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Monday, March 14, 2011

A doctor on "making a truly informed choice."

Making a Truly Informed Choice: Why I Am Against the RH Bill

By Abraham Daniel Cruz, M.D.

In order to arrive at an intelligent decision regarding any issue, it is imperative that we educate ourselves, in order to understand its true complexities. Sadly so many of us have been victims of making hasty generalizations and sweeping judgments. Such is the case with the very divisive Reproductive Health (RH) Bill. People have taken sides, whether, pro or against this bill, and yet when questioned further, the simple act of reading the bill itself has not even been accomplished, and intelligent discussions have degenerated to the hurling of insults, labeling and name-calling (religious fanatics, baby killers, pro-life vs pro-choice, etc.). I honestly fear that bigotry and religious-based violence is not an all too far reality if this matter is not resolved objectively. While my stand against the RH Bill stems from the initial fact that I am a Catholic first and a physician second, this faith must be enlightened with reason, lest we reduce our faith to natural religiosity, sentimentality, and pious intentions. As Pope John Paul II has beautifully articulated in Fides et Ratio (Faith and Reason):

“Deprived of reason, faith has stressed feeling and experience, and so run the risk of no longer being a universal proposition. It is an illusion to think that faith, tied to weak reasoning, might be more penetrating; on the contrary, faith then runs the grave risk of withering into myth or superstition.“

As a lay Catholic, it is my responsibility to understand this faith, despite the limitations of my intellect, for I can never fully grasp the immensity of Christian teaching. Of course, I am not a theologian, and the objective of this article is not to impose Catholic teaching, but for the reader to gain a bigger and better perspective on the issue at hand. Current surveys say 69% of Filipinos are OK with the RH bill, yet only a very minute handful may actually have read the bill. Thus, these respondents may agree with the CONCEPT of RH, but in actuality have not even read the RH Bill. As Filipinos, it is our duty to educate ourselves, so that we can ask our own questions and eventually make a truly informed decision.

In this article, I will focus on certain issues on the RH bill which I find objectionable. However, since the RH bill has evolved so many times in Congress (HB 5043, 96, 101, 513, 1160, 1520, 3387), I am not able to provide the specific articles and sections of the objectionable provisions since I am only beginning to read the new consolidated RH bill (which is 23 pages, by the way). Also, the current version in Congress seems to have been watered down (eg. removing “satisfying and safe sex” from the definition of Reproductive Health, stating that the bill recommends but does not impose a two-child policy, no specific population to attain, etc.) and has added new provisions on HIV/AIDs and STD prevention, and breast cancer management among others. Nevertheless, the contents and ideology of the bill remain essentially the same as with previous versions.

It is important to note that there is actually a broad agreement on both sides regarding many of the issues on RH (reduction of maternal and infant mortality, violence against women, breastfeeding, infant nutrition, care of post-abortion complications, improvement of infrastructure, training and deployment of skilled birth attendants, etc.). These areas are not up for a lengthy discussion. Most discord is actually on the issues of subsidizing (i.e. using taxpayers’ money) and mandating contraception, population control as a solution to poverty, mandatory sex education in grade school and high school, the seeming loss of parental authority in the acquisition of RH services by minors, provision of RH services by employers, and the punitive provisions which make health workers, employers, and any advocate vulnerable to prosecution. We must remember that when people say we they are pro-RH bill, it means they support ALL its PROVISIONS and not merely the concept of RH. But when I say that I am anti-RH bill, it means that I do not agree with SOME of the provisions of the bill, thereby I cannot support the bill that is currently being discussed in Congress. These objectionable provisions are the ones I will tackle.

Do We Need A New Law?

First and foremost, presupposing that I agree with the ideology of the pro-RH camp, the question of the necessity to even put into law something as broad as health care and reproductive health may be raised. This is a valid issue, since amendments in already existing legislation and programs of the Department of Health will achieve the same goals as what the RH bill supposedly wants as well. Why the need to make a new law?

Hormonal Contraception and Other Devices

This will be the meat of the article, since this is the most highly contended issue. I will not tackle the morality of sex, since that is another altogether different issue, and I urge the reader to try to understand what sex means to them, what it does to them, and its implications in their lives. However, sex and the issue of contraception and STD prevention are closely intertwined. The issue on contraceptives and other devices as part of the family planning program and prevention of STDs is very complex, and three things need to be settled. First is on when life begins, second is the mechanism of action and failure rate of these drugs and devices, and last is the issue of State subsidy. The freedom to choose is a non-issue here, since a person can choose any method in the freedom of his/her conscience without fear of coercion.

