The United States government, like those of most western nations, is composed of three branches.
The legislative branch sets priorities, the executive implements the laws set by the legislative branch and the judicial branch settles disputes.
While the legislative branch is primarily charged with determining critical questions that involve the entire nation, such as budget allocations for schools and the military, it may also pass laws that affect behavior and morality.
Prohibition and its subsequent repeal were major decisions affecting personal behavior, as was the Defense of Marriage Act. Ideally, Congress and the state legislatures are attuned to public sentiment. Blue Laws, which required closing businesses on Sunday (later modified to accommodate those businesses whose owners honor a different Sabbath), restrictions on gambling and sale of alcoholic beverages fall within this category.
Commonly, laws governing behavior and morality are used for political purposes. Politicians may support a cause in order to gain the votes of a specific group of voters, with the particular aim of having these voters turn up at the polls. It’s not terribly important whether the cause has majority support as long as it can draw out a large number of people who would otherwise stay home instead of vote.
In contrast to the elected representatives who write the laws, the bureaucrats who write the regulations are expected to be experts, with academic and professional qualifications. While it’s common to hear the term “unelected bureaucrats”, the reality is that while a state legislature or Congress can pass a law mandating clean water, we’re better off having a qualified expert define the number of parts per million of arsenic in water is considered acceptable.
A State Senator may be qualified to say we should have automobile speed limits, but we’re better off if someone who knows the limits of adhesion of a Pirelli P4 Four Season tire on an icy road determine what the speed limit should be. Unfortunately, the elected representatives don’t always honor those divisions.
Recently, we’ve seen a number of Republican candidates embracing the over the counter sale of hormonal contraceptives. The web site Slate describes the change of heart of Cory Gardner who is running for the U.S. Senate in Colorado:
“He has a long and scary track record of opposing contraception access, particularly for low income women, at every turn, including a vote against allowing pharmacists to prescribe emergency contraception in 2006, a vote against requiring insurance companies to cover contraception in 2008, a history of opposing expanded contraception access through Medicaid, and a vote against a bill requiring hospitals to make emergency contraception available to rape victims. He’s also got a history of pushing for “personhood” amendments that anti-choice activists could use to attack the legality of female-controlled contraception methods like the pill and the IUD by falsely claiming they are “abortion.”
Ed Gillespie in Virginia and Mike McFadden in Minnesota are among others who have joined the chorus.
The position appears to be an attempt to counter Obamacare’s mandate for oral contraception and may or may not be politically motivated. Even if we posit that the recommendation is sincere, the determination to sell hormonal contraceptives without prescription should be subject to professional debate.
Just as we’ve seen panels on abortion that included only men, we’re seeing proposals for over-the-counter sale of hormonal contraceptives without discussion with gynecologists, endocrinologists and other specialists. There is a strong case to be made for leaving hormonal contraception on prescription status.
While hormonal contraception has been associated with serious cardiovascular events, including heart attack and stroke, several well conducted studies indicate that most women are safer taking the pill and that the risk of death from oral contraceptives is lower than the risk of death from pregnancy.
An excellent 2010 study published in BMJ (formerly the British Medical Journal) concluded, “Oral contraception was not associated with an increased long term risk of death in this large UK cohort; indeed, a net benefit was apparent.” There is an increased risk for smokers over the age of 35, but even there it’s small, and can be minimized by use of low dose contraceptives.
A more likely problem would be associated with migraine headaches. According to a review from the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital, migraine affects as many as 37% of reproductive-age women in the United States. Unfortunately, the reports can be confusing because there are different kinds of migraine and different kinds of oral contraceptives.
It appears that as many as 10% of women develop migraine headaches directly related to oral contraceptives. A review in the Journal of Headache Pain (August 2013) reported:
“Preliminary evidences based on headache diaries in migraineurs suggest that the progestin-only pill containing desogestrel 75g has a positive effect on the course of both MA (migraine with aura) and MO (migraine without aura) in the majority of women, reducing the number of days with migraine, the number of analgesics and the intensity of associated symptoms. Further prospective trials have to be performed to confirm that progestogen-only contraception may be a better option for the management of both migraine and birth control.”
A 2009 report in the journal Contraception concluded, “Accurate classification of a patient’s headache type can avoid unnecessary restriction of effective contraceptive methods, particularly those containing estrogen.”
From this, there’s a strong argument to be made that while oral contraception is safe and effective, it still requires professional skill to match the patient with the appropriate drug. Instead of making oral contraceptives available without prescription, it might be wiser for the 20 states which have not expanded Medicaid, medical care for the poor, to provide affordable care for women.
The decision to expand Medicaid would allow women to receive contraception and also be able to select the proper products. This too would have political implications, which may be a good reason to leave the politicians out of it.