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Sticking to the Script

New bill tries to keep drugstores filling, rather than preventing, prescriptions for emergency contraception

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Bogomir Kuhar doesn't want pharmacists to fill prescriptions for emergency contraception -- the high-dose birth-control pills that prevent a fertilized egg from implanting in the uterus.

 

"Pharmacists are not mind-numbed robots who operate without critical thinking," Kuhar writes in an e-mail. "They do not park their moral, ethical and religious values at the door, as if they were some kind of schizoid personality."

Kuhar is executive director of Pharmacists for Life International, a small but vocal Ohio-based advocacy group of pro-life pharmacists, and author of Infant Homicide Through Contraception, a book detailing his claims that all contraception is tantamount to abortion.

PFLI considers emergency contraception, also known as Plan B or the morning-after pill, to be an abortifacient, a chemical that induces abortion. Much of the scientific community -- the Food and Drug Administration, for example -- says that's untrue. The debate, of course, centers around whether life begins at contraception, at implantation or even later.

When taken within 72 hours of unprotected intercourse, emergency contraception pills, which are chemically identical to birth control pills but in higher dosages, prevent a fertilized egg from implanting into the uterine wall. It is not the same drug as RU486, which does cause abortion.

In fact, backers say, EC reduces the number of abortions. An article published in the journal Contraception in 2003 says that nationwide, "in 2000, an estimated 51,000 pregnancies were prevented by EC, accounting for 43 percent of the decline in the abortion rate since 1994."

But some pharmacists aren't convinced, and most states, including Pennsylvania, allow pharmacists who object to dispensing EC to refuse to fill prescriptions. Pro-life groups like Kuhar's say all pharmacists should be protected by law from the consequences of refusing.

In Pennsylvania, legislation is pending that would do the opposite: ensure that women's prescriptions are filled. House Bill 2217, written by state Rep. Dan Frankel (D-Squirrel Hill), would also require pharmacists who share views with Kuhar to step away from the situation without stepping in the way. He says women's right to have their prescriptions filled shouldn't be impeded by the views of individual pharmacists: "It's not abortion, it's not an abortifacient, it's something that women should have easy access to, particularly in a time of crisis."

Kuhar disagrees: "Pharmacists who still have a conscience are highly trained, thinking and caring individuals who take an oath to 'first, do no harm,' and secondly 'do good,'" he writes. "They are bound and empowered to prevent known harm to their patients, including those not yet born."

 

Frankel's bill comes on the heels of a Planned Parenthood statewide survey done last year to determine what roadblocks, if any, women in the state were encountering in having their prescriptions filled. Barr Labs, the Pomona, N.Y., company that manufactures Plan B, did not respond to a request for information on the number of prescriptions filled in Pennsylvania in recent years. Planned Parenthood's Downtown family planning clinic dispensed 176 prescriptions over the past six months.

The agency's survey used two methods -- one in which Planned Parenthood callers identified themselves, and a "secret shopper" method in which Planned Parenthood associates posed as patients looking to fill a prescription.

 

The surveys found that about half of all pharmacies statewide stock the drug. But while 55 percent said they did in the official survey, only 47 percent did in the secret-shopper survey. In rural counties, about 40 percent of pharmacies stocked it, while pharmacies in urban counties carried it at a rate between 52 and nearly 59 percent, according to the agency's main survey.

"That's especially problematic," Frankel says. Rural women "don't have the kind of ready access to multiple pharmacy outlets that urban women have. The secret-shopper survey really documents that there is a problem. It seems to me that reasonable people can agree that [EC access] needed a legislative remedy."

Nearly 53 percent of the pharmacies surveyed by Planned Parenthood's public method were unable to fill the prescription on the day it was presented. Since the drugs need to be taken within a fairly tight time frame to be effective, delays in obtaining the drug can compromise its efficiency. The survey identified 21 pharmacists in the state who would refuse to fill an EC prescription.

"I think it's really scary," says Jodi Hirsch, director of public affairs for Planned Parenthood of Western Pennsylvania. Hirsh declined to identify specific pharmacists who refused to fill prescriptions. To do so, she says, would make it difficult to get them to change their minds. "We have to keep coming back to the question of whose rights are at stake. If your conscience disbars you from doing your job, you're in the wrong profession."

