Australian Pharmacist Speaks Out

First, Do No Harm – The Forgotten Ethic

As healthcare professionals, including myself being a pharmacist, our practice is underpinned by a code of ethics. The Hippocratic Oath: "First, Do No Harm" is the basic underpinning of modern medicine. In the current climate of healthcare, it seems our professional bodies are forgetting our commitment to this code, especially with respect to our vow to non-maleficence. We are seeing this deviation from an ethical practice of medicine more and more in the sphere of reproductive "healthcare", and I would like to focus eventually with specificity on medical abortions.

What is medical abortion?

Medical abortion is a form of abortion that is sold as a less invasive, safer and more "humane" form of abortion. In Australia, women have access to this form of abortion up to 63 days (9 weeks) gestation. ¹ It is prescribed by a doctor and the medication (mifepristone plus misoprostol) that is taken to facilitate the abortion is accessed through a pharmacy. The medication causes uterine contractions to occur, which expel the baby from the womb. It is common to hear this process trivialised by being described as just a "bleed" or the passing of "fetal tissue" or a "clump of cells" – The intent in doing so, is to strip all the humanity from the act, in an attempt to make a gravely inhumane process appear to be humane. It mustn't be forgotten however, that what is inside the mother is a growing human, who, at 5 weeks already has a heartbeat and a developing brain, and by 9 weeks already has visible limbs that are forming. ² Moreover, women often have the impression that this form of abortion, given that it is done "earlier" and simply involves taking tablets (self-administered) is without its risks – I will soon show that this is not true.

The changing culture of healthcare

The risks both psychological and physical associated with medical abortion are serious and are not described enough to the women who are seeking it by the relevant health practitioners – both doctors and pharmacists. This in itself, apart from the obvious failure in abortion being aberrantly defined as "healthcare", is a grave failure of the most fundamental role of the health professional – Do No Harm.

A symptom of this failure is the changing culture of healthcare and demands for it to be a buffet of "services" that patients simply select and access at their own discretion – medical abortion falls into this smorgasbord of medical "services" that are possible and therefore because it is possible, the healthcare system deems it a healthcare "right", just because it is possible. Falling into this trap of opening up the immensity of possible medical technologies to everyone and anyone increases the opportunity for atrocities against human dignity being committed, as is clear also in the realms of IVF and voluntary assisted dying. As we accept more technologies in medicine, we also risk falsely quantifying what we view as "freedom" by the range of options available to us, and thus if it is available "I should have a right to it because it is MY freedom and healthcare is a human right!" – lines similar to this are often jammed down our throats, and they represent a wider social disease that has infected healthcare and slithered its way into the minds of its custodians. 

To clarify, autonomy of decision making in healthcare is not a bad thing, in fact it is a good thing – we are fortunate we can get second or third opinions on matters relating to our health and we are fortunate in a lot of situations we can choose who our healthcare providers are. It however becomes problematic when autonomy is weaponised and sought with entitlement. Moreover, autonomy without being equipped with accurate knowledge is blind discretion. It must be understood, that as health professionals, we are not called to simply provide what the patient wants just because it is available and they want it, we are instead called to offer them what they need based on our expertise, and to educate them in full. And we are certainly not called to skim over or paint a more pleasant view of risk just to fit whatever we believe the patient wants to hear – we need to be impartial and use the evidence.

Healthcare is not a buffet

We are often bombarded with the non-sense phrase "my body my choice", and this has infiltrated the healthcare profession specifically in the realm of reproductive health. To demonstrate the senselessness of such a statement, take this example: a drug-user addicted to opioids manipulates a doctor into prescribing him oxycodone for a pain condition that he made up. This person is questioned by the pharmacist and is discovered to have lied to the doctor to obtain the prescription to fuel his addiction. What would be the appropriate response by the pharmacist under his oath to do no harm – say to the drug user "your body your choice, here you go have the oxycodone, it's what you want."  OR "you are addicted to prescription opioids, I want to offer to help you through this difficult part of your life, what you need is help from an addiction specialist, would you like me to refer you to an addiction clinic?" I challenge anyone to argue against the former being an obvious case of grave negligence and the latter being an example of good healthcare. Sadly, what is also obvious is that the offering of medical abortion looks all too similar to the former, and, through the lens of the rhetoric used by those who advocate bodily "choice", the latter would typically be characterised as stripping "freedom" from the patient. Why is it that the healthcare system makes abortion an exception to grave negligence? We must not forget what healthcare is – healthcare is the facilitation by health professionals of the treatment or prevention of disease or illness with the objective of restoring or improving the health of people. Pregnancy is not an illness or disease, therefore destroying the life of an unborn child to end a pregnancy, at any stage, is not justifiable healthcare, especially when doing so also has detrimental effects on the mother. It is a violation of the code of ethics that holds the health system together.

Restrictions to medical abortion access lifted

Lets now focus on a serious example of the implications of this concerning change in the culture of healthcare – the Therapeutic Goods Administration's (TGA) recent lifting of restrictions on prescribers and pharmacists in being able to prescribe and dispense MS-2 Step (Mifepristone and Misoprostol) for use in medical abortion. Before August 2023, doctors and pharmacists required additional certification and registration with the MS-2 Step program and were required to undertake mandatory training in order to prescribe or supply MS-2 Step. ³

Prior to the change³:

• 1 in 10 doctors could prescribe MS-2 Step and;
• 3 in 10 pharmacists could dispense it.

