Fri 14 Dec 2007
Medical care should, in general, be easily accessible. But are there ever times when easy access is medically and morally problematic? This week, Lord Darzi has proposed that the contraceptive pill be made available without a prescription. Girls as young as 13 will have access to the pill after requesting it from their pharmacists. The proposal will be piloted in the New Year and includes examining issues such as how well pharmacists are trained and able to deal with this new responsibility. The purpose of the proposal is to lower teenage pregnancy rates in the UK which are currently the highest in Europe.
It is not the ability of pharmacists that worries me. With the additional training, they will more than likely be able to cope with dispensing the contraceptive pill as indeed they are able to dispense many other medicines that require sensitive questioning and discussions with patients. There is also no reason to doubt that these discussions can take place in a private and confidential setting.
If women and girls are going to use the contraceptive pill then, on the surface at least, it seems only sensible to make it more accessible. It is often more convenient to visit a pharmacy than it is to visit oneâ€™s own GP, queue for hours or risk not being offered an appointment for days. But does making the pill more accessible also increase access to other problems?
Easy access to the pill is a sensible and a safe option for a woman who is above a certain age and has taken it before. In other words, there is no reason why adult women should have to visit their GPs time after time to renew their prescriptions. But for a young girl of 13, a girl who by law is too young to have sex, it seems worrying to apply the same rule. The pharmacist will not have access to the girlâ€™s family history or her own health history to determine if the pill is suitable for her. Neither does the pharmacist have any control over what happens outside of the pharmacy. Greater access to the pill could also mean greater peer pressure to be sexually active. Improving access to the pill is presumably intended for those who want the pill. By making it easier to get the pill, some young girls who are not ready to be sexually active might feel pressured into doing just that. Peer pressure does, of course, already exist even with the pill being available only on prescription but greater access to the pill might increase this pressure. If this happens, we might be helping those who want the pill to get it more easily but might also inadvertently be encouraging more underage sex than occurs at present.
Sometimes access to certain things is restricted in order to protect young people. For example, there are stringent regulations regarding the purchase and consumption of alcohol. Rules also surround the buying of cigarettes. We all know that some people who fall short of the legal age for smoking and drinking still engage in these activities but consider what might happen if we merely made it illegal to smoke and drink before a certain age but did nothing to enforce these laws. The reason why we check identification in these situations is to ensure that people are old enough to buy alcohol or cigarettes. If we did not, it is likely that there would be even more underage people smoking and drinking than we have at present, many of them to excess and unsafe levels.
Other problems that surround the use of the pill will still exist when dispensed at pharmacies. Young girls will have to remember to take it regularly for it to be effective and will also have to bear in mind that the pill does not guard them against sexually transmitted infections. But we must also remember that increasing access to the pill is only useful if it is used. If young girls want to get pregnant, and some of them do, it does not matter how widely the pill is offered. And herein lies a potential problem with the pilot proposals. If, because of peer pressure, more girls are taking the pill when they might otherwise have chosen to delay their sexual activity until they were older, the figures in terms of “pill usage” will be high. But if the target audience for the pill, i.e., those whom we want to stop from becoming pregnant do not in fact use the pill, then we may believe that the new system is working when in fact it is not. We might well end up with a situation in a few years where we find ourselves with the highest levels of teen pregnancy and also with increased levels of sexually transmitted infections among our teenage girls.
A more effective method might be to make the pill available at pharmacies without requiring that a prescription, as suggested, but to limit its access to those who are above a certain age and are not taking it for the first time. Doing so will ease the strain on GPs as a number of straightforward cases will be dealt with by the pharmacies. Moreover, GPs will be able to provide young people with the time and support they need before they make what is for these teenagers a major decision. Without this modification to the proposals, we will at best be trading in the problem of teenage pregnancy for that of sexually transmitted infections but it is more likely that we will not solve the problem we have set out to solve but merely added another to it.