Correspondence

Mifepristone (RU 486) -- An Abortifacient to Prevent Abortion?

N Engl J Med 1993; 328:354-355February 4, 1993

Article

To the Editor:

Glasier et al. (Oct. 8 issue)1 report that mifepristone (RU 486) was an “effective postcoital contraceptive agent.” In their accompanying editorial, Grimes and Cook2 suggest that the drug could reduce the number of unwanted pregnancies and induced abortions. These articles, however, are more likely to confuse than to clarify the debate because they simply recast the language of the controversy surrounding this drug. Popular wisdom understands conception as fertilization of the ovum by the sperm; correspondingly, a contraceptive prevents fertilization by inhibiting ovulation or fertilization. Since contraception is now widely accepted in our society, demonstrating mifepristone to be contraceptive would eliminate the chief moral obstacle to its approval and use.

The action of mifepristone, as reported by Glasier et al., differs from what many people understand as being contraceptive. Mifepristone prevented pregnancy by preventing the implantation of a conceptus. Many people believe that a fertilized ovum constitutes a new human life and that preventing its implantation constitutes abortion. This is the central issue in the controversy about mifepristone. By using the language of contraception to describe the action of the drug, the authors seem to be manipulating public opinion toward an acceptance of it. Redefining the meaning of contraception to include the prevention of implantation does not change the fact that preventing implantation is what many people find problematic with the drug.

We do not take sides in the debate over mifepristone. We agree that reducing the need for induced abortion is important; we do not believe that disingenuous rhetoric will help. As ethicists and feminists, we are more concerned that our society does little to address the social conditions that make the initial premise of Glasier et al. true, that “Despite the availability of highly effective methods of contraception, many conceptions are unplanned.” Why are women and adolescents finding themselves pregnant when they do not wish to be? Attention to the causes of this problem rather than its symptom would be welcome.

Ron P. Hamel, Ph.D.
M. Therese Lysaught, Ph.D.
Park Ridge Center for the Study of Health, Faith, and Ethics, Chicago, IL 60614

2 References

1. 1

   Glasier A, Thong KJ, Dewar M, Mackie M, Baird DT. Mifepristone (RU 486) compared with high-dose estrogen and progestogen for emergency postcoital contraception. N Engl J Med 1992;327:1041-1044
   Full Text | Web of Science | Medline

2. 2

   Grimes DA, Cook RJ. Mifepristone (RU 486) -- an abortifacient to prevent abortion? N Engl J Med 1992;327:1088-1089
   Full Text | Web of Science | Medline

Author/Editor Response

Drs. Grimes and Cook reply:

To the Editor: “Good ethics begin with good facts”1. The biologic fact is that pregnancy begins at implantation and not at fertilization2. When a fertility-regulating method acts before implantation, it is important medically and ethically to explain to patients that the method is not an abortifacient. We understand that beliefs differ about when pregnancy begins, but as we pointed out in our editorial, those beliefs cannot change the biologic process involved.

The hypothesis that “a fertilized ovum constitutes a new human life” apparently considers a preembryo to be the same as an implanted embryo that would be affected by abortion. Opinions differ on this point3. Moreover, the notion that human life begins at fertilization does not necessarily take biologic reality into account. For example, a fertilized ovum may result in a hydatidiform mole or choriocarcinoma, not a human being. Moreover, human reproduction is inefficient. The majority of conceptions that occur either do not implant in the uterus or are lost through spontaneous abortion4. Those of us alive today are the minority who survived this biologic winnowing. Rather than being an aberration of voluntary fertility control, the loss of zygotes is common in human reproduction.

We agree entirely with Drs. Hamel and Lysaught that more attention should be directed to primary, rather than secondary, prevention of unwanted pregnancy. When all children born are both wanted and loved, everyone benefits. Mifepristone may be an important step toward this goal1.

David A. Grimes, M.D.
University of Southern California School of Medicine, Los Angeles, CA 90033

Rebecca J. Cook, J.D., LL.M.
University of Toronto, Toronto, ON M5S 2C5, Canada

4 References

1. 1

   Macklin R. Antiprogestin drugs: ethical issues. Law Med Health Care 1992;20:215-219
   Medline

2. 2

   Hughes EC, ed. Obstetric-gynecologic terminology. Philadelphia: F.A. Davis, 1972:299, 327.
   

3. 3

   McCormack RA. Who or what is the preembryo? Kennedy Inst Ethics J 1991;1:1-15
   Medline

4. 4

   Little AB. There's many a slip 'twixt implantation and the crib. N Engl J Med 1988;319:241-242
   Full Text | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   John M. Dorman. (1996) Emergency Postcoital Treatment: Practical and Ethical Barriers to Use. Journal of American College Health 45:2, 91-94
   CrossRef