholic Teaching on Family Planning? (Shocker)

This post conforms to the blog rules.Catholic doctrine on contraception (including hormonal and non-hormonal, long- and short-acting) is:
  1. Use of contraceptives by sexually active persons breaks up the unitive and procreative aspects of sex, and is grave matter that may constitute mortal sin.
  2. Contraceptives are a band-aid for women's health issues and should not be used for medical purposes in women who are not sexually active.
  3. Contraceptive use is technically occasionally licit (i.e. not objectively wrong), but is always imprudent.
  4. A and B
  5. A and C
  6. None of the above
The answer, shockingly, is F. Humana Vitae (HV) explained why contraception is objectively sinful because it destroys the good in licit sexual acts. The only licit sexual acts occur within sacramental marriages, and HV only touched on contraception in marriage. When sex occurs outside marriage, there is already an objective evil. It is not clear (i.e. it is not yet part of Catholic teaching) whether contraception augments the evil in these actions (like fornication, adultery, and extramarital sexual abuse) or can mitigate it. Theologians who wish to think with the mind of the Church have gone both ways on this issue. Many, like Germaine Grisez and Janet Smith, have opined that contraception is always wrong. Others, like Fr. Robert Landry, maintain that it is not always objectively illicit, but is usually or often imprudent. For more, here's Jimmy Akin.

True or false: It is good that children not come of non-marital sexual unions.

True. It's occasionally uncomfortable to admit it, but it's actually good when children are not conceived outside of marriage. Children have a right to grow up in a family, raised by a father and a mother, and many or most children born today are born with this right infringed. You're not a eugenicist if you think it's good that children's rights are preserved. Don't believe me? Try the next question.

True or false: It is good that children not be born of non-marital sexual unions.

Careful here. It's good when children aren't conceived. But once conceived, their rights must be protected as much as possible, including their right to life. Post-fertilization effects and abortion rob a child of something even more basic than the right to be raised by mother and father.

Catholic doctrine on primary sterilization (mutilating of a human body by removal or altering of otherwise-healthy organs for the sole purpose of destroying fertility) is:
  1. Sterilization is mutilation of the human body, which is dignified not only by creation in the image of God, but also by the Incarnation.
  2. Temporary sterilization is occasionally appropriate even if the principle of double effect does not apply.
  3. The Catechism only specifies that sterilizations on innocent persons are against the moral law.
  4. A and B
  5. A and C
  6. None of the above.
The answer is A. No temporary sterilization, no sterilization ever unless there is a medical reason for removal of a "diseased organ." C is interesting. The second half of a sentence in CCC 2297 states "directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law." But to take this and run off sterilizing prisoners would ignore the first half of the sentence: "Except when performed for strictly therapeutic medical reasons...." With all this information, let's go see a patient.

Case Study: A 32-year-old African-American G5P2113 (pregnant five times, with two children born at term and one born preterm, with one abortion or miscarriage, we don't know which; currently pregnant) at 26 weeks presents to obstetrical triage at Hospital A with abdominal pain. This is her third visit this pregnancy. She consistently maintains that she receives care at the resident clinic at Hospital B, but has likely never established prenatal care. She is unmarried and does not have custody of her living children. She has multiple psychiatric admissions for bipolar disorder, she is not currently on medications, she is currently homeless, and the resident seeing her suspects she just came from selling herself. She has been kicked out of several maternity homes for disruptive behavior. During today's interview in triage, she appears disheveled and emotionally labile. It is clear from her responses to questions about her medical and social history that she is either intellectually disabled or out of touch with reality. She insists that she is full term and that it's time to induce her labor, although her triage workup reveals no evidence of labor, or other obstetric or gynecologic pathology. Upon the patient's discharge from triage from Hospital A, the attending supervising the resident states, "she needs a strong postpartum plan," meaning that she should receive a LARC or be sterilized so that she won't get pregnant again. Hospital A and Hospital B are Catholic. What is an acceptable postpartum family planning option for this patient?
  1. Natural family planning/fertility awareness
  2. Mirena
  3. Paragard
  4. Nexplanon
  5. Essure
  6. Postpartum filshie clip tubal ligation
  7. Parkland method tubal ligation
  8. Depot haldol and social work consult for another group home placement
A: Wrong. There is so much beauty to NFP, but for a woman who doesn't have money for bus ticket and who isn't medicated and out of touch with reality, it is not enough.

B: Wrong. Mirenas can be placed immediately postpartum but rate of expulsion is relatively high. Plus, mirena is a progestin-containing system and has post-fertilization effects.

C: Wrong. Paragard can also be expelled when placed in the postpartum period, and also has post-fertilization effects.
D: Wrong. Can be placed postpartum, but has post-fertilization effects.

E: Wrong. Cannot be placed postpartum, and is a permanent, primary sterilization.

F: Wrong. Even if it can safely be done postpartum and is as close as you can get to a temporary sterilization (you can pop off the clips and re-anastomose the tubes), it's still a primary sterilization and HV condemns even termporary sterilizations.

G: Wrong. That's a permanent primary sterilization.

H: Really? That's the best we can do for her? I am totally dissatisfied with our options. 

This woman is unmarried and her ability to truly consent to sex is in question. Children have a right to be born to a family, raised by a mother and father, and it is better for her not to have children right now. I can't render her sterile because that is objectively wrong. It may not be objectively wrong for me to render her infertile (although it might be imprudent), but all my options for rendering her infertile (aside from condoms, which she can't control) have postfertilization effects.

