Tuesday, June 05, 2007

Outrage and Dissent

Yesterday, the Pedant sent Annie and me two articles, one entitled "The Right to Buy Birth Control," written by Stuart Anderson in Reason Magazine (Jun 01), and a Wall Street Journal Op-Ed piece by Naomi Schaefer Riley. The first article refers to a Montana pharmacist who's refusing to stock birth control. The author compares the issue to "someone who tries to buy eggs at a convenience store that doesn't stock them has been "denied basic food," or that someone who tries to check into a motel that's full has been "denied basic shelter"," asserting that the pharmacist has no duty to stock a medication that, for moral reasons, he doesn't think women should use. You may recall a similar controversy surrounding Plan B, the so-called "Morning after pill." Part of the dispute in that case was that the FDA ruled that women could get Plan B over the counter. Perhaps now that women had more control over their reproduction (instead of a doctor's note telling the pharmacist to give the medication), pharmacists felt queasy about handing out Plan B. Unlike Plan B, however, patients must have a prescription to buy birth control. To clarify for those of us who are confused in any way, this pharmacist REFUSED TO STOCK MEDICATION PRESCRIBED BY A PHYSICIAN. And then he defended himself on moral grounds.

The Op-ed piece, a condescending piece of editorializing, basically claims that poor women get abortions because their baby-daddy drops out of the picture. I'm simplifying a bit, but I'm livid, so please excuse my tone and relative disregard of my duty to fair and unbiased summary. Incensed at both these articles, I had not one, but two concurrent conversations about them, one with Annie and one with the Rooster. The transcripts (edited for length and language) follow.

My discussion with Annie:

Harley: First, Anderson’s analogies are wrong
Annie: Yes, I agree. What if he decided that he didn't like penicillin?
Harley: Or that he were morally opposed to anti-depressants or insulin. Or that, as a Jehovah's witness, he would only carry Bibles. And re: the sex ed article, I am so sick of talking heads treating women like idiots. Nowhere does it mention how difficult it is for women to negotiate contraceptive use or have access to it.
Annie: Yeah, it isn't the lack of info, according to the other roommate, it is that the girls don't know how to negotiate condom use
Harley: Or AFFORD it.
Annie: And that they don't want to take the pill b/c it is going to make them fat
Harley: Or they have a terrible hormonal reaction to it. I know several women who've gone off birth control because it swung their emotions out of control
Annie: Or it is expensive without health care
Harley: Totally expensive and difficult to ascertain which one fits you, if you don't have a good, regular gynecologist, for example. Oh! and also, what about mistakes? Ms. Riley does not once mention that the pill is not foolproof (neither is condom use) and not once in the entire article are men and their contribution mentioned. "Having decided to "unintentionally" get pregnant"? Really? Does she think that inner city women and suburban moms that decide to get pregnant for whatever reason constitute the majority of abortions? The last paragraph is the most insulting and, quite frankly, classist. In fact, the whole article is classist (and I'd say racist, since class and race are so inextricably intertwined in this country, but let's stick to the incontrovertible evidence).
Annie: My roommate often takes her charges (she works at a foster care group home for young mothers) to get abortions. They know how sex works, they had a baby, but they can't/won't negotiate condom use, or the pill, and so they treat abortions like a contraceptive.
Harley: Here's the question I often get when I have this discussion: I was talking to a dude last week and he just didn't get why it was hard to ask that a guy use a condom or not sleep with the dude if he refused and I tried to explain power dynamics, how it seems like a choice between acceptance/love/intimacy and total rejection, and how some women, particularly high risk women from low socio-economic status neighborhoods don't understand that a guy who won't automatically put on a condom is a complete asshole, but I sounded like a total tool
Annie: Often even if suggested,guys don't want to; there isn't a culture of how to say you want one
Harley: So how do we address that?
Annie: Better education
Harley: Can sex ed address it? If teachers honestly and openly discussed it
Annie: Instead of abstinence ed, a culture of how to say no/maybe. We had a wheel in my sex-ed class: common "but I don't want to wear one" phrases, and cutesy responses; i.e., "But I can’t feel anything through it." A: you'll feel even less if you don't have sex
Harley: I remember those. They seemed a bit flippant, but whatever works, I guess
Annie: It teaches you that it can be a dialogue, that condom use is a negotiation

And my much longer conversation with the Rooster (TR). I know it's lengthy, but TR has an insightful and interesting perspective on poverty and pregnancy, so please try to get through it. You can skip my parts if you like.

