The Impact of the Pill ETHICS & MEDICINE 2000 16 . 1 17

For health consumers and health care professionals of an orthodox Judeo-Christian or Islamic tradition, as well as those authentically concerned with the universal respect of unqualified human rights, the asserted capacity of the pill to act as an abortifacient, both in its once-a-day and 'morning-after' permutations, is one of significant moral weight. The research on 'break-through' ovulation' leads moralists, philosophers and human rights' advocates to question the use of the title 'contraceptive' to describe the pill. There is tension in this nomenclature. The term 'contraceptive' refers to a drug, device or chemical that prevents the joining of the sperm with the female secondary oocyte (commonly referred to as the ovum). The problem arises because the female sex cell, the secondary oocyte, may be present in the reproductive tract at or near the time of coitus, hence there exists the possibility that fertilization may occur. Yet, as we will see, the pill alters the receptive structure of the endometrium, making implantation problematical. But are concerned groups justified in moving from a position which states that the pill sometimes fails to prevent 'ovum' fertilization, with the result that new human life may begin, to the position of claiming that the pill has an abortifacient capacity? The first position notes that ovulation occurs in women on the pill and fertilization may occur, but claims there is no evidence that implantation is impeded. The alternate view considers that because ovulation has been detected and the lining of the womb is in an undeveloped state, human life is imperiled. This is a seismic shift in outlook. What merit is there in this latter claim other than supposition or suspicion? Is the pill tarnished with the title of abortifacient on conjecture rather than on fact? This paper will seek to clarify these issues. I will concentrate in some depth on a variety of the implantation factors associated with the microenvironment of the endometrial epithelium. Discussion will also be focused on the mechanism(s) of hormonal dialogue between the 5-7 day old human embryo (the blastocyst) and the cells which line the endometrium. I will also cover the impact of above normal (supraphysiological) levels of estrogen and progesterone on these implantation factors and the role of the pill hormones on the integrity of the endometrium. Particular attention will be given to the impact of the pill on cyclical development of endometrial thickness, and the relationship of this uterine feature to the success of implantation of the human embryo. Central to these issues will be a review of the research on 'break-through' ovulation (also known as 'escape-ovulation'), an event which must occur, otherwise all concerns concerning the pill as an abuser of human rights would be shown to be empty. This paper is of necessity detailed. I hope that the employment of suitable analogies, as well as bracketed discussion of medical terms or concepts, will make it accessible to the scholar and lay reader alike.