How it works: contraception

In the UK, all pharmacies are required to abide by the guidance of the General Pharmaceutical Council (GPhC) that a pharmacist has a right to refuse to sell the contraceptive pill (or emergency contraception) on the grounds of religious or moral beliefs.

Access to effective methods of contraception (including education in contraceptive methods and strong societal encouragement to use contraception except when intending to conceive) is shown to be the only effective method of preventing abortions.

Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly.

From Boots the Chemist:

This is something that nationally affects all pharmacies, and not just Boots. The guidance however, is clear in that where a Pharmacist chooses not to sell or dispense, we expect that they explain this to the patient as sensitively as possible and that they’re directed to an alternative source for the medicine.

Whilst we appreciate that this isn’t great for any of our customers we have an obligation to respect the code of ethics to which all Pharmacists work to. I can, however, share with you that the GPhC are looking to review this particular area of their guidance and once this review has taken place we’ll support all our Pharmacy teams with whatever the changes could mean for them.

Most women are born with two ovaries and all the eggs she’ll ever have. Post puberty, most women go through a predictable hormonal cycle of roughly 28 days, during which one follicle on one ovary will ripen and release an egg, which travels down the Fallopian tubes. Since the dawn of recorded time (literally – there are recipes for contraception in some of the earliest written records in the world) the objective for everyone who enjoys heterosexual intercourse has been to solve the problem of women having unwanted pregnancies as a result. (There are records of abortions being performed even earlier than contraception.)

How the Pill works: Hormones in each pill, progestin and estrogen, restrict the follicles on the ovary from growing, and thus stop the woman from ovulating. No egg, no pregnancy.

Emergency contraception works the same way only more so – a mega-high dose of the hormones. It works when taken early enough after intercourse that it can prevent ovulation while there are still motile sperm in the uterus/the Fallopian tubes.

How Natural Family Planning works (the only method of contraception the Catholic Church approves): A woman using NFP checks her hormonal cycle regularly and becomes aware of exactly when she is going to ovulate. She and her partner refrain from having heterosexual intercourse whenever there might be an egg in the works. No egg, no pregnancy.

You will note that the only differences between NFP and the Pill is that NFP is much harder work and relies on complete cooperation of the woman’s partner.

This isn’t surprising: one of the leading clinical researchers responsible for developing the Pill was Doctor John Rock, a devout Catholic who held that contraception was sometimes medically necessary, often personally desirable for maintaining happy marriages and well-planned families, and essential for those who could not afford many children.

In 1964, Pope Paul appointed a commission on birth control to advise him. As the panel deliberated, anticipation ran high; many journalists, clergy and lay Catholics expected the church to lift the ban. Scottish songwriter Matt McGinn wrote a jaunty tune, recorded by Pete Seeger, about a woman with a house full of children waiting for the pope to “bless the pill.” She buys a package of birth control pills so she will be ready when the church acquiesces. In the final stanza, she hopes to hear the pope’s approval “before my man comes in.”

In 1967, the commission’s report was leaked to the press, revealing that a significant majority of its members favored lifting the ban, including 60 of 64 theologians and nine of the 15 cardinals. The minority who were opposed issued a separate report. After much consideration, the pope issued a formal encyclical, Humanae Vitae (“Of Human Life”) in 1968, siding with the minority and reaffirming the church’s prohibition of any form of artificial birth control.

Catholic leaders quickly criticized the decision. Father Bernard Haring of Rome, widely regarded as the leading moral theologian at the time, called upon Catholic women and men to follow their consciences, rather than the pope’s decree. Countless parish priests agreed and gave sermons to that effect. The pope’s decision had little impact on Catholic women’s use of contraception. Two years after the decree, two-thirds of Catholic women were using contraception. Quickly, the gap between Catholic and non-Catholic women disappeared. According to data from the Department of Health and Human Services, Catholic women use birth control at the same rate as non-Catholic women. The Catholic Church has remained an outlier on the issue, unable to enforce its ban.

…except on an individual, personal level, where doctors and pharmacists are willing to enforce their views on women who do not share them.

From the General Pharmaceutical Council:

As the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in Great Britain, our job is to protect, promote and maintain the health, safety and wellbeing of members of the public in order to uphold standards and public trust in pharmacy. We set standards for conduct, ethics and performance which all pharmacy professionals must comply with. Standard 3.4 states:

“Make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers.”

