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The Earl of Listowel: My Lords, the subject of the Motion last Wednesday was boys growing up without the care of a father. My noble friend Lord Northbourne then stated that,
- "in the age of effective contraception, to conceive an unwanted child is a form of child abuse on the part of both parties".--[Official Report, 24/1/01; col. 305.]
My noble friend Lord Laming, with all his experience of social services and the care system as a former director of the Social Service Inspectorate, said at col. 313 that,
- "every child should be a wanted child ... Adults are free to choose their lifestyles but we must emphasise that this should not be at the expense of defenceless children".
I respect the concerns of the noble Baroness, Lady Young. I also read with interest the briefing of the Christian Institute. However, their concerns are outweighed by the often appalling consequences of unwanted pregnancies. Children have a strong interest in not being born by default but, so far as possible, only after a deliberate choice. I urge your Lordships to reject the Prayer.
Lord Rea: My Lords, with respect I suggest that the noble Baroness, Lady Young, has fallen into one of the most elementary statistical mistakes. She has related two variables moving in the same direction as if one is the cause of the other. Both can be due to a common cause or each due to a cause that is unrelated to the other. I believe that the noble Lord, Lord Carlile, has made it clear that it is very unlikely that the use of emergency contraception has resulted in an increase in the number of abortions.
Although emergency contraception has been available free on prescription on the National Health Service for 17 years, as my noble friend Lady Massey points out it is not used so much by teenagers as by older women. One reason for it is that teenagers do not want the embarrassment of revealing to a doctor who may well have known them from birth that they are now sexually active. As a general practitioner, I know that that is so in a number of cases. The order will allow a teenager to go to a pharmacist perhaps slightly out of her locality who does not know her. Based on the protocols which have been given to pharmacists, they will be able to provide good advice to teenagers. The evidence is that the fright caused by having to use emergency contraception will result in the subsequent regular use of adequate contraception by those who continue to be sexually active.
Lord Monson: My Lords, I apologise for interrupting the noble Lord, but he said that the order
would allow teenagers to go to pharmacies. It will not. The order allows only teenagers aged 16 and over to go to pharmacies. At least four noble Lords who have spoken against the noble Baroness, Lady Young, have deplored teenage pregnancies, so the logic of it is that one must make the pill available to 12, 13, 14 and 15 year-olds as well as 16 year-olds.
Lord Rea: My Lords, one cannot let that point go unanswered. There is a case for allowing pharmacists to make their own judgment in this matter, but they are expected to discover the age of their clients and not provide the drug to girls under 16.
At the moment, 74 per cent of emergency contraception is used by women aged 20 or over, but even there is the deterrent effect the embarrassment of admitting a contraceptive slip-up to their GPs.
Sadly, the high cost of the currently available over-the-counter emergency contraceptive Levonelle-2 (which is a well known synthetic progestogen that has been available for a long time and is well out of patent) will deter its use. My local pharmacist tells me that, of the £19.99 that the drug costs the patient, £11.06 goes to the manufacturer Schering, £5.95 to the pharmacist and £2.98 in VAT to the Government. The same product is available on prescription on the NHS but in that case only £5 goes to the manufacturer. The cost to the manufacturer of producing the material is less than £1. My pharmacist suggests, and I agree, that the same sum--£5--should go to the manufacturer whether the product is supplied on prescription or over the counter. The price to the patient will then be reduced to £11.99, which is a more acceptable figure.
The BMA suggests that this contraception should be free in order completely to remove the price deterrent. I doubt that my noble friend will agree to that. However, at least the product is so non-toxic that there is no danger from an overdose, however much people buy it, other than causing irregular periods.
I very much hope that your Lordships will pass this order and oppose the noble Baroness's Prayer. If we are successful in passing the order unamended, I hope that my noble friend will agree to look closely at the question of how the price of the product may be reduced.
8 p.m.
