An (almost) postscript on the contraceptive benefit debate

An anecdote underscores why liberals will win the contraceptive fight, and why the Church is so misguided to press its particulat views in broader public policy.

I’ve been too bogged down in other work to contribute to the contraceptive benefit debate. I feared I would miss the whole thing. I am pleased, however, with the way it has seems to be playing out.

I am gratified that social liberals are actually winning a health policy debate. I am somewhat astonished that social conservatives are fighting about contraceptives in this day and age.

Liberals have had few such victories after health reform. During the knife fight endgame leading up to ACA’s passage, feminists and the pro-choice coalition often found themselves under the bus for two simple reasons: (1) pro-life Democrats had the marginal votes, and (2) everyone understood that pro-life legislators were ready to bring down the house if they didn’t get their way. Because pro-lifers wanted it more, Nancy Pelosi, Barack Obama, and other liberals gritted their teeth and conceded on many key issues. I believe this was the right political call. It still hurt.  It’s nice to play a stronger hand.

I am also gratified that the Obama administration has reached a dignified accommodation with the Catholic Health Association and with other Catholic organizations that do so much every day to help poor people. Like most of my public health colleagues, I myself reject many Catholic teachings in matters of contraception, abortion, and sexuality. I still believe President Obama is smart and wise to avoid measures that gratuitously insult Catholic institutions when this can gracefully be avoided.

If you embrace the ethos of community-based public health, it’s more important to find common ground with the Church in addressing areas of common concern than it is to bluntly repudiate it whenever we disagree.  These institutions certainly can’t be ignored politically, within the broader American electorate or within many at-risk communities. Catholic Churches, Catholic hospitals, and Catholic Charities on the ground in many embattled communities—feeding the hungry, caring for foster children, housing the homeless, and more–after other do-gooders have gone.

Catholic institutions and organizations deserve everyone’s respect in other ways, too. Aside from its role in service delivery, the Church has stood up for stigmatized and politically weak people who need help. On some issues—the 1996 welfare reform, matters involving undocumented immigrants today—the Church stood up when its natural political allies and many Democratic constituencies chose to stay silent. The Catholic Church—particularly the post-Vatican II Church–is not the enemy of liberal values that many outsiders believe it to be.

I do hope the bishops’ political embarrassment leads them to take a good hard look at the ways they choose to operate and position themselves within the American political system. Some Catholics suggest that liberals unduly relish the opportunity to confront and to humble the Church. There is some truth to that. I’ve heard more than a few nasty references to celibate old men who don’t know anything about sex, and so on. Church leaders might wonder why. At least in part, progressive animus is an understandable reaction to the bishops’ rather open, at-times crude partisanship regarding sensitive issues we liberals care greatly about.

Catholic teachings oppose abortion and contraception. These same teachings pretty much prohibit the death penalty, preventive war, and economic policies which promote undue inequality. In opposing these latter teachings, Rick Santorum is no less the cafeteria Catholic than (say) John Kerry is. Somehow social conservatives seem to receive a free pass.

Church leaders might ponder why they operate with so much greater success and political legitimacy on the issue of abortion than they find on issues of birth control or (increasingly) on issues of equal rights for gay and lesbian Americans. I myself am emphatically pro-choice. I believe abortion is both permissible and justified in many circumstances. Yet as someone who has heard the heartbeat of my two beautiful children in-utero, I can’t really begrudge the Church for taking a contrary view.

One does not need to be Catholic—indeed to hold any religious belief–to appreciate the powerful moral, political, and ethical reasons millions of people have in opposing abortion. Catholics’ moral views are animated by religious traditions and arguments. Yet these arguments fit broadly within what John Rawls called the “overlapping consensus” of our pluralist liberal democracy. Others of us have equally serious reasons to disagree. Yet it’s hardly surprising or objectionable that the Church feels compelled to enter the political arena on behalf of its views to defend (as it understands the question) unborn life.

The contrast with contraception could hardly be greater. Polls indicate that the dominant majority of American Catholics ignore or reject Church doctrine here. Most Catholics appear to agree with the Obama administration’s proposed policy. If the Church could find a way to temper its stand or to reverse itself on this issue, I suspect that even most socially-conservative Catholics would breathe a giant sigh of relief. 

