Pharmacists in the preparation, promotion and dispensing of abortifacients
José López Guzmán.
department de Humanities Biomedicas, University of Navarra.
(Article published in Revista Arbil, issue 63).
1. Introduction
All men have the right to accurate and complete information about their health, especially when the absence of such information may result in harm to others. However, when one studies the pathway followed in the promotion of hormonal and mechanical contraceptives, one can observe how the concealment of data and premeditated omissions have been a constant and decisive factor in this process. The resource used has been based on omitting certain words or data and at the same time creating new terms of ambiguous content to replace the previous ones. The most curious thing is that this "game" has been played not only by users, but also by health professionals such as doctors and pharmacists. In the following sections we will try to show the anti-implantation effect of some of these preparations and the interest in hiding this abortive effect through omissions or biased information. goal Reference will also be made to the participation of the pharmacist in the elaboration, dispensation or promotion of specialities whose purpose is to prevent the implantation of the embryo or its elimination after nidation.
2. Truthfulness: a duty and a right
Truthfulness is the habit of conforming one's outward expressions to one's inner thoughts. According to Ponz, "truthfulness is a moral duty whose fulfilment affects the social dimension of man and facilitates human coexistence"1. The most immediate form of failing to be truthful is lying, and this, in turn, is one of the clearest forms of manipulation2. Euphemisms, when used intentionally to avoid nuances that could cause political, economic or professional setbacks, become "soft lies". But when these euphemisms are used to change opinions or manipulate other people in some way, they cease to have the qualification of soft lies and become real lies. In the case of contraceptives and abortifacients, the use of euphemisms has frequently been resorted to, giving rise to a misleading use of pharmacological and clinical terminology which constitutes, according to López García3 , a real attack on the most elementary professional honesty. Thus, ovulation inhibitor, pregnancy interruption, cycle regulator, anovulatory preparation, ovulistatic, natural ovarian stabiliser, interception or postcoital contraception are some of the terms used that may indicate something, but do not fully define them. agreement In the promotion of contraceptives, any reference to their possible abortifacient or anti-implantation effects is avoided for commercial reasons4. According to framework this "implies the violation of the right of individuals to be informed and the right to freedom of conscience to live in accordance with their chosen ethical code"5. Health professionals must not mislead themselves or their patients, they are obliged to use appropriate, correct and complete terms, to give details of all side effects and mechanisms of action, and to provide all data obtained in the research process. Sometimes, for various reasons, aspects of medicines that are of enormous importance and have a direct influence on the health of consumers are consciously omitted. Thus, it is common for pharmaceutical products that in some countries carry a series of warnings to consumers about their side effects and interactions to be omitted in other countries, mainly in the Third World6 .
3. The embryo
In order to conceptually distance abortion from the death of a human being, the idea has been introduced that the embryo is not a human individual, and furthermore, a classification has been made: embryo and pre-embryo, which can further distance the concept of being and not being, when the only thing that differentiates them is their state of development. Thus, as the human embryo is at a particular stage of its existence in which the human form, as is commonly thought, has not yet been expressed, it is questioned whether its elimination is an attack on human life7. Thus, "The American College of Obstetrics and Gynecology" established, in 1972, that conception begins with the implantation of the blastocyst. According to this definition, the elimination of an embryo before implantation would not constitute an abortion. The "Committee on Medical Aspects of Human Reproduction", in response to a enquiry formulated by the World Health Organisation, also took this view8. However, modern genetic research techniques have confirmed that the human embryo is unique and unrepeatable. It has a genetic heritage distinct from that of its parents, but with chromosomes from both. It is autonomous, but for its growth it needs the mother's organism, just as after birth it will need her care to nourish itself and begin to learn everything it will need for its subsequent development and life together. When pharmacists deal professionally with abortion, they generally do so at this level, as their preparations will be aimed at eliminating the embryo, either before implantation or in the first stages of its development development.
4. Common methods of pharmacological abortion
First of all, it should be noted that not all contraceptives act in the same way: some have only an abortive effect, others combine their anti-implantation action with other mechanisms, and still others do not affect the embryo at all9. Making these parameters clearly established and delimited is the first ethical obligation to be respected by researchers when they develop these principles, by pharmaceutical laboratories when they develop them, by health authorities when they authorise them, by doctors when they prescribe them, and by pharmacists when they dispense them. In addition to their mechanism of action, contraceptives can also be grouped according to the time at which they are administered10:
1) Those that are administered regularly (daily, monthly or yearly). This section includes hormonal contraceptives, IUDs and the hormone HCG.
