The Birds and the B's
Are morning-after pills abortion or contraception?
If you thought it was hard figuring out your views on abortion and birth control, get ready to wrap your mind around something in between.
Emergency contraception, also known as the "morning-after pill" and marketed in this country as "Plan B," is a drug that a woman can take after sex but before an embryo attaches to her womb. If you don't know much about this murky week in the reproductive process, it's time to learn. Lawmakers in many states are deciding right now whether EC will be easy or hard to get. Some say it causes abortions. Some say it only prevents them. And the dirty little secret is, nobody really knows.
The Food and Drug Administration approved Plan B in 1999. Since then, it has become the focus of a political war. Under President Bush, the FDA blocked over-the-counter access to the drug. Proponents of EC have turned to the states; opponents have responded with legislation protecting pharmacists who won't sell it. Battles are raging everywhere. Last Monday, the governor of Illinois ordered a crackdown on pharmacists. Last Tuesday, the Maryland Senate rejected over-the-counter access; last Thursday, the Colorado Senate approved it. Already, EC is a factor in the 2008 presidential race. Republican governors Mitt Romney (Massachusetts) and George Pataki (New York) vetoed EC access bills last summer. Democratic Sen. Hillary Rodham Clinton (New York) is blocking Bush's new FDA appointee over the issue.
The outcome of the war depends on whether EC gets defined as birth control or abortion. Several states have excluded it from insurance coverage or Medicaid-funded family planning. Romney, in his veto message, said if EC were "contraception, I wouldn't have a problem with it." Nor would most Americans. In a Zogby Interactive survey released a week ago, 44 percent of respondents supported over-the-counter access to "the morning-after abortion pill." Change that question to "the morning-after birth-control pill," and the minority would instantly become a majority. Even Supreme Court nominees John Roberts and Samuel Alito, while reserving judgment on Roe v. Wade, endorsed Griswold v. Connecticut, which established the right to birth control.
Many people think EC can't be birth control, since it's taken after intercourse. This is—forgive me—a misconception. Sex-education classes often give the impression that the egg waits for sperm to show up. It's usually the other way around. An egg loses its fertility within 12 to 24 hours. It takes sperm about 10 hours to reach the egg, and sperm can survive in the female reproductive tract for up to five days. If you want to get pregnant, you'd better send in the sperm before the egg shows up. But if you don't want to get pregnant, and the sperm are on their way or already there, you still have time to stop the egg.
That's the idea behind Plan B. "It prevents pregnancy mainly by stopping the release of an egg," says the manufacturer, Barr Pharmaceuticals Inc. However, Barr adds, the drug "may also prevent the fertilization of an egg" or prevent a fertilized egg "from attaching to the uterus."
There's the rub. If you think a fertilized egg is a human being, as anti-abortion activists do, then preventing it from attaching to the uterus is abortion. Some anti-abortion groups—Americans United for Life, the American Life League and Concerned Women for America—assert flatly that Plan B does this. The National Right to Life Committee, however, isn't sure. It's taking no position until Plan B's effects are clarified. The South Dakota legislature, which banned abortions a month ago, exempted any "contraceptive measure, drug or chemical, if it is administered prior to the time when a pregnancy could be determined through conventional medical testing"—i.e., Plan B.
Even the Catholic Church is uncertain. The U.S. Conference of Catholic Bishops authorizes doctors to offer a rape survivor a drug that blocks ovulation or fertilization "if, after appropriate testing, there is no evidence that conception has occurred already." According to the Catholic Health Association, most Catholic hospitals interpret this directive liberally, since conception is hard to verify and there's "no direct scientific evidence" that EC blocks implantation.
Abortion rights supporters are divided, too. Planned Parenthood, the Population Council and similar groups claim that studies prove EC has "no effect on implantation." But Plan B's manufacturer doesn't agree. Neither does James Trussell, a leading authority on EC. Trussell says that while EC usually prevents ovulation, some evidence "suggests a post-fertilization contraceptive effect." A week ago, he warned colleagues, "We cannot conclude that EC [pills] never prevent pregnancy after fertilization."
Who's right? Does EC kill some embryos, or doesn't it? The answer is, we don't know. We can't know, because, as the Catholic Health Association explains, "There is no current method for ascertaining that an ovum has been fertilized until implantation." It takes a week and a half for hormones to register in pregnancy tests. To verify fertilization before then, you'd have to open the woman up. And that would kill the embryo.
Each side spins the uncertainty its way. Opponents of EC say pharmacists are entitled to refuse to sell drugs "suspected" of causing abortions. Proponents demand a "presumption" that Plan B does no such thing. If you're troubled by the moral or factual ambiguities, each side offers the simplifying comfort of semantics. Proponents say EC can't abort a pregnancy, since "medical authorities" define pregnancy as beginning at implantation. Opponents reply that "embryologists" define pregnancy as beginning at fertilization. Everybody wants to give you an authoritative answer, when there isn't one.
If the two camps were to stop spinning and listen for a moment, they might learn something from each other. Proponents of EC, who talk so much about choice and information, might realize that their denials of any abortion risk from Plan B, through semantics or stretching of the evidence, deprive women of informed consent. The right to choose a pill that's probably birth control but possibly abortion includes the right to know that's what you're choosing.
Opponents of EC might realize that the risk of abortion depends on when the drug is taken. The odds that it will abort an embryo, rather than prevent an embryo's creation, are very low. The earlier you get the pill, the lower the odds are. And every successful EC intervention spares a woman the greater danger of ending up with a surgical abortion. Plan B should be available over the counter so it can be what its advocates hope for, not what its enemies fear.
A version of this article also appears in the Outlook section of the Sunday Washington Post.
Will Saletan covers science, technology, and politics for Slate and says a lot of things that get him in trouble.
Photograph of the morning-after pill on Slate's home page by Patrick Farrell/KRT.