The Lord Bishop of St Albans: My Lords, this debate is ostensibly about making available to women a contraceptive in a new way, but I believe that behind it lies not one but a series of moral issues that I should like to try to highlight. If the figures for 1998 provided by the Department of Health can be extrapolated to 2001, by the end of today in this country just under 500 children will be aborted. The weekly figure is 3,290. Every week the equivalent of a large village or small market town filled with children is wiped out.
I find those figures chilling; but I need to add, lest I be misunderstood, that in relation to abortion I am not an absolutist. I can, and do, acknowledge that there are, and will be, situations where abortion may be justified. I certainly would not wish to return to the
situation surrounding abortion which obtained before the 1967 Act. Furthermore, I cannot believe that the rate of abortion in this country is in any way morally acceptable. We are rightly appalled by the abuse we see of individual children, but nationally we remain largely silent about the wiping out of villages filled with children week in and week out.Secondly, I found the debate last week on human embryology fascinating. While the position I took on the subject was rejected by the majority, it was, nevertheless, a huge privilege, and one I shall never forget, to be in this Chamber to listen to and take part in that debate. I want to add some figures from that debate to this one. Between 1991 and 1998 almost one quarter of a million embryos up to the age of 14 days were disposed of as a result of decisions taken in IVF treatment. In that debate I argued that there was a step change going on in the way we human beings now perceive ourselves. I argued, and would continue to argue, that for the moment the utilitarian philosophy in our nation that perceives human life as either a useful or useless commodity has won the day. I shall return to that matter in a moment.
Thirdly, a fortnight ago in this Chamber we had a ministerial Statement about the treatment of corpses in a mortuary chapel in a hospital in Bedford. We were told that an inquiry would be held and that the incident was shocking. I welcome the inquiry; I agree it was shocking.
In this Prayer I have linked three apparently unrelated topics. I have done so deliberately because in each of them it seems to me that we see evidence of a downgrading of the concept that life has sanctity. The powerful Judaeo-Christian concept that we are made in the image of God, which has shaped our society for thousands of years, has now been pushed to the very margins of our consciousness. The sanctity of human life, a concept which philosophically links us as humans to some eternal absolutes, is under such serious pressure that, as a concept, it is being placed in a museum cupboard for inspection in a curiously detached way--forgive the phrase--by generations yet to come. I believe that loss has consequences which we are so far unwilling to face, but which are frightening.
I now confess that I face a dilemma. I have a serious ethical problem with tonight's debate. I am genuinely alarmed by the shifts going on in our society which will lead us to a future where life of any age is seen as mechanistic and where the worth of human life is judged in utilitarian ways. I raise the question: is not involuntary euthanasia found along that very same spectrum? However, in this debate, I am prepared to acknowledge that the morning-after pill may be the lesser of two evils. Better this form of contraception than a steady rise in abortion.
Yet it would be disingenuous in the extreme to suggest that the morning-after pill will have only positive benefits. I suspect that the rise in sexually transmitted diseases will be considerable. I should not like to be the CEO of a pharmaceutical company or a chemist chain when the first litigation arises over what a pharmacist may or may not have said to a young woman who may or may not have been 16 years of age.
Therefore, I find myself absolutely caught. I want to convey very serious concern that the result of well-intentioned legislation is that the sanctity of life is being eroded at a dangerous pace and with potentially dangerous consequences. At the same time, I cannot but agree that the morning-after pill is the lesser of two evils.
In those circumstances the clear message is that far more effective sexual education is needed. I have been a teacher and heard that cry for the past 30 or 40 years. But we must not be naive either. Many of the young people I once taught who became pregnant were desperate to have a baby. They wanted something to love and someone who would love them unconditionally because their own lives were so full of despair, self-neglect and they lacked self-worth. Here is the difficulty. In order to help those young people we will offer a pharmaceutical solution which will play a part in creating conditions in which the sacredness, nobility and purpose of human life is inevitably downgraded.