2) Pre- or post-coital preparations, which are given when sexual intercourse is thought to have taken place during fertile time and without other protection. This group is in turn divided into two others: those given immediately after intercourse and those given late, when menstrual delay is noted. On the basis of these data, the possible abortifacient effect11 of some of these preparations should be detailed:
a) Oral hormonal contraceptives12. Gregory Pincus demonstrated in the 1940s that the ovulatory peak of LH in the rabbit was inhibited by the injection of natural steroids. From then on, the development phase of hormonal contraceptives began. The first preparations contained high doses of hormones, which caused many side effects. To remedy this drawback, the hormone dosage was gradually reduced, but this did not lead to a decrease in the contraceptive effect. This was attributed to the fact that anovulation was not the only mechanism of action of contraceptive pills13. Thus, in 1969, the U.S. Food and Drug Administration established that there were three effects on the body, the second of which was the modification of the endometrium14. Other authors, however, maintain that the mechanism of action of these preparations is quadruple15:
1) Inhibition of LH and FSH release at the hypothalamic-pituitary level.
2) Alteration of tubal motility, oestrogens increase and progestogens decrease tubal motility.
3) Change in the development of the endometrium.
4) It alters the cervical mucus. The second and third mechanisms have a clear anti-implantation (abortifacient) effect if preceded by fertilisation of the egg.
In addition, it has been shown that after a long period of use of these hormone preparations, discontinuing their administration causes miscarriages because the ovary immediately resumes its function, while the endometrium takes about four months to recover. The mini-pill consists of very low doses of hormone, 3 to 4 times less than normal pills. Ovulation is blocked in 50% of cycles16 and contraceptive efficacy develops at the level of the tube, endometrium and uterine cervix. In this sense, it has been proven that mini-pills produce almost normal gonadotropin levels, sometimes LH peaks and ovulations, there is steroid secretion, alteration of cervical mucus and they continue to be contraceptive by altering the endometrial development and embryo implantation17. Due to their action on the endometrium, they sometimes become a means of abortion18. Morning before pill or morning after pill: they are only oestrogen, only progestogen, or an oestrogen-progestogen combination19 , taken for a few days in high doses, before or shortly after a relationship that is thought to be fertile. goal The purpose of this massive intake of hormones is to prevent the implantation of the fertilised ovum. It should be noted that if the embryo is not eliminated after ingestion of these compounds, the likelihood of malformations increases20 .
b) Intrauterine device (IUD). This is a device of various shapes that is inserted into the uterine cavity21 . It has a support material - steel, polyethylene, plastic, silver - which may be copper-coated or contain a progestogen. Its mechanism of action is still debated22. The most widely accepted reasons for their mode of action are that they cause hypertrophy or necrosis of the endometrium, which makes nidation impossible, an alteration of the intrauterine pH due to interaction of the endometrium with the composition of the ring, or an alteration in hormone production23 . In other words, they essentially act by preventing the embryo from nesting in the uterus, thanks to the alterations they produce in the endometrium24. The anti-implantation effect of IUDs is also confirmed by the fact that they are sometimes used after coitus, and that a relationship has been found between IUD use and an increase in ectopic pregnancies25. In this regard, in 1982, an Australian research team, group , demonstrated that 25% of women with IUDs had an increase in EPF (early pregnaci factor), an immunosuppressive substance present four hours after conception. From this it is easy to deduce that pregnancy has already begun even in the presence of the coil26.
c) Quarterly depot injection. It acts on the cervical mucus, making it less permeable to sperm, and also on the endometrium, altering it and preventing implantation. Ovulation can be inhibited, but this effect is not constant27. Thus, it has been shown that the blockage of ovulation that occurs by reducing the production of pituitary hormones (LH and FSH) and hypothalamus hormones (GnRh)28 does not manifest itself. The best known is Medroxyprogesterone Acetate, which is administered every three months in doses of 150 mg.
