Many individuals and business owners are struggling in conscience about whether to purchase health insurance coverage, either for themselves or for their employees, on account of the Health and Human Services (HHS) Mandate. A provision of PPACA (ObamaCare), the Mandate requires “preventive health services” to be covered by all health insurance issuers and all group health plans. Those insurance plans must provide coverage (with no co-pay) for the full range of Food and Drug Administration (FDA)-approved contraceptive methods for women. These include not only surgical sterilizations, but also potential abortion-causing agents such as Plan B (the morning-after pill), intrauterine devices (IUDs) and another form of “emergency contraception” known as Ella. This drug, which the FDA acknowledges may also work against the life of the embryo “by preventing attachment (implantation) to the uterus,” can be taken up to 5 days after sex. 

The chief moral concern, of course, is that by purchasing such mandated coverage, an individual would be subsidizing pharmaceutical abortions, contraceptives and sterilizations for others, and business owners would similarly be subsidizing these procedures for their employees through their health plans. Employers, in other words,  would provide coverage for (and thereby potentially facilitate) various acts of vice on the part of their employees, and all who pay for health insurance coverage would potentially fund and thereby support the vice of their neighbors. This raises the serious moral concern of “cooperation in evil.”

In general terms, any cooperation in evil should be avoided, or at least minimized to the extent prudently possible. By purchasing a policy with problematic inclusions, one would likely cooperate “materially” in the commission of various evils by others, but the debate on this matter hinges on whether that material cooperation should be considered “immediate” or “mediate.” Immediate material cooperation — when your assistance is essential to the evil action — is never morally permissible, but mediate material cooperation — when your assistance is incidental or remote from the bad activity itself — may be allowable under temporary extenuating circumstances. It could be allowable as long as the cooperator manifests resolute opposition to the evil and takes reasonable steps to limit and ultimately eliminate that cooperation. This is a key difference between allowable toleration and tacit approval.

In evaluating the specifics of the HHS mandate, the National Catholic Bioethics Center (NCBC) has reached the provisional conclusion that paying premiums for a policy that also includes coverage for the above-mentioned procedures, devices and drugs (while opposing the mandate) does not appear to involve an individual in immediate material cooperation in evil, because a number of intervening causes are likely to exist between the paying of the premiums by a subscriber, and the action of another enrollee who chooses to engage in one of the immoral activities. The key difference between acceptable and unacceptable forms of material cooperation involves the “causal distance” between what we do by our act of cooperation, and the act of the other person using the abortifacient substance or the contraceptive that is covered by the health plan into which we have paid. The paying of the premiums does not appear to be causally immediate to the chosen action of direct sterilization, abortion or contraception.

To put it another way, payment into a healthcare plan that includes coverage for immoral procedures would only "make possible,” but would not "bring about" the evil action of the principal agent, and hence would represent mediate material cooperation on the part of the person paying into the plan. Such a payment could be made, albeit under protest.

Thus, the position of the NCBC is that individuals purchasing insurance under the HHS mandate could choose to do so licitly as mediate material cooperation assuming a proportionately serious reason, and a lack of suitable alternatives, and an ongoing effort to resist/oppose this unjust mandate through case-appropriate means. A proportionately serious reason is often likely to exist, because of the seriousness of our obligation to care for our health. For business owners, meanwhile, it is a particularly difficult question, and they may find it best to discontinue providing health insurance to their employees (even though they may have to pay associated fines). The NCBC discusses this option, and some of the morally relevant factors surrounding such a decision, in its analysis available at:

https://www.ncbcenter.org/em-openaccess/ethics-medics-august-2012-special-issue

and updated at: 

https://www.ncbcenter.org/em-openaccess/ethics-medics-february-2014

The HHS Mandate represents bureaucratically-coerced personal and institutional involvement in the commission of a intrinsic evils. No person should ever be coerced by the state to be directly complicit in such acts. The HHS Mandate is an affront to every American. It is immoral and offensive. If the government's current attempt to coerce Americans into violating their most deeply held convictions doesn't breach their religious freedom, then nothing does. No individual or institution should have to be concerned about violating their conscience when they merely seek to safeguard the well-being of themselves, their families, or their employees by purchasing health insurance.

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