TR: I don't buy the libertarian argument regarding the pharmacist. You need to be licensed to be a pharmacist and one of the licensing requirements should be that you will provide medicine that is prescribed by a doctor, whatever that medicine is. The sex ed article was better and probably true, but who knows?
Harley: It's not true; I know. I'm surprised-- I thought you'd call it out on the classism
TR: No you do not!
Harley: I do know that her assumption that the majority of women who get abortions, particularly in low income areas, do so because they got pregnant on purpose and then couldn't hook a man is wrong
TR: That is not what she said. That was one example of why a woman might not insist on using contraception; hat was an example. I don't think she said it was the majority, but I think she was too careless switching from the general to the anecdotal.
Harley: “The most common exceptions mentioned--rape, incest and life of the mother--are in fact the least common reasons women have abortions. So what gives? Maybe the answer is obvious: Women get pregnant because they want to have babies.”
TR: Yeah. Also, they are drunk.
Harley: I do know that it's true that a number of women, particularly low socio-economic status women, use abortion as birth control [Ed.: see my discussion with Annie], but that's not because they don't care if they get pregnant in the first place; nor is it because they can't figure out that sex leads to babies. They report that it's because they can't, won't, or don't know how to negotiate condom use with their man and they can't afford or do not have access to birth control (largely the former, but also the latter)
TR: That's what they are reporting. Again, who knows what's in their heads?
Harley: So now we're trusting information that confirms our stereotypes, taken from statistics, but ignoring what these women say themselves?
TR: I know a lot of women who intentionally got pregnant to trap a man, only to find out that the man did not give two shits about her or the baby. Dude, stop living in a liberal bubble. I grew up poor. Everyone lies, no one group of people are virtuous. The "stereotype" you are pointing to has some basis in truth
Harley: Who said they were? First, don't talk down to me just because I didn't grow up poor like you did. Second, who's generalizing from anecdotes now? I didn't say that all women who claimed to have been incapable of negotiating condom use were telling the or that all these women were being truthful
TR: I think you are being naïve. Something to chew on: if the men are insisting on not using condoms, how does that change things? The women should opt not to have sex with them. I am not assigning "blame" here because I don't care about abortions. I don't care if people are getting abortions as birth control.
Harley: No, you're totally right. I'm not excusing the women's behavior or saying they shouldn't take responsibility for their actions
TR: A lot of poor people think having babies is something you do when you are young. This girl I know -- her grandmother told her to have babies right away to "get on with her life"; she was 18. The entire mindset is different
Harley: I had no idea. I know you don't care, but is there any way to address that, systematically?
TR: It's complicated. Education, I suppose. Beat 'em over the head with "condoms & college." Also, more women should be having abortions. (I guess optimally they won't get pregnant in the first place), but soooo many young girls with bizarre religious beliefs are having babies because it's the "right thing to do" and then keeping the cycle of poverty going. I don't mean to generalize too much from my experiences. Also, DRUGS: these people are drunk and stoned when they are having sex.
Harley: The thought of getting pregnant terrifies me. Also, the thought of having an abortion. From what I've heard, not a pleasant procedure. From a personal perspective, although I support a woman's right to get an abortion, I can't even conceive of being in that position without feeling nauseated at the prospect. It truly terrifies me
TR: I wasn't trying to shoot down the notion that people need more information, but I also think that people pretty much know about condoms, and they are very easy to acquire
Harley: It's not that they don't know about them or don't have them. It’s that they're incapable, for whatever reason (power dynamics, for one) of saying: dude, put on a rubber
TR: In terms of classism: I don't mind when people say things that are startlingly and obviously true about a particular class (not that I think the article in question was obviously true). I don't like it when people say that poor people want to be poor and that they are lazy or that they are stupid
Harley: I thought she was basically calling poor people stupid and naïve and I thought it talked down to women, on the whole
TR: Yeah, it did. It was simple-minded
Harley: More anecdotal than a thorough presentation of the evidence