d) Subcutaneous implant. These are silicone capsules or similar material that are implanted subcutaneously, containing microcrystals of a progestogen or an oestrogen plus a delayed-release progestogen. The most widely used implant is Norplant29, which consists of 6 silicone capsules containing a total of 36 mg levonorgestrel. This hormone is released over 5 years30. It works by a similar mechanism to the depot injection, altering the structure and trophism of the endometrium31, and preventing the product of conception from implanting and causing a micro-abortion. There are other preparations that are directly, and without any doubt, abortifacients, for example32:
a) Mifepristone33. RU-486 is a 19 noresteroid that interacts with the glucocorticoid receptor and the progesterone receptor, producing a chemical abortion by blocking the action of progesterone, which is a hormone necessary for the nidation and development of pregnancy34. It has a clear abortifacient effect35, since, after administration after implantation, it causes damage to the vascular endothelium with increased production of prostaglandins, desquamation of the uterine mucosa and increased myometrial contractility, leading to placental detachment and a decrease in chorionic betagonadotrophin, which has an irreversible luteolytic effect36. RU-486 does not cause abortion in "100%" of cases because the drug does not reach sufficient hematic levels to antagonise circulating progesterone. The contraceptive effect is most often seen in early pregnancy, when the progesterone level is still low. Administered to women within 10 days of conception with high levels of hCG, progesterone and oestrogen suggestive of pregnancy, it produced abortion in 85% of cases, with doses between 400 mg (100 x 4 days) and 800 mg (400 x 2 days)37. From day 49 of conception, the placenta produces a high amount of progesterone that cannot be antagonised by RU-48638.
b) Prostaglandins. The prostaglandins that have an effect on the uterine musculature are E and F39. Misoprostol is a prostaglandin that causes contractions and pulsations in the uterus, thus causing the expulsion of the new being. This principle was included in the pharmacological arsenal due to its beneficial properties in the treatment of peptic ulcer, but in some areas, such as Brazil, it has been frequently used as an abortifacient, for the reason mentioned above40.
c) Vaccine against Gch. A variety of immunological methods have been tested for fertility regulation, one of which is the anti-hCG vaccine41. HGH is human chorionic gonadotrophin. This hormone is the signal that the embryo at development sends to the uterus to maintain the necessary growth during the first months of pregnancy, so that the embryo can implant and develop in the uterus. If hCG levels drop during the first 6-10 weeks, the new being would die and be expelled from the uterine cavity, resulting in an early miscarriage42 .
5. Pharmacist and abortion
En torno a la anticoncepción es importante que el farmacéutico reflexione sobre las siguientes cuestiones: a. El farmacéutico en su faceta de investigador, educador o dispensador, debe procurar, en todo momento, delimitar convenientemente los términos que utiliza, intentando no omitir ni añadir nada que afecte a la percepción de la verdad. En este sentido, es una falta ética ocultar o negar que ciertos anticonceptivos se comportan como antiimplantatorios43. El farmacéutico tiene unas obligaciones consigo mismo, con su profesión y con la sociedad. En relación con este último aspecto, hay que destacar la importancia que adquiere la veracidad en la información, debido a que la profesión farmacéutica está dirigida a proteger dos valores de máxima relevancia como son la salud y la vida44. b. El profesional no debe tener únicamente una visión cientifista de su cometido y no puede conformarse con conocer la composición de las especialidades o sus puntuales efectos secundarios. El farmacéutico debe saber que los distintos métodos anticonceptivos no son neutros45 y afectan al nivel biológico46 y psicológico del usuario, y que además pueden llegar a tener consecuencias negativas para el conjunto de la existencia, tanto de la persona como de la pareja47. Boiardi mantiene que la seguridad anticonceptiva es sólo un aspecto del problema, ya que es necesario también definir las leyes biológicas, la integridad de las correlaciones neuro-endocrinas que hay que respetar, la autenticidad del amor humano que debe salvaguardarse, y el valor de la persona, en su total dimensión48. Uno de los riesgos de la planificación contraceptiva radica en caer en el error de convertir a la persona en un simple número49 dentro de un programa de acción. c. La información sobre técnicas anticonceptivas nunca debe ir separada de la educación sobre la sexualidad y el amor. En caso contrario, se estaría traicionando al hombre, ya que el acto sexual no es un hecho aislado del resto de la vida50. Últimamente es frecuente encontrar en la literatura profesional