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abortion, Contraception, Ethics, evidence based medicine, health insurance

An OB/GYN’s opinion on the Supreme Court, Hobby Lobby, and contraception

The Supreme Court, in a 5-4 decision, sided with Hobby Lobby (and much of the religious right in the United States) and ruled that a closely held private corporation does not have to provide insurance coverage for certain birth control methods. Justice Alito, speaking for the majority wrote:

“The owners of the businesses have religious objections to abortion, and according to their religious beliefs the four contraceptive methods at issue are abortifacients. If the owners comply with the HHS mandate, they believe they will be facilitating abortions…It is not for us to say that their religious beliefs are mistaken or insubstantial.”

As an OB/GYN I see six disastrous consequences of this decision:

1) The idea that religious beliefs of some are more important that the religious beliefs of others. Any woman wanting to use one of the 4 methods of contraception listed obviously doesn’t share the same beliefs as the closely held corporation who employs her. Why are her beliefs less important? Why can her place of employment push their religious beliefs (because a place of employment now has the rights of an individual) into the exam room? The First Amendment rights of women seeking health care are less important that the First Amendment rights of a corporation. Thank you Justice Alito for putting us in our place.

2) Legislating a belief over science. The 4 methods of contraception that Hobby Lobby takes issue with are Plan B, Ella, and the two IUDs, ParaGard and Mirena. We call these methods contraceptives not abortifacients because in science, unlike the Supreme Court, we like facts and facts tell us that these methods do not cause abortion (which is by definition the disruption of a pregnancy that is already implanted, no matter how early). But even if we take the evangelical definition of pregnancy (the wandering fertilized egg) we know for sure Plan B has no effect because it is biochemically impossible for a progestin in that dose (or probably any dose) to prevent pregnancy by any definition, scientific or otherwise. The bulk of the medical evidence suggests that the two IUDs in the United States do not prevent a fertilized egg from implanting and the same goes for Ella. We can’t say with 100% accuracy because there is no easily accessible test to tell us that a fertilized egg is wandering aimlessly around the upper reproductive tract and so the information comes from indirect methods like studying the mechanisms of action in lab and animal models and studies that have looked at the time of the cycle that the method is used. Science is fact and apparently facts don’t matter to the Supreme Court. Good to know.

3) A slippery slope for other contraceptives. If you believe the untruth that Plan B (a progestin) causes abortion (by any definition, evangelical or scientific) then all hormonal contraceptives should be excluded for sexually active women as they all contain progestins. Quick start pill taking (starting the birth control pill the day you get them versus waiting for your period) is very common and improves compliance, however, if you share the magical belief that progestins could prevent a fertilized egg from implanting then all oral contraceptives have to go, otherwise every time a woman starts her pills mid cycle a baby might die (never mind the possibility of escape ovulation). Hey, if you want to pervert science you can go down any rabbit hole.

4) A slippery slope for other medical practices that infringe on religious beliefs. Vaccinations, psychiatric care, blood transfusions, and infertility care are all opposed by some religions. While Alito wrote that this decision is “very specific” meaning that it only applies to these four contraceptives in this specific situation, it is somewhat naive (or obtuse or insulting, depending on your perspective) to not consider that other groups might also have”sincerely held religious beliefs.” Justice Ginsberg voiced concerns about these broader implications in her dissent, after all there is real money to be saved in carving out health care based on what a religion allows. Since case-law is integral to the US legal system what is to stop a closely held corporation owned by a Jehovah’s Witness from suing to exclude transfusions and organ transplants? If the court were to say “no” to a Jehovah’s Witness corporation (as Alito’s statement implies) they would be saying that only evangelical Christian beliefs are important and only a woman’s reproduction deserves to be controlled.

5) That contraception isn’t really health care. This legislation fuels the belief that contraceptives are, to paraphrase that wordsmith Rush Limbaugh, “slut pills.” It perpetuates the idea that sex is wrong or only for procreation, when sex is a normal part of life and people who have active sex lives tend to be healthier and live longer. In addition, the benefits of contraception in the health and longevity for women is undisputed. According to the World Health Organization “Women’s and adolescents’ right to contraceptive information and services is grounded in basic human rights. Paying for contraception is no different from paying for vaccinations, diabetes care, or an appendectomy.

6) Restricting access to IUDs increases the risk of unplanned pregnancies and thus paradoxically the rate of abortion. As an IUD costs about $900 (or as Ginsburg pointed out, about a month’s salary for a minimum wage worker). IUDs are by far the most effective method of contraception and they have been shown to reduce the rate of abortions.  Fewer IUDs means more methods with higher failure rates.

The message from the five male justices of the Supreme Court who felt it was within their purview to opine on women’s health care yet ignore medical facts (which I hope was presented as evidence) is chilling. The religious beliefs of privately held corporations are definitely not insubstantial, but the rights of women most definitely are.

 

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