 

That's a gross oversimplification, says Susan Winckler, vice president for policy and communications and staff counsel for the American Pharmacists Association. Requiring pharmacists to go against their beliefs compromises their ability to be health-care providers, she says.

"That would be fine if we were going to tell all professionals that you are automatons or robots," Winckler says. "We need pharmacists to have empathy. Pharmacists, like doctors and nurses, shouldn't be mandated to participate in a practice they object to."

Pat Epple, executive director of the Pennsylvania Pharmacists Association, echoes the sentiment.

"Physicians don't have to perform abortions," Epple says by way of comparison.

Both Epple and Winckler express concerns with the current wording of the bill. The language is broad enough that it could be interpreted as applying to almost any drug, which could be seen, they say, as making it illegal for a pharmacist to refuse to fill a prescription for a medication that could interact harmfully with other medications a patient is taking, to cite one potential problem.

Winckler points out that requiring a prescription to be filled or transferred "without delay," as the current language states, leaves too much room for interpretation as well. "One or two hours wouldn't have clinical implications but it wouldn't meet the letter of the law," she says. "Perhaps it's not available in five minutes, but perhaps in an hour. The pharmacy is not a fast-food restaurant."

 

Frankel says he's meeting with pharmacists and plans to refine the wording of the bill to make it more specific to emergency contraception.

The Pennsylvania Pharmacists Association is unlikely to support the bill even with changes made, says Epple. She says the association's policy leaves room both for pharmacists to remain consistent with their own religious or moral beliefs and for women to access their legal prescriptions without delay.

"We don't really feel this needs to be enacted," she says. "We think it's appropriate for pharmacists who have those kinds of beliefs to have systems in place" to turn the prescription over to a colleague, or to inform women of another nearby pharmacy that does fulfill the prescription. If there is no pharmacy close enough to be accessible to the patient, Epple says, the final option women should be offered is to have the medication delivered overnight.

Overnight, however, may be too long to wait for some women, since the drug loses its effectiveness with the passage of time.

Epple also points to issues of demand. Not all pharmacies get requests for EC, and forcing them to have it available -- the bill could be interpreted as suggesting it, she believes -- is akin to requiring a grocery store to carry every variety of breakfast cereal, even if cornflakes is the only one that moves off the shelf.

 

Frankel says the support of these industry groups would be ideal, but he doesn't expect it, and would be happy with neutrality from them toward the bill. The bill was introduced with 22 co-sponsors -- all Democrats.

"I don't think the opposition has really gelled quite yet," says Frankel. "I do think that a number of my colleagues still believe that emergency contraception is equivalent to abortion, and I think that's something that we need to address."

 

One behemoth pharmacy chain that claims lack of demand for EC is Wal-Mart. The world's largest retailer has always claimed that refusing to stock EC is strictly a business decision, and that morality doesn't figure in.

"We make business decisions on products we sell every day, and this is one we decided on," says Wal-Mart spokesperson Dan Fogleman. Wal-Marts across the country have a policy of referring EC seekers to other pharmacies, except in Illinois, where state law has required Wal-Mart to stock it since 2002, and in Massachusetts, which last week ruled Wal-Mart's refusal to stock it illegal.

Planned Parenthood is planning a demonstration against another big-box retailer that allows pharmacists to refuse prescriptions -- Target. On Sunday, Feb. 25, protesters will picket the McKnight Road store.

"We're not trying to boycott Target," says the agency's public-affairs intern, Lisa Christopher, who is coordinating the protest. "It's to pressure these pharmacists, to let them know that women should have access" to their prescriptions.

The issue could take on a new wrinkle soon. In 2004, the FDA rejected over-the-counter sales of EC, saying that teens would be unable to properly use it without physician guidance. The agency has been reconsidering this recommendation for women older than 16. At last week's U.S. House Appropriations subcommittee meeting, according to the Associated Press, Democrats pushed FDA acting director Andrew Von Eschenbach for a decision on this recommendation. Eschenbach says the agency is mulling over public comment -- about 10,000 comments have come in since August. He could not say when a decision will come, but said it would be based on science, and not politics.

Frankel says most resistance to the bill is coming from misinformation.

"I think it's part and parcel of a polarization that's taking place in this country around the issue of abortion," he says. "Part of this thing is to try to educate the public about what emergency contraception is. It's not abortion. I think everybody, on all sides of the abortion issue, should be able to agree that we want to reduce the number of abortions in Pennsylvania."

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