E107: The Spiritual Domain of Family Planning

Katie: For most of human history, if you gave birth to five children, you could expect to bury two or even three of them before they reached adulthood. Even as recently as 1800 or the pioneer era of our state in Utah, half of all babies born did not make it to their fifth birthday.

Pregnancy was dangerous. Childbirth killed both mothers and babies, and then childhood diseases could completely devastate a community. In fact, in 1735, there was a diphtheria epidemic in New Hampshire, where 90% of the deaths were children under 10. Noah Webster of dictionary fame called it the plague among children.

So, of course, religious teachings, traditions all around the world are filled with prayers for safe delivery, for rituals, and blessings for baptizing babies. When we couldn't understand germs or hemorrhage or the randomness of those things, prayer seemed like all we had to offer. So, of course, communities gathered their spiritual resources around these very terrifying circumstances.

These were traditions that are ancient and they're important, and they existed because life was fragile. But currently, in the current situation we find ourselves, spiritual opposition to contraception, abortion, IVF is not ancient. In fact, it's not even as old as I am.

So this is the "7 Domains of Women's Health." And today we're discussing the spiritual domain of family planning. We've gone through all of the other domains of family planning, and as always, this is the episode that closes out our series.

I'm Katie Ward. I'm a woman's health nurse practitioner and a professor at the University of Utah College of Nursing. As always, I'm joined by Kirtly Jones, an OB-GYN and professor in the University of Utah Department of Obstetrics and Gynecology.

So, Kirtly, when I say this conflict isn't as old as I am, I think that surprises people. I think we assume that the church, especially the Catholic church, has always opposed birth control. But that wasn't really actually fully settled until recently.

Kirtly: Yeah. I want to step back a little bit. I had an epiphany . . . that's kind of a religious term, epiphany . . . about the biology. And the biology in me thinks about the biological imperative of mammals. It's the evolutionary imperative of males to pass on as many genes as they can. And it's the evolutionary imperative for most mammalian females to protect their young until they're independent. That's kind of counterproductive. I mean, if you have too many kids, you can't take care of the kids you've got.

I think of most major religions that way. And most of the major religions in the West and the Middle Eastern religions that I know about, and that doesn't mean I know about all of them, were started by men and are still led by men.

They're mostly, these religions, pro-natalist, have a lot of births, have a lot of babies. And they aren't necessarily pro-child, meaning there isn't a lot of focus on how to care for children, how important it is to get them to adulthood, because probably at the origins we couldn't do very much, actually, if the kids got sick.

So the culture is for women to have as many children as they can and raise them in that faith. Now, that's changed in some Protestant religions, but not really in the Catholic Church.

There's a story I want to tell about Dr. John Rock. And he's known as the father of the pill. Dr. Rock was a devout practicing Catholic obstetrician-gynecologist. He went to mass every day. He and some biochemists studied human reproduction and devised a pill with estrogens and progestins, analogs of the natural hormones, that would block ovulation and allow women to have a period every month, the first birth control pills.

And he believed that this was a natural birth control method and that would meet the Catholic Church's need for natural birth control, and maybe the Catholic Church will allow it.

So he went to Rome to petition the Pope at the time who did not agree. And Catholics around the world were forbidden to use this form of birth control. Abstinence and periodic abstinence were the only options for Catholic women. And this was a profound disappointment for Dr. Rock, who apparently left his faith, as I remember it.

So the concept of how one as a professional deals with one's faith when your religion tells you one thing and your science and your heart tells you another is a complicated one.

Katie: It is. And yeah, I'm a little bit of a history student here when it comes to this. There are some surprises in the history around this. When Roe v Wade was decided back in 1973, the Southern Baptist Convention actually praised the decision. And most Protestant leaders at the time were neutral or even supportive about the Roe decision.

Prior to that, Ronald Reagan, who we think of a little bit differently now, when he was governor of California in 1967, he signed the most liberal abortion law in the country as governor.

Barry Goldwater, another conservative from way back, his wife, Peggy, was co-founder of Planned Parenthood in Arizona.