I am looking for a concerted national campaign to increase the sense of the sacredness of human life; which will increase the sense of self-worth among many young men and women; which will support and encourage all those young people who genuinely do not want to give in to peer or media pressure and who find adults copping-out of their moral responsibility to guide them; and I want something which will recognise that our moral sensibilities about human life are being trampled over with extraordinary lack of concern for the potential consequences for individuals and our nation.
8.8 p.m.
Lord Clement-Jones: My Lords, we have had an excellent debate tonight. I intend to be extremely brief in replying from these Benches. My colleagues on these Benches will be deciding, as individuals, whether to support the noble Baroness in her Prayer against these regulations. I suspect, however, that few of them will be convinced by the arguments of the noble Baroness, sincerely though her arguments were made.
I want to emphasise that, whatever the temptations, tonight's debate is not about the availability of emergency contraception to young girls without their parents' consent or about the limited number of pilot schemes in certain health action zones under what is known as a patient group direction from local GPs. It is not about the quality or quantity of sex education. Indeed, it is not even about the Government's strategy for teenage pregnancy, important though all these issues are. It is simply about the availability in pharmacies of Levonelle-2, the emergency contraception product.
First, what is the product? The noble Lord, Lord Patel, made the action of the product very clear, together with the fact that it does not induce abortion. That is not the action of the product. Levonelle-2, however, is clearly more effective and has fewer side effects than the previous emergency contraception
products, in particular PC4. Research sponsored by the World Health Organisation has clearly shown that. Clinical trials show that the earlier it is used, the more effective it is. As the noble Baroness, Lady Gould, so cogently pointed out, that emphasises how important early access to it is. As the noble Baroness, Lady Massey, pointed out, it is not always easy to have that early access. The retail price of the product will be £19.99. It will hardly be an impulse buy. In my terms, it is rather expensive.I refer now to the process for the approval of Levonelle-2. The Committee on Safety of Medicines and the Medicines Commission have advised that the medicine is safe for pharmacy sale. This advice and the results of a public consultation were put to the Department of Health which approved the change.
What is the role of the pharmacist? Pharmacy status for emergency contraception means that any pharmacist who wishes to do so can supply according to the relevant guidelines after having obtained appropriate information from customers. Comprehensive guidance on best practice for the supply of emergency contraception has been sent to all pharmacists by the Royal Pharmaceutical Society and the Pharmaceutical Society of Northern Ireland. That guidance includes the question of supply to under-16s. This guidance is supported by training provided by the Centre for Postgraduate Pharmacy Education. Those are all responsible steps to have put in place. I am sure that the Royal Pharmaceutical Society will make sure that the supply is carried out in the appropriate fashion.
I welcome the decision by Superdrug to discontinue sales over the Internet since I do not believe that is the way in which this product should be sold. I believe that it should be sold through pharmacies.
I refer next to some of the questions raised in the debate. It has been said that the wider availability of emergency contraception will encourage promiscuity. I have not heard any evidence tonight to suggest that wider availability of Levonelle-2 will encourage promiscuity. What evidence is there that this will adversely affect the level of sexually transmitted diseases, a major problem? We have seen from recent figures, whether for chlamydia or AIDS/HIV, that these diseases, should be taken extremely seriously. The answer lies in better sex education, not in banning emergency contraception.
What evidence do we have that pressure will be put on young girls to have unprotected sex? That is purely anecdotal, drawn from individual experience. I know of no paper which has demonstrated that to be the case. The information from pilot schemes where emergency contraception is available from pharmacies under patient group directions indicates that this emergency contraception is being sought mainly after failure of contraception. The data show that women aged 20 to 29 years are by far the greatest users. As the noble Lord, Lord Patel, said, they account for 53 per cent of users. Women aged 16 to 19 years old comprise 22 per cent, and women aged 30 to 40 years old comprise 17 per cent of users. Very few under-16 year-olds asked for emergency contraception via this route.