These polls don’t capture an even more important difference between the two social issues. There is, of course a long and deep Catholic moral debate over the nature and expression of human sexuality. The richness and humanity of this tradition is poorly expressed in current Church policies. More than forty years after the disastrous encyclical, Humanae vitae, which inveighed against artificial birth control, Church doctrine on contraception literally makes no sense to most people. Catholics might regard conformity with Church teaching as a good in itself—like keeping Kosher or getting circumcised, for example. Yet there is no broadly-comprehensible or compelling secular justification for these latter practices. There is even less justification for imposing Catholic beliefs in this area on the non-Catholic woman sweeping the floors in Advocate hospital, or for that matter her Catholic peer who don’t follow these specific teachings.

If contraception were a trivial matter or were less intimate to our humanity, this issue wouldn’t matter one way or the other. No one cares if Mt. Sinai Hospital does or doesn’t serve pork in its cafeteria. But the stakes are higher here. Women encounter many difficulties in using contraceptives consistently and most effectively. Cost is one important obstacle. $30/month for birth control pills or the (slightly lower) annualized cost of an IUD is serious money for millions of low-income women who have the highest rates of unintended pregnancy. Frost and Darroch found that one-third of U.S. women using reversible contraception would switch methods if they did not have to worry about cost. A 2010 study found that two-thirds of women chose long-acting contraceptive methods when offered the choice of any method at no cost. These findings are especially concerning in light of evidence that women who are dissatisfied with their specific contraceptive method are more likely to use it inconsistently.

In nearly every way, women bear the lion’s share of the financial, relational, medical, and psychic costs associated with unintended pregnancies. It seems right to me that women—particularly young women with limited financial resources—should be able to decide whether, when, and how to manage their reproductive choices free from immediate financial pressures, the hassles of insurance copayments, or the need to explain their reproductive and sexual lives to an employer, a nosy pharmacist, or to anyone else on whom they may rely for financial support.

Some Church officials seem strikingly tone-deaf to the moral complexities of sexual life experienced by millions of people. The New York Times reports that “Archbishop Dolan criticized people who postponed conception with ‘chemicals and latex,’ calling them part of the ‘culture of death.’” At one level, this is simply rude. At another, I’m at a loss to understand what he’s even saying.

How does it promote the “culture of death” for people to deploy “chemicals and latex” to avoid facing the obvious choice in the event of an unintended pregnancy. The Pope himself has acknowledged that condoms may be the lesser evil, as it were, in preventing HIV infection. On other fronts, contraception plays a critical role in creating an environmentally and economically sustainable life for billions of people.

Archbishop Dolan seems equally misguided when casts aside these world-historical issues to consider how we should treat our friends, relatives, and neighbors with dignity closer to home.

I speak with many people who care for adults and children living with intellectual disabilities. One young woman’s child was diagnosed with a serious disorder—at which point she herself discovered that she is a genetic carrier. She visited the archdiocese and asked whether Church teachings would permit her to use artificial birth control. She and her husband were told: No, they cannot. If anything justifies this heartbreaking response, I certainly haven’t heard it.

Fortunately, dogmatic bishops don’t represent the entire Catholic faith or the entire Catholic perspective. Her parish priest–to his credit—provided a more worthy response to a parishioner in pain who approached him seeking consolation and help. In my book, that’s the true pro-life perspective. If his superiors would do likewise, they would spare themselves much trouble.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

28 thoughts on “An (almost) postscript on the contraceptive benefit debate”

  1. I was brought up as a Catholic, and, as a lapsed Catholic, retain something of that in my personal identity. I say that in defensive preface to the expression of emphatic exception to attributing too much good will to the Catholic hierarchy.