The reason I bring all this up is that the tension that we feel right now, the sort of pro-life/pro-choice dichotomy is a movement that was manufactured, and it was manufactured for other political purposes, not exactly spiritual ones.

And so I think that was one of the things I wanted to talk about here, was that what we think of that's been in place for just a couple of generations now, for many people feels like it's relying on ancient interpretations of religious teachings and really isn't. It's been very much manufactured and used for political gain.

This is sort of personal for me, and not something I've always admitted publicly, but it turns out I have an uncle who wrote books with Phyllis Schlafly, who was one of the real thought leaders throughout her career, getting religious organizations involved in politics.

Now, I never met her personally, but she comes from my people and the values of the family that I grew up in. And I did sort of watch this happen where opposition to family planning became a spiritual wedge issue, but the true agenda was much more political.

So I could spend a long time telling the history of how we became so polarized about family planning. And I do think it's important, but it doesn't change the fact that we are where we are now, where people have closely-held beliefs around contraception, abortion, IVF, and these have become both political leverage and a challenge for providers trying to navigate what to do.

With us today is distinguished professor of bioethics Peggy Battin, who is an ethicist and an author of numerous books on thinking deeply about challenging issues.

Katie: So Peggy, welcome. We're so happy to have you help us think about this. It's a thing I'm seeing more and more, and I'm increasingly concerned about. Currently, seven states allow pharmacists to refuse to fill contraception prescriptions or prescriptions for pills that they think might be used in carrying out an abortion without any requirement to refer patients elsewhere. Employers can also refuse to cover whole aspects of family planning care and do. And in fact, Project 2025 proposes expanding these policies nationwide.

I don't know that most people think a lot about what happens if this becomes a national trend, where any given pharmacist in any given pharmacy may not like the prescription that they're being asked to fill and just refuse to fill that.

It's easy to think the pharmacist is just living by their closely-held personal values and shouldn't be made to come in contact with medications they don't agree with. But as a healthcare provider, this is one of these things that I . . . There are certain things that I think are my closely-held values, but I certainly don't impose those values on my patients.

And so I'm wondering, Peggy, how you think about this sort of tension between personal moral compasses and somebody's professional duty to care.

Prof. Battin: There are a couple of things that I think we ought to think about in advance, though. And one of them is to be aware of group attributions. Now, you didn't do that, but it's tempting to do so, to say things like, "Catholics oppose contraception and they only allow natural family planning," or, "Non-Catholics do this or believe that," or, "The view of the such and such group is thus and so." It's that group attribution that often gets us in trouble.

Now, there's another question I think that we also need to consider. You've used the phrase personal moral values, personal moral compass. And the question here is, is there any way to differentiate between genuine conscientious objection and institutionally or politically-motivated objections?

This is a serious problem. I can't speak about the legal ramifications, but I can sure talk about philosophic ones, and whether we have any good way to differentiate between what are claimed to be closely-held beliefs that are actually sincere, deeply felt, and believed at the root of one's character and that are institutionally implanted, let us say.

So when you're thinking about your personal moral compass, this would apply both to clinicians and to patients and to anybody else listening to this, can you figure out where they came from? Did they develop on your own somehow idiosyncratically? Are they the teachings of some group that you belong to? Are they required by some party? Did your parents instill them into you? And so forth. What's the origin of these "deeply-held beliefs"? How deeply held do they have to be so that we take them fully seriously?

Katie: Yeah, I think that's important. And I say historically, the things one holds deeply, you're taught by your parents or you're taught by the institutions that you're connected to, churches and schools. But more and more, it feels like you're getting those from social media, doesn't it?

Kirtly: So in my field, some things have come along that are so new, it's hard to even know whether we . . . Well, we couldn't have been taught them at our mother's knee because they didn't exist there.

There's a story of a famous OB-GYN in my field, reproductive endocrinology, and Dr. Howard Jones and his wife, Georgeanna, set up the first IVF program in the United States and helped bring about the birth of the first IVF baby in the late 1970s.

