Paganelli, Vitale H.

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The Linacre QuarterlyVolume 36 | Number 3 Article 20August 1969A Commentary On ... "Psychiatric Indications forthe Use of Contraceptives"Vitale H. PaganelliFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationPaganelli, Vitale H. (1969) "A Commentary On ... "Psychiatric Indications for the Use of Contraceptives"," The Linacre Quarterly: Vol.36 : No. 3 , Article 20.Available at: http://epublications.marquette.edu/lnq/vol36/iss3/20says: "There can be no doubt that the number of illegal abortions has been dramatically reduced, but they have not entirely disappeared even in countries such as Hungary, where abortion is available on request. It has been suggested that this stubborn survival of illegal abortion is associated with the relative lack of privacy of the official procedure." The present study has presented the experience of Japan and the European countries in abortion, ranging from the use of abortion as a means of limiting population and including the con-seJ,"Vatlve policies of western and southern Europe, through the liberal laws of northern Europe and concluding with the most liberal provisions in eastern Europe. There is every reason to believe that the experiei1ce of Japan and the European countries would be at least similar in the United States if the same type of . laws were enacted. FOOTNOTES 1. Russell B. Shaw, Abortion and Public Policy and Abortion on Trial; Andre E. Hellegers, A Doctor looks at Abortion; Christopher Tietze, M.D., Statistics of Induced Abortion, International Symposium on Abortion, Washington, D.C., September, 1967; and Abortion in Europe, American Journal of Public 196 Health, Vol. 57, Number 11, Nc mber, 1967, pp. 1923 - 1932; The · .tholic Lawyer, Vol. 10, Number 2, pring, 1964 - pp. 168- 169; Legal Ab( .~·on in Denmark, Catholic Medical Q1 rterly, Vol. 4, Number 3, (April, 1951), ). 85-86; Robert M. Bym, The A. 1rtion Question: a Non-Sectarian Ar ·oach, The Catholic Lawyer, Volll, Nu ber 4, Autumn, 196 5, p. 321; 1arles Kindregan, Eugenic Abortion ' 1 the Law (private manuscript); The rrible Choice: The Abortion Dilemma, ntam Books, Ma1ch 15, 1968, pp. 3-59; William N. Bergin, M.D., Som ody's Going to Get Killed, Hawaii , ;dical Journal, Vol. 26, Number 2, Nm nber/ December, 1966; Norman St . rohn-Stevas, The English Experience, A ~rica, December 9, 1967; Jan-Otto 0 ·1 1sson, International Symposium on A l ·tion, Washington, D.C. September, l967; Frederiksen and Brackett, Demo.: 1phic Effects of Abortion, Public ealth Reports, Vol. 83, No. 12, Det nber, 1968, pp. 999 et seq.; Abortl 1.· A Painful Lesson for Britain, Tiine, {arch 7, 1969; The Catholic Lawyer, '\t . 14, Number 4, Autumn, 1968, pp. 3::, -337; Mrs. Jill Knight, M.P., A Repor from Great . Britain, Fourth Intern ional Symposium on Life, Rhythm, Ab tion, Chicago, Illinois, Apri110-12, 196 ': 2. Boston Sunday Globe, June 2, 196 3. Newsletter - National Right t c Life Committee- No.2, November, 19 4. Boston Globe, June 4, 1966 5. Ratner, A Public Health Physician ~"iews Abortion, Child and F amity, Vol. . No. 1 - Winter, 1968 Linacre QuarterlY Commentary On ''Psychiatric Indications For The Use Of Contraceptives'' Vitale H. Paganelli, M.D. Cavanagh's treatise, Indications For The Use Contraceptives" (Linacre Quarter-May, 1969 ), seems to me to be in of some very thoughtful and ll~:are~ful analysis. In what follows I shall tempt a contribution in that IIIClirecticm. In doing so , I assume that I not be developing any new cific knowledge , but rather that the which I advance and the I~IUe~;tions which I pose will lead in to a further development of an understanding of the problem under consideration. Re.ading through Dr. Cavanagh's article, it would appear that both he the Theologians whom he has extensively quoted , depend ultimately upon an application of the thea-philosophic principle of double effect for determining the licitness of the use "the Pill" by Roman Catholic II J,nv·sl'ici·a ms in a selected group of psychiatric patients. argument that Dr. Cavanagh lt •:uvamcl::!s is that mental health is an ll el1Sen1tial aspect of total human health. things follow, namely: (1) that 11trhatev1::!r compromises the former , lt Comnrf1rnises the latter to an ana-logous degree , and, (2) that treatment directed toward the improvement of the mental health of an individual improves the health of his organism taken as a whole. He speculates that since "the Pill" is a specific therapy for a specific psychiatric disease entity ( whic~ same disease ultimately