    Catholic christianity has managed to retain care for the poor and striving for peace as central concerns, which is to be respected, I think. Nevertheless, its morality is an authoritarian one, shaped and reinforced by a hierarchical institutional structure. The Sexual Revolution of the 1960s transformed our culture’s sexual ethics — “revolution” is the right term. We went from a society in which taboo played a very large part in shaping sexual behavior and expression, and in which marriage was a license for sexual intercourse, granted by state and/or Church, to a society in which sexual behavior was a matter of individual choice and responsibility, taboo is rejected as superstition except where the sexual behavior is criminal by reason of its predatory or violent nature, and in our present conception, marriage is a personal contract between two individuals, to which the state and society offer support. For the Catholic hierarchy, which is composed largely of male celibates, the Sexual Revolution is the product of misguided Jacobins, and the ultimate goal is reverse it.

    What I found most remarkable about the debate over contraception and the employer mandate was the common cause so-called libertarians made with the Catholic Church. The claim that the Church has a legitimate ethical squeamishness over contraception is far-fetched at best, but libertarians, always hostile to social insurance, saw a point of rhetorical leverage. That the neo-feudal agenda of the libertarians might be consistent with the feudal agenda of the Church hierarchy is a discovery we will have many opportunities to rue, in the future.

  2. My guess is that the archbishop sees people who use birth control as rejecting God’s plan, basically. The idea is that the possibility of a baby is supposed to be an inherent part of sex, and if you prevent it, you are someone who believes only in momentary pleasure and who rejects any larger vision of your life’s purpose. He also probably thinks only faithless people use it. From there it’s a small step to thinking of them as existentialist and degenerates, basically (sorry, atheists, but a lot of people think that way – not me…) But, he should explain himself! I’m just guessing.

    Of course, most of us don’t see anything wrong with this, since we don’t see sex as inherently fraught with any issue at all, assuming there is adult consent (though that’s a whole story there of course).

    I’m intrigued though that you mention another side to Catholic tradition. Other than from my lefty parents, I don’t recall ever hearing anything about it. (But I didn’t go to Catholic schools for the most part.) Boy do they keep it quiet. Cynically, I would say the difference with HIV is that men get it, whereas when women suffer, that is just nature. But, maybe I’m just bitter!

  3. I don’t know; If you’re trying to achieve a compromise with somebody, shouldn’t you negotiate with them, rather than somebody who is already in fundamental agreement with you? This was rather like the administration going to Americans for Gun Safety to negotiate a ‘compromise’ on a gun control bill. Nobody who was offended has been satisfied by this pseudo-compromise. The issue isn’t really going away, all he’s managed to do is give the press a temporary excuse to pretend it has. But they’re in his pocket, they didn’t need an excuse, just direction.

    Meanwhile those bishops have an awful lot of ‘bully pulpits’ of their own, and no particular inclination to back down.

    I’m not saying he’s necessarilly going to lose this fight, but he has chosen a fight here, and if he wins, it’s not going to be hearts and minds. He’s not going to win this one by persuading anybody, there’s an actual matter of principle at stake here.

    But then, see my earlier remarks on this subject: I don’t think he meant to win any hearts and minds in this fight, just to demonstrate who had the bigger stick.

    1. actually, brett, he’s trying to sell the compromise to the 50% +/- for whom contraception medications and devices represent an important part of their health care. but do go ahead and keep repeating your framing devices if that makes you happy.

      1. He’s trying to compromise with the people who didn’t have a problem with the policy in the first place? That’s what I was saying.

        1. he’s trying to sell throwing a bone to people who oppose him to the people who don’t oppose him. at least you admit, by implication, that this is a matter of singular importance to every female in the country. you usually aren’t so forthcoming.

          1. It’s a matter of singular importance to every woman in the country who has a job with health care coverage, but who can’t afford a condom, that much I’ll admit.

            First, seriously, can we have an end to this absurd pretense that women are, as a group, all on the pro-choice side of the argument? Or even predominantly?

            Second, I realize it’s something of a trope to portray any reversion to the regulatory status quo ante as equivalent to the end of civilization, (For instance, schools not handing out free lunches = mass starvation, even though there wasn’t mass starvation before they started doing it.) but doesn’t that rhetorical ploy involve waiting until the status quo ante IS ante?

            Religious liberty in the matter of employee compensation packages IS the status quo, right now. While the administration is proposing to abolish that, it’s what we’ve got NOW, and the republic is not burning.