referencias a la contribución esencial de los farmacéuticos a los programas de planificación familiar51, abriéndose de esta forma nuevos horizontes en el campo de la fertilidad52. Es lamentable que, en ocasiones, el farmacéutico se inhiba del compromiso que tiene ante la sociedad de informar y educar, convirtiéndose de esa forma en un simple suministrador de especialidades farmacéuticas53. En el aspecto tratado en este trabajo, el de la anticoncepción, la irresponsabilidad de los farmacéuticos ha sido tan manifiesta que ha dado lugar a que se realice un añadido al Código Penal, debido a la exorbitada venta que se realizaba sin prescripción facultativa54. d. Debe haber un conocimiento de lo establecido legalmente sobre la anticoncepción y el aborto55, tanto desde el plano social como desde el profesional, pero dicha visión no puede quedar asépticamente separada del necesario enjuiciamiento moral56. En este sentido, es evidente el cambio de posicionamiento legal que se ha producido en los últimos años con respecto a la anticoncepción, que ha pasado de un sistema de tutela jurídica de la prohibición de la propaganda anticonceptiva, a una situación de total inhibición o hasta incluso promoción57. Así, el Código Penal Español pasó, en pocos años, de castigar58 a los que fabricaban, ofrecían en venta o anunciaban medicamentos, sustancias, objetos, instrumentos, medios o procedimientos capaces de evitar la procreación, a no hacerlo59. e. Moralmente, el farmacéutico puede inhibirse de la investigación, promoción o dispensación60 de aquellos preparados que no estén dirigidos a prevenir o curar enfermedades, cuando su participación en dichos actos pueda entrar en conflicto con su conciencia61. En el caso de los preparados antiimplantatorios, no hay duda de que el fin perseguido es la expulsión del embrión y, por lo tanto, la eliminación de un nuevo ser62. En palabras de Sgreccia, el farmacéutico "puede oponerse a vender aquellos fármacos que, por su composición, no pueden ser usados más que de un modo ilícito y dañoso, según la propia conciencia"63. f. Los casos de conflicto entre el farmacéutico y su conciencia deben ser solventados mediante una participación activa del profesional. Cuando el farmacéutico se niega a participar en la investigación o promoción de un determinado preparado, no debe esconderse en su silencio, sino que tiene que ser coherente y exponer las razones que motivan su conducta. Más aún, tiene que proponer alternativas válidas a lo que él cree ilícito64.
(1) Ponz F. Derechos y deberes respecto a la verdad. In: López Moratalla, N. et al. Deontología Biológica. Pamplona: School de Ciencias de la Universidad de Navarra, 1987, 118.
(2) Ayllón JR. En torno al hombre. Madrid: Rialp, 1992, 105-106.
(3) López García G. Contraceptivos orales... op. cit. p.14.
(4) Marshall RG, Ratner H. Oral Contraceptives: The Medical evidence for covert abortion. Part II. A.L.L. About Issues, 1986; Nov-Dec: 8.
(5) framework Bach FJ. Contraceptives or artificial methods of fertility regulation. Medicine and Ethics, 1993; 4: 53.
(6) Silverman M, Lydecker M, Lee PR. Bad Medicine. California: Stanford University Press, 1992; 40.
(7) Di Pietro ML, Sgreccia E. La contragestazione ovvero l'aborto nascosto. Medicina e Morale, 1988; 1: 19-23.
(8) Tatum HJ, Connell EB. A decade of intrauterine contraception: 1976 to 1986. Fertility and Sterility, 1986; 46 (2): 186.
(9) It should be noted that the distinction between the abortifacient and contraceptive effect of a given principle or specialization program is not always clearly defined. See Noonan JT. Contraception. In: Encyclopedia of Bioethics. New York: The Free Press, 1978; Y: 205.
(10) Di Pietro ML, Sgreccia E. La contragestazione ovvero l'aborto nascosto. Medicina e Morale, 1988; 1: 8-9.
(11) See Flórez J, Armijo JA, Mediavilla A. Farmacología Humana. Pamplona: Eunsa, 1989; II: 694. This text provides a table outlining the mechanisms of contraceptive action of the main forms of hormonal contraception. In this sense, it indicates, for example, how the combined forms act fundamentally by inhibiting ovulation, while the gestagen in silicone capsules or the postcoital forms have little effect on ovulation.
(12) Although there has been much discussion about the effect of these preparations on the endometrium, it should be pointed out that this is a reality recognised even by the manufacturing laboratories themselves. Wyeth-Orfi, in the package leaflet of specialization program Minulet, specifies "and changes are produced in the endometrium that reduce the possibility of egg implantation. In this way, through a triple mechanism of action, effective protection against pregnancy is achieved". However, another laboratory which markets a specialization program with the same composition as the above does not include any reference to these other routes in the package leaflet. Forgotten? in doubt? the right to information that all patients have requires that the information be clear, concrete and truthful.
