What applies to healthy people is also true for the disabled. Both are equally persons and possess the same dignity

When we refer to serious mentally disabled persons, we are not referring to any other situation or condition of disability. In our opinion, the first thing that should be specified is three specific circumstances:

North American figures

  1. To determine the degree of disability of the young person, to have reliable evidence that she does not have sufficient capacity for reasoning to freely exercise her autonomy.
  2. If this is verified, then this is when the possible use of contraceptives can be considered.
  3. If their use is acceptable, only contraceptives whose mechanism of action is in no case anti-implantation, i.e. abortive, could be used; the mechanism of action of the contraceptive to be used must be therefore be very specifically determined, to ensure that it acts via a procedure that prevents conception.

What does Catholic Church teaching say on contraception in serious mental disability persons?

The first text from the ecclesiastical Magisterium that makes reference to sterilization in a person for medical reasons appears to have been the speech by Pius XII at the VII International Congress on Haematology, held on 12 September 1958, in which he set out the moral illicitness of direct sterilization “to prevent the transmission of an inherited disease” (1), a thesis that he had already defended in one of his speeches on 29 October 1951 to Italian midwives (2), and had been mentioned in the Encyclical Casti Connubii of Pius XI (3), on 31 December 1930.


Sterilization remains absolutely forbidden according to the doctrine of the Church


Following the Congregation for the Doctrine of the Faith, on 13 March 1975, in response to a question from the North American Bishops Conference concerning sterilization in Catholic hospitals, he stated that:  “Any sterilization which of itself, that is, of its own nature and condition, has the sole immediate effect of rendering the generative faculty incapable of procreation, is to be considered direct sterilization, as the term is understood in the declarations of the pontifical Magisterium, especially of Pius XII. Therefore, notwithstanding any subjectively right intention of those whose actions are prompted by the care or prevention of physical or mental illness which is foreseen or feared as a result of pregnancy, such sterilization remains absolutely forbidden according to the doctrine of the Church. And indeed the sterilization of the faculty itself is forbidden for an even graver reason than the sterilization of individual acts, since it induces a state of sterility in the person which is almost always irreversible” (4).

We are unaware of the existence of any document from the Church relating to contraception in mentally disabled people. However, in relation to this, Pope Francis, on his return flight from his trip to Mexico on 17 February 2016, was asked the following question: “Holy Father, for several weeks there’s been a lot of concern in many Latin American countries but also in Europe regarding the Zika virus. The greatest risk would be for pregnant women. There is anguish. Some authorities have proposed abortion, or else to avoiding pregnancy. As regards avoiding pregnancy, on this issue, can the Church take into consideration the concept of ‘the lesser of two evils’? The Pope answered: Abortion is not the lesser of two evils. It is a crime. It is to throw someone out in order to save another. That’s what the Mafia does. It is a crime, an absolute evil. On the ‘lesser evil’, avoiding pregnancy, we are speaking in terms of the conflict between the fifth and sixth commandment. Paul VI, a great man, in a difficult situation in Africa, permitted nuns to use contraceptives in cases of rape”.

In relation to this, and complementing these statements, Father Lombardi, the Pope’s spokesperson at that time, declared that, “the Pope clearly distinguishes [between] the radicality of the evil of abortion as suppression of a human life and the possibility of recourse to contraception or condoms for cases of emergency of particular situations, in which you do not suppress a human life, but you avoid a pregnancy. Now it is not that he is saying that this recourse can be used and accepted without discernment, but rather he said clearly that contraceptives, in cases of particular gravity or emergency, can be the object of a serious discernment of conscience.  This is what the Pope said”. After these statements, we have no knowledge of any Church document that has explained or refuted them.

However, for more certainty in our analysis, we consulted professor of Moral Theology of the School of Theology at the Pontifical University of the Holy Cross in Rome, Prof. Angel Rodríguez Luño, about the issue. In his reply, he referred us to volume III of his “Handbook of Moral Theology”, which virtually reproduces what he had already said at the Convention organized by the Congregation for the Doctrine of the Faith in 2007 (5).

In it, he specifies that, “a moral that moves in two different levels does not seem acceptable. The ethics of sexuality are the same for all, healthy and sick. The teaching of the Church on the immorality of any type of extramarital sexual relationship is equally valid for healthy and disabled persons, and the same can be said about the social doctrine on contraception and direct sterilization: what applies to healthy people is also true for the disabled. Both are equally persons and possess the same dignity”.

As regards extramarital sexual relationships, the more serious moral problem does not consist in the fact that they are intentionally infertile or not. The problem, for both the healthy and disabled, is in these same relationships, which have a completely special meaning in the case of the mentally disabled. We shall mention two different figures.

