Helen Alvare, George Mason law professor and former spokeswoman for the U.S. Conference of Catholic Bishops’ Secretariat for Pro-life Activities, has written a piece about how HHS doesn’t speak for her, or for many women. The piece links to a website called Women Speak for Themselves.
Here’s my question: What would it mean for HHS to “speak for” someone? I’m being entirely sincere, because I think this gets at some thorny questions about what public health recommendations are meant to accomplish in a liberal democracy.
The Women Speak for Themselves website elaborates:
Those currently invoking “women’s health” in an attempt to shout down anyone who disagrees with forcing religious institutions or individuals to violate deeply held beliefs are more than a little mistaken, and more than a little dishonest. Even setting aside their simplistic equation of “costless” birth control with “equality,” note that they have never responded to the large body of scholarly research indicating that many forms of contraception have serious side effects, or that some forms act at some times to destroy embryos, or that government contraceptive programs inevitably change the sex, dating and marriage markets in ways that lead to more empty sex, more non-marital births and more abortions. It is women who suffer disproportionately when these things happen.
Okay, first, let’s take a cue from the scare quotes and consider the definition of women’s health. What does it mean to be healthy? And is contraception part of that? And if you say that it is, and you base that claim on scientific data, for whom are you speaking?
If you’ll recall, the contraception provision was included partly because of the Institute of Medicine recommendations in the 2011 study, “Clinical Preventive Services For Women: Closing the Gap.” In the section entitled “Preventing Unintended Pregnancy and Promoting Healthy Birth Spacing,” the study makes the case for thinking of contraception as basic preventive care. From p. 102-104 of the report:
• The unintended pregnancy rate in the United States is high compared to other countries with comparable economies.
• Women with unintended pregnancies are less likely to get early prenatal care and less likely to breastfeed.
• Women with unintended pregnancies are more likely to experience depression and anxiety, more likely to experience domestic violence, and significantly more likely to give birth to babies with a low birth weight.
• Even just having a short interval between pregnancies is associated with worse health outcomes—like low birth weight, prematurity, and small for gestational age births.
• There are some health conditions where it’s very bad for the woman if she gets pregnant. Getting pregnant could make her much, much sicker.
• Greater use of contraception produces lower unintended abortion rates nationally.
Despite criticism to the contrary on the Women Speak for Themselves site, the study then goes on to address, explicitly, the side effects of birth control (p. 119):
As with all pharmaceuticals and medical procedures, contraceptive methods have both risks and benefits. Side effects are generally considered minimal (ACOG, 2011a,b,c; Burkman et al., 2004). Death rates associated with contraceptive use are low and, except for oral contraceptive users who smoke, lower than the U.S. maternal mortality rate (Hatcher et al., 1998). For example, the oral contraceptive death rate per 100,000 users under the age of 35 years who are nonsmokers was 1.5 per 100,000 live births (Hatcher et al., 1998), compared with 11.2 maternal deaths per 100,000 live births in 2006 (age adjusted) (CDC, 2010c).
So those are the data on which the IOM recommendations are based. Who exactly are the IOM researchers “speaking for” in offering these findings? Well, that’s an interesting question. I expect most of us initially hope that the answer is “no one in particular, because that’s not their job.” Isn’t the idea that they’re going out and checking what there is to know about pregnancy and health, and then making recommendations based on data?
Ah, but! To say that, is to miss the part where Enlightenment rationalism got criticized for its hubris. None of us can adopt a pure view from nowhere (so the critique goes), as we are all people who speak from contexts. (At this point I can’t resist linking to this, which I hope all RD readers will recognize as satire. The actual criticism is not quite so ridiculous.)
Indeed, there certainly are value judgments encoded in what the IOM counts as a positive or negative health outcome. A good outcome is one which avoids, not the “empty sex” which so worries Alvare, but physical suffering and death. Philosopher Charles Taylor, in his opus Sources of the Self: The Making of Modern Identity, brands this a uniquely modern concern. Can you criticize that concern? Can you disagree with it? Sure.
But seeing that the United States is in fact a modern liberal democracy without a state church, I suppose I’m left wondering what on earth the alternative would be when it comes to public health decisions? Is Alvare implying that the Institute of Medicine, or the Department of Health and Human Services, should stop “speaking for” those who think that public health has to do with things like lifespan and birth weight? That the government should instead find some way, not just to make space for, but actually “speak for” those who have theologically-motivated ideas about what sex and reproduction are for? How would that work? And if avoidance of suffering is cast aside as a criterion for making public health decisions, who will be asked to suffer?