‘Just Say Oui’ (To An Informed Debate About Emergency Contraception)

by Peter D. Williams

The below was published almost 9 years ago in December 2016 by Right To Life (RTL) when I was Executive Officer there. Changes in the RTL website since I left meant that this was deleted along with other blogs I had written for them, but in the light of today’s news that ‘[t]he morning-after pill will be available without charge on the NHS at pharmacies in England’, the content takes on a new relevance.

As author of the piece therefore, I publish an edited version here for FET as the important distinction I pointed to at the time between contraceptives, contragestives and abortifacient is no less salient now than it was then. 

BPAS has launched a new campaign, Just Say Non, which seeks to attempt to lower the cost of levonorgestrel, an ‘emergency’ contraceptive colloquially known as the ‘morning after pill’ (MAP). The reason for the ‘Non’ is that their fairly well-produced campaign video tries to argue that the £30 it costs to buy this pill at the counter is the same as a very cheap trip to France, where one can buy the MAP for €7, allegedly with change to spare:

As arguments go, this is a fairly flippant way to illustrate their point, and it only works if you don’t give it five minutes worth of serious thought. After all, this is ‘emergency’ contraception we’re talking here; there’s a 72 hour window for a woman to get the drug and use it. Given this, I can’t quite work out whether the calculation involved is more batty or puritanical.

After all, few of us would not love to live in an alternative reality where you can get a last minute plane ticket to Paris for €20. (“While free movement still applies!” – nudge nudge, wink wink, for the Remainers in the audience.) And maybe that really is the sole transport cost if you actually live in an airport and fancy walking from Charles de Gaulle to Kilometre Zero and back. Frankly however, if your idea of a fun holiday in Paris is staying an hour to buy a contraceptive and have a cheap coffee and croissant, then La Ville Lumière is quite simply wasted on you.

Anyway, as enjoyable as pointing out the holes in BPAS propaganda is, you might be wondering why I think that this justifies a blog post rather than a series of Tweets. A recent discussion helpfully illustrates its broader relevance however, and helps us clarify what has often been a confused and under-informed controversy.

The other day, Sky News hosted a segment debate between Ann Furedi and Aisling Hubert, a member of the pressure group Christian Concern, on the BPAS proposals. Hubert has become known in the last year on the issue of abortion due to her attempted private prosecution of two doctors whom a Daily Telegraph investigation in 2012 exposed for sanctioning illegal sex-selective abortions. Her attempt was quashed by the Crown Prosecution Service (CPS), as they shamefully took it over, promptly dropped it, and left her with a legal debt of £47,000. You can see the exchange, here:

If you know the issues at stake, you will have found it a very frustrating discussion. Aside from Hubert’s initial raising of concerns surrounding the taking of powerful synthetic hormones by minors and wider health concerns, elements that were too little touched upon, the rest of the discussion was taken up by both Furedi and Hubert’s disagreement on the nature of the MAP. Unfortunately, both their comments muddied the waters.

In order to see this, and before we go into what they said, it will help first to establish some basic embryological and biochemical facts.

As human beings, we begin to exist as biological entities at fertilisation / conception, when our father’s sperm and our mother’s egg fuse together to become a new entity: the unique embryonic individual that is you or me. This is elementary stuff, and should be obvious to anyone who was paying attention in Year 7 Biology, but I have nonetheless set out the scientific evidence before (for an excellent written account I recommend the website of the brilliant HEAR campaign on the Isle of Man):

In any case, whilst this point marks the beginning of our existence, it is not taken by the consensus of medical science as defining the beginning of pregnancy.

That may seem odd, as we are used to thinking in terms of pregnancy as the period in which a baby, whether at the embryonic or fetal stages of her development, is in her mother’s womb. This initial instinct makes sense, linguistically. The word ‘Pregnant’ is derived from the Latin praegnant-, probably from prae (before) and gnasci (be born). So, our normal idea of pregnancy is that it is the entire period of a child’s existence before birth.