(13) Studies by Grenhill, Starup and Visfeldt showed that 7% of cases were compatible with ovulatory phenomena. See Boiardi G. Aspetti etici della contraccezione ormonale e meccanica. Medicina e Morale, 1984; 34: 54.
(14) Marshall RG, Ratner H. Oral contraceptives: The medical evidence for covert abortion. A.L.L. About Issues, 1986; October: 10.
(15) framework Bach FJ. Anticonceptivos o métodos artificiales. Medicina y ética, 1993; 4: 63. Jiménez Vargas J; López García G. Aborto y Contraceptivos (2nd ed.), EUNSA, Pamplona, 1979; 95-103. López García G. Contraceptivos hormonales: roundtable sobre anticonceptivos (Sponsored by Lab. Morrith), 1973. Navarreta V. La contraccezione e i dispositivi intrauterini: meccanismo di azione ed effetti fisici. In: La procreazione responsabile. Fondamenti filosofici, scientifici, teologici; n°6. Rome: Lateran University, 1984; 22.
(16) Boiardi G. Aspetti etici della contraccezione ormonale e meccanica. Medicina e Morale, 1984; 34: 53.
(17) framework Bach, FJ. Contraceptives or artificial methods of fertility regulation. Medicine and Ethics, 1993; 4: 64.
(18) Navarretta V. La contraccezione e i dispositivi intrauterini: meccanismo di azione ed effetti fisici. In: La procreazione responsabile. Fondamenti filosofici, scientifici, teologici. Rome: Pontifical Lateran University, 1984; 6: 7.
(19) Combination is currently preferred. Determined amounts of ethinylestradiol and norgestrel, administered within 72 hours post-coital, repeating the same dose 12 hours later. See Flórez J, Armijo JA, Mediavilla A. Farmacología Humana. Pamplona: Eunsa, 1989; II: 694.
(20) framework Bach J. Artificial methods of human fertility regulation. Bioethics Notebooks, 1991; 6: 38.
(21) It has been widely used since 1909. In 1989 it was estimated that more than 60 million women were using it. See Cole EM. Intrauterine Devices. JAMA, 1989; 261 (14): 2127-2130.
(22) Chartier M, Cordier O, Cordier P, Ledoux M, Ledoux MM. Le couple et la limitation des naissances. Réflexions et informations sur la contraception. Paris: P Lethielleux, 1966;55.
(23) Garcia CR, Pincus G. Hormonal Inhibition of Ovulation. In: Calderone MS. guide of Contraceptive Practice. Baltimore: Williams & Wilkins, 1964, 258.
(24) Moretti JM, Dinechin O. The genetic challenge. Manipulations, early diagnosis, insemination, contraception. Barcelona: Herder, 1985, 140.
(25) Basso DM. Nacer y morir con dignidad. Buenos Aires: Consortium of Catholic Physicians, 1989, 352-358. Tatum HJ, Connell EB. A decade of intrauterine contraception: 1976 to 1986. Fertility and Sterility, 1986; 46 (2): 185.
(26) Di Pietro ML, Sgreccia E. La contragestazione ovvero l'aborto nascosto. Medicina e Morale, 1988; 1: 12-13.
(27) Navarreta V. La contraccezione e i dispositivi intrauterini: meccanismo di azione ed effetti fisici. In: La procreazione responsabile. Fondamenti filosofici, scientifici, teologici. Rome: Pontifical Lateran University, 1984; 6: 9.
(28) Di Pietro ML, Sgreccia E. La contragestazione ovvero l'aborto nascosto. Medicina e Morale, 1988; 1: 10.
(29) It should also be noted that there have been numerous complaints about Norplant. See Darney PD, Klaisle CM, Walker DM, Ghadially R. The importance of proper insertion of Norplant contraceptive implants. The Journal of Family Practice, 1992; 34 (5): 545-546.
(30) Baird AT, Glasier AF. Hormonal contraception. The New England Journal of Medicine, 1993; 328: 1546.
(31) Navarreta V. La contraccezione e i dispositivi intrauterini: meccanismo di azione ed effetti fisici. In: La procreazione responsabile. Fondamenti filosofici, scientifici, teologici. Rome: Pontifical Lateran University, 1984; 6: 10.
