Contraception, Women’s Health, and Equal Citizenship: The Missing Horn of the Dilemma

What is the moral dilemma that gave rise to the great convulsion over religious freedom that in the last months has coursed through the Catholic Church in the United States?

Within the Catholic community, it’s odd even to ask the question. For those backing the bishops-inspired campaign for religious freedom, there really isn’t a question. There’s not a dilemma or conflict of goods here – at least not of goods properly understood. Rather, the Federal Health and Human Services regulation announced in February 2012 requiring that employees of Catholic hospitals and universities be able to acquire contraception at no cost through their job-related insurance coverage is a case of malevolent government power restricting the free exercise of religion. But even the many Catholics not on board with the bishops in this matter don’t primarily object to the bishops’ position because of a good competing with the good of religious freedom. Rather, they object to the bishops’ position because sound arguments drawn from the Catholic tradition of casuistry show that the HHS regulation is not in fact a violation of religious freedom.

But it’s past time to pay more attention to the other horn of the dilemma – the role of contraception in facilitating the good of women’s health and well-being. After all, the HHS regulation was based on a 2011 report from the prestigious Institute of Medicine that proposed the first-ever Federal guidelines for preventive care for women’s health. The availability of no-cost contraception was one such guideline in the report. On August 1, the Federal law went into effect requiring all non-exempt insurance plans to provide free contraceptive coverage. Moreover, the intersecting drama of contraception, women’s health, and Catholicism has recently appeared in high-profile fashion elsewhere on the world stage. Melinda Gates, co-founder of the Bill and Melinda Gates Foundation, on July 11 announced an ambitious Gates Foundation effort to provide contraceptives to 120 million women worldwide. Gates, a Catholic, acknowledged the church’s doctrine against contraception but said: “We’re not going to agree about everything, but that’s okay.” On August 6, Philippine President Benigno Aquino urged the national legislature to pass a long-stalled reproductive health bill that would facilitate the use of contraceptives and that is opposed by the Catholic Bishops’ Conference of the Philippines. In all of these developments, contraception appears as a key factor in ethical arguments for self-determination and social justice for women.

There are many reasons internal to Roman Catholicism that explain why this other horn of the dilemma has not received much attention in the current American controversy. Perhaps chief among them is the claim of Catholic moral doctrine that artificial contraception is an “intrinsic evil” (meaning it is wrong in itself apart from any purpose for which one might use contraception) which means there’s no point in even considering the possibly beneficial effects of contraception for women’s health.

But Catholicism in the United States and elsewhere shouldn’t settle for avoiding the other horn of this dilemma. St. Thomas Aquinas can help us here. As he puts it, “There is no reason why acts which are the same considered in their natural species [e.g., the use of contraception to block, for instance, the natural passage of sperm], should not be diverse, considered in their moral species [e.g., the purpose for which contraception is used].” Or, in other words, we should be wary of determining morality entirely apart from intention. So what is the intention behind the allegedly offending HHS regulation requiring free access to contraceptives?

The contraception policy was developed as a response to the Institute of Medicine finding that 49 percent of pregnancies in the United States are unplanned, a much higher rate than in other developed countries. The provision of no-cost contraception for all American women is meant to reduce the number of abortions associated with unplanned pregnancies (42 percent of such pregnancies end in abortion). It is also meant to assist the health of mothers and children. “Women with unintended pregnancies are more likely than those with intended pregnancies to receive later or no prenatal care, to smoke and consume alcohol during pregnancy, to be depressed during pregnancy, and to experience domestic violence during pregnancy,” the Institute of Medicine report says. Moreover, the study also notes the importance of contraception in combating the “significantly increased odds of preterm birth and low birth weight among unintended pregnancies” and in allowing for pregnancy spacing that reduces the risks of adverse health consequences for children in the womb. Of course, the report points to many benefits for women of using contraceptives beyond a greater sense of self-determination in having children: These benefits include treatment of menstrual disorders, reduced risks of endometrial cancer, and protection against pelvic inflammatory disease. The HHS regulation’s insistence that women have access to contraceptives at no cost is no free-love gimmick. Instead the regulation is based on findings that many women have no insurance coverage; that even small co-pays can reduce the use of preventive health services; and that when “out-of-pocket costs for contraceptives were eliminated or reduced, women were more likely to rely on more effective long-acting contraceptive methods.”

To be sure, the scientific claims of the Institute of Medicine report and the related policy pose a direct challenge to Catholic doctrine against contraception. Beyond that challenge, the science and policy sound several awkward notes to Catholic (and to non-Catholic) ears. They call for a uniform response – contraception – to a remarkably complex issue. They convey a diminished sense of personal responsibility on the part of men and women facing unplanned pregnancies. And the very insistence of the report on the goal that no pregnancy should be unplanned clashes with core Catholic convictions. One such conviction is that every child – planned or unplanned – is a gift. A second conviction is that grace – and, therefore, reason for hope – is always a possibility in the face of what might be unforeseen and difficult. Unplanned pregnancies can not only be dealt with; they can be the occasion of amazing joy.

But whatever hesitations like these there may be about the science and policy, it is still the case that Catholic people in the United States are obligated by norms of civic virtue to grapple with the case being advanced about such a fundamental matter of public health. Plus, the case being advanced is indeed persuasive.

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David DeCosse is the Director of Campus Ethics Programs at the Markkula Center for Applied Ethics at Santa Clara University, where he is also Adjunct Associate Professor in the Department of Religious Studies.