Is it always better to be PrEP’d? Not for Catholic business owners

In September, a federal judge ruled that two Texas business owners cannot be forced to provide health insurance coverage for “PrEP” drugs if it violated their religious beliefs. This new dispute in the culture war manifests the complexity of contemporary bioethical issues and the need for careful ethical discernment by Catholic individuals and organizations.
 
What is PrEP, and why did business owners go to federal court?
 
PrEP is an acronym for “pre-exposure prophylaxis.” According to the CDC, providing antiretroviral drugs (sold under the brand names Truvada® and Descovy®) can significantly reduce the risk of infection with HIV — by 99 percent for persons engaging in gay sex, and by 74 percent for IV drug users. Curiously, there is less data about risk reduction for heterosexual intercourse. (PrEP drugs cannot “cure” HIV for those already infected or prevent other sexually transmitted infections.)
 
Because HIV infection is so devastating and these drugs appear to be so effective, they are listed as a “preventive service” that health insurance plans must cover without patient co-pays or deductibles — just as contraception and sterilization must be covered under ObamaCare’s HHS mandate. The brand-name PrEP drugs cost almost $2,000 per month; generic versions are much cheaper.
 
This information puts the federal court case into clearer perspective. The business owners have faith-based objections to including these drugs in their employee health insurance plans. They want neither to be associated nor to cooperate with the behaviors making these drugs necessary. Individuals, public health officials, and even some Catholic bioethicists prefer to focus on the harms being prevented. Beyond costs, consequences, and the law, what other considerations does the Catholic moral tradition provide for ethical discernment?

With regard to individual patients, it can be ethically good to avoid injury and disease even if these result from immoral or imprudent actions. For example, it can be ethical to remind teenagers to use seatbelts, especially when one suspects they might drive unsafely, and to provide immunizations against Hepatitis B and HPV even though these infections are spread primarily through sexual contact. In such cases, material harms may or may not be caused by poor moral choices.
 
However, there are additional ethical considerations at stake. First, if a person uses a “preventive means” with the intent of engaging in unethical action (such as using a mask in a robbery), he is not merely “preventing harm” but also confirming his knowledge and freedom to act in a profoundly unethical manner.
 
Second, while clinicians are often justified in helping patients avoid injury and illness—again, even if these may be caused by poor moral choices—to comply with a patient’s demand for PrEP with the expressed goal of engaging in more unethical and risky sexual behaviors (which occurred in a case once submitted to the NCBC) would involve the clinician in formal or immediate material cooperation in the patient’s unethical goals. A clinician would be justified, on ethical grounds, to refuse to provide a prescription. Many clinicians have prudential concerns about prescribing PrEP, since experience shows an increase in the number and nature of risky behaviors by some patients.
 
Finally, Catholic business owners have a responsibility to implement relevant Catholic moral and social teachings by providing safe working conditions, just wages, and health insurance benefits consistent with their Catholic faith. There are consultants and tools that can help to make good decisions, e.g., about drugs such as PrEP. It is not necessary to exclude all use of PrEP. For example, it would not be wrong to prescribe PrEP for the wife of a man who contracted HIV infection due to mistakes in his past. But to make PrEP available on demand—by individuals or by the government—is not ethically justified.

JOHN F. BREHANY, PH.D., S.T.L., is executive vice president of the National Catholic Bioethics Center and past executive director of the Catholic Medical Association.