Now, all pharmacies will be able to stock and dispense the medication and any medical practitioner or nurse practitioner, will be able to prescribe MS-2 Step in the course of their practice. The TGA says this decision "will assist in addressing important access issues for patients who require this medication" ⁴ – setting aside the obvious misuse of the word "require", it appears however, no added work is being made towards importantly addressing the requisite improved access to information about the risks to women of this medication – in fact, healthcare providers are now less equipped and less trained to provide this medication than ever before as a result of this change. The most concerning and predictable flow-on effect of this, will be that women seeking medical abortion will not be counselled and informed adequately of the harms of abortion in general, as the predominant body of health professionals providing medical abortions are no longer specially trained to do so. There is just cause for concern in this area when we look at the rising uptake of medical abortions in Australia:

• The number of prescriptions for mifepristone/misoprostol for medical abortion increased from 3220 in 2014‒2015 to 20,741 in 2017‒2018 ⁵ – this was while restrictions on prescribing and supply were in place!

Expanded access will likely see these figures skyrocket. As a result, many more women will be impacted by the horrors of abortion and it's after effects, both physical and psychological, simply because medical abortion is now as accessible as getting a prescription for amoxicillin from a pharmacy. More importantly we mustn't forget who the most impacted victims are; the many more innocent babies that will be killed as a result of a healthcare system that has paradoxically vowed to Do No Harm.

The risks

So then what are the risks that are not being openly spoken about when it comes to medical abortions?

• Retained fetal or placental tissue or incomplete abortion – this occurs more commonly with medical abortions compared to surgical abortions, and if it occurs, requires an invasive surgical vacuum aspiration. ⁶
• The overall incidence of adverse events was 4 times higher in medical versus surgical abortion in a follow-up study of >40,000 women who had an abortion up to 63 days gestation.⁷
• haemorrhage was 4 times higher
• incomplete abortion was 7 times higher
• Uterine infection – which is most implicated in abortion when there is retained fetal/placental tissue. ⁸
• In rarer circumstances, fatal septic shock may occur after medical abortion with mifepristone/misoprostol. ⁹
• Although mifepristone/misoprostol is prescribed by a doctor and supplied at a pharmacy, the taking of the medication itself is unsupervised and is self-administered by the woman, outside of a clinical environment. Concerns about the medication being taken improperly, women putting off taking it after having second thoughts, but then taking it anyway, potentially after 63 days gestation, and even diverting it to other women must be discussed. Unsupervised use of medical abortion pills is associated with an increased risk of serious complications that require further medical intervention such as: ¹⁰
• incomplete abortion
• failed abortion
• haemorrhage leading to anaemia and requiring blood transfusion
• septic abortion

A cohort untrained

Because we now have a cohort of doctors and pharmacists who are less trained and less educated about abortion due to the TGA's lifting of restrictions on access, it is likely that important information about the harms of abortion in general will be glazed over more so, such as:

• Psychological trauma and post-traumatic stress
• rates of mental health disorders in women who had undergone an abortion were approximately 30% higher ¹¹
• Abortion can function as a traumatic stressor with the potential of causing Post-Traumatic Stress Disorder (PTSD) and Post-Traumatic Stress Symptoms (PTSS) ^{12, 13}
• 40% of women who had underwent an abortion experienced one or more PTSD symptoms in a US study involving >800 women ¹⁴
• Suicidality ¹⁵
• In the year following abortion, women were 3 times more likely to commit suicide than the general population, and nearly 6 times more likely to commit suicide than women who gave birth
• women who aborted had a 154% higher risk of death from suicide compared to giving birth
• Impacts on future pregnancies
• induced abortion may be a risk factor for ectopic pregnancy for women with no previous ectopic pregnancy ¹⁶
• Breast cancer – The link between abortion and breast cancer risk is debated, however, a meta-analysis of the link between abortion and breast cancer risk was conducted in chinese women, which found among these women: ¹⁷
• Induced abortions is significantly associated with an increased risk of breast cancer
• Breast cancer risk increases as the number of induced abortions increase

Women seeking abortion are already vulnerable! ¹⁸

• Past traumatic experiences including past sexual violence are common in women who are seeking abortion
• Pre-existing PTSS are present in 23% of women requesting an abortion

These women need to be supported, not have their trauma fuelled even more so. An undertrained group of health professionals delivering medical abortion as a healthcare solution is far from the answer.

We must listen to the stories of those affected

Are the health professionals listening to the stories of women who have had abortions, who live with grief about their decision? Would their decision have been different if they were better informed? What about the fathers who grieve for their aborted children? When did they get a say? Abortion isn't just a women's issue, it is a human issue. Those brave enough to speak about their experiences can be found many places online, here are a couple:

RIGHT TO KNOW

H3Helpline: (Texas, USA)

Choice at all costs?

The growing trend of healthcare violating its fundamental ethic in order to accommodate the perverted ideal of "choice", by defining the wants of the patient as healthcare needs, simply because advancements in technology allow it, is a growing disease of the healthcare profession. We should accept medical technologies only if they preserve the dignity of the human person and are compatible with the main ethic that allows us to put our trust in our healthcare system – Do No Harm. Healthcare "services" that use death and destruction as a means of facilitating the wants of the patient, such as medical abortion, are a product of this disease, and the custodians of our health system – the professionals and experts that make it up, in whom we place our trust – need to be open and honest about its truths and risks if they are to uphold integrity in their practice, such that this disease in healthcare may be healed. We need pro-life pharmacists, nurses and doctors to continue to fight back, speak the truth, and have their voice heard.

Please contact rtl@rtlaust.com for a full list of references.