Despite some opposition, BC pharmacists to dispense morning-after pill without prescription
Five hundred BC pharmacists are preparing to dispense the "morning-after pill" without a prescription, in part to help reduce the amount of violence against physicians who perform abortions.
Three Canadian physicians who have performed abortions, including one from Vancouver, have been wounded in sniper attacks since 1994. (Arrest warrants have been issued in Canada and the US for an American antiabortion activist, who is also wanted for the murder of a New York doctor.) "With the shootings, we thought we had to do something to reduce the need for abortions," says Brenda Osmond, deputy registrar of the College of Pharmacists of BC.
Improving the availability of emergency postcoital contraception (EPC) is also a public health issue because of the increasing number of teen pregnancies and abortions, she says. According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), the number of teen pregnancies grew by 18% between 1987 and 1994. Making EPC more available is an "urgent health care need, particularly in more remote areas," says Osmond.
In February, the college was considering 2 options that would allow pharmacists to prescribe levonorgestrel and ethinyl estradiol, which has been packaged under the brand name Preven, as an emergency contraceptive. The combined oral contraceptive, known as the Yuzpe regimen, came on the Canadian market last fall.
The first option is to let BC's provincial health officer, Dr. Perry Kendall, delegate all properly trained pharmacists to dispense the drug without a prescription. This follows the precedent set in many Canadian hospitals, where physicians authorize pharmacists to dispense certain drugs without a specific prescription. This method is also used to dispense emergency contraception in about 20 US states.
Alternatively, BC could add Preven to its list of schedule 2 medications, which pharmacists can dispense at their discretion. This isn't normally done at a provincial level, but Osmond explains that federal legislation stipulates that a practitioner is a physician, dentist or any "health care professional" given prescribing authority by a provincial government. This allows BC midwives, for example, to have limited prescribing rights. Officials were confident that the delegation route will be followed.
With both options, the BC Pharmacy Association would provide pharmacists with special training in therapeutic protocols, patient counselling and referrals on contraception, sexually transmitted disease and related subjects. They would also be trained to identify victims of abuse or sexual assault. More than 500 of the province's 3000 pharmacists have signed up for training.
Making dispensing conditional on training and then making the training optional was probably a wise move on the part of the college, since it allowed it to avoid creating an ethical dilemma for those who object to dispensing the drug on moral grounds. According to Osmond, a "small number of vocal opponents" opposed an SOGC resolution on emergency contraception that the Canadian Pharmacists Association (CPhA) has endorsed. The goal of the resolution, passed in November 1998, is to increase awareness and availability of the morning-after pill.1 In addition to pharmacies, the society also wants EPC to be available at family planning clinics, emergency rooms, walk-in clinics and through school health programs. In January, some parents were outraged after France became the first country to give school nurses the right to dispense emergency contraceptives. The parents said the government is usurping the role of parents and is encouraging casual sex and sex without condoms.
To avoid a similar backlash, and before trying to change federal drug legislation, the SOGC tried to ensure that it had broad support by asking 50 medical, pharmacy, licensing and other bodies to endorse its motion. To date 42 groups, including the CMA, have signed on.
Rapid access to emergency contraception is essential because the sooner it's taken following intercourse up to a maximum of 72 hours the more effective it is. The SOGC wants to make the drug available without prescription through family planning clinics, emergency rooms, walk-in clinics and school health programs. The society says it makes sense for pharmacists the most accessible health care professionals to dispense the drug.
Not all pharmacists agree. Some consider prescribing EPCs tantamount to performing abortion and want nothing to do with either dispensing the drug or informing customers about it. Others say that because pharmacists have a monopoly over dispensing drugs, they have a professional obligation to dispense emergency contraceptives, regardless of their views. They say the rights of the patient supersede the rights of the professional in all cases.
So what happens when pharmacists' ethical obligation to help customers conflicts with their moral convictions? While this dilemma may be all too familiar for physicians, it's brand new for pharmacists, and the CPhA's endorsement of the SOGC resolution has resulted in many letters to the Canadian Pharmaceutical Journal (CPJ) and led the National Association of Pharmacy Regulatory Authorities (NAPRA) to propose a "conscience clause."
Barry Creighton, leader of the Concerned Pharmacists for Conscience in Calgary, won't be dispensing EPCs. Creighton, who wouldn't reveal how large his group is, has written several letters to the CPJ and an editorial on the need for a pharmacy conscience clause to allow pharmacists to refuse to dispense. "A prescription that is intended to harm health and/or life is something a health care worker may consider refusing," he wrote recently.2
"Doctors and nurses can say no," he says. "Why can't we say no?"
Michael Izzotti, a Hamilton pharmacist and Canadian coordinator of Pharmacists for Life International, says his group also supports the conscience clause but says "it should protect us completely." Currently, Puerto Rico, 5 US states and BC have adopted such clauses.
Last November NAPRA approved a model statement regarding pharmacists' refusal to provide products or services for moral or religious reasons (www.napra.org/practice/information/refusal.html), and it has been circulated to all licensing bodies.
The statement places the onus on the pharmacist who declines to provide emergency contraceptives to pre-arrange access to an alternate source, either another pharmacist or a physician who has a supply of the drug. It also states that pharmacists "shall hold the health and safety of the public to be their first consideration."
The CPhA is currently revising its code of ethics to include a conscience clause. "The bottom line," says Executive Director Jeff Poston, "is that they have to provide continuity of care, a referral, or provide [the drug] themselves."
Frank Archer, a former executive director of the BC Pharmacy Association who now teaches biomedical ethics at UBC, says these clauses have no clout. The code of ethics for BC pharmacists already says that pharmacists who object to dispensing a certain drug must refer patients to colleagues who will provide the service. However, if no one else is available, the pharmacist must dispense.
Archer is adamant that pharmacists have no right to refuse to dispense a drug because this would be "an abuse of the monopoly right the public has granted our profession."
Izzotti disagrees. "The medical profession is reneging on its responsibility and putting the onus on pharmacists," he says. "Our role is not to prescribe, it's to dispense." He thinks the CPhA is being "manipulated by the SOGC."
Barbara Sibbald is CMAJ's Associate Editor, News and Features.
© 2000 Canadian Medical Association or its licensors