We do not usually give emergency contraception, or the ‘morning after pill’, in Malta since it has been frowned upon as possibly being abortifacient if an egg has been fertilised, and therefore governments have always refused its importation

A couple of years ago the issue made the media as well, with the present minister of health explaining the issue. Now traditionally the Catholic Church says that a woman who has been raped has a right to prevent pregnancy. In the past, before the introduction of ‘the pill’, women used to carry out wash-outs and such procedures. More than likely these were ineffective. The morning after pill had solved this problem for those of a different faith. A British Episcopal Conference had established that if the girl or woman has not ovulated and she indeed has been raped, then the emergency contraception pill could be used as this would simply be prolonging the date of onset of ovulation. So far so good.

But doctors of course take this further and use emergency contraception in this way even for those who have not been raped. This is, in my opinion, acceptable unless one has a general objection of conscience to the use of oral contraception, even within marriage. But for argument’s sake, let us assume the situation where a raped woman comes to your clinic and requests emergency contraception. In our situation we have two problems. First of all we have to ask whether she has ovulated. If she does not know, we can perform an ovulation test. However performing that test without her knowing why you are performing that test amounts to deception, unless of course you explain why you have to do it or even ask the question. Certainly if you tell her why, she can lie; this removes the moral responsibility from the doctor, but we have not really done anything about that embryo.

But there is another quandary. If we can legitimately use emergency contraception in these cases, we still do not have them, as the government does not allow their importation. Women may buy them from abroad for an eventual use but this is rarely the case. What doctors do is give a multiple dose of the normal oral contraceptive pill. The problem with this is that we say that the drug is being used ‘off label’; i.e. a use for which is was not boxed for. If something had to go wrong, the doctor may be in deep trouble even if he/she followed a normal standard of care. Of course one can explain these things and the risks to the patient but the latter, being in a distraught state, to say the least, is hardly in a position to understand. Perhaps future policy statements of the medical associations can make this clear and provide good local guidelines.

There has also been a development in Catholic literature on bioethics, although not officially accepted by the Catholic Church. The argument is that besides the problems mentioned above with performing an ovulation test, medical tests do not have any absolutes and there are many false positives and false negatives to tests, that one statistically may as well use a simple pregnancy test; the inherent risk would be the same. It is more acceptable to ask a woman to check if she is pregnant before offering emergency contraception for the reason that this test is self-explanatory. But the problem remains that we can then only use an off-label drug. I think it is high time that local authorities start to trust the medical profession and people. It is true that is can be used by those who have not been raped. But what is fodder... If I can legitimately make a pregnancy test to ascertain the absence of a fertilised egg, then emergency contraception will not pose risks of abortifaciency.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of

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