Advanced reproductive technology and clinical services are rapidly growing. And again, it's hard to have a doctrine about this because it wasn't here and it wasn't in the various teachings.

The Catholic Church prohibited IVF for Catholic couples. And Dr. Jones went to Rome, again, a trip to Italy, for an audience with the Pope to talk about the technology and what it could offer infertile couples. And he continued to be an advisor for the Catholic Church about the technology, even though the Catholic Church still forbids IVF as it is a conception outside the sexual act of a marriage.

Now, there continues to be difficult legal issues in Catholic countries that may have IVF, but destruction of embryos or egg donation may be prohibited.

And it's important to remember, just as Peggy just brought up, that religion and spirituality are different things. There are many people who consider themselves . . . I'll choose Catholic. They consider themselves Catholic and profoundly spiritual, who still practice IVF and use birth control.

And so there's what the hierarchy might say in the church, and then there's what people do in their practical and own spiritual life. It's sometimes complicated.

Particularly in the area of IVF and creation of fertilized eggs, what do you do with extra fertilized eggs? What do you do with those embryos that are . . . We call pre-implantation embryos, because they're not embryos yet. They haven't started to grow in the uterus. But these are complicated questions in the business of family planning. They're complicated ones for us.

Prof. Battin: Maybe a look back would help us into the recent history of why the religious perspective of one group, Roman Catholic, seems so complicated and so difficult to digest.

So it is in 1963 that this issue comes to the fore. It's right after John Rock, whom you've mentioned already, had developed the pill. And it comes to a head as the then-Pope, John XXIII, is asked whether the Catholic Church can accept the pill or not.

He convenes a papal colloquium on birth control. And there's some turmoil about who was on this commission. Originally, it was quite large and had some lay members, even women. Then they were replaced by 15 bishops. But the bishops voted nine to three in favor of contraception. That's the pill. Nine to three in favor. Four of the bishops, though, wrote a minority report that did not favor it, that is, opposed contraception.

Well, then John dies and is replaced by Paul VI. And the matter hadn't been resolved, but Paul accepted the minority report. Here's the statement that they made in this decision. "Each and every marriage act must be open to the transmission of life." That is, each and every marital act to the possibility of reproduction, to put it another way.

Well, that wasn't the end of the story. This edict was promulgated and resulted in what was called the month of theological anger. There was so much anger from bishops all over the world about this decision.

Remember, of course, that the commission had voted in favor of accepting birth control and only a minority had opposed it.

So this turmoil is not just, let us say, perhaps in the understanding of or conscience of particular members of this church, but in the very structure of the church's decision-making. So no wonder people might be confused and that one's closely-held beliefs, if you want to call them that, might be unstable, let's put it that way, or that they might be complex. "Well, my belief group says no, but I can't see that yet. It seems to me that they should have said yes."

Indeed, they did say yes, but then it was turned into no. How's that for a definitive teaching?

Kirtly: Well, we have this acted out in the clinics every day and in abortion clinics where lovely young mothers come to me and would say, "I know my faith tells me I'm not supposed to have an abortion, but I can't have this baby."

It's how people make decisions. And I'd say that it's great if we believe that decisions are handed on from high, but in fact, they're acted on down with the regular folks, the regular ministers, the regular preachers, the regular priests.

Katie: Yeah. I think I see that so often that there's the teaching and then there's . . . What's the phrase from . . . It's from a movie. "Trying to go one day without a good rationalization." For me, today, this is the choice that I need to make.

Prof. Battin: Remember also the emphasis on the centrality of conscience, individual conscience, which is understood to tap into the good or what's right. Somewhere between 92% and 99% of people in this country who are sexually active have tried or do use forbidden forms of contraception.

And one more thing about the contrast between personally closely-held beliefs or matters of conscience or conscientious objection and the duty to care. The duty to care is established by the medical establishment and it isn't variable in the same way. Your duty to care isn't dependent, as far as I know, on your personal, religious, cultural, or other beliefs. You have a duty to care, right? Am I right about that?