  1. The first corresponds to sexual assaults of which the disabled may be victims (see HERE) and which may be carried out using violence, deception or seduction. In relation to these facts, condemnable from any point of view, the fundamental duty of those who care for the disabled and also of the community, is to prevent disabled people from having these damaging and traumatic experiences. If any of the people who take care of them are involved in the assaults, then mental confusion and disorientation are added to the trauma. Even if the fertility of the disabled were inhibited, the aggression and trauma are equally verified. The issue must therefore be addressed with extreme care. A teaching that — at least in the practical sense — supports a reduction in the guardianship that the disabled have a right to receive by their caregivers and by the community is not tolerable.

Certainly, the legitimate defense of a sexual assault is equally licit for the healthy and for the disabled. The difference, outside of war, is that the disabled person, if they are not autonomous, is entrusted to the care of other people. Anticipating that the disabled will or may suffer a sexual assault means, in general terms, anticipating and accepting that their caregivers are unwilling to properly fulfill their duty of preventing the disabled from having experiences that are brutal and destructive from any point of view considered, and not only because they could initiate a pregnancy. Therefore, generally speaking, the administration of anti-ovulatory drugs cannot be part of due care of the mentally disabled. Taking care of them means above all sparing them from inhuman and traumatic experiences.


Anovulatory agents are only a partial “means of defense” and, from another point of view, represent a certain aggression and relax the care of the people who look after them.


It may be that in some rural areas of undeveloped countries or in very impoverished areas, in which effective guardianship cannot be achieved, some cases may occur, especially when no one continually cares for the disabled person. People who in some way assist disabled people who find themselves in that situation can be faced with serious problems of conscience, which would have to be resolved on a case-by-case base with the help of experts in the area, even appealing to the Apostolic Penitentiary when exceptional situations arise.

  1. A problem other than assault may occur. These are spontaneous sexual contacts between two disabled people. Here it is no longer about violence, but of acts carried out spontaneously without complete freedom, due to lack of sufficient understanding and self-control. From a moral point of view, the violent act and the spontaneous act carried out with incomplete freedom are quite different. Not all sexual behavior that is not fully understood is an assault. In reality, this behavior poses a psychopedagogical problem, which it would be naive to want to resolve with pharmacological, much less surgical means. A human problem of comprehension, maturity, self-control, development is not resolved with a drug.

In the mentally disabled who have sufficient physical autonomy as to remove themselves from the vigilance of their caregivers, and who due to their mental condition spontaneously seek sexual experiences, very difficult extreme cases can occur. These people need particular protection, which perhaps their parents or caregivers cannot guarantee 24 hours a day every day of the year.

If in any case, despite paying the closest possible attention to them, there is real danger, a serious problem of conscience can also be created here, that would have to be studied very carefully. If there were exceptional circumstances in a singular case, I believe that the Apostolic Penitentiary could be consulted.

Finally, it must be said that, in any case, even very exceptional ones, the use of surgical sterilization must be ruled out. In this regard, I think it worth considering what the Italian National Bioethics Committee has written in a document on this topic: sterilization serves the purpose “of obtaining consistent savings in terms of care of the disabled by institutions and, more generally, by people who have a duty to care for them”. Thus “the body of the disabled person is violated, triggering extremely serious and objectively anti-therapeutic reactions […] at the global level of their personal identity; and it indirectly approves neglect on the part of the community of people who, in the name of the fundamental right to health, are entitled to a treatment that truly helps them, and not to simple techniques of indirect control of their sexuality”.  This is the text of Rodríguez Luño so far

Consequently, it appears that, in the case of duly diagnosed mentally disabled people, in which there is no possibility of permanently watching them 24 hours a day, some type of contraceptive drug can be used, provided that it acts exclusively through a mechanism that prevents conception.

However, great care must be taken so that the use of contraceptives is not a reason for parents or guardians to lessen their watchfulness and education in mentally disabled people or to reduce it, because doing so would be exposing them to experiences that could be very harmful and which, without fail, must be avoided.

That is, if parents or guardians duly protect the mentally disabled person, but they are afraid that the person may occasionally elude their control, in that case it seems that they could use contraceptive drugs of the aforementioned characteristics, which we shall later analyze in detail. But given that this solution may always merit an equivocal moral judgment, it is thus recommended, for more confidence, to present the problem to the Apostolic Penitentiary, in which case one would have to conform to its ruling.


Following on from the above, we shall to review the contraceptive methods currently used, to see which of them might be ideal for use in the specific circumstances mentioned in this report.