The right reverend Prelate the Bishop of Southwark had it absolutely right, in my view, in his analysis of the benefits of the current pilot scheme in Lambeth, Southwark and Lewisham. I live in the same health authority as the right reverend Prelate. Certainly, the benefits vastly outweigh the disadvantages or the reservations.
The remainder of requests are made by women over 40 years of age. This profile is confirmed by the Department of Health's statistics that show that most abortions are performed on women in their 20s rather than on teenagers. This suggests that the take-up of the pharmacy product will be among the more mature age group. Effectively, we are giving older women the freedom to control their own lives so that they are able to avoid abortion. My noble friend Lord Carlile of Berriew made this point: it is a matter of choice for women.
What evidence is there that emergency contraception leads to multiple use? All those concerned in the development and marketing of Levonelle emphasise that it should not be seen to be an alternative to long-term reliable forms of contraception. Moreover, a recent British Journal of Family Planning paper which studied over 15,000 women taking emergency contraception showed no significant trend to multiple use. My noble friend Lady Walmsley made it quite clear why, physically, that is so.
In conclusion, there are legitimate concerns about unlawful supply to under-age girls. I hope that the Minister can give assurances about the strength of the guidance to pharmacists and how this will be enforced. The product is a safe and effective method of preventing pregnancy where a woman has had unprotected sex or something has gone wrong with her usual method. The benefits for the older age group vastly outweigh the problems of access by the under-16s. This is not a measure principally directed at teenage pregnancy rates. Pharmacy supply will be a very welcome additional route for women to access emergency contraception with minimum disruption to their work or family lives.
I do not believe that by simply being available at pharmacies it will encourage a casual attitude to sex. There is absolutely no evidence of this. On the contrary, it is another step to ensuring that only children who are wanted are born in this country. The noble Lord, Lord Davies of Coity, added, absolutely rightly in this respect, that if passed this Prayer would not help older women or the young, as the noble Baroness claims; it would penalise them. As my noble Lady Walmsley said, it is vital that women should have access to this emergency contraception. Certainly I shall not be supporting the noble Baroness, Lady Young, in her Prayer. I prefer to support the views of the Family Planning Association, the Royal College of General Practitioners, the Royal College of Nursing, the Royal Pharmaceutical Society and the Community Practitioners and Health Visitors Association, let alone those of the vast majority of adults in this country. I hope that my colleagues will join me in voting against the Motion.
8.15 p.m.
Earl Howe: My Lords, it is a pleasure and at the same time a difficult job to follow my noble friend Lady Young in speaking to the Motion. I find myself, as ever, deeply impressed by what she said. We should not doubt for an instant that she speaks for very many ordinary, moderate people who are deeply worried by the order before us and its implications. I cannot hope to better her in arguing the case she has put.
I shall concentrate on a few particular aspects of this issue which cause me profound disquiet. They are aspects that relate to patient care. To many it might seem odd that a measure of this sort which has met with the approval of the Royal Pharmaceutical Society, the BMA and the Royal College of Nursing could possibly be considered detrimental to patient care. Clearly, to take issue with such reputable bodies is not something to be undertaken lightly or wantonly.
We all agree that pharmacists represent an under-utilised resource in primary care. Pharmacists are highly skilled, professional people. It is absolutely right that we should look for ways of broadening and developing the service they provide for patients. However, this does have to be done in a manner that is safe. The point at issue here is whether the direct supply of the morning-after pill by pharmacists is something that can be done both safely and ethically in all cases.
Reading the pharmaceutical press, as I do each week, it is apparent that pharmacists are alarmed at what is being asked of them and so are some members of the medical profession. Part of their concern can be summed up as follows. The more that young women at risk of an unwanted pregnancy are enabled to bypass their doctor or avoid even a cursory clinical examination, whether by a doctor or a nurse, the more risk they run of damage to their health. My noble friend Lady Young mentioned sexually transmitted diseases. The statistics published last week saw large increases in gonorrhoea and chlamydia during the year 2000 as well as the highest ever number of new cases of HIV. The highest rates of chlamydia are in 16 to 19 year old females and 20 to 24 year old males. The diagnostic rates for gonorrhoea were also the highest in those age groups.
