Prescription Only Medicines (Human Use) Amendment (No. 3) Order 2000
Baroness Young (Conservative)
My Lords, I think that there has been some misunderstanding about the order and my purpose in tabling a Prayer against it. Therefore, let me start by saying what I am not against.
The Prayer is not against the principle of prescribing the morning-after pill. The pill has been in existence since 1985, although in its present strength for only a short time. It is currently available on prescription from GPs, 1,300 family planning clinics and a great many hospitals. Indeed, last year some 800,000 morning-after pills were supplied.
If my Prayer is carried this evening, the law will remain as it was before 1st January this year. My concern in tabling the Prayer is that pharmaceutical chemists will be able to sell the morning-after pill over the counter to women aged 16 and over, and that it will inevitably be bought by girls under the age of 16.
I am not in any way against the principle that pharmaceutical chemists ought to be able to prescribe a wider range of medicines and so help the community at large and take some weight off GPs and the NHS. As proof of this, perhaps I might add a personal note and say that my father-in-law was a pharmaceutical chemist, as were his two brothers. They must have been good at this work as, between them, they won two gold medals and one silver medal from the Royal Pharmaceutical Society. I therefore see pharmaceutical chemists as a very important part of the health provision of our country, and I have on more than one occasion been very grateful for the help given to me by the local chemist.
My concern about the order is twofold; the first constitutional, and the second in principle.
The order is introduced under the negative resolution procedure, the weakest of all parliamentary procedures. The order was laid before Parliament on 12th December 2000. It must lie on the Table for 40 days after publication, before it becomes law, in order to give an opportunity for debate. In this case, the Government brought the order into force on 1st January, although the 40 days do not expire until 4th February. This order has been brought in, therefore, without any proper parliamentary scrutiny or debate. The debate in the committee in another place was on 24th January and it is in your Lordships' House today.
There was a time when the Government talked about the importance of openness and transparency, but this, if I may say so, is an example of trying to bypass Parliament on an issue of great importance to a great many people, without discussion.
On a separate but related issue, an important order was laid on 17th July last year. I refer to the Prescriptions Only Medicines (Human Use) Amendment Order 2000. Under that order, the Government made it possible for the morning-after pill to be distributed free by school nurses and some other health professionals. Under this order it is also possible for chemists to dispense the pill free to girls under the age of 16 where the local health authority has made an appropriate patient group directive. I suspect that few have heard of this order, or whether or not a patient group directive applies in the area where they live.
Clearly, this is an issue of great concern to parents. This order, however, was not debated in Parliament because it was a general enabling power for health authorities. However, it had wide implications: it makes the pill available to girls aged 16 and under. My point in raising the issue is that it makes much more important the debate on the order before noble Lords this evening.
The second constitutional point is that the order applies throughout the United Kingdom. In Northern Ireland, the age of consent is 17, and the order would appear to conflict in law with that part of the United Kingdom by stating that it will be available to girls at the age of 16. I appreciate that the order was signed by the Northern Ireland Minister, Bairbre De Brun. It would, however, be helpful to know whether the order has the full support of the Northern Ireland Assembly and what the position is in that part of the United Kingdom.
I turn now to the principle. I have often been accused in the past of being concerned only about boys. That has never been true, but today I am concerned about girls. My concern, as always, is the protection of young people, and 16 year-olds are children in law. I have also said on more than one occasion that all law sends a signal. So what signal does this order send? First, it says that unprotected sex is all right. This is exactly the opposite of what the whole sex education industry has been saying for at least 20 years. It is of course a very dangerous signal because it will increase the incidence of sexually transmitted diseases.
"Virtually all the sexually transmitted infections (STIs) are increasing. The number of attendances at departments of genito urinary medicine/sexually transmitted diseases now totals 1 million per year, a doubling over the last decade ... Chlamydial infection seen in clinics has risen by 21 per cent between 1996 and 1997, and a further 13 per cent from 1997 to 1998 (latest figures). Population surveys have reported rates of chlamydia as high as 20 per cent, particularly in young women. There has been no reduction in the annual number of new diagnoses of HIV made, and the latest annual figures (1999) saw the highest number of new HIV diagnoses ever recorded".
I, for one, think that we should take those figures very seriously.
The Government's Teenage Pregnancy White Paper quotes a boy as saying:
"I have used a condom, but I don't like it. It puts you off. What's the use of having sex if you don't enjoy it?"
The pressure will be on for the morning-after pill. In other words, it will be an encouragement to unprotected sex.
Secondly, promiscuity will be encouraged. Everyone, including GPs, health authorities and now chemists, and, as I have already mentioned, nurses and youth workers, will be making the morning-after pill available to young girls. One can picture the scene. The boy will say to the girl, "why not; you can take the morning-after pill?" The girl will think: "Why not? I could take the morning-after pill and be all right." The consequences of sleeping around will be thought to be dealt with by the pill. I am sure that this is not what the Government will say because this is not intended.
As I have discovered, there is no difficulty in getting an ID card. Teenage magazines are full of advertisements showing how to obtain one. Not only will the chemist not know the true age of the girl, but he or she cannot consult the girl's GP and find out anything about her medical history. I heard only this morning of the case of a 14 year-old girl getting the pill from a chemist in Newcastle. I think that we should take this situation very seriously. We are saying that young, under-age girls, can buy for £20 a very strong pill, and the chemist can supply it without knowing anything at all about her medical history.
"It is an offence under the Medicines Act 1968 for pharmacists knowingly to supply the product to women under 16. The chance of the measure having the effect of increasing the amount that young women use emergency contraception is highly unlikely".
On what evidence did she base that statement? It certainly flies in the face of all experience. I hope that the Minister will tell us more.
That further development means that girls can obtain the morning-after pill without the knowledge of their parents. That undermines family life. How many of us would like such medicines to be given to members of our family without our knowledge? In many cases, the current approach ignores the wishes of parents and of many religious people, especially Muslims, who have made very strong representations to me on this matter. They are greatly concerned about the effect of such provisions on their family lives and on their girls.
I was interested to hear that Superdrug was selling the morning-after pill on the Internet as recently as last Friday. I also heard that the Department of Health had asked Superdrug to withdraw it. I understand that the company will resume the scheme after a clarification of the guidelines by the Royal Pharmaceutical Society. However, what Superdrug was doing is perfectly legal under the order. If it is agreed to, the home delivery service of the morning-after pill will start again, and the drug will be even more readily available to young girls.
The Government want to halve the number of teenage pregnancies by 2010. Currently, 90,000 teenage girls become pregnant each year, of whom 8,500 are under 16. That is a tragedy for the girls and the babies. The figure has remained at the same level for the past 10 years, despite the fact that millions of pounds have been spent on sex education and on the provision of advice from clinics and doctors. The same is true of the overall abortion rate, which is higher now than it was in 1990. Those developments occurred despite an increase that is almost in four figures in the use of the morning-after pill. If the order's purpose is to bring down the number of teenage pregnancies, the figures do not suggest that it is likely to be successful.
