It’s a classic confrontation of values. A woman walks into a drugstore to fill a prescription – maybe an unmarried student who wants birth control, maybe a woman who requests emergency contraception to stop pregnancy. The pharmacist doesn’t believe that what she’s asking for is morally right, so he or she refuses to provide the medicine – and in some cases, won’t release the prescription so the woman can take it to another drugstore.
In March 2010, President Barack Obama’s Affordable Health Care Act was signed into law, which required many health plans to cover preventive health services. In August 2011, the U.S. Department of Health and Human Services added additional guidelines for women’s preventive services to the law –including covering contraception, emergency contraception and sterilization without cost sharing in new health plans. So far, attempts by many religious organizations to be granted an exemption from what has commonly been called the HHS mandate have been unsuccessful.
Following the law, “conscience clause” legislation is being considered at the national level and in the statehouses to protect the right of a pharmacist to follow his or her conscience when deciding whether to fill prescriptions for contraceptives. Meanwhile, some pharmacists who have lost their jobs or been disciplined have filed lawsuits.
A national debate has intensified over whether health care professionals should be required to provide care even if they find it morally objectionable – a debate that extends far beyond pharmacists and emergency contraception. Ethics experts say it has implications for an expanding number of health care issues, from infertility to end-of-life care.
Might a certain regimen of pain-relief medication hasten death? Can Catholic hospitals refuse to perform tubal ligations or vasectomies? Could pharmacists refuse to provide medication to treat depression or hyperactivity in children if they don’t believe in treating those conditions with drugs?
Competing laws, increasing debate and more lawsuits. Together, they are asking a question that has yet to be settled: When there’s a difference in moral views between a patient and a health care provider, whose beliefs should prevail? ReligionLink offers resources for covering this issue.
Why it matters
Some consider conscience clause legislation to be an emerging front in the war in battle over abortion, and, as with abortion, religious beliefs are a determining factor. For some health care providers, withholding certain services is a non-negotiable matter of religious faith. The implications for patients are enormous: They may be denied access to treatment or medication even when it’s legal and they can pay for it.
Angles for reporters
- Talk to pharmacists and drugstores about how they approach emergency contraception. Do they routinely stock it? If they don’t, are they willing to order it quickly if a patient asks for it or to transfer the prescription to another pharmacy? Should a pharmacist be required to transfer the prescription even if he or she considers dispensing the medication to be morally wrong?
- If a pharmacist doesn’t want to provide emergency contraception, how does the drugstore handle that? What instructions are the major pharmacy chains giving their employees? Must pharmacists divulge their unwillingness to prescribe certain medications in advance?
- How easy or difficult is it for women in your community to obtain emergency contraception? What’s the picture like for rural areas and small towns as opposed to bigger cities?
- Are hospitals, clinics and pharmacists informing rape victims that emergency contraception is an option? Should they have to, even if they have moral objections? If the FDA decides to allow drugstores to provide emergency contraception without a prescription, how will local pharmacies handle that?
- What ethical dilemmas beyond contraceptive issues do pharmacists and other health care providers confront? What are the toughest matters of conscience they’ve dealt with in patient care? What are the moral questions posed for pharmacists, nurses and physicians in end-of-life care? What about treatment of mental health or infertility?
- What do women from your area have to say about emergency contraception? Do they think it should be readily available or not, and why? What do local doctors, particularly those who treat women, have to say? Talk to college students and other young adults and check with campus health clinics.
Definitions
Emergency contraception: Medication consisting of the same hormones found in birth-control pills but in higher doses, which can prevent pregnancy when taken within 72 hours of intercourse. The pill can contain either a combination of estrogen and progestin or only progestin. According to the U.S. Food and Drug Administration, emergency contraception — such as Plan B — can delay or inhibit ovulation; prevent sperm from fertilizing the egg; or prevent implantation of fertilized egg in the lining of the uterus. Emergency contraception typically is taken when birth control has failed or none was used and is available without a prescription.
Abortifacient: A medication that terminates an established pregnancy. Some pharmacists who oppose abortion refuse to provide certain forms of birth control because they contend that type of contraception is “abortifacient,” meaning that it can prevent a fertilized egg from implanting in the wall of the uterus. They consider that to be a form of abortion. That view does not follow the standard accepted definition of pregnancy – for example, both the National Institutes of Health and the American College of Obstetricians and Gynecologists define pregnancy as beginning when a fertilized egg is implanted into the wall of the uterus, not before.