            Let me be blunt about this: Catholic hospitals are not the only employer in the nation. If somebody wants something the Catholic church thinks reprehensible as part of their compensation package, they can, (ahem) damned well find a different employer.

          2. Brett, there is religious liberty in health benefits: if the user of the benefits is a Catholic uncomfortable with contraception, or a Christian Scientist uncomfortable with blood transfusion, or a Scientologist uncomfortable with psychiatry, they need not avail themselves of those benefits. What there isn’t is company-imposed religious practice of the sort envisioned by Senator Blunt, where your boss tells you his morality is inconsistent with your receiving any of the above.

            And contrary to your statement, in many places Catholic hospitals are the only employer. That is, the only employer of people with the relevant job skills in the area. And Catholic hospitals, contrary to what you imply, are not the Catholic Church. They’re big enterprises that employ a lot of people of varying backgrounds and serve patients of equally varying backgrounds. Pushing a mop in a Catholic hospital is not the same as joining a nunnery.

            Also, “religious [imposition] in the matter of employee compensation packages” is not what we have now: in at least ten states, employer-provided health care already has to cover contraception. Somehow this never was previously the End Of Religious Liberty.

          3. You guys are slipping! You let Brett pass this one through “First, seriously, can we have an end to this absurd pretense that women are, as a group, all on the pro-choice side of the argument?”

            using contraception is not pro-choice! To suggest that, or that this is what the debate is about, reveals a lot about Mr. Bellmore.

        2. Similar policies were in effect in either 20 or 28 states. The didn’t say sh*t until a Democratic President did something.

  4. The Catholic Church—particularly the post-Vatican II Church–is not the enemy of liberal values that many outsiders believe it to be.

    Who am I to believe, you or my lying eyes?

  5. Like other liberal men who have been weighing in on this controversy, you give too much credit to the Catholic position. The fact that the bishops reserve their threats and maledictions for issues involving women’s sexuality says it all. They may have expressed a position on immagration and welfare reform, but I don’t recall threats to excommunicate office holders who took the Republican position on these issues, or on the death penalty.

    Yes, Catholic organizations may do good works with their charitable organizations (as do other religious groups.) However, I am deeply concerned that municipalities have been signing over their hospitals to Catholic control throughout the country. There are now many places where women cannot get local hospital based reproductive health care due to the imposition of Catholic religious strictures on patients who do not share these beliefs.

    I sincerely hope that the Republicans get clobbered for sucking up to the bishops on this issue.

  6. Some Catholics suggest that liberals unduly relish the opportunity to confront and to humble the Church. There is some truth to that. I’ve heard more than a few nasty references to celibate old men who don’t know anything about sex, and so on. Church leaders might wonder why. At least in part, progressive animus is an understandable reaction to the bishops’ rather open, at-times crude partisanship regarding sensitive issues we liberals care greatly about.

    How about it’s a reaction to the absurdity of ostensibly celibate men lecturing the rest of the world about what the “purpose” of acts that they have forsworn never to engage in is?

    Basically, the criteria by which the church leadership is selected is basically guaranteed to generate leaders who know less than your average college freshman about sex. I can’t think of a group of people whose opinions about sexuality are entitled to less respect (and of course, on the merits, they got the whole thing dead wrong).

  7. Shows how much you people know. The Pill causes prostate cancer!

    http://merrimack.patch.com/articles/merrimack-rep-claims-the-pill-has-been-linked-to-prostate-cancer

    Rep. Notter mentions a Dr. Bernstein, but she meant Dr. Brownstein, a natural MD who told her about the link at http://www.newsmaxhealth.com/dr_brownstein/Prostate_Cancer_The_Pill/2012/02/06/432113.html

    Newsmax health is where I get all my medical information. Newsmax news is where I get all my other information. Dr. Brownstein can melt your prostate cancer away naturally if you are unfortunate to get it from oral contraceptives.

    BTW, http://www.ncbi.nlm.nih.gov/pubmed/22102643
    has the ecological study that launched the story. Free access.