I want to make a final point. Many people, in your Lordships' House and outside it, have put to me the argument that it would be better for a girl to have the morning-after pill than an abortion. As I have already said, the evidence shows that the more morning-after pills there are, the higher the number of abortions.
What, someone might ask, if a girl has had unprotected sex and is at risk? What would your Lordships do? Give her the morning-after pill, or what? Under those circumstances, I would say that she should go, preferably with her parents--or one of them--to her doctor or a clinic or hospital, because that is a far better and safer route. If she went to her GP, she would go to someone who knew her medical records and her family and who could give good advice. That is far better than going to an anonymous chemist, who would know nothing at all about her. If I were in that position and one of my daughters was concerned, that is what I would choose.
Is the morning-after pill safe? Each treatment, I understand, is 50 times more powerful than the previous contraceptive pill. What adults choose to do is a matter for them but, as I have said before, we have a responsibility to the young. The order is one more example in a series of provisions that give unsound and wrong advice. There are very few parliamentary opportunities to take a stand as a matter of principle and to help the young. This is one, and I believe that we should take it.
The Earl of Longford (Labour)
My Lords, we are undoubtedly faced with a difficult decision. Good men and women can be found on both sides of the argument.
Like others, I have received many unsolicited briefings from people on both sides of the argument. Those who support the Government's policy strongly suggest that the number of teenagers with unwanted pregnancies will diminish. On the other hand, it is argued with equal strength that adultery and fornication will increase. No one can predict exactly what will happen or how far the evils in question will be apparent. If we had to choose between reducing the number of teenage pregnancies and reducing the occurrences of fornication and adultery, I know which I should choose. I know that some Christians will disagree with me, but I cannot imagine how a Christian could think that adultery and fornication were the lesser evil. However, that is a matter of opinion--this is a free country and we sit in a free House.
We have a Government who contain five Christian socialists. To that extent, they are, potentially, the most Christian government in my time. I should add, although the Government may not welcome such comments from me, that this is the best government we have had in my time, except for the government over whom Lord Attlee presided between 1945 and 1950, who were equally good. The present Government are very successful and get things right 90 per cent of the time. Just occasionally, they get things wrong, and it is the duty of candid friends to say so. I could not possibly vote for a policy that would make fornication and adultery more likely--there is quite enough of it already.
Baroness Gould of Potternewton (Labour)
My Lords, I rise to oppose the Prayer and to support the order which will allow emergency contraception to be sold over the counter to women who are over 16. I must, however, declare an interest as the president of the Family Planning Association.
The noble Baroness, Lady Young, concentrated some of her remarks on the need to protect young girls and to reduce the number of teenage pregnancies, which of course are important. I fully support the need to protect young girls and to reduce the number of teenage pregnancies. I shall return to that later.
The order was introduced to reduce the number of teenage pregnancies, but it is more about providing access to emergency contraception for mature and older women, and I shall concentrate my remarks on that.
There is a presumption that it is wild, immature young women who will need emergency contraception. In truth, it is mature women in stable relationships--women in their mid or late 20s--who are most likely to wish to prevent an unplanned pregnancy and who need access to the morning-after pill. All the professional bodies support the order as part of a national strategy to reduce the number of unwanted pregnancies and abortions. That view is supported by organisations that are involved with public health and family planing, by community and hospital pharmacists and by the majority of the adult public.
One might argue, as the noble Baroness did, that the fact that we can obtain emergency contraception from GPs, family planning clinics, NHS walk-in centres and some hospital and A&E departments makes its sale in chemist shops unnecessary. However, easy access is absolutely essential.
For emergency hormonal contraception to be effective, it is essential for it to be taken with some speed. It is 95 per cent effective if taken within 24 hours, 85 per cent effective if taken within 25 to 48 hours and only 58 per cent effective if taking the drug is delayed to between 49 and 72 hours.
Time and again, women call the Family Planning Association helpline saying that they have rung their doctor but cannot get an appointment within the 72-hour period, that they have not been able to get time off work to see their doctor or that they were embarrassed to discuss the reason that they needed an urgent appointment with the doctor's receptionist. Women often ring the helpline in tears of frustration and despair. A woman who has had unprotected sex, or whose regular contraception has failed, knows that speedy access to emergency contraception is key to preventing an unplanned and unwanted pregnancy. Those calls for help account for about one-fifth of the calls to the helpline. That is particularly true on a Monday or after a bank holiday. But these women or men--men also ring for advice--are not irresponsible, reckless or promiscuous. They are acting responsibly in trying to prevent an unwanted pregnancy in a world where there is no 100 per cent safe method of contraception and where human beings are fallible.
Allowing EHC to become available directly from Britain's 12,000 pharmacies has many advantages which should not be lost. Women will be able to buy it conveniently, at weekends and when GPs' surgeries are closed, and without embarrassment in an area out of earshot of other customers. Most importantly, it will increase the chance of access to advice from professional pharmacists and will limit the number of unwanted pregnancies and abortions.
I want to comment briefly on the point raised by the noble Baroness, Lady Young, in relation to teenagers. No one would deny that it would be preferable for teenagers to delay having sex. But surely it is also preferable to prevent pregnancy rather than to refuse help. We must accept the reality that one-quarter of teenagers will be sexually active before their 16th birthday. A recent survey in Scotland showed that that is true for 35 per cent of girls and 30 per cent of boys.
My view is that the social and psychological impact of an unwanted pregnancy far outweighs concerns about the morality of prescribing emergency contraception. The noble Baroness, Lady Young, also raised that point and related it to the question of abortion. I want to refer to the remarks of Dr Trevor Stammers, spokesperson for Family and Youth Concern. He made it clear that, although a school's sex education policy should have as its basis providing assistance to young people to resist the pressure to have sex, the morning-after pill is the lesser of two evils--rather the pill than the trauma of a possible abortion.
The noble Baroness, Lady Young, is wrong to believe that providing emergency contraception will tempt young people to try sex for the first time. By the time it is prescribed, sex has already taken place. Voting against the Prayer will in no way prevent teenage pregnancy; a vote in favour will.
After going through all the proper procedures, the Committee on Safety of Medicines and the Medicines Commission have advised that taking the morning-after pill is safe and effective and does not constitute an abortion. Medical care is about providing the right support and the right medication at the right time. That is exactly what emergency contraception provides. It provides a useful avenue of accessibility for women and teenagers, and its use is highly responsible in the face of a potential, unwanted pregnancy. Voting for this Prayer tonight will deny many women the right to take that responsible action. I urge noble Lords to vote against it.
Lord Moran (Crossbench)
My Lords, I listened very carefully to the eloquent case made against the Prayer by the noble Baroness who has just spoken. However, I am afraid that I am not convinced. The government official in Nigeria--the father of Damilola Taylor, the boy who was murdered not long ago in Peckham--spoke three days ago of a breakdown in moral values in Britain. I am afraid that he may be right.
Week after week, we in this House are faced with government proposals for sexual licence: Section 28, the reduction in the age of consent, and now this. Clearly, the Government are helping to create the climate of permissiveness which is bringing about the breakdown of which Mr Taylor spoke.