Actually, the issue of when life begins should also be a non-issue. It begins at the moment of fertilization (the union of the egg and sperm). This has been settled, not by faith, but by science. Consult any embryology textbook, and all will say that the fertilization is time zero of human development. Before the 1960s, the terms fertilization and conception meant one and the same thing. Now, if the embryo, the zygote, is not alive and is not human, then I don’t know how else to describe it. Yet doubt is cast even over this simple fact because the International Federation of Obstetrics and Gynecology (FIGO) , in the 1960s, defined the onset of pregnancy not during fertilization but during the implantation of the blastocyst into the endometrium – what they now term as conception. Surprisingly, this was not brought about by any scientific breakthrough during that time but coincidentally was made at around the same time that the first oral contraceptive pill was sold in the market. The implications of this “redefinition” will be seen in the mechanism of action of oral contraceptive pills (OCPs), where our pharmacology textbook (Katzung) states that:

The combinations of estrogens and progestins exert their contraceptive effect largely through selective inhibition of pituitary function that results in inhibition of ovulation. The combination agents also produce a change in the cervical mucus, in the uterine endometrium, and in motility and secretion in the uterine tubes, all of which decrease the likelihood of conception and implantation. The continuous use of progestins alone does not always inhibit ovulation. The other factors mentioned, therefore, play a major role in the prevention of pregnancy when these agents are used.

By virtue of the FIGO definition of conception, the post-fertilization effect of preventing blastocyst implantation does not equate to the abortifacient effect of OCPs, since abortion is defined as the termination of pregnancy before the age of viability (20wks), and you cannot terminate something that hasn’t even started yet. However, I will not insult your intelligence. We can see that it is all a matter of semantics and word play in order to make the OCP “palatable”, and that the prevention of implantation terminates life. While it may be argued that the prevention of implantation is not the primary mechanism of action, it happens nonetheless, as evidenced by breakthrough ovulations and failure rates of OCPs. However, the extent to which it does cannot be empirically measured, since it is logistically and ethically impossible to determine it which “successful” prevention of pregnancy is due to inhibition of ovulation, fertilization or implantation. This is where the concept of precautionary principle is applied. When we are unsure of whether these drugs and devices can harm life itself, it is always better to err on the side of life, because we cannot afford to risk even one human life.

The intrauterine device (IUD) does not even prevent ovulation. Fertilization does take place and the IUD works by causing an inflammatory reaction on the endometrial lining, making it hostile to implantation. The condom and other barrier methods, while preventing fertilization, can fail. There’s no such thing as “safe sex”. Multiple scientific studies show that they only reduce the risk, but are not 100% effective, with conservative figures going as high as 10% - 15% failure rate.

We must realize that these failure rates, however low they seem, are not just numbers, they are people – your brother, your sister, your best friend. The truth of the matter is that the use contraceptives is like playing Russian roulette – it is a matter of life or death. If the contraceptives fail in preventing pregnancy, you gain a life; if they fail in the prevention of STD/HIV/AIDS, you lose a life. Sadly, most OB-GYNs turn a blind eye to to this fact, relegating failure rates to mere statistics. Are we really willing to put actual lives at stake? Is the State going to subsidize the purchase of drugs and devices that can harm lives, even when the Constitution states that “life must be protected from conception to natural death?”

Reducing Maternal Mortality

It must be acknowledged that the RH bill provides actual solutions to reducing maternal mortality by improving and increasing infrastructure and providing transportation for mothers who are about to give birth, improving prenatal care, and training and deploying more skilled birth attendants. That we can agree upon. The questionable measure is advocating contraception in this situation, because multiparity apparently increases the risk of uterine atony and hemorrhage, which is the leading cause of maternal death. In short, RH bill proponents are saying that to reduce the number of maternal deaths, we should prevent women from getting pregnant. For me, this is an absurd concept. For sure, we will reduce NUMBERS, but are we actually reducing mortality in terms of PERCENTAGE? Take this for example: The performance of a school in the board examination is not measured in terms of reducing the number of those who fail by not allowing students to take the exam, but in counting those who passed over all who took the exams. Similarly, the efficiency of a program designed to reduce maternal mortality should not be solely measured by reducing the number of maternal deaths, but in counting those who survive over every delivery that occurred. This goal can be achieved without the need for contraception.

Population Management and Poverty

The current bill states that “there shall be no demographic or population targets and the mitigation of the population growth rate is incidental to the promotion of reproductive health and sustainable development”. However, the bill also states that in the context of sustainable development, having two children is the ideal family size (but is not mandated) and that family planning is part of the multidimensional approach to fight poverty. While the words have been watered down in comparison to the previous versions of the bill, the ideology is still the same -- too much people make a country poor, and we need to reduce the number of people because we have limited resources. While this is still a debateable issue, numerous economic studies have shown that there is no correlation between poverty and population. Nobel Prize winner Simon Kuznets’ research has shown that there is insignificant empirical association between population growth rates and output per capita (economic growth). Rather, it is the rate at which technology grows and the ability of the population to employ these new technologies efficiently and widely that permit economic progress. What we need is to provide laws and opportunities that will provide stable, secure, well-paid jobs with good benefits and higher education. Ultimately, poverty is not caused by too many people, but is a result of wrong economic policies, poor governance, human greed, and systemic corruption. These are the three things that the government should focus on, and I hope our President will be true to his campaign battle cry – “Kung walang corrupt, walang mahirap.”

