Three Years of Hell to Become the Devil: Anecdotal Post, Yet of Some Substance

Amber Taylor over at Crescat Sententia is conviced that it's a good idea for Emergency Contraception to be purchased over the counter:

Setting aside the obvious mathematical error in this statement (emergency contraception is not fifty times stronger than regular birth control pills; in fact, many birth control pills can be used as EC if taken in multiples), I eagerly await the FRC's [ed: Family Research Council, with whom Amber is taking issue] lobbying efforts against permitting minors to purchase more than a single dose of any medication without a doctor's oversight. After all, we allow children to purchase 100-count bottles of Tylenol, which is of course potentially fatal if misused.

I'm speaking well out of my expertise here, but hopefully some of my doctor friends will chime in, because I simply don't buy this. I might as well argue that I look forward to the day in which Amber advocates getting rid of prescription medication altogether, since any medication on the market is presumed to be safe if it's properly used. This is some powerful stuff, and fits my layman's knowledge of what is properly 'prescription.'

I remember running into emergency contraception during my first year at Oxford: I believe the English were a little swifter to get it to market than we were, though this could be my memory. The women who took it looked pretty dreadful: either the emergency contraceptive pills or merely taking multiple doses can result in severe nausea, cramping, and basically an awful lot of misery. This Amber acknowledges, then writes:

If any teenage girl gets the idea in her head that she doesn't need to go on the pill and can just use EC every time she has sex, she will be disabused of that notion in short order. If people are worried about overdosing, the danger is equally present with other over-the-counter drugs.

True. Nonetheless, EC in its working order can normally make one sick as a dog, and that's not counting for outliers. For a 14 year old living with parents, this may result in all sorts of problems. For instance, a young girl struck with nausea may be taken to the hospital, where (supposing she doesn't say what she's done) she may receive inappropriate treatment. And that's just off the top of my head. I'd want to know the data for contraindications among very young women, and how this might be affected by their ability to get medical attention in situations in which they had good reason not to give their parents (or possibly caregivers) full medical information.

Having taken a look not just at the newspaper, but the FDA's advisory board's opinion suggesting approval and the FDA's non-approval letter, the accusations of political influence in the press and by Amber seem a bit premature. First, the commission seems open to a plan for making the drug OTC for women over 16 and prescription-only for those younger. Secondly, it looks as if approval would be forthcoming if they showed that the drug is within safe tolerances for very young women, and my guess (although it's not discussed) is they'd have to show that no risk is posed by young dependent women going through physical trauma without their parents knowing the reason.

Again, I'll just go back to layman's knowledge: that's powerful stuff. And it's powerful not just in an 'overdose' kind of way, but in its recommended dosages. The argument doesn't pass the political stink test for me, but in the other direction: while true, folks like the FRC live for the (never to come) day when contraception will be unGriswolded, there are others who want to make sure that no one, no where, can tell a girl no matter how young that she is not allowed to have sex, nor to avail herself of the equipment allowing her to do so. If that might be dangerous to her... well, 'tis a pity. I'm not one of those people, and I'm not willing to accuse the FDA of that without a lot more evidence.

(Oh, in case you're wondering why I'm 'wasting time' reading stuff like this: it's good practice for Reg. State fact patterns. Especially reading the back-and-forth between the arguments on both sides, which are so full of it as to provide endless grist for the fact-pattern mill.)

UPDATE: Will Baude writes in a later post: "I also think Amber's point about containers of aspirin pretty adequately disposes of the argument that 14-year-old girls are going to overdose on Plan B any more than they overdose on all of the things we already let them buy."

But none of the FDA's non-approval letter seems too concerned about overdose. Nor do any of the commenters in the Washington Post article mention overdose as the risk to 14-16 year olds. Indeed, the (admittedly somewhat histronic) letter of the Concerned Women for America mentions risks of what young men might do with such pills:

The potential for the morning-after pill to be slipped to women without their knowledge or consent; and the probability of the ready availability of the morningafter pill being used to exploit and coerce women � particularly minors � to engage in risky sexual activity.