The selling of the morning-after pill over the counter by chemists seems to me to be a mistake. Although it may, if used soon enough, protect against pregnancy, it does not protect against sexually-transmitted diseases--genital warts, chlamydia and gonorrhoea, among others--which may lead to HIV or cervical cancer. Inevitably, it will lead to an increase in unsafe sex and will give the green light to "sleeping around", resulting in a substantial increase in the already very high level of promiscuity.
The drive to provide explicit sex education at ever-decreasing ages and the availability of the morning-after pill on prescription for the past 10 years have not succeeded in improving matters. Abortion rates have not been reduced, and teenage pregnancy rates in this country--already the highest in western Europe--continue to rise.
It is surely very unwise to allow pharmacists to sell this pill to women. They are not allowed to consult the doctor concerned; they have no access to medical records; nor can they check the age of girls who seek to buy the pill. I gather that the pill should not be taken by women who are or may be pregnant, have high blood pressure or heart disease, or have had a stroke or breast cancer. Pharmacists often cannot know whether those who come to them fall into any of those categories. Therefore, risks to health will multiply. Meanwhile, doctors cannot know how often their women patients have used the pill. That can seriously affect decisions about medical treatment and be dangerous to the women concerned.
The selling of the morning-after pill over the counter gives the green light to "sleeping around" and will result in a substantial increase in the current level of promiscuity. For those reasons, I support the Prayer introduced by the noble Baroness, Lady Young. I am sure that she is right.
Baroness Walmsley (Liberal Democrat)
My Lords, I must confess that the speech of the noble Baroness, Lady Young, leaves me somewhat puzzled. I believe that I live in the real world. In the world where I live, people of all ages have sexual relationships. In the world where I live, these days most couples take responsibility for their own fertility. They take advantage of the fabulous advances which have occurred in medical science over the past 50 years and use the hormonal and barrier products which ensure that, when they have a child, it is a wanted child. Surely that is what we all want: that every child is a wanted child, born into a home where it will be loved and looked after properly.
However, in the real world where I live, things sometimes go wrong with the normal methods of contraception used by responsible people. Condoms split or come off; women forget to take their pills; or they may be sick and lose the pill. Human beings are not perfect. In those situations, surely a responsible, mature woman must not be condemned to bear a child which she does not want simply because she cannot obtain the help that she wants easily and readily. Of course not.
In the real world where I live, young people are very street-wise. Although there are shortcomings in our provision of sex education, most young people know that if they have unprotected sex they are in danger of pregnancy and infection--dangerous infections which can kill. Fortunately, every woman who is in a sexual relationship today can readily obtain contraceptive advice and treatment without undue cost.
But--and this is a big "but"--people sometimes behave under the influence of powerful chemicals which can interfere with their normal good judgment. No, I do not mean alcohol, Ecstasy or any similar drug; I refer to testosterone and oestrogen. Those chemicals are incredibly powerful and are particularly plentiful when young people may not yet be used to their effect. Therefore, should we be trying to punish women of all ages who suspend their normal good judgment or have an accident by forcing them to bear children they do not want by taking away the help that they need? That would be the effect of the proposal of the noble Baroness, Lady Young, if it were carried today.
We have heard that we in this country have the highest rate of teenage pregnancy in Europe. How can that be when we have sex education and free family planning facilities? We seem to have done everything to inform, advise and supply treatment, yet still these tragedies happen. Well, we have not done quite everything. One thing we have not done is to make provision for the accidents, the unplanned errors of judgment and the coercion and abuse situation--until now. Now we have a weapon which should help so long as it is made easily available at no undue cost.
In doing so, we may also be able to reduce the number of abortions. Recently, evidence has been published showing that 90 per cent of pregnancies that were terminated could have been prevented by emergency contraception, and 70 per cent of women seeking abortion would have used emergency contraception if they had known about it and known where to obtain it quickly.
Some people who oppose the availability of this medicine over the counter believe that it may lead to irresponsible attitudes to sex. This is nonsense. Those who say so have not done their homework. Recent studies have shown that only four per cent of users wanted the product more than twice a year.
It is obvious to any woman why that is. Frequent use will disrupt the normal pattern of periods and there is nothing women hate more than periods that have gone haywire. It drives them mad; it cramps their style. If we do not know that, the advertisers of sanitary protection certainly do because they base their advertisements on the fact. Women who acknowledge they are at risk of an unwanted pregnancy and take action are to be commended, not stigmatised. They deserve the safeguards which have been put in place by the Government.
There is one more thing we could do, and I wish we would. We could stop talking about sex as if it were some terrible immoral activity that causes untold harm to society and start accepting it as normal human behaviour, We should learn to discuss it with our children openly, frankly and without embarrassment. As long as it is something hidden and "naughty", children will want to do it. And they may want to do it before they are ready for it, understand it or are prepared to deal with its consequences. What we should be doing today is saying to the Government, "Well done, keep going, extend the arrangements that make the product free to those for whom cost might be a barrier to getting help."
I welcome the checks on pharmacies carried out recently by some members of the press to ensure that pharmacists are following the guidelines. But I have to say that it is much more of a tragedy for a 15 year-old girl to have a baby than to have a pill that she should not have had. These tests, one hopes, will put pharmacists on their mettle and ensure that they follow the guidelines conscientiously. None of them wants to be exposed by the Daily Mail. I also welcome the fact that Superdrug has shelved the idea of selling the product over the Internet. The safeguards and advice available through this method are just not good enough.
One of the most important aspects of advice given by pharmacists and nurses is that unprotected sex can lead to dangerous infections as well as pregnancy. Most young people know this very well and take appropriate precautions. However, there is no evidence that the availability of this product will make women so careless of their own health that they will take dangerous risks.
What is important now is that the properties and availability of this product are made part of an integrated sex education programme for both adults and schoolchildren which informs but does not judge, which protects but does not control, which understands but does not patronise.
The Bishop of Southwark (Bishop)
My Lords, I can well understand the desire of the noble Baroness to prevent pharmacists selling the morning after pill over the counter. She has marshalled powerful arguments for her viewpoint. These stem from her deep humanitarian and religious sense of values and her concern for the welfare of young people.
The Church shares these values. There is no doubt that the gift of sex is a precious gift of God, to be used within a loving marriage relationship. That is what we teach, have always taught and will continue to teach. However, that teaching is not always heard and, if heard, is not always accepted. Sexual intercourse is not confined to the marriage partnership and while, in these enlightened times, many might say that what adults do in their private lives is a matter for themselves alone, some of the figures concerning teenage sex must surely concern us all. Your Lordships are well aware of them, and they have been rehearsed this evening: the worst teenage pregnancy figures in Europe, appalling rates of teenage abortions and young teenage mothers, no older than children themselves sometimes, struggling to bring up a baby while losing education and training opportunities, being trapped into a spiral of poverty which gives the worst possible start in life for the new infant.
