Part I

Now for Friedersdorf’s second argument.  

If we broadly agree that we value “treating disease” and “fixing the broken body,” in what category do we put taking birth control? … [P]rogressives want to put it in the category of “preventative care.” But it is at least different than less controversial sorts of preventative care: 1) A small number of Americans have a moral objection to it. 2) The condition being prevented, pregnancy, isn’t identical to a disease. 3) The condition being prevented, pregnancy, can be avoided through an alternative approach, abstinence, that is completely effective and free – or a very cheap method, condoms, that have various advantageous and disadvantages that the thoughtful reader can supply him or herself.

Like a ‘good’ philosopher, he goes on to compare subsidies for birth control to subsidies for somewhat fantastical counterfactuals:  pills that enable straight folks to enjoy mind-altering substances without addition or harmful effects, or get orgasms from yoga.  The argument seems to be that birth control is a matter of consequence-free pleasure, not medicine, and thus not legitimately subsidized on medical grounds or as preventative medicine.  (I emphasize ‘seems’ because I’m not certain about this reading.  Still, I can’t come up with a better one.)  

Friedersdorf’s account of medicine involves exactly three aims:  

  • Treating disease; 
  • Fixing bodies (whether damaged through accident or disease, presumably); and
  • Preventing the causes that necessitate the first two.

Or, more succinctly, trauma medicinepathology, and preventative medicine.  The crucial claims, then, are that (PC) pregnancy is a matter of neither trauma medicine nor pathology and that hence (BC) birth control is not preventative medicine.  

But (PC) reveals – spectacularly, I think – the inadequacy of this account of medicine.  This claim, plus the account of medicine and the obvious claim that pregnancy is not a matter of preventative medicine, imply that pregnancy is not a matter of medicine.  Which, as any expectant mother will tell you, is absurd.  I suspect that pregnancy is the single most common reason for medical intervention in our society today, and I know that historically it’s one of the most life-threatening conditions a human being can be in.  

It’s true that for most women in our society pregnancy the risks of pregnancy are virtually non-existent.  In 2007, there 12.7 maternal deaths per 100,000 live births in the US; even among non-Hispanic Black women the rate was only 28.4.  For contrast, in Mexico in 2008 this rate was 85, and in Uganda it was 430.  I’m also sympathetic to feminist arguments that pregnancy has been excessively medicalized in our country, and that this excessive medicalization is used to dominate both pregnant and ‘potentially pregnant’ women in unjust ways.  

But the world-historical drop in maternal deaths is, of course, due to the  medicalization of pregnancy, the development of sanitation and antibiotics, and, yes, birth control.  Women who would have had a half-dozen pregnancies or more – at a increased risk of death from sheer physiological exhaustion – now have only a few, and without sacrificing physical and emotional intimacy with their sexual partners. This suggests that the right approach to pregnancy – at least, with respect to medicine – is one that attempts to balance the benefits of medicalization with respect for women’s sexuality and reproductive justice.  

Perhaps this can be done in terms of Friedersdorf’s account of medicine:  the medicalization of pregnancy is, when not invasive or oppressive, preventative medicine. But then birth control is also preventative medicine.  Like both abstinence and regular checkups with an OB/GYN, birth control is a very reliable way to avoid pre-eclampsia. So, like regular checkups with an OB/GYN – for both pregnant and ‘potentially pregnant’ women – birth control seems to be good preventative medicine, and the subsidy seems justified.  

Note that I am not arguing here that birth control is good preventative medicine for ovarian cysts or painful menstruation.  I think it’s good preventative medicine for those things as well.  But those arguments don’t support subsidizing birth control as birth control.  They support subsidizing it under some other description.  Here I’m arguing that birth control is good preventative medicine for all of the life-threatening complications surrounding pregnancy.  

Friedersdorf might be trying to pre-empt this argument when he points out that ‘[t]he condition being prevented, pregnancy, can be avoided through an alternative approach, abstinence, that is completely effective and free’.  Maybe I don’t understand the argument he’s gesturing out – it’s not actually spelled out any more than this, I think – but it strikes me as utterly uncompelling.  In general, for a given end E, there are indefinitely many courses of action (means) M1, M2, M3, …, that can reliable realize E.  Some of these courses of action will be better in all respects than others.  But, I claim, there will still be indefinitely many courses of action such that, for any two M1 and M2, M1 is better in some respects than M2 and M2 is better in some respects than M1.  For example:  

  • Abstinence is effective when it comes to voluntary intercourse; it is absolutely free; has no health side-effects; but for most people it is extraordinarily difficult to do consistently; and it is useless when it comes to rape.  
  • Natural family planning is difficult to do well, which makes it stress-inducing in its own particular ways; is more-or-less free (one has to pay for the thermometers and calendars); has no health side-effects; but is not terribly reliable; and is also useless when it comes to rape.  
  • Condoms are inexpensive; but slightly to modestly diminish the pleasure of intercourse for most people; can break; and are also useless when it comes to rape.  
  • Regular birth control is as effective as any of the others, and indeed is the only one of these not useless when it comes to rape; but it requires taking a pill at the same time every day; can have some negative health side-effects; and does cost more than condoms.  

All four of these options have something to say in their favor, but none is clearly superior to all of the others.  This argument is like saying that, from South Bend, one can get to Chicago by plane, train, or automobile:  not a good reason to not subsidize one of the options.  

::: {#footer} [ March 14th, 2012 1:04pm ]{#timestamp} [gender/sex]{.tag} :::