The colloquial understanding does not correspond however, to what the British Medical Association (scroll to page 1, and sub-section What is abortion?) and indeed the courts have said. These define ‘pregnancy’ as beginning at implantation, when the already conceived human being forms a biological connection with her mother and begins to be given nutrients from her.

Such a definition has its own understandable reasoning. After all, the biological reality is that conception takes place not in the uterus, but in one of the two fallopian tubes. The newly conceived unborn child must then pass down into the uterus, and attach to the endometrium, the uterine wall of her mother’s womb. It is at this point that ‘gestation’ begins (that is, ‘[t]he process or period of developing inside the womb between conception and birth’; from gestationem via similar words meaning ‘to carry’), and this is also when the current consensus defines ‘pregnancy’ to have begun.

I say ‘consensus’, because the established understanding is not due to some magisterial statement from a medical authority, but has come about as responses to the political debate around abortion. Perhaps partially due to this, and the more common – and you might argue, common sensical – understanding of what pregnancy entails, this is all a matter of some legitimate controversy. Nonetheless, this is the established state of things, and there seems little point arguing the toss: the human being begins at conception, and pregnancy (the carrying or gestation of a new human being) begins at implantation.

What is the relevant consequence of this? Quite simply, it determines the language we use when we talk about drugs that are used to ‘prevent pregnancy’, based on the different potential effects they may cause. There are three distinctions we must make:

• Contraception: Derived from ‘contra-’ (against), and a shortened form of ‘conception’, this is any method that prevents conception from occurring (i.e. prevent sperm from meeting an egg).
• Abortifacience: This describes drugs (‘abortifacients’) that cause a miscarriage through causing the degradation of the endometrium or womb lining that develops in pregnancy, and which gives nutrients to the unborn child. One example of this is RU-486, also known as the ‘abortion pill’. This is an anti-progestin, which means that it blocks progesterone, a hormone necessary for the maintenance of the womb lining. This causes the lining to break down, and starves to death the developing embryonic or fetal human being.
• Contragestion: This is the third much lesser known action. The word ‘contragestion’ is derived from ‘contra-’ and gestation, so ‘against gestation’, and was coined in 1985 by the French biochemist and endocrinologist Étienne-Émile Baulieu, who concluded that a technical term was needed to describe the prevention of implantation, which did not fit the traditional definitions of either ‘contraception’ or ‘abortion’. What contragestives do is prevent the already conceived child from implanting in the mother’s womb by disrupting the development of the womb lining, which is necessary for the embryo to implant in her mother’s womb. This as with abortifacience prevents her from receiving the nutrients she needs to survive, and so she perishes.

What distinguishes abortifacients and contragestives is therefore their biological effect: abortifacients end the gestation [pregnancy] of an already implanted unborn child, whilst contragestives prevent the implantation (and thus gestation) of an already conceived child. This is what leads to the medical and legal distinction: what is seen to be ‘aborted’ in abortion is a pregnancy, and thus if implantation has already happened, then pregnancy has begun, and the disruption of this is the aborting of a pregnancy. If implantation has not yet occurred however, then the prevention of this taking place is a ‘contra-gestion’ (an action against the beginning of pregnancy). So, since contragestives do not end an already beginning pregnancy, they are not counted as abortifacients, but as a distinct chemical agent.

This is a neat distinction, but of course what should be immediately obvious is that contragestion is essentially morally equivalent to abortifacience. In both cases, the already-conceived unborn child is killed by being starved of the nutrients she needs to survive, either by the ending of a gestation that is already taking place or of one which is about to take place.

