Cheaper by the Dozen

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

As a bioethicist, I appreciate the fact that the American public has become deeply engaged in a number of important health policy debates.

For example, should local, state and national agencies forcibly quarantine travelers coming from countries affected by the Ebola virus? Should public and private companies be required to provide employees with health insurance plans that include oral contraceptives if doing so runs counter to the religious beliefs of the owners? Should terminally ill cancer patient Brittany Maynard have the right to end her own life (which she did this past Saturday)?

One interesting story that slipped under the radar, however, was the recent announcement that two major corporations, tech giant Apple and social networking service Facebook, will now pay for female employees who want to freeze their eggs. These companies will cover the costs of extracting, freezing and storing eggs, even when this is done for non-medical reasons. This is a pretty substantial benefit, as the extracting the eggs can cost $20,000 or more. Storage fees can run an additional $1,000 a year.

This should be up for public discussion and debate. Although many people may disagree with me, I believe that these two companies (and those that follow their example) are making a big mistake. That is not to say that I don’t think that companies like Apple and Facebook shouldn’t provide coverage for fertility-related treatments like egg freezing as part of a comprehensive health insurance plan. They should, but only for medically justified reasons.

The technical name for egg freezing is oocyte cryopreservation, and it is a physically invasive and potentially risky procedure. Women must first take a cocktail of drugs called gonadotropins to hyperstimulate egg production, tricking their ovaries into producing a dozen or more eggs rather than one or two ova that are normally released during the normal monthly fertility cycle. Doctors then insert a long needle through the vaginal wall and into the ovary, sucking out the eggs and preparing them for long term storage.

As you might imagine, this is an extremely uncomfortable procedure. Most women experience bloating and abdominal pain, but more severe side effects are not uncommon. Nearly half of all women will experience a condition known Ovarian Hyper Stimulation Syndrome (OHSS), which may require hospitalization to treat the bleeding and severe fluid buildup that results. Errant needles can cause injury to the bladder, bowel and kidneys. Finally, the ovaries can develop scar tissue at the site of puncture or the drugs used for hyperstimulation can trigger early onset of menopause, resulting in infertility in both cases.

Moreover, while new techniques for freezing and storing eggs have improved to the point where over 90% of all cryopreserved oocytes survive the freeze-thaw process, far fewer of those eggs will lead to a successful birth via in vitro fertilization (IVF). According to the Society for Assisted Reproductive Technology, for instance, the rate of live birth among women aged 30 who used cryopreserved eggs for IVF is less than 25%. That rate drops to less than 10% for women over 40.

These concerns – safety, efficacy, and potential physical risks — are why professional organizations like American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) only support the use of egg freezing when medically necessary. Egg freezing should be done only as a last resort to protect fertility in women undergoing ovary-destroying cancer treatment, for example, rather than as a way to delay childbearing as a matter of choice.

Unfortunately, the latter is exactly what companies like Apple and Facebook are promoting. Covering the costs of oocyte cryopreservation for non-medical reasons reinforces the idea that professional women must choose between having a fulfilling career and raising a family. Moreover, even if a woman successfully delays childbirth by freezing her eggs, she has only delayed the inevitable. She must still confront a corporate culture that sees mothers as an economic liability.

If companies like Apple and Facebook truly want to support their female employees, they don’t need to pay for egg freezing. What they need to do is provide both female and male employees with the services and benefits necessary for meaningful work-life balance, including paid leave for new biological and adoptive parents, family sick leave, and subsidized daycare and preschool programs. Better yet, they should use their wealth and political connections to lobby our leaders in Washington to make such benefits the law of the land.

Until then, we’re still leaving most working women (and many working men) out in the cold.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on November 6, 2014, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

If Hobby Lobby Wins, We All Lose

by Dr. Patricia Mayer, Bioethics Program Alumna (2009)

Late last month, the US Supreme Court heard oral arguments in the case of Sebelius v. Hobby Lobby Stores, Inc. The Supreme Court is currently considering whether Hobby Lobby, a privately owned chain of 640 arts and crafts stores, may deny its employees insurance coverage for things like birth control pills, emergency contraceptives and IUDs. Under the Affordable Care Act (ACA), employers are required to provide health care that covers all forms of contraception at no cost. However, the evangelical owners of Hobby Lobby argue that the company should not be required to provide contraceptive choices that violate the owner’s religious beliefs, particularly birth control methods that they believe “induce abortions”, such as the morning-after pill or the IUD.

Hobby Lobby’s owners are appealing to the Supreme Court for an exemption to the ACA contraceptive requirements on the basis of the Religious Freedom Restoration Act of 1993. That act stipulates the government “shall not substantially burden a person’s exercise of religion even if the burden results from a rule of general applicability”.

Now Hobby Lobby’s owners are not asking for exemption from the obligation to provide insurance. In fact, they believe that providing heath insurance to their 14,000+ employees a moral obligation, but they do not want to pay for an insurance plan that covers certain types of contraceptives. They’ve even stated publicly that this obligation to provide their employees with health insurance is so strong it precludes them from discontinuing insurance coverage (instead of paying a new tax under the employer obligations of the ACA) even though this would then allow their employees to obtain insurance through the new health exchanges. Insurance plans available through the exchanges all provide complete contraceptive coverage in accordance with the ACA.

But should for-profit businesses be exempt from the Affordable Care Act’s contraception mandate? Do these companies have the same rights of religious freedom as individuals under the Religious Freedom Restoration Act?

I believe it would be wrong for the Supreme Court to grant Hobby Lobby’s request for an exemption. A private for-profit company, even one with religiously devout owners, should not dictate which legal, available, medical treatments an employee may receive by contradicting a federal law that represents a national decision – though not a consensus. While the Supreme Court has allowed exemptions to the contraceptive mandate of the ACA, they are few and highly specific, such as church employers. Even religiously-owned health care institutions (such as Catholic hospitals) have not been granted this exemption.

To grant such an exemption would represent unjust discrimination against a group of employees based on morally irrelevant factors such as youth, gender, and reproductive capability. The ACA clearly stipulates particular health care services must be provided. So it is not for a group of individuals (such as the family that owns Hobby Lobby), by way of a for-profit nationwide corporate employer, to deny its employees those services.

It is also not for the Supreme Court to damage the integrity of the ACA by granting such exemptions.

The owners of Hobby Lobby are free to make business decisions in accordance with their faith (such as closing on Sundays). But they are not free to impose their beliefs on their employees by seeking to control their personal health care choices.

Hobby Lobby has a viable option for avoiding involvement with contraceptive choices: by getting out of the health insurance business. Hobby Lobby could drop its employee insurance coverage altogether and pay the modest $2,000 per person yearly tax incurred by doing so. Employees could then obtain their own insurance through the exchanges. Hobby Lobby’s attorney points out this would cost the corporation the current tax breaks it receives from providing insurance and might also force the company to pay higher wages to attract employees willing to buy their own insurance. These statements may be true, but they are also irrelevant.

In a pluralistic society, we tolerate a variety of beliefs without allowing persons to impose those beliefs on others. If the Supreme Court agrees with Hobby Lobby, why would other for-profit corporations not follow suit with other objections? What would prevent corporations from declining coverage for other services based on “religious objections”? What if corporations want exemptions from covering HIV treatment based on religious objections to homosexuality or exemptions from treating Trichinosis on the basis that it is immoral to eat pork?

No corporation should make health care decisions for its employees. Hobby Lobby should abide by the provisions of the ACA, or get out of the way of its employees by paying the “penalty” tax, increasing wages if it must, and allowing employees to select their own plans from the insurance exchanges.

[The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]