The Morality of Contraception

Those of us who have been involved in the abortion debate for many years will have found the question of contraception arising from time to time. It is an issue that is related and yet different.

First of all what is the basis for accepting that it is permissible to plan our family sizes? What is the basis of the contrary Roman Catholic position? Current RC teaching goes back to Augustine. He believed that anything distracting the mind from a spiritual plane, even the satisfaction of sexual desire within marriage, was to be avoided. However, procreation was right and necessary. It was taught, therefore, that marital intercourse was morally justified. The good motive of procreation somehow cancelled out the fleshly enjoyment of the act!

The account of Onan (who practised coitus interruptus, Gn 38:9) was interpreted as teaching that any form of contraception was wrong. In fact, the wrong was Onan's avoidance of producing an heir by his deceased brother's wife, as was the custom, not the principle of avoiding pregnancy as such.

Papal encyclicals published this century have simply affirmed the long held views that the chief purposes of marriage are procreation and the education of children. It is argued that the natural end of sexual intercourse is the conception of a child and that anything which interferes with this process is contrary to nature and unlawful. Concession is made, however, where pregnancy cannot occur such as when the wife is post-menopausal, already pregnant or the couple are infertile. Intercourse is not then unlawful.

Early this century more was being understood about the female reproductive cycle and in particular the process of ovulation. In 1952 Pope Pius XII and again in 1968 Pope Paul VI allowed the use of the 'rhythm' and other 'natural' methods and abstinence for their followers. It was taught that artificial contraception which separates the unitive (relational) and procreative aspects of intercourse breaks moral law. These views still stand officially today.

The case against contraception can also be argued from a number of other viewpoints: There is the general Scriptural injunction to 'be fruitful and multiply' (Gn 1:28).

The advent of freedom from the 'risk' of pregnancy was associated with the so-called sexual revolution of the 60's and 70's and its associated woes.

As well as the destruction of unborn children through abortion, there is the harm done to women's bodies by certain artificial methods of contraception (eg oestrogen and venous thrombosis).

There has been a rise in incidence of some sexually transmitted diseases.

The status of women may be demeaned now that sex is possible without any strings attached (ie women may be treated as sex-objects).

There have been instances of enforced contraception and sterilisation for political gain (eg China).

There would seem, however, to be a stronger case for contraception than against. Some of the disadvantages listed above have weighed against the undoubted blessing that more effective fertility control has brought to countless numbers of women.

The Bible clearly shows that there are more purposes for sex within marriage than simply procreation. In any case children are looked upon as an additional blessing in the Scriptures (Ps 127:3-5), not an automatic event. God provided a companion for Adam in the Garden (Gn 2:18) with no mention of children in that context.

The unity between husband and wife in marriage, throughout the OT and NT, is spoken of as a mystery (Eph 5:25-32) expressing the relationship between Christ and his Church. In that context it seems to have nothing to do with producing children. And regardless of Augustine's teaching there is nothing in Scripture that prohibits the enjoyment of sexual pleasure within marriage.Paul in the NT teaches that a limited period of abstinence may be appropriate (1 Cor 7:1-7) but that otherwise normal sexual relations should take place. Procreation is not mentioned in this context. The point he is making is that one of the best antidotes to adultery is a satisfactory marital relationship. Contraception is neither condoned nor condemned.

The Morality of Various Methods of Contraception

If we accept that contraception in principle is acceptable what are the moral implications of the various methods - given that the beginning of human life is at fertilisation?

The egg and the sperm on their own will soon disintegrate, but a successfully fertilised egg, provided with a favourable environment, will develop into one of us. Contraception which prevents egg and sperm meeting therefore has very different moral implications from a method which acts to destroy, albeit microscopic, newly formed human life. Reversible barrier methods, such as diaphragms, caps, condoms (with or without spermicidals) and the more irreversible male or female voluntary sterilisation should present no difficulty for most Christians.

At the other extreme very early abortion, so-called menstrual extraction or regulation, should clearly be ruled out. Early abortion also may be carried out these days medically. RU 486 was developed in France as an early abortifacient during the 1980's and is now licensed for use in this country under the name Mifegyne (mifepristone). It works against the natural hormone progesterone which sustains the placenta in its very earliest stages.

Emergency contraception is freely advertised in GP surgeries and elsewhere,[1] it is now as readily available as abortion. Yet it is not so many years since the 'morning-after-pill' was under discussion in the High Court.[2]

Four high dose combined contraceptive pills taken within 72 hours of unprotected sexual intercourse will prevent pregnancy in about 95% of women. This method works either by preventing a fertilised egg implanting (if ovulation has already occurred) or alternatively by preventing ovulation. The individual woman would never know what had happened, she simply has a 'withdrawal bleed'.