I'd not thought of that: I can't see why you'd slip a woman a mickey like that to have sex with her--at least not if you want to do it twice--but if you're a 15 year-old boy who's really annoyed with a classmate and wants to go one-up on the Ex-Lax in the chocolate milk trick? Yikes.

Anyhow, Will is quite correct that Amber adequately disposes of an overdose argument. Still, no one serious seems to be making it.

Comments

The problem here, Tony, is also that emergency contraception is not generally used to contracept, but as an abortifacient. It is at least used when people aren't certain. Why not call it emergency abortion? If one is pro-choice, they should be pro-informed choice. I once saw a Princeton faculty member (an MD who teaches biology) on the Music Television explaining that "this isn't abortion because it prevents implantation, and that's when pregnancy starts." Note the misdirection--when does "pregnancy" start is not the same as when is conception. It is one thing to believe in abortion. It is another to conceal it. It makes those of us who oppose it wonder what the other side really believes. Indeed, this site at Princeton repeats the canard--http://ec.princeton.edu/questions/ecabt.html--that you can't have an abortion until you're pregnant. That's a verbal shell game. So this is why some people think that kids shouldn't be able to buy pills that medical authorities won't even tell the truth about. Not because, under Casey, they don' t have a choice--but because they have a right not to be misled in what choice they may be making.

Posted by: Fr. Bill | May 7, 2004 8:19 PM

I wish I had the time to post a substantive comment! Too bad I'm going to be running around like a headless chicken for the next few days... I hope you'll keep posting over the summer, when I have time to sit down and read them all.

Posted by: Carey | May 7, 2004 8:39 PM

I can think of a variety of OTC drugs that a stupid teenage boy might decide would make it easy for him to get sex: pretty much anything with a sopoforic effect, for example. Maliciously slipping someone something and causing dire illness can be accomplished with nearly any OTC drug as well, given sufficient quantity. I don't see that EC is unique in this regard. On your example of the girl taking EC and then being improperly treated at the hospital if she does not disclose the reason for her nausea: this is also not unique to EC. A similar situation could arise through allergic reaction to latex, for example, but we don't prevent teens from buying condoms. I was careful to remove the more pessimistic political theories for EC's rejection from my post to Crescat, and I'm not a doctor. Maybe the FDA's reasons were good ones. Some of EC's critics did not seem to have meaningful objections to its potential status change, and that's what particularly bothered me.

Posted by: Amber | May 8, 2004 12:28 AM

I think, however, you're missing some important distinctions: I can think of a variety of OTC drugs that a stupid teenage boy might decide would make it easy for him to get sex: pretty much anything with a sopoforic effect, for example. Presuming the boy was sexually-motivated, the reason he's use Plan B as a mickey wouldn't be as an aphrodisiac--it's not known to cause arosal. It would be to ensure that he could have unprotected sex with his victim without having to worry about her getting pregnant--even though she'd be very ill shortly thereafter. Maliciously slipping someone something and causing dire illness can be accomplished with nearly any OTC drug as well, given sufficient quantity. I don't see that EC is unique in this regard. Yes, and that 'sufficient quantity' is often why we make a difference between prescription and non-prescription drugs. A normal dose of Plan B will likely cause nausea, cramps, and generally some unpleasant menstruation. Even assuming an OTC drug can cause such an effect, slipping that much drug into anything is a bit of a challenge. 'Given sufficient quantity' is a non-answer. On your example of the girl taking EC and then being improperly treated at the hospital if she does not disclose the reason for her nausea: this is also not unique to EC. A similar situation could arise through allergic reaction to latex, for example, but we don't prevent teens from buying condoms. Give me a break, Amber. Again, a reaction to latex sufficient to cause severe nausea and the kind of nastiness that is just par for the course with Plan B is rare in the extreme. Similarly, a girl brought to the hospital suffering from a latex allergy is not likely to suffer from contraindications (or reduce effectiveness of the latex) if drugs are administered later. Some of EC's critics did not seem to have meaningful objections to its potential status change, and that's what particularly bothered me. Which would be fine, if you'd answered any of them. If you consider the ideas above too 'pessimistic,' you're only doing it by undermining the entire reason we have prescription drugs: because they're more potent (so you don't need massive 'sufficient quantities') or their more likely to have severe effects. Your argument isn't a compelling reason for making EC available OTC, unless it's also a compelling argument for getting rid of the requirement for any prescription requirements on medication.