(32) 20% sodium chloride solutions can also be included in this section , as they would be made by hospital pharmacists. See Severyn KM. Abortifacient Drugs and Devices: Medical and Moral Dilemmas. Linacre Quarterly, 1990; 57 (3): 52.
(33) Mifepristone is not marketed in Spain, although there are frequent demonstrations calling for its incorporation specialization program into our therapeutic arsenal. A proposal in this sense was made at the workshop held in Madrid on "Maternity and voluntary interruption of pregnancy" organised by the Women's Secretariat for the Defence of Public Health, in collaboration with the Women's Institute, the Sexology Society of Madrid and the Federation of Family Planning, in JANO, 1993; 1040: 26. The Minister of Culture, Carmen Alborch, has also signed a manifesto, together with 3,000 other personalities from different social and health sectors, supporting the distribution of the abortion pill in Spain. In: Las Provincias, 24 January 1994, 57.
(34) framework Bach J. Artificial methods of human fertility regulation. Bioethics Notebooks, 1991; 6: 38.
(35) On psychological and economic aspects of surgical and pharmacological abortion, see Macrow PJ. Political, Economic and Ethical Aspects of use of medical abortifacients. PharmacoEconomics, 1994; 5 (4): 269-273.
(36) Tejerizo López LC, Lanchares Pérez JL. Early and late postcoital contraception. Información Terapéutica del Sistema Nacional de Salud, 1993; 6: 162.
(37) Flórez J, Armijo JA, Mediavilla A. Farmacología Humana. Pamplona: Eunsa, 1989; II: 688.
(38) Di Pietro ML, Sgreccia E. La contragestazione ovvero l'aborto nascosto. Medicina e Morale, 1987; 1: 17-18.
(39) Severyn KM. Abortifacient Drugs and Devices: Medical and Moral Dilemmas. Linacre Quarterly, 1990; 57 (3): 53.
(40) Macrow PJ. Political, Economic and Ethical Aspects of use of medical abortifacients. PharmacoEconomics, 1994; 5 (4): 271.
(41) Spieler J. Mise au point de méthodes immunologiques de régulation de la fécondité. Bulletin de l'Organisation mondiale de la santé, 1988; 66 (2): 171-175.
(42) Human Life International Newsletter, 1994;49:7.
(43) It is curious how the abortive effect of contraceptives is not directly mentioned, although it is indirectly and underhandedly admitted. See Tejerizo López LC, Lanchares Pérez JL. Early and late postcoital contraception. Información Terapéutica del Sistema Nacional de Salud, 1993;6:157-164.
(44) Moreover, one of these rights is protected by art. 15 EC, and the other is protected by art. 43 EC.
(45) In this regard, it should be noted that for a long time the idea of the "amorality of science" was maintained. After the events perpetrated by Nazi Germany, scientists began to question certain ethical principles, and tried to give a moral justification to their research. See Sidel VW, Sidel M. Biomedical science and war. In: Reich, WT. Encyclopedia of Bioethics. New York: The Free Press, 1987;4:1699. Boardi states that even if science were neutral, the man of science is not; therefore, he must seek and approach the truth and not stray from it. See Boiardi G. Aspetti etici della contraccezione ormonale e meccanica. Fondamenti filosofici, scientifici, teologici. Medicina e Morale, 1984; 34: 47.
(46) In this respect, the WHO's recommendations on the side effects of hormonal contraceptives are clear, proposing prior medical examination, limiting their use from the age of 35, and taking breaks of at least one month every three months. See framework Bach J. Artificial methods of regulating human fertility. Bioethics Notebooks, 1991; 6: 35-36.
(47) Moretti JM, Dinechin O. The genetic challenge. Manipulations, early diagnosis, insemination, contraception. Barcelona: Herder, 1985; 149.
(48) Boiardi G. Aspetti etici della contraccezione ormonale e meccanica. Medicina e Morale, 1984; 34: 47-48.
(49) Shivanandan M. Personhood, Contraception and Population Control. The Linacre Quarterly 1994; 3: 41.
(50) Rodriguez Luño maintains that the contraceptive procedure is introduced into the internal and immanent dynamics of sexuality. See Rodriguez Luño A. Differenza morale de antropologica fra la contraccezione e la continenza periodica. In: La procreazione responsabile. Fondamenti filosofici, scientifici, teologici. Rome: Lateran University, 1984; 7.
