An Epiphany

This post is not about magi. It's about a revelation that is changing or might change my career.

Last time I posted asking whether you knew what Catholic teaching said about contraception. You may have been surprised to discover (or rediscover) that the Church has only said contraception is illicit within marriage. Although there have been many occasions to broaden this proscription, the Church has not done it.

I learned this at a local CMA guild event. Myself, a few other residents and a few attendings of various stripes (pediatrics, psychiatry, OB) gathered at the convent of the Religious Sisters of Mercy (who included pharmacists, a med student, two nurses, and one of the attendings). The topic, ostensibly, was birth control in the mentally ill. I went because I had patients like that on a PAG rotation in med school, and I have patients like that today.

But the conversation broadened to what Catholic teaching is on contraception outside of marriage. The facilitator pointed out that it has never been defined, although he stressed the issue of prudence in preventing promiscuity.

We were all terrified, because none of us had ever realized this. One of the pediatric attendings thought that we should never discuss this--her "Catholic" hospital was already handing out condoms...how terrible would it be if they started handing out hormonal birth control! She was afraid that one of the nation's largest "Catholic" pediatric hospitals would suddenly start handing out birth control if they were better educated on Catholic teaching. How sad!

At the same time as I felt sad and afraid, I was also tempted to shrug. Why would a marginally Catholic institution that already doesn't care about God's will suddenly care about God's will when given new ground? A "Catholic" hospital that doesn't want to follow in God's footsteps will not care about "prudence" that would want to protect pediatric patients from promiscuity (or STDs, pregnancy, statutory rape, etc).

Still, argued the pediatrician, if we can keep the real boundaries of the teaching quiet, we can keep hormonal birth control from harming a few lives (in spite of the Catholic hospital).

I asked myself whether I should talk about this with others at all. Would I only create situations where people would be imprudent?

I decided to post about it because if we don't articulate what the teaching really is, we get pharisaical about it. We draw large margins of safety around established rules, which are burdensome and nonsensical. I found a few unfortunate examples of people who believed that all use of contraception is mortally sinful. (Although I have heard recent challenges to the Peoria protocol from the Linacre, so stay tuned.)

I feel like this is a big shift in my understanding of what makes up the culture of death. Contraception is not in the category of objective evil all the time, at least we don't know that it is. It's not per se like abortion*, against which I must fling my whole self because I understand it to be the taking of a human life. Granted, it still is contributing to the horrible idea that sex and procreation are totally different things, and that sexual life is for the self-satisfaction of two consenting individuals. It's still chemicals women don't always need. It's still a bandaid most of the time. But it's now a crutch without which some of us could be thrown into worse chaos.

If only I had a big glowing orb in the sky to tell me where to go.



*By this I mean that the act of using a contraceptive is not known to be objectively evil. Post-fertilization effects are akin to abortion.

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

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?