Posted by: A. Rickey | May 8, 2004 12:41 AM

Perhaps I should have used the word "misuse" or "abuse" in place of "overdose." And perhaps I estimate too highly the ability of teenage girls to read package inserts and properly use medications. My lack of concern for the scenarios you bring up is partially based on their probable rarity. How many cases of extreme, hospitalization-worthy nausea will there be from Plan B? How many of those will be teenage girls deceiving their parents and physicians? Similarly, how many teenage boys will be amoral enough to sicken their sex partners by slipping them a mickey but forward-thinking enough to realize the benefit of preventing pregnancy? Given that these examples will occur rarely, and given that 14-16 year old women can safely take EC (which they apparently have been doing in Britain and France for some time), I see much good in the reduced teen pregnancy rate and little danger, for a net social benefit. You are correct that this is part of my larger belief that FDA's approval requirements for drugs are too strict, and more drugs (if not all) should be made freely available.

Posted by: Amber | May 8, 2004 3:21 AM

But in England they're only available over the counter to women over 16. The FDA has seemed open to this approach--indeed, that's what the Non-Approval letter is mostly about--but wants a plan in place for how that will work. (Our pharmacy system isn't set up in the same way, after all.) Even the non-approval letter seems As for the 'probable rarity' of any of the events above, again we're talking about relative issues. How probable are those events in comparison to other drugs of non-prescription strength? Almost certainly higher. I'm willing to credit the FDA for delaying a decision--by a handful of months to a few years, more than likely--until it has data to answer the questions of critics. The data--beyond 'it works in France and the UK, two countries with vastly different health care regimes--simply isn't there yet.

Posted by: A. Rickey | May 8, 2004 11:20 AM

Reduced teenage pregnancy rate? Well, we'll never know since some of the girls will have been pregnant but aborted it very early in the course of this treatment. 'Similarly, how many teenage boys will be amoral enough to sicken their sex partners by slipping them a mickey but forward-thinking enough to realize the benefit of preventing pregnancy?' That is nuts. Just nuts...and what if the dude decides that he wants to make sure she doesn't get pregnant...all this talk about 'women's autonomy' and yet you couldn't even care less about giving the woman a choice as to how she wants to 'prevent pregnancy'. It's her body, not his...and before she is pregnant, there is no child that she is obligated to look after..so, how is this 'forward-thinking'? He wouldn't care less whether the drug makes her sick, as long as she doesn't have his baby. That is the point....if you think that is forward thinking, then we are on completely different planets... the guy would be better to have a vasectomy if he really wanted sex with no consequences rather than go to the extreme of surreptitiously slipping her the pill... All of our choices have consequences.

Posted by: Sarah | May 8, 2004 11:56 PM

Reduced teenage pregnancy rate? Well, we'll never know since some of the girls will have been pregnant but aborted it very early in the course of this treatment. 'Similarly, how many teenage boys will be amoral enough to sicken their sex partners by slipping them a mickey but forward-thinking enough to realize the benefit of preventing pregnancy?' That is nuts. Just nuts...and what if the dude decides that he wants to make sure she doesn't get pregnant...shouldn't it be a woman's choice as to how she wants to 'prevent pregnancy'. It's her body, not his...and before she is pregnant, there is no child that she is obligated to look after..so, how is this 'forward-thinking' even assuming that this pill doesn't have abortive effects (which it does)? If you think surreptitiously slipping the pill is forward thinking, then we are on completely different planets... He wouldn't care less whether the drug makes her sick, as long as she doesn't have his baby. That is the point. The guy would be better to have a vasectomy if he really wanted sex with no parental consequences rather than go to the extreme of coercing his 'sex partner'. All of our choices have consequences.

Posted by: Sarah | May 9, 2004 12:00 AM

Oops, sorry about that....

Posted by: Sarah | May 9, 2004 12:01 AM