TR: My perspective on these things is such that I am constantly pissing off everyone. I think society has a moral obligation to lift poor people out of poverty, but I don't know how. What people do not get is the sense of utter hopelessness. It's the constant fear that everything is going to be taken away: shelter, food, whatever. You can't go to the doctor because you can’t afford to go to the doctor. So you are always nervous that you are going to break something and then you are going to spend the rest of your life paying off a broken arm. It's about survival. And the only respite you get is getting drunk on the weekends; it's the poor man's vacation. But I fucking HATE these goddamn "Good Will Hunting" bullshit stories that people buy into: some fucking kid breaks out of it, goes to college and he's treated like a goddamn saint. The New York Times runs articles like that constantly: "Omar's dad was in prison, he grew up on welfare..." So fucking what? It's never like the way they describe. It's bullshit.
Harley: It's the cult of the American Dream. It supports the capitalist system. It feeds into our inaction. And say, "well, if they really wanted to do better..."
TR: It's a way for rich people to feel good about themselves. "If Omar can do it, then anyone can..." Omar probably has an IQ of 135. If he were born rich he'd be finishing his astrophysics PhD. The ones who get out are always super bright, which is not something they earned, it is something they were born with. It's not virtuous. Poor people are EXPLOITED, plain and simple, but they still make stupid decisions. The difference is, when they make stupid decisions, they are FUCKED. Now, I am just ranting. I get so angry. So many of my friends have miserable lives and they did not have a goddamn fighting chance. My friend was raised by a schizophrenic who thought she was a goddamn witch and now he's a heroin addict. Well, what the fuck else was going to happen? I have to say, going back to that article, it did remind me of certain situations that ended up fucking my friends pretty badly. Girls used to tell people they were pregnant, even when they weren't, to "test" how their boyfriends would react and then deny they ever said anything when asked about it by their boyfriends, after the rumor started. The sexual politics were fairly insane. The girls, of course, completely identified themselves vis a vis whomever they were dating, which doesn't speak well for their self esteem. The guys always had more money, too, which created a power differential, but not really because the girls had the power of the pussy, so they had the real power or so they thought until they were pregnant for real and then they were fucked. What I am getting at is that ALL people suck in their own way. Sometimes I feel that my friends speak valiantly of the poor, but they have no idea. Poor people do get shit on by society, which seems reason enough to help them out. You don't have to turn them into saints; everyone sucks; and rich people suck the most because they have the power and the entire system is crafted in their favor. They are getting rewarded even when they don't realize they are and then they congratulate themselves for all their hard work
Harley: I think the real distinction, which you pointed out, is that everyone sucks, but that helping people out who need it isn't because they're a good person who deserves it, it's because the system is unfair and to not help them would be unfair. Both of my parents chose careers in which they could easily have worked with wealthy populations and done well and been happy. Both of them chose to work with people that they felt deserved it by virtue of their situation in a fucked up system. My (adopto)mom, a special needs/staff development teacher, spent the majority of her career working with underprivileged, emotionally and mentally disturbed kids, with learning disabilities. She has encountered as much evil, idiocy, and racism from one side of the class line as another: idiot parents who don't know or care what's in the best interest of their child, mean and spiteful children who've moved beyond damaged into a point of no return, and a broke, corrupt, bureaucratic school system that has plenty of time to construct rules and regulations, but neither the time, the money, nor the interest to see that those rules and regulations are in the best interests of the students. It's always an uphill battle for her and it never ends, but she does it because the alternative is to sit on her ass and let the ruling class rule and the impoverished class stew. I guess it may be in large part because both my parents grew up dirt poor (and my mom, as I've mentioned, grew up in an area where she was regularly shat on because of her Jewishness).
TR: I am torn between two impulses: the desire to try to help people, in my own way, and the desire to let the whole world destroy itself
Harley: I'm with you; particularly because of the hopelessness of the situation. I figure that regardless of what I do, the world is fucked regardless, but I couldn't live with myself if I didn't at least try to make someone's life better (someone other than myself, that is).