Given the neatness of the biological distinction, and the consequential moral equivalence, it isn’t difficult to see why language in this area is so frequently confused. Even Baulieu, the aforementioned coiner of ‘contragestive’, used it in reference to RU-486, a drug that is properly speaking abortifacient in the way it works. Worse, even though as we have seen the word ‘contraception’ classically refers to the preventing of conception, it is colloquially used to describe:

‘The deliberate use of artificial methods or other techniques to prevent pregnancy as a consequence of sexual intercourse. The major forms of artificial contraception are: barrier methods, of which the commonest is the condom or sheath; the contraceptive pill, which contains synthetic sex hormones which prevent ovulation in the female; intrauterine devices, such as the coil, which prevent the fertilised ovum from implanting in the uterus; and male or female sterilisation.’

So, the irrationally and unhelpfully wide semantic domain of ‘contraception’ now effectively conflates both contraceptive and contragestive agency, even though these are biologically distinct chemical effects.

Given how careless our language is on these issues, it’s little surprise that the concept of contragestion is relatively unknown, and that so many people on either side of the abortion debate see only a strict dichotomy between contraceptives and abortifacients. On the one hand, right-to-lifers can often assume that when we talk of abortion, we mean any action from conception onwards that kills an unborn child, and so they label drugs that have contragestive effects as abortifacients. On the other, abortion lobbyists, seeing that contragestives are not defined as abortifacients, assert blindly that they are therefore purely contraceptives.

Further, and coming to the nub of the issue, this linguistic problem is compounded by chemical reality: there are no pure contragestives, because chemicals with contragestive qualities are always primarily meant as ‘emergency contraceptives’.

Ulipristal acetate (Ella) for example, like RU-486, is an anti-progestin. It blocks progesterone, and works mainly by stopping or delaying the ovaries from releasing an egg. Since (again, as with RU-486) the blocking of progesterone retards the womb lining, this means that it carries the potential to be contragestive. Consequently, the U.S. Food and Drug Administration (FDA), which regulates all chemicals that act to prevent or to end pregnancy, states that:

‘[Ulipristal Acetate] works mainly by stopping or delaying the ovaries from releasing an egg. It may also work by changing the lining of the womb (uterus) that may affect attachment (implantation).’

That is, whilst it is primarily a contraceptive, it can have a secondary contragestive effect. Crucially for the Sky News exchange between Furedi and Hubert, the same is true of levonorgestrel, the MAP. This does not block progesterone, but is a pill with a progestin hormone (a synthetic version of progesterone). Contrary to what Hubert claimed, there is no NHS statement of the contragestive effect of the drug (in fact, both national and local information I have looked at is entirely silent on that specific issue). The Family Planning Association (FPA) does admit it however, and the FDA states in the same page as previously linked to that:

‘[Levonorgestrel] works mainly by stopping the release of an egg from the ovary. It may also work by preventing fertilisation of an egg (the uniting of sperm with the egg) or by preventing attachment (implantation) to the womb (uterus).’

Consequently, both Hubert and Furedi were quite right, and quite wrong. In her beginning comments, Hubert was absolutely correct to point out that:

‘[T]his is also about preventing implantation, which is when the sperm and the egg [have] already met, and you’ve got a unique, whole, alive, human being, and it’s going to be prevented from implanting inside the womb… It is actually causing the end of a unique, whole, human life.’

Equally, Furedi was accurate when she responded in stating that:

‘[I]t is really that everybody understands that… this pill cannot cause an abortion. If you’re already pregnant, it doesn’t work.’

As we can see, however, these two statements are not mutually exclusive. Levonorgestrel cannot cause an abortion, but it does end the life of a unique human being, and regardless of what we call it this is (as Hubert points out) a human rights concern.

Unfortunately however, this point was obscured by Hubert’s claim that ‘this isn’t just preventing pregnancy’, and that ‘it has abortifacient qualities’. In fact, the MAP is just about preventing pregnancy, as defined by the current medical and legal consensus, and is therefore not an abortifacient. By repeatedly and erroneously insisting that it is, as well as unfairly calling the denial of this a ‘lie’, Hubert enabled Furedi to employ the medico-legal consensus in her favour by again correctly stating that:

‘If this Pill were a method of abortion, it could only be used in an abortion clinic. It could not be issued by pharmacists at all because the abortion law regulates abortion’.

