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EXPERT OPINION
Pap Smear Ransom –Is It Ethical to Refuse to Refill
aPatient’s Birth Control Until They Come in for Their
Annual Exam?
This article was published in the following Dove Press journal:
International Journal of Women's Health
Greg J Marchand
Katelyn M Sainz
The Marchand Institute for Minimally
Invasive Surgery, Mesa, AZ, USA
Abstract: A review of the common but questionably ethical practice of refusing to refill
a patient’s birth control prescription until they are seen in office for, and presumably pay for,
a yearly examination. This forced decision between making time for the appointment or
risking an unintended pregnancy is comically referred to as “Pap Smear Ransom.”This short
review examines the limited data to support or decry this common practice.
Keywords: annual exam, birth control, contraception, office gynecology
Like death and taxes, a plethora of refill requests from all the major pharmacies in
the area clogging up the fax machine of your office is completely inevitable for any
busy OBGYN.
The most common of these requests for most OBGYNs is going to be birth
control. With 62% of the reproductive age women in the United States currently
using birth control,
1
and essentially 100% percent of pharmacies faxing over
a request if the patient is more than 1 day late, the fax volume is bound to be
substantial for any practice.
What varies widely, however, is what the response to those faxes is. For some
providers, the faxes go directly into the shredder, feeling that any matter worth
addressing is worth doing so only during a paid office visit, which certainly makes
some sense. A fair number of these practitioners will probably trickle into the second
group when pressed again on the subject, either by an irate patient or an impatient
pharmacist, pandering them relentlessly to refill the prescription by phone. The second
group is those providers with a philosophy that everything gets signed and faxed back
on the spot, perhaps benevolently wanting to help eliminate all barriers to a patient’s
treatment, or perhaps just believing in the unquestionable wisdom of the requesting
pharmacy. A passing glance to be sure that no controlled substances (which would be
very rare in 2020), have found their way into the mix is usually in order.
It is the third group of practitioners that I would like to bring our attention to,
namely those practitioners who use the faxes to encourage patients to present for
their appointments by refusing to refill birth control until the patient is seen. This
sets up a kind of “Pap Smear Ransom,”as we fondly refer to it in my offices, where
the patient must either risk pregnancy or present for a visit.
First, let us discuss the arguments against this practice. Approximately 45% of
pregnancies in the United States are considered unplanned or unintended.
2
Of those
Correspondence: Greg J Marchand
The Marchand Institute for Minimally
Invasive Surgery, 10238 E. Hampton, Suite
212, Mesa, AZ 85209, USA
Tel +1 480 999 0905
Fax +1 480 999 0801
Email gm@marchandinstitute.org
International Journal of Women's Health Dovepress
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http://doi.org/10.2147/IJWH.S246220
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pregnancies, approximately 42% will be aborted, and the
majority of the rest will go to term.
3
The average cost of an
abortion service in the US is in the range of $470,
4
and the
cost of raising a child is clearly significantly higher.
Therefore, one could argue that a practitioner who denies
a birth control refill is selfishly placing an inappropriate
burden on the US healthcare system to manage these unin-
tended pregnancies, all for the hopes of charging a patient an
additional annual exam fee, which averages less than $200.
5
While, to the knowledge of this author, no major orga-
nization has directly issued a guideline or committee opi-
nion on this particular practice,
6
there has been one
incidence where ACOG has come close. In 2014 ACOG
released their “Statement on OTC Access to
Contraception,”which goes pretty far as to state that
birth control should not require a prescription.
7
While the
statement also states that having access to OTC
OCPs “does not obviate the need for women to see their
gynecologist each year,”it does logically seem to question
the ethics of refusing a prescription for a drug that should
not need a prescription in the first place.
This brings us to the arguments for the practice of with-
holding the refill until the patient is seen. The first argument
would be concern for contraindications. If it’s been more than
a year since the prescription was written, what has changed?
Are there new migraines with aura? Did the blood pressure
creep up with the addition of a few more pounds? Has the
patient started smoking? Clearly, these are concerns for the
blind signer. There is a very reasonable concern for the possi-
bility of liability. Are you responsible if the refilled OCP
causes a stroke? You may have discussed the risk at the visit
you prescribed it, but is there liability if it is refilled without
seeing the patient? If not, would there be liability in refilling it
for a third year, or for 10 years? Clearly, physicians are
responsible, at least in part, for the medications they prescribe
and refill, I will admit I was unable to find any cases of
malpractice suits arising specifically from an OCP refill.
Last, if you do refill the prescription, will not it be less
likely the patient will show up? What about all the other
important components of the annual exam, the pap smear,
the depression screen, the mammogram? Is not this care so
important as to force the patient to come in with any
means you have? Some would argue the moral high
ground is in saving the woman from preventable cancer
and diseases at the risk of an unintended pregnancy.
Of course, the obvious right answer here may be
a mixed approach. I have overheard many of my collea-
gues receptionists saying something to the tune of “Okay
but this is really the last refill until you come in for your
exam, you are very overdue!”The idea being that maybe
one or two additional months can be refilled as leeway to
help accommodate the busy patient, with the understand-
ing that this will not go on forever.
It is very likely that as we advance in eliminating
barriers to women’s healthcare, more ethical questions
will be raised as to the safety and ethics of each decision.
Finally, I would challenge each of my colleagues to con-
sider the options fully, and be sure that their approach to
the “Pap Smear Ransom”conundrum embodies the ethics
and values that best represent their practice.
Disclosure
The authors report no conflicts of interest in this work.
References
1. Hurt KJ, Guile MW, Bienstock JL, Fox HE, Wallach EE. The Johns
Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams &
Wilkins; 2012.
2. Sawhill IV, Guyot K. Preventing Unplanned Pregnancy: Lessons from
the States.2019.
3. Finer LB, Zolna MR. Declines in unintended pregnancy in the United
States, 2008–2011. N Engl J Med.2016;374(9):843–852. doi:10.1056/
NEJMsa1506575
4. Jones RK, Upadhyay UD, Weitz TA. At what cost? Payment for
abortion care by US women. Womens Health Issues.2013;23(3):
e173–e178. doi:10.1016/j.whi.2013.03.001
5. Marchand GJ, Sainz KM. A Simple and Novel Technique for Cleaning
Up after the Ovarian cystectomy of a dermoid cyst. J Minim Invasive
Gynecol.2018;25(7):S239–S240. doi:10.1016/j.jmig.2018.09.617.
6. Machlin S, Chowdhury S. Expenses and Characteristics of Physician
Visits in Different Ambulatory Care Settings, 2008. Agency for
Healthcare Research and Quality; 2011.
7. ACOG. ACOG statement on OTC access to contraception. American
College of Obstetrics and Gynecology. September 9, 2014. Available
from: www.acog.org. Accessed April 3, 2020.
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