Limiting a doctor's options [Commentary]

As physicians in training at Johns Hopkins Hospital, we are deeply concerned about the consequences that Burwell v. Hobby Lobby Stores, Inc. will have on our ability to provide comprehensive, quality health care to our patients. Under the Hobby Lobby ruling, coverage for four specific forms of contraception may be denied to women employed by closely held corporations, which represent thousands of American businesses employing millions of American women.

The forms of birth control that can now legally be withheld from insurance plans include intrauterine devices (IUDs, both hormonal and non-hormonal) and emergency contraceptive pills (Plan B® and Ella®). Despite rumors to the contrary, none of these contraceptive options can interrupt a pregnancy and thus are not abortifacients. The truth is that IUDs are among the most effective contraceptive options available and are the most common form of reversible birth control used worldwide. Taking this option away from women's insurance plans increases their risk of unintended pregnancy and interferes with our ability to practice good medicine by interrupting the physician-patient relationship. We applaud action taken by Sens. Patty Murray and Mark Udall, Democrats from Washington and Colorado respectively, to introduce legislation to prevent for-profit companies from opting out of covering the full range of contraception for their employees.

Many proponents of the Hobby Lobby decision insist that it doesn't limit contraceptive choice, as there are 16 other forms of covered contraception available. However, not all contraceptives are equally effective and not all contraceptives are appropriate for all women. Specifically, the IUDs have a greater than 99 percent efficacy, compared with a 92 percent efficacy for birth control pills with real-life use. As patients, we would never tolerate our employer telling us to use less effective blood pressure medications knowing that better options are available. Contraception should be held to the same standard. As physicians, we rely on medical research to guide our recommendations, and the medical literature overwhelmingly supports IUDs as safe, low-risk and highly effective. Less effective birth control equates with more unintended pregnancies and potentially more abortions.

Additionally, although pregnancy is a natural part of life, it can be extremely dangerous for many of our high-risk patients, like women who have clotting problems. These women are at further increased risk during pregnancy of developing blood clots in their lungs — a potentially fatal condition. We must, as medical professionals, be able to offer options to all patients that provide the highest likelihood of success.

Beyond their contraceptive effects, IUDs, which are no longer covered for women working for Hobby Lobby, have many critical medical uses. Notably, a study published in the New England Journal of Medicine found that hormonal IUDs are the best treatment for heavy menstrual bleeding. Untreated, such bleeding can lead to anemia, blood transfusions and even hysterectomies. Hormonal IUDs can be used to treat endometrial cancer, the most common gynecologic cancer afflicting over 50,000 American women each year.

Some people also protest that this ruling involves only a couple companies and a few employees. Not so. As defined by the IRS, a closely held corporation has more than 50 percent of the value of its outstanding stock directly or indirectly owned by five or fewer individuals at any time during the last half of the tax year. This includes not only Hobby Lobby stores, employing more than 30,000 employees, but behemoths like Mars Inc., employing about 72,000 employees and Cargill Inc. with 140,000 employees.

In Maryland, there were over 1.2 million women of reproductive age in 2010, and almost 280,000 of them needed financial assistance to access contraception. These women deserve the same contraceptive options as their peers. A move by employers to limit covered contraceptive choices is unjust for employees who cannot afford the full range of contraception options. In particular, the IUD can cost $500 or more without insurance coverage.

The Hobby Lobby decision is about much more than taking a few birth control options off the table for a few women. It is about leaders of closely held organizations imposing their religious beliefs on thousands of women, their health and the health of their families. This Supreme Court decision has started us down a dangerous path on which the religious beliefs of a third party enter the examination room and interfere with the doctor-patient relationship. This is an obtrusion we fear will prevent us from providing our patients the best health care possible.

Authors Pooja Singal and Adi Rattner are Johns Hopkins medical students, and Dr. Meghana Desale is a Johns Hopkins Gynecology/Obstetrics resident physician. Johns Hopkins medical student Kate Miele and Gynecology/ Obstetrics resident physicians Drs. Esther S. Han, Elizabeth Oler, Lauren Owen and MaryAnn Wilbur also contributed to this op-ed. They may be reached at JHphysiciansintraining@gmail.com. The opinions stated reflect the authors' personal opinions alone and do not represent the views of the institution.


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