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Informed consent is issue
After years of controversy, the Food and Drug Administration (FDA) approved the over-the-counter status of emergency contraception without age restriction in June 2013. Therefore, a prescription is no longer necessary for minors to obtain emergency contraception.
"Based on my experiences taking care of young women and adolescents, I support the over-the-counter status of emergency contraception and the advanced provision of this safe medication for minors," says Julie Chor, MD, MPH, assistant professor in the Department of Obstetrics and Gynecology at The University of Chicago (IL). "That being said, I understand that those who oppose these practices may have several concerns."
Minors are legally permitted to consent to contraceptive services in 26 states and the District of Columbia, and specific categories of minors are able to consent to contraceptive services in 20 additional states.1 "With regards to parental rights and concerns about a minor’s ability to make sound decisions about her reproductive health, the majority of states recognize by law that minors are capable of making such decisions," says Chor. "Furthermore, minors frequently do discuss these decisions with a trusted adult."
Young women may not understand how emergency contraception works and how it is different from nonemergency contraception. "Part of what underlies this concern is that minors may not be able to give fully informed consent to use emergency contraception — or even nonemergency contraception. Some people believe that parental consent is necessary, precisely for this reason," says Lisa Campo-Engelstein, PhD, assistant professor at the Alden March Bioethics Institute and Department of Obstetrics and Gynecology at Albany (NY) Medical College in New York.
Impinging on young women’s access to emergency contraception increases the likelihood of unintended pregnancy, according to Chor, and prohibiting physicians’ ability to prescribe emergency contraception for young women is an intrusion into the doctor-patient relationship. "Young women should be able to seek counsel from their providers regarding sensitive topics such as reproductive health," she says. "Physicians, in turn, must be able to provide counsel and medical care deemed appropriate based on their encounters with patients."
Prescriptions in advance?
Is it ethical for physicians to write prescriptions for emergency contraception in advance? "In general, the idea of prescribing in advance rather than when it’s needed tends to overcome the rationale for having prescription drugs in the first place. Normally, drugs are prescription-only drugs because it is considered appropriate to have physician input and monitoring," says G. Kevin Donovan, MD, MA, a pediatrician and the director of the Pellegrino Center for Clinical Bioethics at Georgetown University Medical Center in Washington, DC.
Donovan says that the greatest ethical concerns involve the possibility that emergency contraceptives might be prescribed in advance to children. "There are some medical concerns about that. The FDA would not customarily allow a drug to be marketed for children if it hasn’t undergone testing in children, and neither of the classes of emergency contraceptives have been," says Donovan.
If there is no physician relationship and no monitoring done by a physician, this means there likely won’t be any monitoring for sexually transmitted diseases either, says Donovan. Furthermore, a patient might delay medical care for an unrecognized ectopic pregnancy. "There are also social concerns, especially the lack of parental input and the likelihood that both young teens and women may decide to use these in a serial fashion as a substitute for normal preventative contraception," he adds.
Donovan notes that the marketing site for an emergency contraceptive points out that prescriptions are available to men as well. "Any older man who is preying on a child, could have these available in advance without having to discuss it with a physician," he says. Donovan notes that there have not been well-documented problems with access to emergency contraception. "I’m not sure where the argument is that it has to be done in that fashion," he says. "It seems that the questions of access have been more theoretical and ideological rather than actual."
A committee opinion from the American Academy of Pediatrics supports advanced provision of emergency contraception.2 According to a 2011 review of the literature on advanced provision of emergency contraception for women older than the age of 24, young women who receive advanced provision use emergency contraception sooner when needed and do not have increased sexual risk-taking behavior or negative effects on continued contraceptive use.3
"Advanced provision and access to emergency contraception has not been demonstrated to result in increased sexual risk behavior," says Chor. "Furthermore, physicians prescribe medications in advance frequently — for example, giving a pain medication as needed."
When weighing children’s autonomy versus parental obligation to nonmaleficence and beneficence toward their children, some believe that parental paternalism is justified because parents are best situated to make decisions for their children, says Campo-Engelstein. In contrast, some argue that young women’s reproductive autonomy should be upheld, even if they are younger than 18.
"Because sexuality and reproduction is such a personal matter, as well as a controversial political matter, some claim that reproductive decisions are best made by individuals themselves and not by their parents or others, such as health care providers or the government," says Campo-Engelstein.
Some may see the request for a preventive prescription for emergency contraception as an example of mature and responsible behavior that is further evidence that young women are capable of making reproductive decisions for themselves, she adds.
"Given that half of all pregnancies in the U.S. are unintended and that close to half of all unintended pregnancies end in abortion, allowing prescriptions for emergency contraception could reduce the prevalence of abortion," adds Campo-Engelstein. "Discussions about emergency contraception with health care providers could also lead to more overall responsible reproductive behavior."