A pharmacist working for Walgreen's in Milwaukee, Wisconsin refuses to fill a prescription for emergency contraception (EC) . In Louisiana, another pharmacist sends a couple, instructed by their physician not to get pregnant for 2-3 years following cesarean section, 30 miles out of their way because he believes birth control is "œtantamount to abortion" and he "did not want to commit a sin" .
In Texas, a rape survivor is turned away by three pharmacists refusing to fill her EC prescription on moral grounds .
In New Hampshire a woman with a legal prescription for EC was not only denied the medication, the pharmacist refused to transfer the prescription and instead lectured her on his religious beliefs and chastised her for being "irresponsible" .
These are but a few of the examples of a growing trend.
While it may be shocking to learn that women holding valid prescriptions for legal medication are being refused these medications by certified health professionals, the opposition to fertility control is not new.
Since the introduction of oral contraceptives (the pill) in 1964, a quiet battle has been waged to prohibit women from obtaining the pill. The most vocal opponents of the pill are those that believe it to be the roots of the breakdown of traditional family values, and those that believe any manipulation of a woman's fertility is a "sin against God", and therefore immoral. The latter viewpoint has prompted a growing number of pharmacists to claim a "conscientious objector" status toward dispensing products such as birth control pills and emergency contraception.
A conscientious objector (CO) is one who is opposed to serving in the armed forces and/or bearing arms on the grounds of moral or religious principles . To be granted CO status, a man found qualified for military service by virtue of his age and/or health, must appear before a local authority to explain his beliefs, and provide testimony to show that these beliefs are long held.
In other words, one cannot simply decide that joining the military is a good idea until his or her unit is deployed for battle. Reasons for requesting CO status are often religious in nature, though they need not be. "Beliefs may be moral or ethical; however, a man's reasons for not wanting to participate in a war must not be based on politics, expediency, or self-interest." .
Given this definition it would seem that these "moral" pharmacists are well within their rights to refuse prescriptions for contraception. And, in fact, the long held position by the American Society of Health-System Pharmacists is:
"To recognize the right of pharmacists, as health care providers, and other pharmacy employees to decline to participate in therapies they consider to be morally, religiously, or ethically troubling; further, to support the proactive establishment of timely and convenient systems by pharmacists and their employers that protect the patient's right to obtain legally prescribed and medically indicated treatments while reasonably accommodating in a non-punitive manner the right of conscience; further, to support the principle that a pharmacist exercising the right of conscience must be respectful of, and serve the legitimate health care needs and desires of, the patient, and shall provide a referral without any actions to persuade, coerce, or otherwise impose on the patient the pharmacist's values, beliefs, or objections." .
In other words, on one hand we have the "pharmacist's right of conscienceâ" and on the other we have the "patient'™s right of access". But, how do we balance these divergent goals? In a city the size of Los Angeles finding a pharmacist to dispense contraceptives is easy. If pharmacist "A" declines to fill your prescription you can try your luck with pharmacist "B" (provided pharmacist "A" has returned your prescription to you). But, how do we ensure that women living in rural America have access to federally approved, legal medication, when the only pharmacy for 30 miles is staffed by a pharmacist claiming his or her right of conscience? Furthermore, how do we determine which pharmacists are declining to "participate in therapies they consider to be morally, religiously, or ethically troubling" and which pharmacists are basing their decision on "politics, expediency, or self-interest?" Is there a governing body, similar to the one employed by the military, that reviews these issues?
At present, the answer to that question is no. That is not to say, however, that the issue is not being addressed at both the state and federal level.
On June 6, 2007 house representative Carolyn Maloney (D-NY) introduced H.R. 2596, the Access to Birth control Act in order "To establish certain duties for pharmacies to ensure provision of Food and Drug Administration-approved contraception... "If passed, this bill would require ... If a customer requests a contraceptive that is in stock, the pharmacy shall ensure that the contraceptive is provided to the customer without delay."
Full text of H.R. 2596 here: http://thomas.loc.gov/cgi-bin/query/z?c110:H.R.2596
Of the 50 United States, only California and Illinois have passed, into law, legislation requiring pharmacists to dispense contraception to patients with valid prescriptions.
