Marysia asked what we thought of the proposed HHS rule on “provider conscience”, so as promised, here’s my letter to the Department of Health and Human Services:
Dear Secretary Leavitt:
I am writing to express concern about the “provider conscience” regulation that was formally proposed by the U.S. Department of Health and Human Services (HHS) on August 26, 2008.
It is my belief that medical professionals must be allowed to refuse, and in fact should refuse, to harm or risk harm to patients under their care unless there is a compelling medical reason to do so. I believe that medical professionals should not be compelled to participate in executions or torture, and neither should they be compelled to participate in abortions that are not medically necessary for the mother.
However, the proposed regulation does not rule out the possibility that medical personnel who refuse to provide contraception, including emergency contraception, would be protected as well. Many people, including many medical professionals, believe that hormonal contraception inhibits implantation of an early embryo and thus leads to embryonic death; however, this has never been proven to be the case. Recent research by Croxatto and colleagues indicates that emergency contraception, specifically “Plan B”, most likely does not have any anti-implantation effect. Although indirect evidence about changes in endometrial lining has been offered to suggest that combined oral contraceptives (COCs) prevent implantation, the supposedly abortifacient effect has never been proven. Furthermore, there is reason to doubt whether the endometrial lining is hostile to implantation in those cycles when a woman taking COCs ovulates. In short, even if one considers the unborn child to be a person (and a patient) from conception, the risk to the unborn patient is purely theoretical and is not definitively known to exist at all.
Not only is the harm theoretical in the case of contraception, but so is the patient. The entire purpose of contraception is to prevent conception – there is no existing child at the time it is prescribed. When I was trying to conceive, I was warned not to take the Imitrex I had previously been prescribed, because it was believed to cause an increased risk of miscarriage. However, no physician would refuse to prescribe Imitrex to any women of reproductive age on the grounds that they might be sexually active, might conceive, and that the medication might cause them to miscarry. We would recognize that such a physician was ignoring the definite needs of an existing patient in favor of the hypothetical needs of a purely theoretical patient. Refusing to prescribe contraception to women is just as imbalanced.
I ask you to withdraw the regulation as currently written and draft more specific language that would not threaten women’s access to contraceptive services.
Thank you for your consideration.
1 Croxatto, H.B., V. Brache, M. Pavez, L. Cochon, M.L. Forcelledo, F. Alvarez, R. Massai, A. Faundes, and A.M. Salvatierra. 2004. “Pituitary–ovarian function following the standard levonorgestrel emergency contraceptive dose or a single 0.75-mg dose given on the days preceding ovulation,” Contraception 70(6): 442–450.
2 Ortiz, M.E., R.E. Ortiz, M.A. Fuentes, V. H. Parraguez, and H.B. Croxatto. 2004. “Post-coital administration of levonorgestrel does not interfere with post-fertilization events in the new-world monkey Cebus apella,” Human Reproduction 19: 1352–1356.
3 Muller, A.L., C.M. Llados, and H.B. Croxatto. 2003. “Postcoital treatment with levonorgestrel does not disrupt postfertilization events in the rat,” Contraception 67(5): 415–419.
4 DeCook, et.al. “Hormone Contraceptives: Controversies and Clarifications.” American Association of Pro-Life Obstetricians and Gynecologists, 1999. http://www.aaplog.org/decook.htm . Accessed 24 Sep 2008.