Contraceptives and the Law

THE OBAMA ADMINISTRATION AND THE CATHOLIC Church are in conflict over the implementation of provisions of the Patient Protection and Affordable Care Act (HR 3590) requiring that all US Food and Drug Administration–approved contraceptive agents, not including abortifacients but including so-called morning after pills and sterilization procedures, be offered free of charge by all institutional insurance health plans, with no exception for institutions having religious objections. However, the Administration has compromised its initial directives, suggesting that insurers would have to offer free contraceptive coverage to individuals otherwise covered by such objecting institutions. These proposals are not of benefit to institutions that self-insure and do not exempt employers who have no clear association with religious institutions. Jost has discussed the purely legal disagreements between the Obama Administration and the Catholic Church; however, there has been little comment from a medical standpoint. As faculty members at the Creighton University School of Medicine—one of 4 Catholic medical schools in the United States—we question whether the public health benefits of mandated contraception coverage in the United States are so substantial that individuals and institutions should be forced to take actions that violate their collective moral conscience, thereby doing unnecessary harm to the principle of religious freedom. Because there are 629 Catholic hospitals—which account for more than 15% of patient admissions—in the United States, and there are 4 US medical schools and dozens of other health sciences schools affiliated with Catholic universities, this fundamental difference of opinion affects many patients and health care professionals, and resolving this controversy has important implications for health care in the United States. The Catholic Church offers all of its programs to the general public irrespective of religious belief, but because the Church’s health care ministry originates from its primary spiritual mission, the services provided must be consistent with Catholic ethical tenets. The Church opposes artificial means of birth control based on the belief that each and every marital sexual act must be open to the possibility of the transmission of life. This tenet is part of Church teachings wherein sexuality is incorporated as only one aspect of a framework for understanding the sanctity of the relationship between a man and a woman. A similar system of beliefs is shared, in part, by other faiths, including Orthodox Judaism and certain other Christian churches. Proponents of birth control procedures hold that women have a right to participate in sexual acts without the anxiety, burden, and medical risks of undesired pregnancy, and couples should be able to plan their families using artificial means as they choose, consistent with their life interests as well as their personal resources. The US government has taken the position that such control of reproduction is an essential health service and has mandated that it be offered by all health plans, including those sponsored and paid for by Catholic-affiliated institutions. So, for example, employees of a Catholic university would receive contraceptives, including postcoital agents and sterilization procedures, free of charge. Student health insurance policies at Catholic schools would cover these same measures, directly contradicting efforts to teach students the moral tenets of the Church. A number of preventive health services, including immunizations, mammography, osteoporosis testing, and screening for gestational diabetes, have received such free coverage based on unequivocal evidence of a health benefit to the US population. However, provision of contraceptive services should not be elevated to that same level as a public health priority. It is not clear that birth control is a truly “preventive service” in the sense of avoidance of disease or disability. Whether pregnancy may be undesirable for some women, it is not an illness. Moreover, the risk of venous thromboembolism, with a community incidence exceeding 1 per 1000, is increased 10-fold by the use of oral contraceptives. This