This gave Furedi quite a bit of cover whilst she herself mischaracterised the nature of levonorgestrel. Just as Hubert wrongly insisted that the MAP is an abortifacient, so Furedi misleadingly asserted that the MAP is a contraceptive on the grounds that that ‘[t]echnically, contraception stops a pregnancy from being established’. We have seen that as a matter of definition this is true, but it is not the whole story, since the normal meaning of ‘contraception’ wrongly includes the distinct concept of contragestion.

It also allowed Furedi to undermine Hubert’s intellectual trustworthiness by caricaturing her as having:

‘[A] completely fundamentalist attitude to what contraception is… [and] a perverse and very unscientific notion of what abortion is and what pregnancy is’.

This was false, as Hubert rightly accounted the embryological facts and the potential biological effect of levonorgestrel, even if she mistakenly cast it as abortifacient. Still, this followed on from Furedi’s adoption earlier in the discussion of a very typical abortion lobby trope. Whilst Hubert later unfairly accused Furedi of lying, earlier Furedi similarly imputed a degree of mendacity to Hubert, when she exhorted her to:

‘… [b]e honest and say that [you oppose the MAP] for moral reasons, it’s that “we don’t think that these young people should be having sex”, because there is absolutely no other reason why it shouldn’t be available…’

The common abortion lobby slur here is that right-to-lifers are less interested in human rights than they are controlling the bodies or sexuality of others. That Furedi should genuinely employ this silly instance of the abortion lobby’s deluded demonology only illustrates the confusion and incomprehension of her appreciation of this topic. Yes, the MAP is a contraceptive, but it is also a contragestive, which is why Hubert was crucially correct in stating that, ‘of course this is a moral issue’: that distinct effect kills an innocent unborn human being at one of the earliest stages of their existence.

If you know, as Furedi certainly does, the case for the humanity and personhood of the unborn child, and that this necessarily applies after the human being begins to exist at conception, then there is no way you can claim that ‘there is absolutely no other reason why’ someone might oppose the availability of contragestive drugs. Unless, that is, you are unaware of this element of the MAP’s biological effect. Only this charitably explains how she can straight-facedly paper over this distinct effect and search for alternative explanations as to why someone else would oppose it.

The Furedi / Hubert Sky News segment was hugely flawed then, but also very helpfully illustrative. One thing it shows is the importance of care and precision for right-to-lifers in our use of language. It might be tempting for some to consider the terminological consensus fundamentally broken, or even deliberately biased, and insist on referring to contragestives as abortifacients because there is no moral difference between them. All such people will achieve, however, is their effective exclusion from the primary discussion, or else an undermining of their advocacy, as they allow themselves to be presented as unscientific rubes, or dishonest peddlars of crypto-religiose woo. The current language is largely rational; a better tack would be to use it well enough so as to be able to bring out the ill-informed and irrational arguments of our opponents.

This is quite literally vital, because of what else was illustrated by the segment: the confused and ill-informed public awareness regarding the science and ethics of emergency contraception. A lot of time was wasted in what was a conversation spoilt by a failure to note important distinctions. And I say ‘important’ for good reason. These nuances aren’t just matters of pedantry, but inform the way that ordinary right-to-lifers morally live their own lives in consistency with their own principles. It isn’t just Levonelle and Ella, but according to the NHS also IUDs, and according to the American College of Obstetricians and Gynaecologists (ACOG) and the FPA, even progestin-only pills and injections, that have contragestive effects.

Much can be debated about whether various forms of contraception are contragestive, and we should be open-minded and throughly evidence-based in considering such matters. By knowing as best we currently can the full effects of these drugs and devices however, and carefully describing them according to the accepted terminology, not only can those of who are anti-abortion be better informed and able to live out their conscientious principles, we can more effectively advocate for them in the public square, and show that it is our position that is most in keeping with physical and moral reality.