Making Sense of Bioethics: Column 038: Sex and Little Pills: Viagra and Birth Control
A prominent politician was once asked to comment on the "unfair situation" of health insurers reimbursing for Viagra but not for birth control. He declined to reply, and the ensuing firestorm led to accusations of gender bias (and even misogyny) on his part. Other commentators took the argument and ran with it: Why should men be able to get drugs so they can have sex, but women cannot be given the same access to needed drugs so they can have sex without the risk of becoming pregnant?
Behind these questions are some misguided views about sex, pregnancy, and morality, as well as some basic confusion over the respective actions of these two drugs. Viagra and birth control serve two very different purposes, and each one has its own unique ethical considerations. Viagra, at a minimum, treats an actual dysfunction, while birth control does not. In fact, one might say that Viagra fixes a broken system, while birth control breaks a perfectly working system.
Whenever the pill is used as contraception (its major use in America today), rather than as a treatment for irregular cycles or bleeding, it tosses a wrench into a healthy, properly-functioning biological system, and enables a married couple to act against their own natural fruitfulness. A grave moral violation occurs whenever we turn marital sexuality into a radically lifeless transaction through the use of contraception. Pregnancy and fertility are not health anomalies, and do not need to be treated as if they were a pathological state. In our society, however, the over-brimming desire for sex, and especially for sex separated from its consequences, has pushed millions to act against the proper order of their own marriages by adverting to birth control.
Meanwhile, in the case of erectile dysfunction, a normal biological process may have become impaired due to age or injury, and through the use of Viagra, this impairment can sometimes be remedied. Viagra does not aim to disrupt normal function, but rather to restore it. Within marriage, the medical use of Viagra for such restorative functions does not generally raise moral problems.
Some might still argue that it is natural and normal for a male to lose erectile function by a certain age. Should we assume that a male is entitled to keep having sex beyond the age of erectile impotence, when we wouldn't try to force a woman to remain fertile beyond the age of menopause? If a man is too old to continue doing what "nature" used to allow him to do, the argument goes, then it would seem to be improper for him to use Viagra, and he should simply accept his limitations with grace. But this parallelism between men and women is not a compelling one, as women have a rather strict and well-defined natural age limit on their fertility, while men do not, with many remaining quite capable of fathering children even when they are elderly, often without any assistance from drugs like Viagra. The use of these drugs, then, even by older married men, cannot somehow be construed as “against nature.”
Viagra has other uses, though, which do raise significant moral concerns. Viagra is used among men who have sex with other men, sometimes for the purpose of overcoming the erection-inhibiting effects of alcohol or street drugs such as ecstasy and crystal methamphetamine. Even in the absence of erectile dysfunction, Viagra is coming to be seen by some as a lifestyle, recreational, or even a "party" drug. Serious moral objections exist, of course, to virtually any use of this drug for erectile purposes outside of marriage.
Coming full circle, then, we can ask whether insurance reimbursement for Viagra, but not birth control, makes sense. The use of Viagra does seem to involve a lifestyle choice more than a health issue per se, so perhaps health insurance should not be expected to cover it. Although Viagra fixes a broken system, it is not, strictly speaking, an essential system for physical health or personal survival.
The question about birth control coverage is even more clear. Considering that birth control pertains to a lifestyle choice and disrupts a healthy bodily system (and even carries significant health risks like blood clots, strokes, and heart disease), insurance coverage ought not reasonably be expected. However, it is clear that the strictly medical uses of birth control pills (to address gynecological problems like irregular cycles or bleeding) and certain medical uses for Viagra (like treating pulmonary hypertension) would constitute legitimate health treatments where insurance coverage could reasonably be expected. Each little pill, in sum, is unique in its properties and uses, with significant ethical distinctions between them as well.
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