  8. I’m sorry, but I think these churches can get stuffed. They’re compensating their workers, who can spend the money however they want. Because of our screwed up health care system, getting insured through your employer is about all there is. So I’ll be damned if they think they have the high ground. Oh, and their actual beliefs are idiotic. But there’s religion for you – where idiocy gets dressed up in finery and paraded about like a sow in heels.

  9. I don’t get it. Who’s forcing Catholic hospitals to use birth control? Catholic hospitals can’t get pregnant, nor can they go to Hell.

    How are their “rights” as employment organizations being violated? Or have the Republicans reified corporations to the point where they can commit sins and get pregnant? (Did Citizens United accomplish that, in addition to finding that these entities have the right of free speech?)

    For that matter, who’s forcing nice, reverent, devout Catholic employees to use birth control? Far as I can tell, if they want to exercise their right of conscience, they can skip the birth control part of their insurance benefits, and even skip the sex.

    Why does so much of right-wing religious doctrine focus on getting *other* people not to sin? Didn’t Jesus say, “Take the plank out of your own eye first?” Whatever happened to that whole “personal responsibility” conserva-meme, or is that so 1990’s?

    1. More to the point, why does all of right-wing religious doctrine focus on sex? When the wing nuts mention the word “morality” is it ever about anything Jesus mentioned in the sermon on the mount? Nope! It’s abortion, abstainance, gays, porn, sex ed, condoms in the classroom, etc. That’s it. That’s all they got. That’s all they care about.

      Now let’s get back to bombin’ some brown people, throwin’ some poor folks in jail or into the street and bustin’ some unions! That stuff is more fun than sex, Youbetcha!

  10. At the risk of repeating my earlier comments, I would again recommend Professor Cochran’s op ed in order to understand why the HHS is being so offensive here. it has nothing to do with religious freedom and certainly nothing to do with whether contraception is a good thing, and whether women (and men for that matter) should have access to it. I will happily stipulate that all should (and do). I will also stipulate that Republican objections have not been well communicated 9they are as guilty as Dems at going for the easy political soundbite).

    The question is whether the federal government, by regulation, can and/or should dictate that contraception be included in all acceptable insurance plans unded ACA. In fact, the deeper question, eventually to be decided by the judiciary, is whether the federal government should be dictating the provisions of anyone’s insurance plan by regulation. And my answer is no, for several reasons, but the most obvious and easiest for even the lightweights who frequent this website to understand is that it is not an insurable risk. Beyond that, there is a cost to the benefit, however nominal, which should be subject to negotiation between the parties (employer and insurer in this case).

    Finally, for those bellyaching about access, everyone now has access if they have a few dollars and the sense of personal responsibility it takes to walk to the drugstore and buy a contraceptive. If there are people without even a few dollars, presumably, they will be on medicaid rather than employer sponsored insurance. Since the government is a party to medicaid, let them cover contraceptive devices. Does medicaid cover them? I assume it does, but if it doesn’t then the HHS has achieved new vistas in arrogance by making everyone else cover them.

    Finally, it has been pointed out here that a number of states do require contraceptive coverage, but this has occurred as the result of legislative mandate. Now I think such legislation is a bad idea and is a significant part of why insurance coverage is so expensive, but if the good citizens acting through their legislatures pass such a law, so be it. However, when regulators substitute their judgement for the legislature (and by proxy, the people) the line has been fatally crossed.

    1. Those evil federal regulators! Next thing you know, they’re going to set standards for the amounts of perfectly harmless minerals in drinking water or completely natural bacteria allowed in meat. And then they’re going to tell car companies exactly what components have to be in every automobile sold in the country. All with just the merest legislative delegation. How dare they!

    2. But insurance covers all kinds of non-insurable risks. The issue for me is that contraception is a health care product, and part of one’s personal health care decisions that has profound consequences for their health and lifestyle. It is a matter that should be between a patient and doctor, period. This goes to the access point because much of healthcare is about one’s relationship with their healthcare provider, and often includes cultural and behavioral dynamics in which the patient takes on a degree of humility towards the larger project – of which the doctor and health care provider are the main facilitators – of ensuring they are on a path towards wellness in general. “Wellness” definitely includes whether one chooses to use contraception, the use of which can easily be thought of as a “treatment” for serious medical consequences.

