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Nonprescription sales of Plan B still murky waters
Requests for morning-after pill may drop
The recent federal approval of nonprescription sales of the emergency contraceptive Plan B (Barr Laboratories; Woodcliffe Lake, NJ) to women and men ages 18 and older may have quieted what was a brewing controversy in emergency medicine. However, the ethical issues that gave rise to the debate still are very much in play, emergency department (ED) experts say.
The issue came to the forefront when, in July 2006, an ED doctor at Good Samaritan Hospital in Pennsylvania cited his Mennonite beliefs and refused to prescribe a morning-after pill for a rape victim. The incident touched off a national debate on emergency contraception.
Despite the recent federal approval, however, "The underlying ethical principle is still open for discussion," asserts Mark Debard, MD, an emergency physician at The Ohio State University Medical Center in Columbus, who wrote much of the information used in sexual assault protocols in his state's EDs.
While emergency medicine experts note that the vast majority of rape victims are older than age 18, they agree this does not make the issue moot. Some states, for example, are moving to make access to the pill in pharmacies more difficult.
John Banja, PhD, a medical ethicist in the Center for Ethics at Emory University in Atlanta, poses these scenarios: A patient is in a rural area and can't get emergency contraception at the hospital. Or, the pharmacy closest to a patient won't provide the pill.
Banja notes that Georgia legislature has passed a law that allows pharmacists to refuse to prescribe the pill without fear of prosecution. "The assumption of widespread availability may not be correct," he says. "Just because it is approved does not necessarily mean women will be able to get the drug."
As part of their preparation for dealing with staff who object to prescribing the pill because they are opposed to abortion, Banja says it's critical to understand exactly how Plan B works.
"For pregnancy to occur, of course, three things must happen: The woman's ovaries have to secrete an egg into the fallopian tube; the male sperm has to fertilize the egg in the fallopian tube; and the fertilized egg has to implant into the lining of the uterus," Banja summarizes. "The morning-after pill can work in one of three ways: It can stop ovulation from happening, it can stop the fertilization from happening, or it can prevent the fertilized egg from implanting."
Generally, fertilization will not occur within the first 24 hours of unprotected sex, Banja says. Thus, in most rape victims in the ED, the Plan B pill is going to prevent ovulation or fertilization, he says. "To the extent it does that, we are not talking about abortion," he asserts.
Still, Banja concedes, there will be ED staff members who reject that rationale or who are opposed to any form of contraception.
Finding a balance
"We have a long-standing tradition of allowing physicians a great deal of autonomy in what they are allowed to do [or not do] within the rule of law," says Debard. "There is no question that doctors with ethical and religious scruples about not performing certain acts are not required to perform them." Thus, he says, in the case of the Pennsylvania physician, "there's no question he acted within proper professional ethics."
Still, Debard counters, "Just because he was within his ethical rights does not mean he doesn't have other ethical obligations."
Those obligations always have existed, he says. "To the point where even when doctors did not want to prescribe birth control pills because it was against their religion, they were traditionally required to provide information about others who would — in other words, how the patients might obtain that prescription," Debard says.
So, how does this translate into ED operations? "To my knowledge, such a protocol or policy rarely exists in the ED — but it probably should," Debard says. "Such a policy would acknowledge the rights of the physician not to prescribe the drug, but it also should acknowledge the patient's rights to information on how to obtain that prescription."
The approval of over-the-counter sale of Plan B has not changed the policy in the ED at Emory University Hospital in Atlanta, says Matthew T. Keadey, MD, medical director.
First of all, he notes, rape victims younger than 18 represent a "small volume" for his ED. "It's often a date-rape incident and alcohol-related, involving campus freshmen," he notes.
"Our position in general has been that we will provide post-exposure prophylaxis to anyone who requests it," he says. If someone in his group does not feel comfortable providing that care, "usually the staff will call me, and I will be happy to call the prescription in for the patients."
Have a backup plan
While it is admittedly difficult to delve into someone's religious belief, it is nevertheless important to know how your staff feel about these issues, says Keadey. "If there is somebody who feels, for whatever reason, uncomfortable about caring for this problem, you need to have some sort of backup plan to facilitate the care of the patient," he notes.
Banja agrees — to a point. "To the extent that the emergency room physician would routinely have written a prescription for a birth control pill, it should make no difference," he says. "On the other hand, suppose he is even against contraception — now, what do we do?"
Banja notes that while there is great political controversy in the United States about abortion, "women do have the absolute legal right to an abortion during their first trimester, and to the extent that the hospitals are licensed facilities and have to obey the law to maintain that license, they have to respect the rights of the patient."
However, says Banja, the ED manager should respect the conscience of the physician and allow him not to prescribe the pill. "But if I am the ED director, I will have another doctor available to fill it," he says. He "absolutely" recommends making this action part of the ED's policies and procedures.
Even in cases involving younger victims, there are ways for the victims younger than 17 to ask for Plan B, says Debard. Most states have laws that allow for the examination and care of a minor with regard to sexually transmitted diseases and pregnancy, he says. "If a sexual assault has occurred, this approach can certainly be conceived of under those circumstances," he says, "But in general, I would do it in association with the parents being present."
While the physician still would have the right to refuse care, "I think it would be a very small minority," says Debard. Even then, he says, "There would be an ethical obligation to educate the patient and their parents about where they could get the pill."
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