Katie: Yes.

Kirtly: And you have to respect patient autonomy. You have a duty to care and part of that's based on doing the right thing and being a good, competent clinician, but then the other is respecting the patient's autonomy, the patient's ability to choose the path that they are going to take, or understand it.

Katie: Yeah. And I do think most religions really value the individual's humility and individual's ability to care, right? It's always a teaching of every major religion that you're caring about your community. And so for those of us as healthcare providers, my community is my patients and helping my patients figure out what is the best thing for them. It almost does feel spiritual to me.

Kirtly: It feels that way to me.

Prof. Battin: We also need to consider the role of men in decisions about family planning. And I realize we're here in a series on women's health. It's their business. It's their body. It should be their decision. End of story. That doesn't take into account male roles in family planning, which in some couples will be central, in others absent.

It also doesn't take into account that research in male forms of contraception that are effective and long-acting has been sorely lacking. It's coming much more into public consciousness now, and there's much more development of new technologies for males. But the family planning, ideally, is a decision, a choice made by two people in concert, not just the woman's business.

Katie: Yes. And we did just talk about some of the male contraception on the market in our environmental episode. Listeners can go back and hear a little bit about what's coming out for men.

Peggy, do you anticipate that when males have access to a wider variety of contraception that maybe the spiritual landscape will change and there'll be some pressure on them from that perspective?

Prof. Battin: That's a neat question. It's clear that the legal landscape will change because it's possible now to identify the heritage of any conceptus, right? So there's no more rolling stone, just come into town, and leave a baby.

Katie: The baby looks so much like his father. I think every woman's programmed to say that, right?

Prof. Battin: But it's also the DNA if the baby looks a lot like its father as well, right? And now we can determine who the parent is. That means males are much more on the hook than they used to be. I assume you've said this before.

But the question here is does that change their . . . And it's hard to generalize about men in general. Does it change anything about their spiritual situation? I'm not aware of any church that has spoken very clearly or directly to this issue.

The Catholic Church has included the condom as among artificial contraceptives that are prohibited. There have been some exceptions for disease transmission, but in general, as a contraceptive, they're prohibited. Will it change its tune now? Can you imagine? Would this be an opportunity for an organization like the Catholic Church to rethink its teachings? So talking about spirituality, both in terms of personal commitment and institutional teaching.

Katie: I know you've thought about this a lot, and we'll mention your book again, "Sex and the Planet: What Opt-In Reproduction Could Do for the Globe," because you have thought about this in so many different ways. And if people are interested in spinning out this brave new world, your book is widely available, right, Peggy?

Prof. Battin: Yeah.

Katie: Well, thank you so much for joining us. Thank you for joining us for all the 7 Domains of Family Planning. This one, as I think we've mentioned many times, is personal for both Kirtly and I.

The option to control your fertility, the freedom to choose whether and when to have children, and the confidence that you're unlikely to die in childbirth or lose your child in childhood, these are remarkable changes in the human story. And they've been brought to us through science.

Science alone doesn't protect them, though. Protecting these rights requires political vigilance, and personal humility, and the humility to recognize that caring for someone means allowing for a variety of beliefs.

That is the thing that keeps me going on a daily basis, is to protect my ability to provide care, the political work that needs to be done to protect that, and participating in the science. I feel so honored to get to be at that intersection.

So as we wrap up our series on family planning, I want to remind people that you can get this episode and all of the episodes on family planning and lots of other topics on all the major podcast platforms and at womens7.com.

And Kirtly, I think you have . . .

Kirtly: I'm going to lead out with a haiku. And I also want to thank everyone for listening to our domains of family planning. For many, planning a family is just a practical, logical exercise, but for many others, it's profoundly spiritual and life-fulfilling. For me, as a reproductive endocrinologist, fertility doctor, contraceptive doctor, abortion provider, wife, and mother, it has been both.

So I'll leave you with the family planning haiku.

A baby? Maybe?
What will be your chosen path?
The world is your child.