How are we to respond? With this debate in mind, I consulted one or two teachers of teenage children in our inner city secondary schools. In their view, some teenagers will engage in sex and some will not. Those who will not have taken that decision because they respect what they have been taught by home, church or school. Or they will not because they believe that in the future they will have a happier and more loving relationship because sex is special and it will have a special place in their lives.
In my view, these young people are right. I wish that all teenagers believed and acted like them. Of course we should all do what we can through our teaching, our preaching and our parenting to strengthen their resolve and spread it to others. However, popular culture is against us. Judging by much of the media, sex is compulsory for all, at any age. So it is not surprising that another group of teenagers do indulge in sex from time to time. We may preach against it, and we do; we may teach against it, and we do; but it goes on happening.
The question then is: do we make the best the enemy of the good? The best is sex within marriage. The good is surely to enable all teenagers, even foolish weak-willed teenagers, to survive their teenage years without the burden of an unwanted baby, pregnancy or abortion. The availability of contraception has surely saved many teenage girls from this fate. I know there are those who believe that the availability of contraceptives has encouraged teenage sex, but that is not a universal view. The teachers I talked to believe that without contraceptives we would see an increase in unprotected teenage sex, with a consequential increase in pregnancy.
Many people view the morning-after pill as an emergency form of contraception--emergency because regular use might well bring health problems; emergency because the pill is expensive, certainly to the teenage pocket. But the one-off use of the pill might save a one-off abortion or a one-off birth of an unwanted child. Thirty-three community pharmacists in the health action zone where I live in south London have been involved in a pilot project testing out the procedures in the new order. The project has been part of a strategy for reducing unintended young pregnancies and it is reported that the response has been almost universally positive. It has proved to be the case that the pharmacist's is a less threatening place for some vulnerable young women to approach than the doctor's surgery or clinic.
There is no question that we must strengthen long-term methods of teaching morality, developing good sex education for boys and girls, and increasing hope and choices for girls in areas of deprivation. All these things we must continue to do, but in the meantime the morning-after pill provides an emergency last resort for those who have fallen through the sexual net. I believe it is right for us to be very uneasy about the right way forward in this debate. I, for one, am uneasy for I certainly do not believe that all the moral arguments are on one side. But speaking for myself, I believe that unwanted teenage pregnancies are such a great evil which blights lives that we must not let the best be the enemy of the good. So, with regret, I shall not be following the noble Baroness into the Lobby tonight.
Lord Davies of Coity (Labour)
My Lords, it is well known in the House that I supported the noble Baroness, Lady Young, when she opposed the promotion of homosexuality in schools and we had a debate on Section 28. I spoke and voted in this House not to allow a reduction in the age of consent of homosexuality. But in all honesty I cannot support the proposition that has been put forward this evening. Of course I will support measures that I believe will reduce promiscuity. I will certainly support, as indeed we all will, any measure that reduces the transmission of sexual diseases. But I cannot accept the proposition that the taking away of a measure after the event somehow controls what happens when the event takes place.
The measure proposed by the Government is twofold: to prevent unwanted pregnancies and to prevent more abortions taking place; that is, to prevent the kind of things none of us wants to happen. We want to see family relationships established and built considerably. However, I cannot see how such relationships, those between teenagers and those between parents and teenagers, can in any way be conditioned by not having the measure of the morning-after pill. The reasons for the measure are sound and good. I believe that the House should vote against the proposition of the noble Baroness.
Lord Patel (Crossbench)
My Lords, I speak in support of deregulation of progesterone-only Levonorgestrel emergency hormonal contraception. I speak on the efficacy of this pill as an effective contraceptive and not on any procedural or constitutional issue. I had rather a long speech. However, it was considerably shortened after I listened to the notable speech given by the noble Baroness, Lady Walmsley. I cannot but agree with just about everything she had to say. She spoke as a teacher. I speak as a gynaecologist who has seen many unwanted pregnancies.
There are many reasons why this deregulation measure is necessary, not the least of which is as one of the many measures needed to reduce the rate of teenage pregnancies in this country. We heard about the high rate of unwanted pregnancies which end in termination in the United Kingdom compared to the rest of the western world, except the United States. There were 173,000 in England and Wales alone in 1999.
Evidence from smaller studies carried out in Scotland suggests that in women between the ages of 16 and 29 who take emergency contraception, the rate of unwanted pregnancy has been reduced. Larger studies are currently being conducted. The progesterone-only pill, Levonorgestrel, works by delaying ovulation and preventing fertilisation. It is not an abortifacient. The pill is safe and effective. I do not know what the noble Baroness, Lady Young, meant when she said that the pill is 50 per cent more powerful. It is certainly 50 per cent more effective.
In trials which have been reported, including those by the WHO, few complications have been reported, nausea and vomiting being the main ones. That, too, has been in far fewer women compared to those using the combined emergency contraceptive pill. No serious complications have been reported. There are practically no contraindications. In trials reported by the WHO, the rate of pregnancy was 1.1 per cent among the progesterone-only pill group. The effectiveness of the pill relates to the time of taking it following unprotected intercourse. The noble Baroness, Lady Gould, stated the correct figures, as reported by WHO. There has been a 95 per cent success rate in terms of avoiding unwanted pregnancy if the pill is taken within 24 hours of unprotected intercourse. That is the crux. The sooner the pill is taken after intercourse, the more effective it is. If taken inappropriately, or if pregnancy occurs, the trials reported no adverse foetal outcomes.
Therefore, the pill has to be easily available. Making it available only through general practitioners, family planning clinics, A&E departments of hospitals or even patient group directives--not all of which are funded for this--will delay women receiving the pill. Despite the low levels of complications reported, the Royal Pharmaceutical Society has issued guidance to pharmacists.
Concern has been expressed that women will use the emergency contraceptive pill as regular contraception or that there will be an increase in sexual activity in young people. As we have heard, and I concur, neither of those concerns is borne out by the evidence. The age group with the highest incidence of the use of emergency contraceptive pills is that between 20 and 29. The lowest incidence is in the group aged 16 to 19 and below 16. Evidence from trials in other countries and in the Lothian area of Scotland does not suggest repeated use of the pill. A small number of women used emergency contraception on more than two occasions in a year. Couples who normally rely on other forms of contraception, such as the pill, the inter-uterine contraceptive device or condoms, may, for a variety of reasons, need to use the emergency contraceptive pill where there is a risk of failure of the usual form of contraception.
In such situations, emergency contraception offers women peace of mind from unwanted pregnancy. Levonorgestrel is the safe choice. However, I agree that the cost of obtaining the pill from pharmacists, nearly £20, half of which I understand is the cost of the pill and half the dispensing cost, may reduce its use. It is interesting to note that the cost of a similar product in France is equivalent to £5. But that is no reason for us to stop Levonorgestrel being available through pharmacists. The progesterone-only emergency contraception pill, taken in 0.75mg tablets, 12 hours apart within 72 hours of unprotected intercourse, is safe, effective and free from complications. I hope that it will help to reduce the incidence of unwanted pregnancies. Anything that we can do to make it more easily available has to be good.