The rise in diagnoses in young females suggests that there has been a significant increase in heterosexually transmitted gonorrhoea. If one goes into a chemist shop to buy emergency contraception after having unprotected sex there is no one to pick up the warning signs of sexually transmitted disease. If chlamydia is allowed to develop--and it does so insidiously--it can render a woman sterile. It is important for the country as a whole, and vital for patients, that there should be effective monitoring and reporting of all sexually transmitted disease. There is not a shadow of doubt in my mind that this order will hinder that process.
Pharmacists cannot hand out the pill without questions being asked. There is an extensive list of questions that the Royal Pharmaceutical Society has devised which chemists are recommended to follow. But the sheer length of the list is enough to make one
question the wisdom of what is supposed to happen. The pharmacist must first ascertain from the woman what circumstances have led her to believe that she needs the pill. He must then try to determine whether or not she is already pregnant. From the answers he gets he must be able to distinguish chlamydial infections, which can cause bleeding between periods, from pregnancy or miscarriage. He must find out whether the woman has used the morning-after pill since her last period. He must find out whether she is taking any of 11 drugs which react adversely with the pill. He must ascertain whether the woman has a severe liver dysfunction or whether she has any condition associated with the malabsorption of drugs such as Crohn's disease. He must ask whether she has previously experienced any allergic reaction to oral contraceptives. And, crucially, he must be satisfied that the patient in front of him is over the age of 16.Now, chemists have been told that in cases of doubt on any of these questions, they should refer the patient urgently to a GP or family planning service and not dispense the morning-after pill. I do not see, and nor do many responsible pharmacists, how it is possible for a pharmacist, during a brief interview, to be satisfied that by dispensing the pill to a particular woman he would not be running a risk with that patient's health. Pharmacists, however conscientious, are not permitted to perform a physical examination of the patient. They cannot contact the patient's GP. They must rely on the accuracy of the answers they get to a checklist of questions. It is quite interesting that one of the main risks of taking the morning-after pill--which is the risk of having an ectopic pregnancy--is not even mentioned in the guidance prepared by the Royal Pharmaceutical Society. Nor does it mention some of the other warnings contained in the patient information leaflet from the manufacturers; for example, that the pill should not be taken in cases of high blood pressure or diabetes or where there is a history of breast cancer.
Responsible pharmacists will find all this out. But this is the point. Patients are entirely dependent on the ethical and professional standards of individual pharmacists. There is no requirement for a pharmacist to undergo training in order to be able to supply and dispense this medication. Specific training is entirely voluntary. Even those pharmacists who wish to receive training have in many cases not yet received it. Perhaps that should not surprise us. Pharmacists were not consulted on whether the morning-after pill should be available nation-wide over the counter. The first they heard of it was when the Government announced it to the press. It does not take a genius to work out that, with pharmacists demonstrating different degrees of assiduousness and different degrees of training in regard to the protocols to which they are meant to adhere, patients will simply gravitate to the chemist's shop where they know there will be the least hassle.
And that is where the trouble is likely to begin. I had a brief conversation with the noble Lord, Lord Clement-Jones, last week in which he indicated that I would be unlikely to persuade him that opposing the
order made any sense at all. Well, I invite him to consider the point that I am now making. It is not what happens when everything goes right with an over-the-counter supply that I am worried about. It is the unintended consequences when things do not go as they should.
Many noble Lords will have seen the article in the Daily Mail a few days ago, which described how a girl of 15 was able to obtain the morning-after pill from two chemists in London with the minimum of questioning. She was not asked her age. One of the chemists took only two minutes to hand over the pill to the girl. On the other hand, another chemist did ask her age and took considerable trouble over the interview before referring the girl both to her GP and to her parents. The point here is that while the Royal Pharmaceutical Society without doubt approached this whole issue in a completely responsible and professional way the same cannot necessarily be said of all its members.
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