(51) Population Reports,1989; J: 37. In: Información Terapéutica del Sistema Nacional de Salud 1990;10:290-291.
(52) Pérez Mª T. Fertility control. Introduction: the pharmaceutical committee . El Farmacéutico, 1995; 152: 64.
approve (53) With regard to this point, it should be noted that pharmacists cannot publicly admonish their customers either, as this would violate their right to privacy. Such "conflict" situations should be handled with respect and discretion. See Lowenthal W. Ethical dilemmas in Pharmacy. Journal of medical ethics, 1988; 14: 31.
(54) Art. 343 of the 1973 CP (BOE, 12.XII.1973) which states that "those who dispense medicines without complying with legal or regulatory formalities shall be punished with major prison and a fine of 5,000 to 250,000 pesetas", is modified in the 1978 CP (BOE, 11.X.1978) as follows: "those who dispense medicines of any kind class or contraceptives without complying with the legal or regulatory formalities shall be punished with the penalties of major arrest and a fine of 20,000 to 100,000 pesetas".
(55) See Martínez-Pereda Rodríguez JM. La responsabilidad penal del médico y del sanitario. Madrid: Colex, 1994; 561-586.
(56) Pharmacists will frequently find themselves involved in the moral/legal controversy of abortion or those products or specialties that may become abortifacients. See Cowen DL. Pharmacy. In: Encyclopedia of Bioethics. New York: The Free Press, 1978; 3: 1213.
(57) Mongillo D. Rifessioni morali sulla libera e legalizzata vendita dei contraccettivi. In: Angelini F. Medicina e Morale 1971; 4: 53.
(58) Art. 416 of the 1973 Criminal Code (BOE of 12 December 1973), states that those who, in relation to medicines, substances, objects, instruments, devices, apparatus, means or procedures capable of provoking or facilitating abortion or preventing procreation, carry out any of the following acts shall be punished: .... 4° The dissemination in any form whatsoever of those intended to prevent procreation, as well as their public display and offering for sale; 5° Any kind of contraceptive propaganda.
(59) In 1978, Art. 416 of the 1973 CC was amended by deleting the reference to "preventing procreation" from the first paragraph and paragraphs 4 and 5 (Law of 7. X. 78, No. 45). In the Decree of 1978 (Royal Decree of 15.XII.78, n° 3033, implementing Law 45/78) the characteristics of the issue and advertising of contraceptives were determined.
(60) In this regard, it should be noted that from 1957, when the FDA approved the pill as a contraceptive, the definition of a drug changed. Until then, any product used to diagnose, prevent, cure or alleviate a disease was considered a drug. Since 1957, it has been established that a drug is also a drug that modifies a function. See Alvarez de la Vega F. Ethics of dispensing contraceptives. El Monitor de la Farmacia y la Terapéutica 1989; 2206: 194-195 and Melgar Riol J. Objeción de conciencia y farmacia. Cuadernos de Bioética, 1993; 14: 40. Many countries have adopted this definition, as is the case in Spain, which includes it in the Law on Medicines.
(61) However, some believe that the pharmacist's freedom of conscience must yield to any request from the patient. Thus, Mendez states that when pharmacists are asked for a contraceptive or committee on contraception, they should not "ignore the fact that they are being asked in their capacity as healthcare professionals, with the sole purpose of asking report on matters that fall within their competence and in the certainty that if they wanted a philosophical, moral or religious committee they would have contacted other people and not a Pharmacy". See Mendez Carpe F. Modern contraceptive systems. Pharmaceutical Informative 1985; 167:52.
(62) Various associations have proposed models to ensure pharmacists' conscientious objection. For example, Pharmacists for Life has developed the Model Pharmacist's Conscience Clause, and The Center for the Rights of the Terminally Ill the Resolution to Protect the Rights of Conscience of Health Care Personnel. See Severyn KM. Abortifacient Drugs and Devices: Medical and Moral Dilemmas. Linacre Quarterly, 1990; 57 (3): 61-62.
(63) Sgreccia E. Dispensazione al pubblico dei mezzi contraccettivi e/o abortivi. Medicina e Morale, 1989; 39:746.
(64) Such as, for example, promoting the lifestyle of natural methods. See Vaitoska G. For Men of Our Time.... Linacre Quarterly, 1994; 61 (4): 37-47.