It is interesting to read the editorial comment in the New England Journal of Medicine, a prestigious medical journal. The conclusion states:
"Making emergency contraception more easily obtainable does no harm and may reduce the rate of unwanted pregnancies".
Lord Elton (Conservative)
My Lords, I rise first to assure the noble Baroness, Lady Walmsley, that my noble friend Lady Young lives in the real world. I have often met her there and she speaks from it, from a wealth of experience gathered in many ways, particularly as a parent and grandparent.
I find this a difficult and sad debate. There are genuinely important considerations in both directions. One cannot simply rely on habit or friendship when making up one's mind. However, considering the context in which we hold it, I am saddened by the change in the attitude to love which has taken place in the past half-century and the relationship between sex and love. That relationship is central to a healthy society. If we divorce the two, we revert to the animal. If we ally the two, we move towards the human and the spiritual. I am sorry if that leaves some of your Lordships completely baffled. To me, it is real and important.
I am troubled by the fact that the Government have shown so little willingness to offer what I would regard as common-sense moral advice. They are happy to tell people that it is wrong to smoke, and the consequences of so doing. They are happy to tell people that it is wrong to drive and drink, and the consequences of so doing. But nobody has said that it is wrong to take the risk of siring or begetting illegitimate children. The purpose of the sexual mechanism in the human race is to produce children. That is completely forgotten in most of our contemporary literature and contemporary films. It is seen as an end in itself. My noble friend referred to a child who asked, "What's the point of having sex if it isn't fun?" The answer is that it is tremendous fun but that is not the end purpose. The end purpose of it is to have children within marriage; and if we stop doing that, we stop having a viable society. Therefore, there is a political as well as a spiritual priority and I deeply regret the Government's reluctance to see that, to take it on board and to give moral as well as medical advice.
I hope that the noble Lord will not disappoint me by failing to offer such advice in the context of his reply. If the issue is treated purely as mechanical and medical, I shall find myself unable to go other than with my noble friend into the Lobby. If he can tell us that it is about something else, I shall find it much more difficult to accompany her.
Lord Carlile of Berriew (Liberal Democrat)
My Lords, I wish that like some noble Lords who have spoken in favour of the Prayer I was confident in the belief that I had a special insight into the conscience of the nation. I do not claim that credential for speaking in this debate. However, I claim two other credentials. The first is the special misfortune during the past 30 years of having appeared all too frequently in cases involving the deaths of babies who were virtually condemned to death when they were conceived in haste. The second is the much happier credential of being the parent of three adult women.
Some parents, unlike me and many of my friends, may have been extremely lucky. Their daughters may have passed seamlessly from the age of reason to the age of responsibility. But I do not believe that that is the general experience of many of us. We must protect our daughters and the girls of this country by the best means available, combining good moral sense and good medical science.
There is a moral issue which concerns me greatly. I start from the viewpoint that in this country there are far too many abortions of viable foetuses well embarked upon gestation. My observation and understanding is that abortion is physically and emotionally a potentially disturbing experience for almost all who undergo the process and that for many it is a completely ruinous experience which affects and damages for them for the rest of their lives.
Wherever it is realistically appropriate to avoid abortion, abortion should be avoided. I do not accept for one moment the proposition put by the noble Baroness, Lady Young, that the use of the morning-after pill prescribed by pharmacists will increase the number of abortions. That seems a completely perverse misuse of logic.
Another moral issue seems to me to be held in the answer to the following question--
Baroness Young (Conservative)
My Lords, I am sorry to interrupt the noble Lord and thank him for giving way. The point I made was that although more than 800,000 morning-after pills were supplied last year, the number of abortions has risen.
Lord Carlile of Berriew (Liberal Democrat)
My Lords, the noble Baroness will know that the sexual habits of young people are complex issues. I know of no research material which suggests that the availability of such a pill over the counter from a properly regulated pharmacist will do anything other than reduce the number of abortions.
However, another important moral issue seems to me to be held in the answer to the following question. Are we prepared to respect women of 16 and upwards as the custodians of their own bodies, in the absence of a paramount public interest to the country? After all, girls of 16 may lawfully have sexual intercourse, so why should they not control the consequences of that sexual intercourse? They can purchase contraceptive devices before they have intercourse, so why should they not purchase a contraceptive device, as the noble Lord, Lord Patel, described it, after they have had intercourse--because that is the scientific way in which it works? They may even marry lawfully at the age of 16.
It seems to me that to allow young women the option offered by the order is both consistent and logical in giving women greater custodianship of their own bodies. That is particularly so, as the scientific advice is clear, because the new morning-after pill is far safer than its oestrogen-strong predecessor. Furthermore, let us not forget that the Royal Pharmaceutical Society, which is an extremely responsible professional body and regulator of its profession, has introduced and will enforce stringent professional standards concerning the supply of these pills.
It has also been suggested by some noble Lords that this order--this change in the law--will lead to more casual sex by the over-16s. I am afraid that that view beggars reality. That particular horse bolted years ago! Appalled as I am--and I genuinely am--by the sexual content of many teenage magazines aimed at girls--I recall an occasion when my wife went around the house throwing out every one she could find because of its content--I believe that one must recognise the truth of their content. They are no more than a reflection of their readership's life and times. However uncomfortable are the facts of life for older teenagers, the life of facts is that most teenage girls are sexually active before they reach the age of legal consent.
The noble Baroness, Lady Young, spoke of the desirability of dealing with these issues by girls going with their mums, or possibly their dads, to see their nice GPs who knows the family history. I have to ask the noble Baroness whether she has looked at the demography of this country and at the lack of interest of some parents in what happens to their children. I ask with great respect to the doctors in the House whether the noble Baroness really believes that one can rely on the wisdom of every general practitioner in this country to aid that process. The truth of the matter is that, as regards young women over the age of 16, now that the science is safe these matters are surely best left in their hands.
The order recognises changes in science and in society. I hope that this House will not thwart that recognition.
Baroness Massey of Darwen (Labour)
My Lords, I shall speak but briefly today. However, I am extremely concerned about the issue. I believe that anyone who is concerned about abortion rates and about unintended pregnancies producing unwanted children, cannot support the noble Baroness, Lady Young, tonight.
I shall not concentrate particularly on young women but on women in general, for it affects them. "Emergency contraception", to give it its correct title, is not an encouragement to promiscuity; it extends a woman's choice of whether or not to risk pregnancy in emergency. I emphasise the word "emergency". Emergencies happen; condoms split and people have unprotected sex whether or not that is wise or responsible. Pharmacies are convenient and accessible, as was stated by my noble friend Lady Gould. People go to their pharmacy for advice and service for many items. It is not always easy to get to a doctor or a clinic. Your Lordships have heard the medical evidence described so clearly by the noble Lord, Lord Patel.
There is no evidence that women are using emergency contraception repeatedly, either in the UK or in France where it has been available since 1999. I stress what other noble Lords have said; that one survey showed that only 4 per cent of women used emergency contraception more than twice a year. That is a small number.