impairs the health of the human organism in its totality) the use of "the Pill" is licit at least in' the psychiatricilly patho-logical situation which Dr. Cavanagh describes and illustrates with four case histories. Let me take first the points or premises with which I concur. Every modern physician must, I believe, agree with Cavanagh that men tal health is an essential participant in the general health of the total human organism. There is, however, a prob-lem in therapeutics which medicine shares with the moral Theologians. At the risk of being superficial, I cite from among the innumerable situa-tions of organic disease , the treatment of Leukemia with antimetabolite medications. These drugs carry with them potentially serious side effects in a moderate proportion of cases in which they are employed. Because of 197 ~ '. ~· '· '··. (or .. ': ~.t .. ·:'.·: ,1 ' 1. · I ' , t ·" , , •' ... .. . : ,· •' ;.,· . .. .. , . . I , : '•,~o\ t., "iil~ ' ' .. ·· .. •·. ~ .. . '1.'. "· · , ~.:. .. • ,• , ~ .... ' :t' ; ' . , . .. . .. . ' ,J. · · ' ... r their relative effectiveness, however, it ·is considered ethical by the secular physician to use them in spite of this calculated risk. On the other hand, it would be unethical to use an anti-metabolite in the treatment of this same disease (Leukemia) which in effecting a cure in 100% of cases left all these patients with a permanent serious side effect, e.g., loss of the individuals ability to reason properly. The profession, I believe, would con-sider this reduction of the human person to a vegetative state too high a price to pay for the cure of this disease and rightly would condemn the use of this drug by the individual physician. Thus, looking at the problem solely from the secular point of view, the disease state, be it in the organic sphere -or in the psychiatric sphere either in itself or as it relates to the total health of the human organism, is a valid object of the physician's therapeutic concern. But the obvious second point is that the cure must not be worse than the treatment. However, another dimension in the moral sphere is added for the Catholic physician (as well it might be added for all physic-ians) of the licitness of both the means used and of the ends to be effected in a therapeutic problem. In this critique I am only concerned about means having already admitted that treat-ment and cure of mental illness (the end) is a morally valid goal for the physician to pursue. The classic example of the_ applica-tion of the principle vf double effect in Catholic medical ethics involves the rationale for treatment with radium of cancer of the cervix of the uterus, which uterus contains a normal pregnancy. The traditionally accepted reasoning here has been that since the death of the fetus is neither directly 198 intended nor willed, the di ased cervix may be treated With L iiurn even though the death of the f{ us is foreseen as an inevitable result The understanding of this nuanc of reasoning demands clear recognit n of the fact that there is a vast diffl ~nee between intending or willing the eath of the fetus and of being at ~ to foresee its death as a result c the directly willed or intended treat .ent. It is on this point that I find a fl w in Cavanagh's speculations. If I have understood Cav 1agh correctly, he states that -a pathol ~ical mental state results as a direct feet of "a fear of pregnancy". I' the classical illustration I have given <J ove, it would be fair to say that this pathological mental state produc j by "fear of pregnancy" holds a p tion analogous to the cancerous pre 1ant uterine cevix. Next, Cavanag_l in-dicates _that in order to removt this "fear of pregnancy" and its res1 tant pathological mental state the eat-ment requires the use of "the 'ill". Again, returning to the ch. sical example, this would be analogo .s to the use of radium in the treatmt 1t in the cancerous cervix. Finally con-cludes Cavanagh, though stt i lity results from the treatment (an i we shall prescind entirely in thi~ dis· cussion as to whether it is "; ~mp­orary" or "permanent") it is \ illed only "indirectly" and then fore , though it is in itself an evil effec it is tolerable because of the greater ~ood to the total human person whicl will flow from the cure of his psyd atric pathology. Returning for the last time t( > the classic illustration, it is implied that the sterility that is "indirectly w1lled" is comparable to the · death o t · the fetus; "the greater good" which floWS Linacre QuarterlY a result of treatment in Cavanagh's blem is cure of mental disease; the