Monday, November 12, 2007

I Really Wish...

I could post something that was good news, because right now I'm breaking into the blogosphere with a crash of pessimistic thunder and accompanied by an armada of dark storm clouds.

Unfortunately, I hope you brought your umbrella, because a federal judge just suspended a state law requiring pharmacists to dispense emergency contraception, otherwise known as "Plan B." According to the article, the law unconstitutionally violates pharmacist's freedom of religion:

The rules appear to force pharmacists to choose between their own religious beliefs and their livelihood, Judge Ronald B. Leighton of the U.S. District Court in Tacoma wrote Thursday.

Some pharmacists believe the emergency contraceptive pills, also called "morning-after pills," are tantamount to abortion because they can in some cases prevent implantation of a fertilized egg.

"Whether or not Plan B ... terminates a pregnancy, to those who believe that life begins at conception, the drug is designed to terminate a life," the judge wrote in a 27-page order granting a preliminary injunction.

As a little background, Plan B consists of a package containing two 0.75 mg tablets of levonorgestrel, a form of progesterone. One tablet is intended to be taken as soon as possible, with the second tablet following 12 hours later. The sooner the first dose is taken, the better; this is a drug where time is crucial. Because Plan B is now available "over the counter," it may be true that if one pharmacist refuses to dispense the drug that the patient can simply go to another pharmacy. But what kind of option is that? Every minute counts. And isn't it possible that every pharmacist within reasonable distance of your home might refuse you EC just because they don't think you should be permitted to have it?

It doesn't help that few people actually understand the science behind Plan B, even pharmacists. 25% of pharmacists surveyed in North Carolina thought Plan B was an abortion pill like mifepristone (RU-486), which will actually terminate an early-term pregnancy. 5% who knew that it wasn't RU-486 still thought it could somehow directly induce an abortion. They've apparently forgotten their physiology; part of the way that the body maintains pregnancy is jacking up serum progestins to keep the endometrium from sloughing off and dumping out an implanted fetus with the next menstrual load. No wonder they're opposed to it; they have no idea how it works! In fact, RU-486 works because it's an synthetic anti-progestin steroid. And it's commonly cited that Plan B works by preventing implantation, which is only partly true; like other oral contraceptives, Plan B also alters cervical mucus and the action of the fallopian tubes. It may even prevent ovulation entirely, depending on where the woman taking it is in her cycle! It may, in many cases, prevent union of sperm and egg altogether. Even if it didn't, refusal to dispense EC but dispensing other oral contraception is logically inconsistent. They have identical mechanisms of action.

Think about it this way. Suppose you were seriously injured and losing large amounts of blood. You desperately need a blood transfusion. The attending physician at the ED appraises your condition and shakes his head. "This patient is bleeding to death," he says to his colleague, "but there's nothing we can do. It's for his own good that we not save his life. I won't be responsible for condemning his immortal soul."

Sound impossible? Maybe. But a woman recently died during delivery of twin babies for refusing a blood transfusion. She was a Jehova's Witness, and her religious beliefs prevented her from recieving blood transfusions. It is common legal and ethical precedent that physicians cannot treat patients without their consent. And a doctor who refused to treat patients on the basis of his or her religious beliefs could potentially be sued for malpractice. Why can't the same be done for a pharmacist? Pharmacists have been sued over this issue in the past; why in the world would a court overturn that ruling now?

Perhaps the issue is one of urgency. Any layman can tell you that severe hemorrhage is potentially fatal, and very quickly so. But what about symptomatic iron-deficiency anemias? Treatment protocol for patients experiencing significant shortness of breath or other potentially serious problems includes an infusion of red cells. Can you imagine a doctor telling a patient, "it's okay, just take iron supplements for the next month, eventually you'll get better without a blood transfusion?" It might potentially be true, but does that mean it's good medicine? It's vastly subpar care with no medical basis or scientific evidence to back it.

The article mentions that most people "can get Plan B without a pharmacist," but as I understand the matter, that's an issue of state law as well. Where I work, a patient must present an ID to purchase Plan B, and all sales must ultimately go through the pharmacist. If the pharmacist refuses to sell Plan B and finds out that a technician has violated this decision, the technician could very easily be fired. How many technicians will risk their jobs like this?

In summation, I really have to agree with one of the activists quoted by the article:

"I think this is another step on the assault on women's rights to control our own bodies," said Helen Gilbert, an activist with the group Radical Women. "If [pharmacists'] beliefs are in conflict with doing this job, then they should do a different job." [Emphasis mine.]

Absolutely. To quote a pharmacist I used to work with, refusing to dispense oral contraceptives or emergency contraception is like a Christian Scientist getting a medical degree and then refusing to treat anyone except with prayer. Why would you take the job if you find it incompatible with your belief system? You are responsible for certain things as a medical professional. If you don't like them, find another line of work.

2 comments:

PalMD said...

Shameful. Sure, it's technically OTC, but it's usually behind the pharmacy counter. It's a pharmacists job to safely and accurately compound and dispense ordered medications, not to decide which medications are appropriate.
If dispensing legal medicines is against their religion, it's time to get a new job--like minister.

Anonymous said...

"And it's commonly cited that Plan B works by preventing implantation, which is only partly true; like other oral contraceptives, Plan B also alters cervical mucus and the action of the fallopian tubes. It may even prevent ovulation entirely, depending on where the woman taking it is in her cycle! It may, in many cases, prevent union of sperm and egg altogether. Even if it didn't, refusal to dispense EC but dispensing other oral contraception is logically inconsistent. They have identical mechanisms of action."

No, don't tell them this. Because instead of seeing Plan B in a better light, they are just as likely to expand the crusade and include non-emergency oral contraceptives as well.