This pill is not an abortion pill, as is sometimes stated. It cannot terminate a pregnancy which has begun. I am not pro-abortion as such. I am pro women having choices about whether or not to have children. Women who make that choice are behaving responsibly, not irresponsibly--and it is mainly women who make the choice. Methods of male contraception are limited; certainly, there are no emergency contraceptives for men.
Who is most likely to use this pill? Not teenagers. The notion that under-16s will line up to pay £20 for this contraceptive in a pharmacy, or that it will be doled out in schools, is ludicrous and untrue. In a pilot scheme in Manchester the average age of women who used emergency contraception was 24, not the under-16s. That is not surprising, given that most unintended pregnancies occur in women aged between 20 and 25, not the under-16s. The average age of first sex in England is 17. Of course some have sex earlier and, unfortunately, become pregnant. Those who avoid having an unwanted child are behaving responsibly, not irresponsibly. Unwanted pregnancy can still result in young women in particular attempting to use dangerous methods to self-abort. None of us wishes to return to that, certainly not parents. Emergency contraception is legally available to the over-16s. Some girls under 16 will obtain it--even when not sent in by newspapers. I doubt that there will be many genuine cases.
I respect principles, idealism and certainly love. There is a good deal of moral advice in the new personal and social health education guidelines for schools. People should behave responsibly. I do not advocate that anything goes as long as pregnancy does not occur. However, to be charitable, I believe that idealism must be tempered with pragmatism and reality. People will continue to have sex and some will take risks or make mistakes. We should do all that we can to ensure that those risks and mistakes do not result in unwanted children. Emergency contraception is safe and extends a woman's choice over her fertility. A women is unlikely to make much use of this method of contraception, and in the vast majority of cases it will be used by women over 16.
The noble Baroness, Lady Young, has spoken in this House about fighting to the death for principles. I and others will fight to the death to preserve and extend a woman's right to control her fertility. If we remove one possible method--the ability to purchase emergency contraception from pharmacies--we shall not be thanked.
The Earl of Listowel (Crossbench)
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 (Labour)
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 (Crossbench)
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 (Labour)
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.
The Bishop of St Albans (Bishop)
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.
Lord Clement-Jones (Liberal Democrat)
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.
Earl Howe (Conservative)
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.
Lord Peston (Labour)
My Lords, I am sorry to interrupt the noble Earl and I do so reluctantly. I must declare an interest as an honorary member of the Royal Pharmaceutical Society. My listening to the noble Earl suggests that his view is that the Royal Pharmaceutical Society is, first, irresponsible in strongly advocating this intervention and, secondly, does not speak for the overwhelming majority of its members. Does he accept that the Royal Pharmaceutical Society is completely responsible in what it says and does speak for the overwhelming majority of its members? Will he say that in terms, speaking from the Opposition Front Bench?
Earl Howe (Conservative)
My Lords, I believe that the Royal Pharmaceutical Society has adopted an entirely responsible approach. I could pick holes in the detail of the guidance it has given. I certainly accept that it is acting with the approval of the majority of its members but I am also saying that a significant minority of its members--the noble Lord will know this from reading the pharmaceutical press--are worried and concerned for the reasons that I am now giving.
"The whole thing is turning into a bit of a hotchpotch and it needs looking at again. I do not think it is properly thought through. We must avoid the fragmentation of health care which could be dangerous".
The dangers arise from any failure to ascertain vital information from the patient and from the absence of the kind of care which, with the greatest respect to the pharmaceutical profession, only a doctor or a nurse can provide.
I have already run through the list of medical contra-indications, any one of which renders the supply of the pill unsafe. I have not read out the long list of other items that a chemist is supposed to cover with each patient--warnings about side effects, about the need to repeat the dose if you vomit within three hours of the first one, about what to do if you are taking an ordinary oral contraceptive as well, or if you are breast-feeding. The list goes on. Responsible chemists will follow it, and it is to be hoped that patients will understand it all. But it is no substitute for seeing a doctor or a nurse. There are just too many pitfalls.
Before I finish, let me make one thing clear. The issue of unwanted pregnancy and of abortion are ones I understand completely. I understand about busy doctors' surgeries and the embarrassment that girls feel in going to their doctor. But in the light of the risks I have identified, we believe that a better alternative to making the morning-after pill available over the counter would be to allow practice nurses to prescribe it. That measure of deregulation would allow greater flexibility for patients yet keep emergency hormonal contraception within the context of a general practice setting.
In our judgment, the order compromises patient care. I urge all noble Lords to reject it and in so doing allow the Government to think again.
Lord Hunt of Kings Heath (Parliamentary Under-Secretary, Department of Health; Labour)
My Lords, I am very glad to have the opportunity of responding to the debate on the order. We have certainly had a wide-ranging debate. I listened with great interest to the right reverend Prelate the Bishop of St Albans as he touched on a number of moral, religious and ethical questions. But I want to start with some fairly straightforward points about the background to the order.
I believe that women and their partners have the right to make responsible choices about the size of family they have. As noble Lords have pointed out, the effectiveness of hormonal emergency contraception is greatest the sooner it is taken after unprotected intercourse. The option of rapid availability from a pharmacist without the need for attendance at clinic or GP surgery is therefore to be seen as a welcome addition to responsible family planning measures.
There has been positive support for pharmacy availability from a wide range of professional bodies. I say to the noble Earl, Lord Howe, that pharmacists are professional and responsible and will receive full guidance in the safe supply of this medicine from the Royal Pharmaceutical Society of Great Britain. Pharmacy supply will improve and build on existing links between pharmacists and family planning services. This network will help to ensure that the under-16s and other women who need to see a doctor for contraceptive advice can be referred on quickly.
The background to the order is an application by Medimpex UK to change the legal classification of Levonorgestrel. The application was to change its legal classification from that of a prescription-only status to that of a pharmacy status, which means that it can be sold over the counter by a pharmacist. Under UK law, a medicine is legally classified as "prescription only" if it needs to be supplied under the supervision of a doctor to ensure that it is used safely. It can be sold in pharmacies only if the legal criteria for listing medicines as prescription only no longer apply.
The Government are committed to making medicines more widely available where it is safe to do so. The most effective way of doing that is through the reclassification procedure for licensed medicines as I have described. The UK has considerable experience in this regular and routine procedure. I pay tribute to the last government, who, in 1992, established the well-ordered procedures to enable this to happen. As a result of that action, more medicines have gone down this route and the public have benefited enormously.
It is down this route that Medimpex UK has gone. When the company applied to the Medicines Control Agency, a standard procedure was followed. First, the Medicines Control Agency assessed the safety of the medicine in use in the light of the legal criteria for prescription only status. Then the application was referred to the advice of the Committee on the Safety of Medicines. That committee recommended that the order should be amended to allow the non-prescription supply of this medical product. The matter was then put out to public and professional consultation. Virtually all the main medical and pharmaceutical bodies which responded were in favour of a move to pharmacy supply. Furthermore, they did not raise any concerns about the safety of supply in a pharmacy setting. Both the Committee on the Safety of Medicines and the Medicines Commission carefully considered all the available evidence. They advised that Levonelle can be supplied safely under the supervision of a pharmacist for emergency contraception.