ter good" which flows in the · example is the restoration of organic health of the mother. , however, that in the classic • :"amtple, the death of the fetus was willed either "directly" or point, it might be well to our understanding of the IIPnn<;tple of double effect. For this , I take Karl Rahner's defini-of "Double Effect Of An Action" m his Theological Dictionary, and Herder, New York, 1965, 167 (Rahner and Von Grimier). of its importance, I beg my indulgence while I quote in "In that the 'outward' orientation the free human act always projects subjective 'world' of the respective (the end he has in view, his , his intention) into a par-environment among his fellow-that act in principle may have a effect. The problem for moral then arises where the unin-evil consequences of such an is in fact unavoidably connected it a:nd foreseen, though not fore-as such. Is such an action licit? answer is that the evil which is 'tted must not be the means to attainment of the good end but an incidental effect; the import-of the good intended has to be 1• ei2t1ed against the harm to be done the double effect; other means to desired end must, so far as possi-' have been exhausted; the possibili-of giving the 'other man's' right 11Prec~~de1nce over one's own aspiration, the need to . do so, must be con-... ~~re:d (love of neighbor)". important points can be from this definition. One is ' 1969 that the evil consequence of the act, though it be foreseen, must not be fore-willed and here no distinction whatsoever is made between fore-willing the effect "directly" vrs. fore-willing the effect "indirectly". The second thing that is noted in this definition is that the evil which is permitted must be merely an in-cidental effect to the attainment of the good end and may not ever be its means. Cavanagh throughout his . article has quoted . and used such phrases as "indirect sterilization" and "indirect means of preventing neurosis". It is easy to slip from these terms and to make them equivilent with, equal to, or substitutable for "indirectly willing". However, as will be immediately evident from another example, to accept this would be fallacious. An indirect sterilization takes place, for example, in the treat-ment of Endometriosis with "the Pill" but this sterilization is not "indirectly willed". In order that double effect be valid the evil effect may not be willed either "directly" or "indirectly"; it is merely foreseeable. The second _problem in Cavanagh's speculations rests in the psychiatric problem itself. "Fear of pregnancy" is somewhat an ambiguous phrase which Cavanagh is never at great pain to define clearly. He notes in the para-graph entitled "Premenopause", "there is frequent fear of a 'pre-menopausal pregnancy"'. If it is "frequent" in the premenopausal area, then one can hardly call it abnormal, for what falls at the maximum of the classic biologic bell curve is "frequent" and is therefore normal. But if it is not abnormal, then one questions the validity of treating it at all! More importantly, ·let me return to the question of what constitutes "fear of pregnancy"? It is evident from the 199 .,..-, ·t', ._, ·'' ~-·~ '· '-··. ··' : . ·., ~J. ~ . ·• /-: ,1: , '· 1 • , -· .. • ' .. .. ·. . .. !·,·· .. ··. ' . . ·. 1 . : • '.~. I ... } ... · ··-~·· .,. ,._ . '(' ; . il ' • : •• .. ~.1 ~: .; ~ .· ·: . .· .. ~· ... ' .... . .: '.•, , .. . ' . ,J • • .. ' ... case histories that Cavanagh has cited that it is not necessarily the specific number of children which causes a "fear of pregnancy" nor need it be that the mother herself has the pri-mary "fear of pregnancy". (In case II, the husband developed a psychotic state as a result of his "fear of preg-nancy" in his wife). Furthermore, in the existential situation "fear of preg-nancy" may be and probably is found in some unmarried females. Finally, in the married state "fear of pregnancy" may be related as much to a first pregnancy as to a tenth or to circum-stances of relative economic affluence as well as to those of abject poverty. Thus, "fear of pregnancy", at least as used in Cavanagh's essay, is not a well defined syndrome. Another important question which Cavanagh fails to resolve satisfactori-ly is whether the "fear of pregnancy" is superimposed on a basically normal personality which then becomes pathological (mentally ill) or whether the "fear of pregnancy" is not in fact superimposed on an already existing and underlying pathological personal-ity which then manifests itself by increasing bizarre behavior. In the former instance, Cavanagh's argu-ment wouid have a great deal more to say for itself. In the latter instance, it is possible that "fear of pregnancy" may be found to be the direct con-sequence of an underlying pathological state of mind rather than its cause, thereby further weakening his specu-lative position! In any event, in the cases illustrated by Cavanagh, it seems evident to me that a sterile state must be willed. Perhaps this will become more clear in what follows: If, as Cavanagh indi-cates, "fear of pregnancy" is a basic 200 pathological process and not ~ ply a· symptom of an underlying atho-logical mental state, then the t ~ rapist · is obliged to direct his treatrnr. 