Another emergency method involves inserting an intra-uterine device (IUD) which can be fitted within 5 days and will abort a very early pregnancy by preventing implantation.

The question of IUD's in general is somewhat vexed. Many Christians had been using them in good faith until the 70's when the mode of action was more clearly understood. It was thought that they worked principally by preventing a newly fertilised egg from implanting.

More recent research (for instance by the admittedly pro-abortion body WHO) has found that prevention of fertilisation may be the dominant mode of action. This is particularly the case for copper containing devices.[3]

The most recent development is a progestogen-containing intra-uterine device.[4] It is being hailed as the answer for other gynaecological conditions such as menorrhagia. The mode of action in this case is alteration of cervical mucus and prevention of sperm migration. The hormonal and foreign body reactions are combined, making fertilisation even less likely.

The subtleties of contraception become even more complex when we examine the mode of action of the pill. Traditionally the higher-dose combined preparations contained a big enough dose of oestrogen to inhibit ovulation. In the 1950's women were taking two and three times the dose of oestrogen than they are in the 90's - with all its attendant risks of blood clotting etc.

As the dose of oestrogen declines there is more likelihood that ovulation is not supressed, but of course the agent is much safer. Pregnancy is still prevented but the mode of action is then supposedly like the progesterone-only-pill.

For fertilisation to take place ovulation is necessary but also the sperm has to reach the egg swimming up through the cervix. It is here that the so-called mini-pill, or progesterone-only-pill, has its chief effect. Cervical mucus is rendered thick and hostile to sperm.

The long-term injection (Depo-provera) and the newer implant under the skin (Norplant) work in the same way. These latter agents have been controversial though not for their contraceptive mode of action as such. The concerns focus on the adverse effects on some women such as troublesome bleeding.

Recently Norplant has had a bad press in this country because of inadequate training of doctors involved in the insertion and removal of the match-stick sized silastic rods. The spectre of enforced sterility, albeit reversible, has been raised in some quarters, especially in the USA.

Most researchers accept that the pill has a number of possible actions. The hormonal response of the individual woman may determine whether the combined preparations stop her ovulating or not. People vary, just as some women stop having periods altogether on the pill. The same woman may respond slightly differently from month to month.

However, ovulation and fertilisation may occasionally occur on the modern low-dose preparations, both combined and progestogen-only. In that event a back up mechanism of action would include prevention of implantation resulting in the expulsion of a very early embryo.

Implantation may occur in the wrong place causing ectopic pregnancy. However, if fertilisation takes place and the egg implants in the uterus then of course normal pregnancy will result.

A detailed investigation of recently published literature[5] confirms that many of the modern, widely-used contraceptive agents occasionally allow fertilisation and may on rare occasions prevent implantation. However, experts in the field of contraception at this level differ in their views.[6]

Contraception in Personal Practice

As a hospital-based gynaecologist, without a specific family planning role, prescribing contraceptives as such does not represent a major part of my job. I am not involved in abortion nor post-coital contraception. However, hormonal treatments are prescribed for a wide range of gynaecological problems.

A well recognised example would be the teenager with debilitating periods, losing time off school and with exams looming. After counselling the girl and her mother a prescription for the pill could well be the best solution. Such treatment is therapeutic not contraceptive. It just so happens that the contraceptive pill conveniently packages the lowest dose of hormonal treatment and is therefore the safest treatment.

At the other end of the reproductive age spectrum the older woman with period problems may ideally be best managed on one of the newer pills with a low dose of oestrogen and a so-called 'lipid-friendly' progestogen. Again the usage is therapeutic but perhaps also there is the added requirement for contraception. One could argue that natural fertility is waning by the time a woman reaches her 40's and 'breakthrough ovulation' is even more unlikely. The new progestogen containing intra-uterine device also finds application in this age group.

The fact remains that those of us who are prescribing or receiving low-dose pills or the new IUD for contraceptive purposes may unwittingly be using an agent that possibly on very rare occasions causes the expulsion of a newly formed embryo.

There must be thousands of Christian women in this country today on a low-dose pill.

In counselling patients perhaps we should explain the possible effects more openly. We need to be particularly sensitive with Christian women. There could be a mass turning away from the pill, as there was in the 70's in reaction to the (pre-copper) coils, and an upsurge of unplanned pregnancies!

Personally I am continuing to prescribe in good faith as medically indicated where the principal aim is the alleviation of a disorder. The challenge remains to further consider the implications of such practice and ask for God's enabling to 'think Christianly', to use John Stott's phrase, and be prepared to adapt in the light of new revelation.