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In this scenario, you are required to work through an ethical dilemma brought to your attention. You must justify your actions taken.
Please ensure that this scenario and mark scheme aligns with the most up-to-date guidelines from the UK NICE and the BNF when using it for your OSCE assessment.
You will need a student pharmacist and an actor for this OSCE station.
Alternatively, this can be a non-interactive station.
Emergency Contraception
Gillick Competency
Fraser Guidelines
You are a pharmacist working in a community pharmacy. A 14-year-old girl comes in asking for the ‘morning after pill’ as she has had sex the night before with her 15-year-old boyfriend who she has been with for 10 months. They have had sex before using a condom but did not use one this time. She is scared of her parents finding out and does not want them to know she has a boyfriend.
To do:
Work through an ethical dilemma that has been brought to your attention. You need to provide a clear justification for your Decision-Making process.
Discuss the questions you may ask the patient, reasons for asking them and your treatment plan for this patient.
You must state whether you would supply the medication or not.
You have 10 minutes. You may use this time to think or write down your thoughts.
NOTE: The examiner must not provide any guidance on how to conduct the scenario.
If an examiner is present, they may use the following prompts during the station to guide the student:
“Are there any other considerations you would make?”
“Are there any other concerns you might have?”
“Are there any actions you might take before making a decision?”
Encourage a definitive answer:
“With the available information, what actions would you take?”
Mark scheme guidance:
Use the mark scheme and the points included below together to grade the student. The student may also mention points not included in the example arguments, if that information is correct and justified, please award full marks!
Example arguments are provided at the end.
Any criteria in red must be met to pass this OSCE station.
Example arguments:
The student must justify their arguments for or against and show that they understand the complexity of the nature of the problem.
For:
Autonomy and decision making
Her coming to get the morning after pill indicates that she has a proactive approach to her sexual health, and she has the maturity to take steps to mitigate risks based on the consequences of her actions.
Giving her the emergency contraception respects her autonomy and empowers her to make decisions about her own body and reproductive health. It also reduces the risk of her going to another pharmacy and lying about her age.
Preventing pregnancy
This is a time sensitive intervention
You would want to avoid unwanted and unintended pregnancy
Confidentiality and trust:
Patients between 13 to 16 years old, have the same rights to confidentiality as an adult. Healthcare workers may encourage these patients to consider telling their parents or carers but should not force them.
Respecting the girl's confidentiality and providing her with the medication reinforces trust in healthcare providers and the healthcare system.
This trust is essential for ensuring that adolescents feel comfortable seeking out healthcare services and discussing sensitive topics related to sexual health, both in the present and in the future.
Public health
Access to emergency contraception aligns with broader public health goals by reducing rates of unintended pregnancy and related health risks among adolescents
Providing timely and effective contraception can contribute to improved reproductive health outcomes and lower rates of abortion and maternal morbidity.
Clinical:
EllaOne manufacturer guidance says, "This medicine is suitable for any woman of childbearing age, including adolescents."
Not receiving treatment now, could reduce the patient’s trust in healthcare, and prevent them from seeking important healthcare advice in the future.
Capacity:
Although a child needs parental consent, if the child has capacity then a decision has to be made by the pharmacist on what decision would be in the child's best interest.
Guidelines:
Child under 13 is legally too young to consent and instances should be treated seriously.
Sexual activity with a child under 16 is an offence but lawful if consensual. Pharmacists can give advice / contraception to those under 16 years of age, but they should judge on case-by-case to prevent harm to pt and their welfare.
Against:
Legal:
Parental consent is required for the treatment of a young person under the age of 16 unless the treatment can be justified on the grounds of necessity, or it can be demonstrated that the minor was capable of giving an informed consent.
According to the Sexual Offences Act 2003, it's a criminal offence for any kind of sexual activity to take place between two people where one or both participants is under 16.
Parental Involvement:
In some cases, parents may have valuable insights into their child's health history, emotional state, and overall needs, which could inform the Decision Making process regarding emergency contraception.
Medical Risks and Side Effects:
Emergency contraception, like any medication, carries potential risks and side effects.
Without a thorough medical evaluation, including consideration of the girl's medical history and potential contraindications, there may be increased risks associated with providing the morning-after pill.
Healthcare providers have a responsibility to prioritise the girl's health and safety, which may involve assessing these risks before prescribing the medication.
Potential Psychological and Emotional Implications:
Providing emergency contraception to a 14-year-old girl without addressing underlying emotional or psychological factors may overlook important aspects of her well-being.
It's essential to consider the potential emotional distress, guilt, or confusion that the girl may be experiencing and to provide appropriate support and counselling services alongside medical interventions.
Long-term Health and Wellbeing:
The emergency contraception is the patient's immediate need but you need to think about long term contraceptive options.
This is because the child cannot be using the morning after pill as a form of long term contraception and come seeking for this ‘quick fix’ each time she has unprotected sexual intercourse.
Things to consider:
Does she have capacity?
Was the sex consensual?
Any risk of coercion?
STI risk?
Why doesn’t she want to tell her parents?
Medical vs moral obligation for the pharmacist - Would their view change based on their own beliefs?
Red Flags missed: 0
Failed missed: 2
Referral Criteria for Emergency Contraception:
Refer to A&E if:
Difficulty breathing, swelling of the face or throat, or severe rash after taking emergency contraception: This could indicate a severe allergic reaction requiring immediate medical attention.
Severe abdominal pain or signs of an ectopic pregnancy (e.g., sharp pelvic pain, shoulder pain, fainting, or dizziness): Ectopic pregnancy is a medical emergency and requires urgent intervention.
Uncontrolled heavy vaginal bleeding: This may suggest a significant underlying issue such as a haemorrhagic event or other serious conditions that need urgent assessment.
Refer for an urgent GP appointment if:
Persistent or severe side effects such as ongoing nausea, vomiting, or severe headaches: These symptoms may require management or alternative contraceptive options.
Symptoms of pregnancy after taking emergency contraception (e.g., missed period, nausea, breast tenderness): This indicates that the emergency contraception may not have been effective, and further evaluation is necessary.
Unexplained or severe lower abdominal pain: This could suggest complications such as an incomplete abortion or pelvic inflammatory disease, which need prompt medical evaluation.
National Health Service (NHS), 2024. Emergency Contraception. [online] Available at: https://www.nhs.uk/contraception/emergency-contraception/ [Accessed 23 August 2024].
EllaOne, 2024. Emergency Contraceptive Pill (ellaOne). [online] Available at: https://www.ellaone.co.uk/ [Accessed 23 August 2024].
British National Formulary (BNF), 2024. Levonorgestrel. [online] Available at: https://bnf.nice.org.uk/drugs/levonorgestrel/ [Accessed 23 August 2024].
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