1t first toward the removal of that ·ear of pregnancy", that is, to direc y will that his treatment (whatevel be its modality) results in the cure 0f the "fear of pregnancy". Using "the Pill" as the moe !ity of therapy in the removal of a ear of pregnancy", so far as is now nown, depends solely on a single cam ·effect relationship, namely, that " t .! Pill" · relieves the "fear of pregnar: y" by insuring that pregnancy simpl. ;annot occur, i.e., by inducing a ·· 1te of sterility. (It does not, for e ample, effect an effacement of "fear preg· nancy" by a direct hormonal i1 1uence on the cerebral cortex in a aanner comparable to a phenothiazin acting in the same area of the brain) There· fore, what is then both willed . a first effect · and foreseen as a result ,f "the Pill" therapy is the state of str lity. It is not simply an unwilled but oresee· · able effect or in Cavanagh' term-inology, an "indirectly willed · effect. Producing a state of sterility eli eves the "fear of pregnancy" which, according to Cavanagh, then tum cures, or at least favorably in uences the abnormal pathological ~ dte of mind and thus total human he8 ch. But what if the primary psj hiatric condition is an underlying path logical state of mind, for example, a 5chizo-phrenia, one of whose manY "? symptoms is "a fear of preg! .mcy · Directly willing the sterile statt is even less licit in this instance sir ;e this represents merely the treatme tt of a symptom of a disease with a lirectlY willed means (sterilization) hich is per se evil. Therefore, not onl·\, is the Linacre Q evil and willed directly but it is disproportionate to the good to accomplished (it merely cures a tom of the underlying disease), the surgeon cuts off the foot to the pain of a plantar's wart. disagree with Dr. Cavanagh's in several other less pressing . For example, there is no con ... evidence to indicate that rhythm even its .failure always gives adverse tric results; ( cfr. voni-lilde-' "The Encyclical Humanae Vitae, Sign Of Contradiction", Franciscan d Press, ·chicago, 1969) or that is always an improvement in a 's sexual desires as a result of Paul has suggested in Vitae" that the love and implicit in conjugal intercourse be lost in the totally free dis-of the act even within the , felicitous marital relationship. the Pope implies that conjugal intercourse, as much as the kiss , lose its meaning and values in our rn society. Is this speculation on part of the Pope drawn from valid · atric findings? Here certainly be a fertile , useful research field st, 1969 for both . psychiatry and sociology to explore. Finally, one wonders whether psychiatry is only tackling symptoms rather than diseases. One need only point to the development of a vaccine to prevent German measles, rather than the use of abortion to reduce congenital newborn defects as a case in point. I find myself in this essay in art uneasy though I believe not altogether untenable position. As a general prac-titioner whose understanding of philosophy and theology is all but self taught,. I have challenged a specialist with a broad familiarity in the other aforementioned fields who is art acknowledged expert (by me, by the profession, and by the church) in the areas to which he devotes and addresses himself. I dare to do so only because his speculations have pro-voked serious questions of conscience for the individual practitioner. I have almost daily refused to prescribe "the Pill" in situations in which I can without stretching clinical definitions identify "a fear of pregnancy" leading to neurosis. Am I morally justified to refuse such a prescription? 201 ... ~. ' . ' .. ( -· , , · ' J'•· . 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A Commentary On ...  Psychiatric Indications for the Use of Contraceptives

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A Commentary On ... Psychiatric Indications for the Use of Contraceptives

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