      As for cost, I can only imagine that covering contraception would be profoundly cheaper to the degree that it limits expensive, unwanted pregnancies.

      1. Cheaper for the county, sure. But if they can shift the cost onto the employee (and that’s assuming the employee pays the cost), not cheaper for the insurer.

        Note the same evil logic works for anything the insurer can chisel its way out of covering.

    3. The “not an insurable risk” thing applies to a whole bunch of things health insurance covers, though.

      I’m guessing your position is basically “Indeed! That’s a problem!” I think that’s arguable. I grant that “normal” insurance (property-casualty insurance, fer instance) does not cover stuff you could call routine maintenance. Thus, health insurance is a bit of an oddball.

      But with health insurance, I don’t think it’s so simple. My insurance covers checkups with zero copayment. Not, as far as I know, because of a law (I admit I’m not 100% sure of that). The idea is to get people to get checkups and catch certain things earlier.

      Basically, your objection seems to be about how we pay for healthcare in this country, including especially the ACA.

      Which… leads us to the GOP attempt to nullify the law via “moral objections” to coverages.

      1. Redshift is right, but all that shows is that health insurance is not in any meaningful way truly insurance any longer. As a society, we have made the decision that treating citizens’ health as something to be insured leads to unacceptable outcomes. Community rating and requiring coverage for those with pre-existing conditions completely defeats the purpose of insurance. That purpose is precisely to charge more to those who are riskier to cover and to prevent the most risky from getting coverage at all.

        If, as Redshift desires, there were no restrictions on what policies could be offered, then the promise that those with pre-existing conditions receive coverage would be a sham. Companies would simply write policies in a way that those who have them wouldn’t receive any benefits from said policy. Much like the coverage mandate as a whole, requiring standard policies is an essential element of the plan.

        Unless your belief is that those who have certain pre-existing conditions should simply be forced into bankruptcy and then death, you must support policies that pretty much wreck the free market solution to health care. Your only choice is exactly what form you want to see those deviations take. A free market in insurance, by definition, *can’t* solve that problem.

        Granted, this means that insurance companies won’t really add any value to the health care system, since the basic actuarial reasons for their existence will be shredded. They certainly won’t justify continued profits. It would be nice to just go around them altogether, but the American public, to say nothing of that public’s representatives in Congress, seems to be terrified that doing so would constitute socialism. Hence the ungainly kludge that is coming into effect.

    4. What I don’t get about this supposed “compromise”, and would like to see a lot more discussion of, is where the freak the President got the power to order insurance companies to provide free benefits to their customers. Did they sneak that power into the legislation, or is the President just assuming dictatorial powers here?

      I seriously, seriously do NOT like this trend towards ordering private firms to do stuff, instead of the government paying for it on budget. What’s next, ordering grocery stores to hand out free food to the poor, instead of having welfare programs?

  11. “In opposing these latter teachings, Rick Santorum is no less the cafeteria Catholic than (say) John Kerry is. Somehow social conservatives seem to receive a free pass.”

    True, but you see the Catholic hierarchy is compromised of social conservatives. Thus they take positions that are socially conservative and ignore those which are not. Which is why the Church preaches against abortion regularly but never speaks out against the death penalty.

    You also dismiss too easily the charge that the Church is compromised of old virgins. I think that is something worth exploring. Why else would the Catholic Church decide this is the issue on which to hang themselves? Because ancient Greeks believed that sperm carried little people inside? Or maybe because these old virgins have never been married. Have never felt the relief of your wife announcing she’s had her period and thinking “thank God, I was not ready for another child”. Because these old virgins have never raised a child, never had a child, and cannot really fathom the idea that one doesn’t want to spend the next year not sleeping at night.

    Finally, your essay had way too many words. Much to rambling. Be concise. Your best argument was the hypocrisy of the Catholic Church and its conservative members who chide so called “cafeteria Catholics” regarding socially conservative teachings but ignore the socially liberal ones.

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