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ss nucleus - spring 2003,  Ethical Enigma 2

Ethical Enigma 2

Response to Enigma 2: A 16 year old girl comes to see you wanting to start on the oral contraceptive pill. What advice can you give her about the available options? What might you as a Christian be able to bring into this consultation that most GPs wouldn't bother with?

Initially you need to take a good history that includes gynaecological basics such as details of her cycle. You also need to consider the reasons behind her request. Before launching into a lecture about contraception, make sure you have elicited all her ideas, concerns and expectations.

Further questions would include: is she in a sexual relationship? If so what method of contraception, if any, is she using? Has she had any casual sexual relationships? Is she being put under unwelcome pressure to sleep with her boyfriend? After that you are in a strong position to move on to counselling her about her various options.

In medicine today there is a strong culture of ensuring that patients are fully informed about their decisions. Unfortunately in the areas of abortion and contraception this is generally not the case. Side effects of abortions, especially psychological, are glossed over, and there are many women who have no idea how their contraception works. It is our responsibility as Christian doctors to ensure that our patients can make fully informed choices about any medication they take or procedure they undergo. We should not use tactics of scaremongering, but we should speak the truth in love so that they understand the consequences of their chosen course of action. This has already been covered in detail by Nucleus [1] but here I have provided a quick summary of the mechanisms of action of the most common oral contraceptives (see box).[2]

Once you have explained the options clearly you may want to offer your patient the chance to ask questions or to go away and consider her options. More than likely a girl of her age will choose the COCP. You do need, however, to be prepared for her to choose the POP or another method that largely relies on preventing implantation. What will you do? Will you prescribe it?

I strongly believe that each human life begins at fertilisation. This is the point at which the DNA blueprint of a new individual is formed; all later milestones in development are far less significant. For me, therefore, prescriptions of the POP and emergency pill are out. When I've been asked for the POP I have taken the history and asked another doctor to issue the prescription. With the emergency 'contraceptive' I take a history and find out whether the treatment is indicated by the time in her cycle. If it is I explain gently why I don't feel able to prescribe it and then ask another doctor to see her. You may feel this is a lot of pratting about for the same ends (ie she still gets the pills) but the difference is that I can go home with a clear conscience, and the conversation may make the patient think further about her actions.

Finally, at some point you should look for the opportunity to share some of God's wisdom with your patient: 'Why not wait until you are sure that the person you are going to have sex with is committed to you long term?' Genesis 2:24 is God's plan for us and we would do well to remind others of it. The teenage pregnancy rate in the UK remains the highest in Europe but the government is only just realising that sex education is not the answer. In the USA schoolchildren are taught to wait until they are ready - it's cool to be a virgin. Challenge the status quo and prick some consciences on the way. In some cases it will open doors for further discussion about your faith.


Methods of action of some contraceptives

The combined oral contraceptive pill (COCP)
This essentially puts the ovaries to sleep by confusing the female hormone system into thinking it is pregnant. If taken correctly with no pills missed, ovulation will be suppressed. If pills are missed or the seven-day pill-free interval is extended then the ovaries may wake up and ovulation occur. In that case its fall back mechanism is prevention of implantation and reduced cervical mucus permeability to sperm.

The progestogen-only pill (POP)
Progestogens reduce cervical mucus and prevent implantation. However, it is thought that in at least 60% of cycles ovulation is also prevented.

The emergency 'contraceptive' ('morning-after pill')
The Levonelle 750mcg high dose progestogen, taken between 24 and 72 hours after unprotected sex, relies significantly on preventing the implantation of a fertilised embryo. It is therefore by definition not a contraceptive as only rarely does it prevent conception.


Enigma 3

You are a medical house officer looking after an 86 year old man with metastatic lung cancer, admitted with severe pneumonia. He and his family decided not to have active treatment with antibiotics; he wanted to be made comfortable and be allowed to die. In the past 24 hours his symptoms have been well controlled with single doses of diamorphine and midazolam. At present he is settled. His family are with him but are tired and distressed by watching their father die. His daughter asks you if there is something you could give her father 'to help him on his way'. How would you respond?

References
  1. Saunders P. Contraceptives' Mode of Action. Nucleus 1999; January:19-22
  2. Further details can be found in Guillebaud J. Contraception Today (4th edition). London: Martin Dunitz, 2000
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