Contraceptive methods and their mechanism of action

Introduction

Contraceptive methods are considered contraceptive, when they prevent fertilization, and interceptive when they do not prevent fertilization but act in the subsequent implantation process, preventing nesting of the embryo in the endometrium.

Types of contraceptive methods: mechanical, chemical and surgical methods.

  • The first include condoms, both male and female, the vaginal sponge and the diaphragm, which are barrier methods and act by preventing the sperm from reaching the cervix (7).
  • A second type of contraceptive is the intrauterine device (IUD), which has a mechanism of action that is both mechanical and chemical, when it contains copper or releases progesterone hormones.
  • Chemical methods include spermicidal creams and hormone preparations.
  • The hormonal methods include oral contraceptives, both progestogen-only and combined with estrogens, and dermal and intramuscular implants, which contain progestogens.
  • Finally, the surgical methods are vasectomy and tubal ligation.

Note: The efficacy of the different methods is variable (7)

Suitability of the different methods in the case of mental disability

Regardless of the ethical assessment made above, the choice of contraceptive method in the case of mentally disabled persons should be conditional on the possibilities that one or other method offers as regards compliance of the persons involved with the administration regimens, which excludes physical methods and spermicidal creams. A hormonal method should be chosen, preferably long-acting, intrauterine, intradermal or intramuscular, which ensures sustained plasma drug levels to guarantee its efficacy. These may include the IUD, long-acting progestin injections and subdermal implants.  *See table Valencia Regional Government. Department of Universal and Public Health (7)

  • Hormonal contraceptives

As regards the mechanisms of action of the different contraceptive methods, prominent among those that are considered contraceptive mechanisms are modification of the cervical mucus, making it difficult for the sperm to penetrate, and inhibition of ovulation. Among those considered interceptives are alteration of tubal motility, which affects the progression of the embryo in the event that fertilization has occurred, and finally, alteration of the uterine endometrium, which would prevent nesting of the embryo and progression of the pregnancy.

  • Oral contraceptives

Although these are the most widely used hormonal contraceptives, the need for regular daily administration to ensure their efficacy means that they are not indicated in the case of mental disability, where treatment adherence could be compromised. The mechanism of action most responsible for the contraceptive efficacy of oral hormonal preparations is the inhibition of ovulation, although the number of ovulatory cycles is higher than that of implants and injections (8); in these cases their contraceptive efficacy must be attributed to a greater extent to the anti-implantation effect, together with thickening of the cervical mucus to a lesser degree.

  • Intrauterine device (IUD)

IUDs can be copper and inert, or hormone-releasing. The mechanism of action of IUDs is a combination of several of these, which range from interference in sperm progression to alteration of the endometrium, with this, i.e. anti-implantation, the main mechanism of action of the different types of devices, both inert or copper-containing (10,11) and hormone-releasing (12-16). The magnitude of the anovulatory effect of the different types of IUD does not represent a significant mechanism of action responsible for its contraceptive efficacy (16), even in the case of hormone-releasing IUDs (Mirena®), in which the amount of levonorgestrel released daily, 20 mcg, is clearly less than the 50 mcg needed to inhibit ovulation (17).

  • Subdermal implants

Subdermal implants act mainly by inhibiting ovulation, although they also modify the cervical mucus, making sperm progression difficult, and they alter endometrial proliferation; this is a possible interceptive mechanism that should be taken into account, although to a lesser degree than the previous (18). However, the data on anovulatory efficacy differ according to the type of progestogen in the implant. In the case of etonogestrel (Implanon), most cycles are anovulatory after 3 years, while in the case of levonorgestrel (Norplant), up to 50% of cycles are anovulatory after 5 years of use. In these cases, the contraceptive efficacy of the implants must be mainly attributed to their anti-implantation effect (19).

  • Long-acting contraceptive injections

    Injectable long term    contraceptive method

    Long-acting progestogen injections, such as Depo-Provera®, are the most reliable for preventing ovulation. The active substance is a progestin, a substance similar to progesterone, and the route of administration is intramuscular, providing sustained anovulatory activity up to 14 weeks after a 150 mg injection of medroxyprogesterone, the active substance of the drug (20,21).

Side effects

Long-acting progestogens, which are the most widely prescribed for the establishment of hormone contraception in cases of mental disability, present side effects and contraindications, the most common of which are: liver disease, clotting disorders such as venous thromboembolism, vaginal bleeding of unknown origin, breast cancer, severe hypertension, porphyria, pregnancy or allergy to one of the components of the preparation ( https://www.medicines.org.uk/emc/medicine/11121).