Conclusion: I want to think with the mind of the Church. I know Catholic teaching, like every appropriate body of law, does not include dicta for every particular situation. But I know Catholic teaching grasps the truth whenever it speaks on issues of faith and morals. And it works, because it's the truth. 

But right now, there is nothing that works for patients like my case study (and I have seen her for three of those four triage visits). Where is the truth here? Do I need to develop something new?


  1. Not to make things even more complicated, I wanted to add that not only do "Children have a right to grow up in a family, raised by a father and a mother, and many or most children born today are born with this right infringed." But according to paragraph 2376 of the Catechism, children have a "right to be born of a father and mother *known to him and bound to each other by marriage*." Being adopted, I can tell you the inherent grief of this loss. Adoptees are 4x more likely to attempt suicide than the average person. So not just "any family" is truth here. Love how you grapple with all this. I hope the direction you should go makes itself known.

    1. Amy, thanks for your comment. I apologize that replying to you fell through the cracks and that this is coming so late. I love adoption and always encourage it as an alternative to abortion and single parenthood, but you're right--it's not the same as biological parenthoood. Do you think adoption is legitimate? It sounds like you might think the CCC excludes it.

  2. Hi Mmatins,
    I am a medical student and Ave Maria University grad who came across your blog, and I just wanted to comment on the issue. One of my great professors at AMU, Dr. Steven Long explains well how in reality answer choice "A" is Church teaching even if it has not been explicitly clarified as such by the CDF.

    "Of course, this is intentionalism. It is to argue that because one intends prophylaxis, therefore such condom use is not contraceptive. This is precisely the effort to define "direct" and "indirect" with respect to moral action by reference solely to intention while excluding essential reference to the nature of that which is chosen. Yet the putatively good effect achieved through condom use--that of preventing dissemination of disease--is in heterosexual intercourse achieved only by means of the evil effect of a contraceptive blocking of the transmission of procreative matter. Fr. Rhonheimer does not wish to call this "contraception" because for him, not the nature of the act, but rather, exclusively the intention of the agent, determines whether contraception occurs."

    1. Hi medRx, it's a real pleasure to meet you! Thanks for reading and for caring about this. I know that many faithful and intelligent Catholics like you and Dr. Long are very close to the truth. The quote you cited is specifically about barrier contraception and STD prophylaxis, which is a slightly different issue that I covered separately. A quick read of Humanae Vitae shows that Pope Paul VI didn't really separate the natural law and revealed truth about sacramental marriage because he couldn't imagine the world we live in, where most sex is extramarital and contracepted. But I do think theologians and "men of science" can do more to help CDF clarify the truth. I think there is a truth that we can find and obey, but I think it's complex. I want to help find that truth, part of which is uncontestably that contraception is ALWAYS wrong in sacramental marriage, ALWAYS denigrates human dignity and sex, and ALWAYS has ill effects on society.

    2. Thanks for your reply mmatins, and it really is a difficult issue. And I think you are right in your reasoning that Humanae Vitae technically only prohibits contraception as always wrong in Conjugal act for married spouses. However, I just don't think we can reason from Paul VI's noncommentary on extramarital intercourse to a lack of Church teaching that barrier contraceptives do not destroy a good in nonmarital sexual acts. Following the rabbit trail of theological arguments, I think there is a very strong case for the intrinsic evil of condoms in all free sexual acts (obviously excluding rape which is no free act) reiterated throughout Church teaching. What's amazing about Humanae Vitae is that Paul VI exactly predicted predicted the widespread extramarital sex and objectification of women (I don't think he'd be too surprised at today in fact haha). But besides all that, what it boils down for us is can I as a med student or physician give condoms to people who are for sure going to engage in extramarital acts that will most likely result in a child out of wedlock. Can I be party to an evil (extramarital sex and frustration of a sexual act, making a lie of the language of the body even in nonmarital acts) to prevent a worse evil (child w/o stable mom and dad). Another situation similar that's been put to me is shouldn't we be referring women committed to having an abortion to the safest clinic since they are going to do the deed anyways. I think as Catholics we don't need to wait for the Church to come down on every individual situation to discern God's will for us in these situations. But it is difficult nonetheless, I do wish the CDF would make it crystal clear, but I don't see coming out any time soon as much as I love Pope Francis haha!

    3. I agree that we can't "reason from Paul VI's noncommentary on extramarital intercourse to a lack of Church teaching that barrier contraceptives do not destroy a good in nonmarital sexual acts." Even outside of marriage, there is a natural law that applies to any voluntary sex. Barriers break up the nature of sex, which is still unitive and procreative (even if not exactly the same way within sacramental marriage).

      I don't think there is an intrinsic evil of condoms with all free sexual acts. In homosexual anal sex in an HIV discordant couple (no possibility of conception) it is good for one partner to use a condom to prevent spread of HIV. This was famously pointed out by Pope Emeritus Benedict XVI.

      Giving condoms to heterosexual people is another matter. Contracepted extramarital sex is farther from God's view of sex than is uncontracepted extramarital sex. Every time a condom is used, it brings people further from God's view of sexuality. And you're right--we can never cause evil to prevent evil. What we can do is choose the lesser of two evils, like voting for a politician who will be more pro-life or less pro-choice. I wonder whether this might pertain to the issue at hand.

      Regarding referral for abortion: the suggestion I have heard is to refer them to the phone book to find an abortion provider, while providing information for Rachel's vineyard or a similar service.