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Health Care Ethics USA Treating Victims of Sexual Assault Within Catholic Health Care Facilities The treatment of victims of sexual assault within Catholic health care facilities is a contentious issue. Some argue that health care professionals ought never prescribe antifertility medications (e.g., Ovral) to a woman who may be pregnant from a recent sexual assault because they would function as an abortifacient if she was indeed pregnant. Others argue that health care professionals ought to prescribe antifertility medications to the woman as long as she consents because she should be able to defend herself against a possible pregnancy for which she is not responsible. What is the Catholic approach to this divisive issue? Principles The truth of the matter is there is not one Catholic approach to treating victims of sexual assault because the issue has never been settled by the moral magisterium of the Catholic Church. Thus, we must arrive at a well reasoned approach that is consistent with current guidelines in the Catholic moral tradition. In constructing such an approach, we look to the Ethical and Religious Directives for Catholic Health Care Services (ERDs) for guidance. Directive 36 specifically addresses the issue of treating victims of sexual assault: A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of the fertilized ovum.1 Based on Directive 36, as long as the woman is not pregnant, antifertility medications may be given to prevent ovulation, sperm capacitation, or fertilization. The problem is that a pregnancy test is unlikely to be positive as the result of a recent sexual assault. Therefore, some Catholics argue that the type of care provided hinges on ovulation. For instance, Fr. Benedict Ashley and Fr. Kevin O'Rourke delineate three treatment scenarios contingent upon ovulation: If ovulation has not occurred within a current menstrual cycle, antifertility medications may be administered to prevent ovulation. If it is certain ovulation has occurred within the menstrual cycle, antifertility drugs may not be used because their effect could only be to inhibit the implantation [of a fertilized ovum]. If there is doubt as to whether ovulation has occurred or not within the present menstrual cycle, antifertility drugs may be used with the purpose of preventing ovulation. The doubt in question concerns the fact of ovulation, not the fact of conception.2 In essence, what Ashley and O'Rourke are claiming here is that since we cannot determine with certainty whether a pregnancy has been established in a woman who has been sexually assaulted recently, we should use ovulation as the criterion for decision making. If any doubt exists concerning the issue of pregnancy, we must determine whether the woman has ovulated and should not interfere with antifertility medications if she has in fact ovulated. Discussion While the Ashley and O'Rourke approach to treating victims of sexual assault is the morally safest, it is not morally required within Catholic health care facilities for three primary reasons. First, ovulation is not the moral criterion upon which the treatment of victims of sexual assault hinges. Rather, as Directive 36 prudently states, the actual moral criterion is pregnancy. Second, the occurrence of ovulation only suggests that pregnancy is a possibility, not a biological or moral certainty. A positive ovulation test does not provide moral clarity to the difficult and delicate situation because the fact of pregnancy will still be in doubt. Third, even if the woman may have ovulated that does not necessarily mean that a fertilized ovum is present and antifertility medications will interfere with implantation as Ashley and O'Rourke imply. There is still the real possibility that the antifertility medications will merely prevent sperm capacitation or fertilization. What is more, fertilization is a complex process that unfolds over a 24-hour period and results in the formation of a human being with the moral right to respect and protection. Perhaps the United States bishops recognized these problems with using ovulation to determine the morally appropriate form of care for victims of sexual assault and instead chose to focus on the broader criterion of pregnancy in Directive 36. Without question pregnancy is the more precise moral criterion for decision making, but even so cases may arise that pose personal problems for health care professionals. For instance, a woman in her fertile period who has been assaulted sexually may come into the emergency department more than 24 hours after the assault when she could possibly be pregnant because the fertilization process would have concluded (if it had actually started). If the woman's pregnancy test comes back negative, health care professionals within Catholic facilities could offer the woman the option of determining whether she has ovulated to absolutely rule out the possibility of pregnancy and can perform the ovulation test with her consent (if available). If the test indicates that the woman has in fact ovulated and it is clear that the woman is beyond the 24-hour period since the sexual assault occurred, health care professionals within Catholic facilities can refrain from providing antifertility medications that may interrupt a possible, though not certain, pregnancy. However, health care professionals in Catholic facilities are not morally required to withhold antifertility medications from the woman. As Directive 36 points out, "If, after appropriate testing [for pregnancy], there is no evidence that conception has occurred already," the woman may be treated with antifertility medications. No matter what the ovulation test shows, it still does not provide sufficient evidence of pregnancy to morally prohibit health care professionals from administering antifertility medications for the woman if she so chooses. What is morally required on the part of health care professionals within Catholic facilities is that they do not remove, destroy, or interfere with the implantation of a fertilized ovum. Thus, it seems to follow, that barring a positive pregnancy test, health care professionals within Catholic facilities may provide antifertility medications to the woman upon her consent. It should not go unsaid that if health care professionals within Catholic facilities choose not to treat a woman who is in the ovulation phase of her menstrual cycle and is beyond the 24-hour period since the sexual assault occurred, it is imperative that they enter into discourse with the woman regarding options available to her at other facilities in the surrounding area. Here the health care professionals would be providing the woman with information about other avenues she could legitimately explore to defend herself against a possible, though not certain, pregnancy. Conclusion While health care professionals within Catholic facilities should be mindful of the moral issues involved in treating victims of sexual assault, they should never lose sight of the woman in need when discerning how to proceed morally. Regardless of what the pregnancy test shows or where the woman is in her menstrual cycle, compassionate and understanding care should always be provided to her. This care should be directed toward three goals. First, the primary focus of care should be on the woman's physiological, psychological, and spiritual needs. The woman must be treated with dignity and respect, and provided competent and compassionate holistic care. Second, health care professionals must be very delicate when caring for the woman. Care should be provided in a way that allows for the collection of physical evidence for police support and possible identification of the assailant. Third, if the woman is already pregnant or pregnancy results from the sexual assault, then care should be provided in a way that does not harm or jeopardize the developing embryo.
Michael Panicola, PhD Suggested Readings Eugene F. Diamond, "Ovral in Rape Protocols," Ethics & Medics 21 (October 1996): 1-2. Dan O'Brien, "Pregnancy Prevention and Rape," Ethics & Medics 18 (February 1993): 1-3. S.S. Smugar, B.J. Spina, and J.F. Mertz, "Informed Consent for Emergency Contraception: Variability in Hospital Care of Rape Victims," American Journal of Public Health 90 (September 2000): 1372-76. Questions for Discussion
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