Conclusion

Consequently, providing that the ethical requirements specified in the first part of this article are met, long-acting contraceptive injections appear to be those recommended for use in the case of mentally disabled people, due to both their sustained anovulatory activity and their method of administration, which ensures treatment adherence and, therefore, efficacy.

 

 

 

 

 

 

Justo Azanr  and Julio Tudela

Bioethics Observatory

References

  1.  Discurso de Su Santidad Pío XII al VII Congreso de la Sociedad Internacional de Hematología. Friday 12 September 1958.  Accessed 30/05/2017.
  2.  Discurso del Santo Padre Pío XII al Congreso de la Unión Católica Italiana de Obstétricas con la colaboración de la Federación Nacional de Colegios de Comadronas Católicas. Monday 29 October 1951. AAS 43 (1951) 843 ss.
  3. Carta Encíclica Casti Connubii del Papa Pío Xi sobre el Matrimonio Cristiano. 31 December 1930.  Accessed 26/06/2017
  4. Sacred Congregation for the Doctrine of the Faith. Respuestas a las dudas propuestas por la Conferencia Episcopal de los Estados Unidos de América acerca de la esterilización en los hospitales católicos. AAS 68 (1976) 738-740; DOCUMENTA 25.
  5. Rodríguez Luño A. Tavola rotonda en AAVV, Dignità e dirittidelle persone con hándicap mentale. Atti del Simposio promosso dalla Congregazione per la DottrinadellaFede, Roma gennaio 2004, Librería Editrice Vaticana, Città del Vaticano 2007:143-5
  6. 6. ComitatoNazionale per la Bioetica. Il problema bioeticodellasterilizzazione non volontaria,20 November 1998, pp. 24-25
  7.  Generalitat Valenciana. Conselleria de Sanitat.   Accessed 21/6/2017.
  8. Pierson RA, Archer DF, Moreau M, Shangold GA, Fisher AC, Creasy GW. Ortho Evra™/Evra™ versus oral contraceptives: follicular development and ovulation in normal cycles and after an intentional dosing error. Fertility and Sterility. 2003;80(1): 34-42.
  9. Benagiano G, Pera A, Primiero FM. The endometrium and hormonal contraceptives. Human Reproduction. 2000; 15(1):101-18
  10. Spinnato JA. Mechanism of action of intrauterine contraceptive devices and its relation to informed consent. Am J Obstet Gynecol 1997;176: 503-6.
  11. Hagenfeldt K. Intrauterine contraception with the copper-T device: effect on trace elements in the endometrium, cervical mucus and plasma. Contraception 1972;6:37-54.
  12. Stanford JB, Mikolajczyk RT. Mechanism of action of intrauterine devices: Update and estimation of postfertilization effects. Am J Obstret Gynecol 2002;187:1699-708.
  13. Lahteenmaki P, Rauramo I, Backman T. The levonorgestrel intrauterine system in contraception. Steroids 2000;65:693-7.
  14. Barbosa I, Olsson SE, Odlind V, Goncalves T, Coutinho E. Ovarian function after seven years’ use of a levonorgestrel IUD. AdvContracept 1995;11:85-95.

15. Xiao B, Zeng T, Wu S, Sun H, Xiao N. Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use. Contraception 1995;51:359-65.

16 Attia, A. M., Ibrahim, M. M., &Abou-Setta, A. M. (2013). Role of the levonorgestrel intrauterine system in effective contraception. Patient preference and adherence, 7, 777.

  1. Bednarek PH, Jensen JT. Safety, efficacy and patient acceptability of the contraceptive and non-contraceptive uses of the LNG-IUS. International journal of women’s health,2009;1:45-58.
  2. Croxatto HB. Mechanisms that explain the contraceptive action of progestin implants for women. Contraception,2002;65(1):21-7.
  3. National Institute for Clinical Excellence (NICE). Long-acting Reversible Contraception: The Effective and Appropriate Use of Longacting Reversible Contraception. 2005 NICE, London.
  4. Kaunitz AM. Long-acting injectable contraception with depot medroxyprogesterone acetate. American journal of obstetrics and gynecology,1994;170(5):1543-9.
  5. Jain J, Dutton C, Nicosia A, Wajszczuk C, Bode FR, &Mishell DR. Pharmacokinetics, ovulation suppression and return to ovulation following a lower dose subcutaneous formulation of Depo-Provera®. Contraception. 2004;70(1):11-8.
  6.  Agencia Española de Medicamentos y Productos Sanitarios. Accessed 23/06/2017