[Ed.: The Rooster does not disavow what he said, but he is capable of being less pissed off, especially between the hours of 9:00am and 10:00am.]


Sarah said...

I'd also like to point out that in certain geographic areas--I'm thinking here in particular of Greenpoint, Brooklyn, but there are obviously other places that fit the description--there may not be one single pharmacy that will stock Plan B. Not one. I've looked. I'm totally comfortable buying condoms, but if I lived there (as opposed to just visiting my boyfriend there), I would be scared of seeing someone I know. Hell, I already sneak out of the apartment to avoid the landlord's evil eye. Anyhow, if that neighborhood weren't in New York, where I can get condoms elsewhere with a quick hop onto the subway, I'd be in trouble.

montana urban legend said...

Actually The Rooster is wrong (regarding the libertarian argument). As interested as I am in there being widespread access to this, a pharmacist's job is simply NOT to "provide medicine that is prescribed by a doctor, whatever that medicine is." I have not found radiopharmaceuticals in many community pharmacies. Nor have I found many retail chains providing parenteral nutrition for home infusion or cardiac resuscitation meds, among many other, more pedestrian possibilities. This issue simply reflects a change in clinical practice, and the time period when a pharmacist just dispensed - no questions asked - was actually a short historical anomaly that is now changing. If you don't want a pharmacist to exercise their clinical judgment, then I can assure that many people will be dying from taking medication they were allergic to, that interacted with other medication, etc., etc., etc., and this professional modification has come to be no less expected in an outpatient setting than in hospitals. And with such professional obligations comes the assumption that they should not be made to conflict with an individual's ethical principles - just as no individual doctor, nurse, etc., can be made to perform or assist an abortion - even if Plan B does generally work before fertilization occurs.

But once again, as someone who is generally in favor of access to Plan B - with the reservations pertaining to issues of professional autonomy that I wish people would try to be more understanding of - geographical considerations might become an issue, as Sarah indicates. Although I am perplexed that certain areas of NYC would fit this bill. Maybe that anecdote just goes to show that there might be something more at play than just issues of conscience, or whatever you want to call it, when to comes to perceptions relating to access to post-coital contraception. But having actually brought the pharmacist - (imagine that! res ipsa loquitur) - into the equation, I would also suggest that having a third class of drugs - common in other Western countries, where a medication could be dispensed at a pharmacist's discretion from behind the counter (without a prescription) - would remove the need for having to be seen by a doctor first, which I would think would be more of a problem when considering issues of access. I think such an approach would be much more productive at improving accessibility than whining and complaining about what every pharmacist should do, as if they should all be sweatshop automatons without consciences, even when some of their consciences (and I would guess a small minority, at that) conflict with what we are told by our own. Pharmacists did not get to become one of the most consistently trusted professions by checking their consciences at the door. I don't think that should change. And politically, it won't.

montana urban legend said...

Ahh... so it was about oral contraception (upon re-reading the complex, original post), not Plan B (which was the impression I got from the first comment). And thanks for refreshing my memory on the FDA ruling. Not sure how this would affect what I wrote, other than to note that it would be even infinitely less likely that a pharmacy would choose not to stock that. I have never heard of (or seen) that. Didn't follow the links, but I would venture to say that such a scenario would be so infinitesimally unlikely as to be a practical non-issue - other than to make for a single, salacious, emotionally-charged expose with which to further discussions of policy, etc., that would have virtually no bearing on changing much of anything in the first place.

There are many formulations of oral contraception (OC). While pharmacies typically stock the gamut of these varieties, less commonly they might not have one or another. And since some are especially formulated to have different amounts of the different hormones for clinical reasons, some might be ever-so-slightly less easy to come by. Based on volume in the market alone it's a stupid financial decision for a pharmacy not to stock Ortho Tri-Cyclen, et al, and this is likely why you're going to have a much harder time finding a single retail pharmacy that doesn't carry those than one that doesn't carry interferon beta-1a, for instance. And if that lends credence to the "libertarian" argument, so be it.