A full list of past and present refusal clause legislation can be found here: http://www.ncsl.org/programs/health/conscienceclauses.htm
States that have passed legislation allowing pharmacists to deny access to contraception include Arkansas, Georgia, Mississippi, and South Dakota. Many of the bills currently being considered favor either the pharmacist or the patient. Few take into consideration the best interests of both parties.
But, what are the best interests of both parties? And do one party'ss best interests supersede the best interests of the other? Kim Gandy, President of the National Organization for Women in testimony to the House Committee on Small Business, Hearing on Freedom of Conscience for Small Pharmacies had this to say;
"As this committee hears testimony from pharmacists who want to refuse legal pharmaceuticals to their customers, it is important to recognize the potentially devastating implications those actions would have on consumer rights and on the healthcare needs of millions of women ... The issue before you today offers a choice between protecting women's access to basic health care and permitting pharmacists acting as small business owners to impose their personal beliefs on their customers. Pharmacists' personal beliefs are just that, personal. They must never compromise a customer's health needs and while we respect self-determination and free speech, these values should never in any way endanger a patient's health or compromise another individual's safety -- In addition, the assumption that birth control is only used for family planning denies women's reliance on contraceptives for other health benefits, including regulating menstrual cycles and treating endometriosis. They should not have to explain this to pharmacists in order to pass a "morality" test."
Full text of the testimony here: http://www.now.org/issues/abortion/testimony7-25-05.html
This argument rests on the foundation that pharmacist's choose to enter a profession bound by fiduciary duties, or, a duty of care. This is to say that we have entrusted them to provide us with the best standard of care available. While the pharmacist may have a compelling desire to hold to his or her moral standard when they refuse to fill a prescription for birth control, they most often do not know the circumstances under which the medication was prescribed. Even if they did, picking and choosing which circumstance are OK, such as for treatment of endometriosis and those that are not OK, such as for prevention of pregnancy, amounts to a little more than a judgment call and does not provide the patient with the best standard of care available. And while pharmacists should exercise independent judgment when determining if a medication being prescribed is safe when taken with other medications prescribed, it is not acceptable to make a professional decision based on a judgment of morality.
Some would argue that people morally opposed to medications such as birth control should choose another profession. But should a pharmacist be compelled to disregard their morals as a condition of employment? If you consider that they are entering a profession in which the decisions they make have a direct impact on the health of the people they are bound to serve, then the answer is yes. Just as a persons right to wave their fist in the air stops at the tip of your nose, so does their right to determine what is and is not moral for you. This becomes particularly true if that determination endangers your life or livelihood.
Not surprisingly, many of the pharmacists that claim a conflict of conscience in regards to dispensing birth control are also opposed to abortion. The fact of the matter is that pregnancy prevention, by default, prevents abortion. If a woman, denied birth control, becomes pregnant and chooses to terminate the unwanted pregnancy is the pharmacist then an accessory to what he or she would consider murder? When viewed in this light you almost have to wonder if there aren't greater issues at play. The ability of a woman to control when and how many children she bears is integral to our emancipation from the myopic role as homemaker. Therefore it could be argued that this is less about morality and more about rolling back the clock to a time when women's choices outside the home were limited to that of nurse or teacher. If so, would these pharmacists be making a decision "based on politics, expediency, or self-interest"?
This issue may take many years to fully resolve, and in the meantime it is largely women' health that is effected. But if the recent findings that Viagra may interfere with the ability of sperm to penetrate an egg pharmacists just may have to start denying access to the "little blue pill" .
1. Rob, S., Pharmacists' rights at front of new debate, in Washington Post. 2005.
2. CBSnews, The drugstore wars. 2004.
3. Cantor, J. and K. Baum, The Limits of Conscientious Objection -- May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception? N Engl J Med, 2004. 351(19): p. 2008-2012.
4. NWLC. Pharmacy refusals 101. 2005 [cited; Available from: www.nwlc.org.
5. Selective-Service-System. [cited; Available from: http://www.sss.gov/FSconsobj.htm.
6. Pharmacists, A.S.o.H.-S. Pharmacistâ€™s Right of Conscience and Patientâ€™s Right of Access to Therapy (0610). 2006 [cited; Available from: http://www.ashp.org/s_ashp/bin.asp?CID=6&DID=4011&DOC=FILE.PDF.
7. BBC. Viagra use 'may damage fertility'. [cited; Available from: http://news.bbc.co.uk/1/hi/health/3585161.stm.