Perhaps I may turn to the safety issues. Considerable experience of worldwide use has been gained. In the UK the active ingredient has been available in other contraceptives and HRT products for 30 years, although only more recently as an emergency contraceptive. It has been used for emergency contraception in other parts of the world since the 1980s. In France it has been available from pharmacists since 1999. I understand that Norway and Portugal have since agreed to do the same.
I am advised that the side-effects of this medicine are usually mild and short-lived. The most common side-effects reported from clinical trials are vomiting and nausea. The committees therefore considered that the medicine had an acceptable safety profile to supply under the professional supervision of a qualified pharmacist and that women would be able to use the product correctly.
Perhaps I may now turn to the safety issue in relation to women aged under 16. I have been asked for reassurance on this point and I am happy to give it. The most important point to make here is that, while under this order the product can be bought from a pharmacist only if the person is aged 16 years or older, the same product can be prescribed by a doctor with no age limits. There is no biological significance to the age limit of 16 years and over. Indeed, the original licensing of the prescription product used evidence from a large, randomised control study that included women under 16 in the trial.
Having considered the safety issues and on the basis of the advice received from the Committee on the Safety of Medicines and the Medicines Control Agency, we have laid the order before the House tonight. In support of this change, the Royal Pharmaceutical Society has set professional standards and developed comprehensive guidance for pharmacists on the retail supply of emergency contraception. I should say to the House that it is primarily the responsibility of the Royal Pharmaceutical Society to enforce the Medicines Act in this area. It is the regulatory body.
While pharmacists are already familiar with the product through prescription supply, additional training is being provided, a distance learning programme is being sent to all pharmacists ahead of the product launch and workshops are also available. The noble Earl, Lord Howe, referred to the minimum standards set by the Royal Pharmaceutical Society. Those are in place to ensure that pharmacists have sufficient knowledge of emergency hormonal contraceptives to deal with requests personally and to decide whether to supply the product or to refer; to ensure that they provide all the necessary advice and information about the medicine to the patient; to handle requests sensitively, respecting a woman's right to privacy; only in exceptional circumstances to supply the product to a person other than the patient; and wherever possible to take reasonable measures to inform the patient about regular methods of contraception, disease prevention and sources of help.
I do not share the concerns expressed by the noble Earl, Lord Howe. The pharmacy profession has had considerable experience in the move of medicines from prescription only to pharmacy. I believe that pharmacists are ideally placed to provide advice on regular methods of contraception and local family planning services to help women avoid the use of emergency contraception in the future. Furthermore, I am satisfied that the overall rigorous approach to regulation within the pharmacy profession will ensure that sufficient safeguards are put in place.
Lord Mackay of Clashfern (Conservative)
My Lords, I wonder if the noble Lord could develop that point? Can he tell the House whether the supply over the Internet of this drug by Superdrug was lawful in terms of the standing regulations?
Lord Hunt of Kings Heath (Parliamentary Under-Secretary, Department of Health; Labour)
My Lords, I understand that it is lawful to supply over the Internet, but the issue is whether in so doing, the company would follow the minimum standards laid down by the Royal Pharmaceutical Society. If it did not follow those minimum standards, a pharmacist involved in Internet supply would fall foul of the regulatory provisions set by the Royal Pharmaceutical Society. On that basis, the intention to supply over the Internet has been withdrawn until discussions can take place between Superdrug and the society.
This order will be welcomed by many women. A number of noble Lords referred to the 800,000 women who were prescribed emergency contraception in 1999. The medicine is far more effective the earlier it is taken. Waiting to see a doctor may cause delay and therefore reduce the chance of it working. Providing for direct sale through pharmacies will be an important additional route, in particular at times when traditional services may not be available. That is a very pertinent point. Huge numbers of women in this country will know the frustration of trying to track down emergency contraception over the weekend after contraception has let them down.
Much of the debate has focused on under 16 year-olds and the feeling that this will encourage teenage promiscuity. I should like to place on the record the fact that the company which holds the licence for the product applied for the age limit of 16 years for pharmacy availability and that the expert advisory committees accepted that that was reasonable. This is not the only pharmacy-supply medicine that has an age restriction and I am confident that pharmacists have the experience and judgment to determine which clients should be referred to a doctor. The guidance from the Royal Pharmaceutical Society reflects that position. It states that,
"Pharmacists should make every reasonable effort to satisfy themselves that clients are aged 16 or over. Pharmacists should ensure that where they believe a client to be under 16, the request is dealt with sympathetically and the client is offered appropriate help and support to enable her to obtain emergency hormonal contraceptives by another route".
The point I should like to make is that every day, pharmacists have to make judgments in their pharmaceutical outlets. The members of that profession are extremely well trained and I believe that they can be expected to operate the law effectively.
I do not believe the suggestion that this will all encourage promiscuity, for the following reasons. First, there is evidence from a study in Scotland, where women were given advance prescriptions for emergency contraception to be kept at home. It found that women did not change their sexual behaviour or their use of regular contraception. A further four-year study of 95,000 women aged 14 to 29 found that repeated use of emergency contraception was rare, and that many women used regular contraception for the first time after the use of emergency contraception. Indeed, as the noble Baroness, Lady Walmsley, suggested, we know that the regular use of emergency contraception disrupts a woman's menstrual cycle, which means that she will have irregular periods and breakthrough bleeding. This will be unacceptable to most women, and they will quickly seek medical advice.
On top of that, there is the matter of cost. I tell my noble friend Lord Rea that the cost of the product, at £19.99, is a matter for the company concerned, but, whatever one's view on the price, I think we can all agree that it will be a deterrent to regular use.
I share the view of my noble friend Lady Gould of Potternewton on the balance to be arrived at between access to emergency contraception and a potential abortion; as the right reverend Prelate the Bishop of Southwark suggested, one-off use of emergency contraception may prevent an abortion. Noble Lords have tonight referred to the very high figures of abortions being performed in this country. They are very high, and this Government remain concerned about that. If emergency contraception can help to reduce the level of abortions, surely it is to be welcomed.
The noble Baroness, Lady Young, talked about parents. Recent research among parents, commissioned by my department, found that over 80 per cent supported the provision of confidential contraceptive advice for the under-16s. Of course, I fully recognise the role that parents play in supporting their children in sex and relationship education. Indeed, it is pretty clear that the more open parents are about sexual issues with their children, the later those children become sexually active and the more likely they are to use contraception if they do become sexually active.
But we have to face the fact that not all parents manage to talk to their children. Indeed, one study showed that one third of girls had not been told about periods before they started. So there is much that we have to do in relation to health education generally. Good comprehensive sex and relationship education can help young people delay first sex and make them more likely to use contraception when they do become sexually active. Countries that report low or falling rates of teenage parenthood all include sex education as part of their overall programme. That is why the Government have issued new guidance to schools to improve the quality of sex and relationship education, to give young people the information and skills they need to resist peer pressure to have early sex and to negotiate safe and responsible relationships. As my noble friend Lady Massey of Darwen said, there is plenty of moral value to the guidance, including that pupils should be taught about the nature and importance of marriage for family life and bringing up children.
