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The refusal by individual pharmacists to fill prescriptions is a contentious issue, and state laws governing such acts vary. But Wal-Mart was running the only national pharmacy chain that categorically refused to stock emergency contraception in its stores. Soon after my patient's run-in, Julie Battel (a nurse-midwife), Katrina McCarty (a policy analyst who works to combat sexual assault and domestic violence), and I each obtained a prescription for Plan B and presented it at a Wal-Mart pharmacy. As expected, the pharmacists refused to fill our prescriptions. So, on February 7, 2006, with the aid of a Boston law firm and two reproductive-rights organizations, we filed a lawsuit against Wal-Mart under a Massachusetts regulation requiring pharmacies to stock all "commonly prescribed medications" necessary to "meet the needs of the community."1
By the next day, the story had been reported by media outlets worldwide, and several women's advocacy organizations and lawmakers announced their support. The image of women being denied a medication prescribed by their doctors received broad exposure. Within two days, Wal-Mart announced that it was "rethinking" its policy.
On February 14, the Massachusetts Board of Registration in Pharmacy voted unanimously that its regulation required Wal-Mart to stock Plan B. In early March, after we threatened to pursue legal action in state after state until the national policy was changed, Wal-Mart declared that it would stock the product in all stores (as it now reportedly does).
Many low-income women have few affordable alternatives to shopping at Wal-Mart for their daily needs. In rural areas, Wal-Mart may also provide the only accessible pharmacy. The store's refusal to provide patients with needed medication obstructs timely medical care and puts them at risk for unintended pregnancy. In the United States, half of all pregnancies are unintended, and half of these end in abortion.2 A recent study by the Guttmacher Institute found that unintended pregnancy disproportionately affects low-income and minority women, who face the greatest barriers to care (see graph). Among women living below the poverty line, the rate of unintended pregnancy increased by 25 percent from 1994 to 2001.3
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But Plan B is not all that is under attack. Limiting access to all contraception appears to be the goal of a growing U.S. movement. Anticontraception organizations cite concern about promiscuity, which they argue is promoted by open access to contraception. This movement is bolstered by the refusal of the Bush administration to seek realistic solutions to the U.S. and global epidemics of unintended pregnancy. One of this administration's first actions was to cut funding to international family-planning groups. Our government has been burying its head in the sand, pretending that sex does not happen. This agenda sets women back decades, threatening their right to achieve equally in society by robbing them of options for planning their childbearing. The women of my mother's generation, who fought so hard for these rights, never foresaw this debate.
Faced with common misunderstandings about Plan B, many clinicians are trying to educate the public and to make this medication more widely available through a three-pronged strategy: preemptively providing prescriptions to patients, creating protocols to allow pharmacists to dispense the medication without a prescription, and supporting over-the-counter availability. ACOG recently launched a national "Ask Me" campaign to encourage patients to ask for Plan B and physicians to provide advance prescriptions. Nine states currently provide "behind-the-counter" access,5 but the Food and Drug Administration rejected the manufacturer's application for over-the-counter status, despite the support of its own advisors.
Impediments to contraception can be legal as well as procedural and financial. In our current cultural climate, the right of women to obtain contraceptives is being called into question. Given the threats that unplanned pregnancies pose to public health — in poor prenatal care, increased maternal morbidity, and increased rates of abortion — we need to decide whether we are willing to even put this right up for debate.
During the past decade, our patients' need for our advocacy has expanded in unexpected ways. As physicians, we are coaxed into involvement in areas of public life that are tangential to medicine; we find ourselves wrangling with insurance companies, retail corporations, and pharmacists who interfere with our responsibility to patients. These new roles present challenges. Because of the Wal-Mart lawsuit, I received threatening e-mail messages, letters, and telephone calls at home and at work. I was called "Hitler" by a letter writer who accused me of trying to "depopulate" the human race. On national radio, Rush Limbaugh insulted those of us who filed the lawsuit. Derogatory comments still appear on "pro-life" Web pages.
Yet advocacy on behalf of patients is part of our mission as physicians. We are all patient advocates in the examination room, the research laboratory, the media, and Congress. We may not choose such embroilments for ourselves, but more and more, our engagement in them is what our patients require.
Source Information
Dr. Gee is an obstetrician-gynecologist and a fellow in public policy and health care research at the University of Pennsylvania, Philadelphia.
References
6.02(4)
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