We have also issued guidance “Guidance on the provision of pharmacy services affected by religious and moral beliefs”. This gives guidance to pharmacy professionals on what they need to do if their religious or moral beliefs affect the provision of pharmacy services to patients and the public. Pharmacy professionals may also need to consider their contractual obligations, such as the NHS Terms of Service, if they are unable to provide a service. It also provides guidance to employers on what they need to do if they employ a pharmacy professional whose religious or moral beliefs may affect a service they provide.

People usually react to this with: This is all very well if you’re going to a pharmacy in the middle of Edinburgh and the only pharmacist on duty objects to filling the prescription but can direct you to three other pharmacies five minutes walk away. The likelihood of all of them having religious scruples about allowing you to take contraception is minimal. What about a pharmacist in a small village which is the only one for miles, and a woman who needs to refill her contraception prescription that day – or needs emergency contraception right now?

But there are two questions to be asked here.

One of them is: Why should a pharmacist be allowed to let their religious beliefs be the decider about whether you get contraception? There is no such guidance (for example) allowing a Catholic who’s a shop assistant in a pharmacy – or anywhere else! – to refuse to sell condoms. Why has it been allowed to become a matter of ethics or religion that a pharmacist is allowed to refuse to fill a prescription for someone else?

As a matter of personal faith, no one should have their right to refuse medication abrogated. But as a matter of religious freedom, no one should try to abrogate the right to choose medication for anyone else.

The second question is based on the pro-life justification for making contraception provision a matter of conscience: that the Pill is an “abortifacient”.

(In case you think this is purely an American delusion similiar to creationism, herewith a link to a booklet on the SPUC organisation’s website: Birth-control methods which can cause abortion, published July 2002. The SPUC could be among the organisations allowed to give “counselling services” to pregnant women considering abortion, if Nadine Dorries gets her way. Unlike BPAS or the NHS, the SPUC is unlikely to be counselling women about how best to avoid having an abortion again by correctly using contraception.)

The problem with this as a justification for a pharmacist is that it’s scientific nonsense. The Pill works, when it’s used correctly, by preventing ovulation. It doesn’t take advanced and specialised training to understand that.

A pharmacist who claims to believe that emergency contraception (or even regular daily contraception) is an “abortifacient” is either lying in order to justify imposing their religious views on other people, or is allowing their religious beliefs to overrule their scientific training. Either way, they’re not fit to be pharmacists, and the ethical question before the General Pharmaceutical Council ought to be not “How do we continue to let these people hold jobs?” but “How do we arrange to have these terrible pharmacists identified and struck off?”

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Update, 11th December

The pharmacy can also refer you on to the local A&E. Who may be staffed by someone like this tweeter who complains:

Lots of ladies coming in for emergency contraception – you should get this from your pharmacy #tweetwell

— Salford Royal NHS (@SalfordRoyalNHS) December 11, 2012

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Update, 21st December 2012

Nelson Jones reports that Pope Benedict has signed a decree stating that Paul VI, Pope from 1963 until 1978, “had lived a life of ‘heroic virtue’ and would henceforth be known officially as ‘venerable’.” We await a confirmed miracle to be attributed to Paul VI’s intercession before Benedict or his successor can give Paul VI beatification and make him yet another Saint Paul:

His 1968 encyclical Humanae Vitae reaffirmed, indeed strengthened, the long-standing Vatican opposition to artificial forms of birth control, insisting that “each and every marital act must of necessity retain its intrinsic relationship to the procreation of human life”.

In so doing, he went against the majority advice of a church commission set up to consider the matter a few years before. He also ensured an ongoing split between the institutional church and the majority of ordinary Catholics. In the west, some statistics suggest that up to 98 per cent of married Catholics have continued to use contraception regardless of the church’s teaching. The main damage has been to the Vatican’s reputation. In other parts of the world, the effects of Humanae Vitae have been more serious, with the ban on contraception helping to fuel a population boom and, especially in Africa, Vatican opposition to the use of condoms proving highly damaging to the fight against HIV.

Paul VI’s sentiments are, though, well in tune with those of the present pontiff, who has this year led opposition in the USA to President Obama’s birth control mandate.

I assume that a miracle will be confirmed in good time so that the new saint will be available in the Vatican’s political fight against women’s human rights. After all, what is a saint for these days?