Abstract
This article defends the public funding of abortion in the Canadian health care system in light of objections by opponents of abortion that the procedure should be denied public funding. Abortion opponents point out that women terminate their pregnancies most often for social reasons, that the Canadian health care system only requires funding for medically necessary procedures, and that abortion for social reasons is not medically necessary care. I offer two lines of response. First, I briefly present an argument that characterizes abortion sought for social reasons as medically necessary care, directly contesting the anti-abortion position. Second, and more substantially, I present a justice argument that shows that even if abortion is not regarded as medically necessary care, the reasons that typically motivate women to seek abortion are sufficiently weighty from the moral perspective that it would be unjust to deny them public funding. I finish by drawing the more general conclusion that health care funding decisions should be guided by a broader concept of necessary care, rather than by a narrow concept of specifically medical necessity. A broad concept of necessary care has been debated in health care policy in the Netherlands, and I suggest that such a concept would be a more just and defensible guide for funding decisions than the concept of medical necessity.
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Notes
R. v. Morgentaler [1988] S.C.J. No. 1 (QL).
Bill C-43, An Act Respecting Abortion, 2nd Session, 34th Parliment, 1991, was defeated in the Canadian Senate 31 January 1991. Abortion protests in the province of Ontario led the attorney general to seek and win an injunction prohibiting protest activity within 160 feet of abortion clinics in the case Ontario (Attorney General) v. Dieleman, [1994] O.J. No. 1864 (Ont. Ct. (Gen. Div.)). The province of New Brunswick refuses to pay for abortions performed in private clinics, and requires two referrals from physicians to have an abortion in a hospital.
See for example, Jane Doe 1 v. Manitoba, [2004] M.J. No. 456 (Man. Q.B.); Morgentaler v. Prince Edward Island (Minister of Health and Social Services), [1996] P.E.I.J. No. 75 (P.E.I.S.C. (A.D.)); Association pour l’accès à l’avortement v. Québec (Procureur général), [2006] J.Q. No. 8654 (C.S. Qc.); and the ongoing case Morgentaler v. New Brunswick.
Canada Health Act, R.S.C. 1985, c. C-6. The wording of the CHA makes these claims in a roundabout way. It states “the health care insurance plan of a province must insure all insured health services” and then defines “insured health services” as “hospital services, physician services … provided to insured persons”. “Hospital services” are then defined as services “medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability”; and physician services are defined as “any medically required services rendered by medical practitioners” (CHA 1985).
See the comments by Canadian abortion provider Garson Romalis that in Canadian hospitals “septic shock from illegal abortion is virtually never seen” (Romalis 2008).
A reviewer for this journal pointed out the possibility of abortion being used as aesthetic surgery. Besides the absence of evidence that abortion is used in this way, the claim that abortion is often used for aesthetic (and therefore trivial) reasons does not make any sense. Any woman who would contemplate an abortion for “aesthetic” reasons (a) is faced with an unplanned pregnancy (b) for which she is clearly unprepared. Given that having a child is one of the most momentous and life-changing events in one’s life, being unprepared to face this challenge is not a trivial reason for having an abortion.
However, we should not use this valuation of reasoning to justify the mistreatment of infants, people with cognitive disabilities, or elderly people with dementia. One can recognize that taking away or denying someone cognitive abilities that they could otherwise have—for example through causing a head injury, or through neglecting a child—is to threaten their well being. Nonetheless, the lives and interests of people without these abilities are not rendered any less worthy for lacking the capacity to reason. See Nussbaum’s sensitive consideration of this issue in Frontiers of Justice (Nussbaum 2006, pp. 191–193).
Besides abortion, another way of dealing with unintended pregnancy is by giving the baby up for adoption. But this course of action entails its own set of physical and psychological burdens. Some women choose adoption, but for those who abort, the burdens of adoption are sufficient to motivate women to choose abortion over adoption. The denial of public funding for abortion could force indigent women to bring unintended pregnancies to term, but even though such women could give their children up for adoption, this is hardly a just solution.
While I agree that Viagra is usually not deserving of public funding for health care, I will leave open the question of whether it is never deserving of such funding. One might make the case that Viagra could be used to help an otherwise infertile young man conceive a child. I will not speculate on whether such a case warrants funding. Prescription drug coverage is not required under the CHA, but it is possible that a principled moral argument could make this exclusion seem questionable. See my comments in the following paragraph on the likelihood that the justice argument could be used to justify public funding for other health care goods that are difficult to characterize as medically necessary, but that further another essential non-health dimension of well being.
One implication of the argument presented in this paper is that social programs more generally designed to relieve poverty are morally required by considerations of justice. I accept this implication and assume that anyone who is persuaded by the justice argument for the public funding of abortion would accept this implication as well.
For example, the same kind of justice argument used to justify public funding for abortion might also be used to justify public funding for the morning after pill, Plan B (levonorgestrel)—although the argument would have to deal with the fact that pharmaceutical coverage is not required under the CHA. I have already given the example of Viagra to show that the justice argument has plausible limits. Another example would be neonatal male circumcision, which is no longer funded by provincial/territorial health care insurance in Canada. The justice argument cannot be used to justify public funding for circumcision because being uncircumcised does not imperil any essential elements of well being.
I thank an anonymous reviewer for this argument.
This argument appears in (Erdman 2007, p. 1,144).
Beal v. Doe, 432 U.S. 438, 448 (1977) (Brennan J., dissenting).
The other interpretations are the professional interpretation, in which care is regarded as necessary when it is the appropriate therapy for the indication for which it is used; and the individual perspective, in which the focus is on the medical need of the individual patient (Hoedemaekers and Oortwijn 2003, p. 289).
A previous version of this paper was presented at the European Conference on Philosophy of Medicine and Health Care, Cardiff UK, August 2007. I thank my audience for their helpful comments. I also owe a debt to Jocelyn Downie for her critical review of several drafts of this paper.
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Kaposy, C. The public funding of abortion in Canada: going beyond the concept of medical necessity. Med Health Care and Philos 12, 301–311 (2009). https://doi.org/10.1007/s11019-008-9164-9
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DOI: https://doi.org/10.1007/s11019-008-9164-9