The truth of the matter is that the Philippines isn’t poor. We are capable of doing great things to uplift the lives of those less fortunate than us. Typhoon Ondoy brought out the best in us, for it showed that we have more than what we need, judging from all the donations that were gathered. In the fight against poverty, we need throw away our complacency, get our get our butts out of our comfort zone and do the dirty work. We cannot expect the government to do everything for us.

Women’s Rights and Freedom of Choice

Another issue is that of the advancement of women’s rights and the freedom of choice. Of course, the State must promote these rights, but up to what extent? At the expense of the life of the embryo? Is there currently a curtailment of these choices in the first place? No. I can even easily go to a drug store and buy a month’s worth of pills WITHOUT a prescription. Are women with post-abortion complications not being treated by our hospitals? No. Not even in Catholic-run hospitals. For women’s rights advocates, the promotion of these rights seems to equate to UNIVERSAL (State-subsidized) access to RH services as what the RH bill proposes. However, subsidy means taxpayers money. That is the issue. As taxpayers, we must have a say on where our taxes should go, and as health professionals, we must base the allocation of our resources on the top causes of morbidity (diarrhea, bronchitis, pneumonia, influenza, hypertension, TB, diseases of the heart, malaria, measles, chicken pox) and mortality (diseases of the heart, pneumonias, accidents, cancer, pulmonary tuberculosis, renal failure, diabetes mellitus, asthma, peptic ulcer, liver cirrhosis). While some may argue that bringing the population down may alter these picture in relation to a projected improved quality of life in the FUTURE, Filipinos are suffering and dying of these diseases TODAY. We must allocate and prioritize our resources to where there is an immediate need, using burden of illness as the parameter.

My take on the issue? If you want to purchase a contraceptive, use your own money. It would seem so odd to walk into a barangay health center with no antibiotics for pneumonia but overflowing with free condoms and other contraceptives. And, let us not forget that CONTRACEPTION IS AN INDUSTRY, with pharmaceutical industries and allied health professionals set to gain millions of dollars from the passage of this bill, and politicians who will undoubtedly find a way to overprice and pad their accounts in the purchase of these items.

Freedom of Conscience and Religious Expression

For us Christians, we are all invited to live our faith not only during Sundays, but also in the concreteness and ordinariness our everyday lives. This includes its application on issues with regard to family life, sex education of children inside the family, professional practice, legislation, economics, and health care. This is the true embodiment of religious expression. It is lived. Now, whether or not the rest 80% of Filipinos who are also Catholics accept, live and express this faith is another issue altogether, and what this means to our Catholic President, who will approve or reject this bill, is not up for public debate. Nevertheless, the Catholic teaching on artificial contraception, on sexual intercourse being always open to life in the context of marriage, and on responsible parenthood – these ARE Catholic teachings concretely expressed, and the State must recognize and respect this exercise freedom of religious expression. The freedom of conscience as well as freedom from coercion in religious expression must be guaranteed by the State. One cannot be Catholic and be pro-RH Bill. It is an oxymoron. Yet Church leaders are being accused, even by its own members, while invoking the separation of Church and State, of meddling with the affairs of the State, when all it is doing is proclaiming its teachings, no matter how unpopular they seem to the majority. It is sad that people praise and thank the Church when they agree with church involvement in the fight against corruption and environmental problems, etc., yet label its leaders as meddlers and hypocrites when Church teachings make them uncomfortable with their personal and lifestyle choices. And yes, the Church has problems of its own, but these issues do not diminish its role as a guide to its flock, and neither do the recent scandals forfeit the Church’s role in speaking out when corruption rears its ugly head.

In all these, the State, through the RH bill, threatens those who disagree and do not follow its mandate with imprisonment of one to six months or a fine of ten to fifty-thousand pesos. These are the “would-be criminals” , the people/institutions you might see being prosecuted – schools that don’t want to teach sex education classes, employers who don’t provide RH information and services to their employees, advocates whose stand on contraception and other issues are interpreted as forms of “malicious disinformation”, and hospitals and health care service providers who refuse to extend reproductive health services and information to a patient and do not refer the said patient to a health service provider who will do so because of ethical or religious reasons. If that is not oppression and coercion, then I don’t know what it is.

Last Words

These may very well be my last words on this issue because when HB 4244 passes, and it just might, I might be hauled into prison (hopefully, there will be Christain lawyers who will defend me). All too often, Church teaching on reproductive health and responsible parenthood has been marred with regulations, technicalities, and abstract concepts, making it difficult to understand and eventually accept. But above all, reproductive health and responsible parenthood are about love. As Dean Tony Lavina of the Ateneo School of Government said, it is:

“… the love between husband and wife, love for children and family that is the fruit of that love, and ultimately the love of God that forgives us and that enables us to be faithful to the Word in spite of our sinfulness and scarce resources. This is a beautiful message and the Church should not be ashamed of it.”


  1. Wow! Spot on! Excellent perspective! - JJRey

  2. read it just now, but WOW too