With regard to the issue of sexually transmitted infections, there is of course concern about their level in this country, and the Government are committed to doing all they can to reverse that trend. But, as the noble Baroness, Lady Walmsley, suggested, no method of contraception is 100 per cent effective, and if an accident happens emergency contraception is an effective method of preventing pregnancy. I have seen no evidence to suggest that the availability of emergency contraception would lead to a rise in sexual disease.
This has been an extremely interesting and wide-ranging debate. I share with the right reverend Prelate, the Bishop of St. Albans, a sense of the sacredness of human life and the need for us to encourage self-regard in young people. But I believe that what we are talking about tonight is a sensible and entirely justified course of action, reached after very careful consideration and after the proper processes have been gone through, the processes laid down by the party opposite in 1992. It is action endorsed by the Medicines Control Agency and the Committee on the Safety of Medicines, which advised that this product can be safely supplied under the supervision of a pharmacist for emergency contraception; action supported by the BMA, the Royal College of General Practitioners, the RCN, the Royal Pharmaceutical Society and many other responsible bodies; and action which will encourage improved links between pharmacists and family planning services and help to ensure that under-16s and other women who need to see a doctor for contraceptive advice can be referred on quickly.
Surely women have the right to take advantage of the option of rapid availability from a pharmacist without the need for attendance at the GP or family planning clinic. Surely women and their partners have the right to make responsible choices about the size of their family.
I hope that the House will reject the Prayer.
Lord Monson (Crossbench)
My Lords, the noble Lord the Minister has said nothing about the Northern Ireland anomaly, although the noble Baroness, Lady Young, raised the point. The age of consent in Northern Ireland is 17, not 16. Is it not therefore the case that a chemist in the Province who supplies the pill to a 16-year-old may be guilty of aiding and abetting a criminal offence?
Lord Hunt of Kings Heath (Parliamentary Under-Secretary, Department of Health; Labour)
My Lords, that clearly is a matter for the Northern Ireland Assembly and the Northern Ireland Health Department. But I can tell the noble Lord that the decision has the full support of the Northern Ireland Health Department, and, as the noble Baroness, Lady Young, suggested, was signed by the Northern Ireland Health Minister. That Minister raised no objections, and I do not believe that that point impacts on the decision made in the order.
Baroness Young (Conservative)
My Lords, I should first like to thank very much those who have supported me this evening, and, as always, to thank the noble Earl, Lord Longford, who speaks with great moral authority. I only wish that I were as good a Christian as he is. We should all take note of his courage and sincerity. I also thank my noble friend Lord Elton for what he said. He was the one speaker who drew attention to the importance in all this discussion of love, commitment, responsibility and marriage. It is extraordinary how those four words are left out of every debate.
The two right reverend Prelates who have spoken will not be surprised to hear that I am very disappointed by what they said. I am bound to say to the right reverend Prelate the Bishop of Southwark that to argue that the best can be the enemy of the good, and that therefore we should not have the best, seems to me an extraordinary moral argument. But I am not here to discuss that.
I was even more surprised to hear that the theological position of supporting the lesser of two evils is a good one to take up. When the Pope went to Ireland he was told that the IRA was protecting the Roman Catholic population against Protestant oppression, and his reply was quite simply "Murder is murder". We need to keep a firm hold on moral principles when we are talking about these matters.
We have had a very full debate. I started my remarks by saying that I thought there had been a great deal of misunderstanding about the issue. As I listened to the debate, I realised that those words were rather truer than I thought when I wrote them.
We have heard a great deal, at great length, with great emphasis and great force, about the importance of contraceptives, about a woman's right to choose and that every baby should be a wanted baby. It was as though somehow I was arguing against any of these principles. As I made abundantly clear at the beginning of my remarks, I am well aware that the morning-after pill has been available since 1985; that emergency contraception has been available to women since 1985. It is not new. I made it perfectly clear that if my Prayer against the order carries this evening, that situation will be the same; nothing will change. Listening to many of the speeches today, one would think that I was saying that emergency contraception would never be available again. I have not said that; I do not think it; it is simply not the case.
We are talking about whether or not these emergency contraceptive pills should be available across the chemist's counter. At this point I remind your Lordships of what my noble friend Lord Howe said about the role of pharmacists. Of course I recognise that the Royal Pharmaceutical Society has laid down good guidelines--I would expect it to. I would expect pharmacists to do their best. But, as my noble friend Lord Howe pointed out, the reality is that we have all seen the queues in the chemist's shop. I do not know where all this consultation will take place. I looked into my local chemist in preparation for this debate to see where it might take place. There did not seem to be anywhere but the most public place, in front of the counter. Perhaps other chemists are different.
The questions that the chemist should ask are very important. We are putting at risk the health of young girls. I do not want that responsibility. We need to take these matters very seriously. The guidelines are correct but, as we all know, guidelines are not always adhered to, especially in a busy chemist's shop late in the evening. I ask the House to recall, very clearly, what my noble friend Lord Howe said.
Perhaps I may conclude by answering two or three points, which I believe to be important. I was very sorry that the noble Lord, Lord Hunt, kept referring to 16 year-olds and under as women. This illustrates the attitude of the Government. In law, they are not women, they are children--and we should recognise what we are talking about.
I am sorry that he thought there would be no increase necessarily in sexually transmitted diseases as a result of increased use of the morning-after pill. Of course the morning-after pill encourages unprotected sex--that is one of its purposes. That is one of the reasons why young people look to it.
Finally, I should like to make a point about parents. Some of the talk about parents has been rather casual. One of the reasons--not the only reason--that we have one of the highest rates of teenage pregnancies in this country is, of course, the high rate of marriage breakdown and the undermining of family life. Taking steps which undermine family life is very serious. I shall be perfectly frank, I do not like the fact that school nurses can provide the pill without parents knowing.
What is being said to parents is a kind of general, blanket question: "Would you like your children to be helped to understand sex, contraception and all the difficulties of growing up"? Most parents think it is a good idea. What they do not know is that the result of all this is that somebody, without telling them, is giving their child the morning-after pill and contraceptive advice.
We are contriving and conniving at undermining parents. Whatever I may think about it--and I have been a parent--I know that I would never want for other people's children what I would not want for my own. One thing we should have learnt is the importance of keeping teachers, parents and doctors all speaking with one voice to their children. One of the troubles that we have today is that they do not do so.
There are a lot of people in the country--I mention, once again, representatives of the Muslim community, who have been to see me on more than one occasion--who are very concerned about this matter. I would not have taken up the time of your Lordships' House today, or, indeed, on any other occasion, if I did not believe that in this world today--which, the debate has shown, is immensely confusing and uncertain for young people, with terrible tragedies waiting to happen, with the teenage pregnancy rate and so on--this move to give the right to chemists to supply the pill over the counter is an opportunity for one more ratcheting up of society. I do not believe it will help people. Women need the help; they have got the help. We should pray against this order today in the interests of young people.