RU-486: Also known as mifepristone. A pill used to trigger abortions of implanted embryos in the early stages of pregnancy. This product is available only to physicians and is not available to pharmacists. The FDA approved it for use for termination of pregnancy in 2000. It is available by prescription with certain restrictions.
National sources
For conscience clauses
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U.S. Conference of Catholic Bishops
The U.S. Conference of Catholic Bishops has raised concerns about a range of freedom of conscience questions related to protection of life issues and supports including conscience provisions in proposed funding bills.
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Mario Díaz
Mario Díaz, Esq. serves as legal counsel of Concerned Women for America in Washington, D.C., which tries to bring biblical principles into public policy.
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Kim Colby
Kim Colby is senior counsel at the Christian Legal Society in Springfield, Virginia, and has worked at the society’s Center for Law and Religious Freedom since 1981.
Against conscience clauses
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Rebecca Wind
Rebecca Wind is press contact for the Alan Guttmacher Institute, a nonprofit organization in New York and Washington, D.C., focused on sexual and reproductive health research and policy analysis.
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NARAL Pro-Choice America
Ilyse Hogue is president of NARAL Pro-Choice America. The nonprofit advocacy group supports “near-universal contraception coverage.” The website lists affiliates around the country.
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Religious Coalition for Reproductive Choice
The Religious Coalition for Reproductive Choice in Washington, D.C., pushes for more health care options for women, not fewer. It sponsors a National Black Religious Summit on Sexuality each year. Michael Mitchell is director of communications.
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Gretchen Borchelt
Gretchen Borchelt is senior counsel at the National Women’s Law Center in Washington, D.C. The center fights against pharmacy refusals and state bans on insurance coverage of abortion. Contact Maria Patrick.
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Jennifer Dalven
Jennifer Dalven is director of the ACLU Reproductive Freedom Project, which has been involved in the debate over health care workers refusing to provide services to women. Contact her through the media line.
Professional associations
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American Pharmacists Association
Michelle Spinnler is the spokeswoman for the American Pharmacists Association, with 62,000 members.
It says pharmacists should have the right to decline to fill prescriptions out of moral conviction, but if a pharmacist does so, a system should be in place – for example, by having another pharmacist fill the prescription or by referring the patient to another drugstore that will fill it – to ensure the patient is able to receive the medication.
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American Society of Health-System Pharmacists
Ellen Wilcox is public relations director for the American Society of Health-System Pharmacists in Bethesda, Md., which tracks legislation involving pharmacists and represents close to 40,000 pharmacists who work in hospitals, long-term care facilities and other health care systems.
The association supports both a pharmacist’s right to refuse to fill prescriptions based on moral beliefs and a patient’s right to have a prescription filled.
Legislation
State
- Legislation regarding pharmacists and conscientious objection cuts both ways. Some states have passed laws that protect pharmacists who won’t fill prescriptions because of their moral beliefs. Other states have laws that require pharmacists to promptly fill all prescriptions that are valid and legal.
- The Alan Guttmacher Institute tracks reproductive legislation in the states, including laws about dispensation of contraception and insurance coverage of abortions and contraceptives.
Federal
In March 2013, House Republicans introduced the Health Care Conscience Rights Act, which would amend the Affordable Care Act by exempting employers whose religious beliefs conflict with the HHS mandate and providing protection for health care professionals who choose to opt out of administering abortions.
Articles
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“Republican House Members Introduce Conscience Protection Act”
Read a March 5, 2013, article in Catholic Education Daily about the 2013 Health Care Conscience Rights Act.
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“Emergency contraception use grows, access does not”
Read a February 27, 2013, article at Salon.com about hurdles to obtaining emergency contraception.
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“Missouri House OKs Pro-Life Bill for Religious Conscience”
Read a March 12, 2013, article on a pro-life news website about Missouri’s House of Representatives passing a bill that would exempt anyone from participating in medical services that are contrary to his or her religious beliefs.
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“Prescription for Injustice”
Read an opinion piece by sociologist Florence A. Ruderman from the September 1, 2005 New York Times about a pharmacist who refused to fill her father’s prescription for morphine when he was dying of cancer and in severe pain, and how that’s affected her views of pharmacists’ responsibilities.
Regional sources
In the Northeast
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Nancy Audet
Nancy Audet is director of communications for the Family Planning Association of Maine.
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Anita L. Allen
Anita L. Allen, a professor at the University of Pennsylvania Law School, has taught about contemporary ethics and bioethics and is the author of The New Ethics: A Guided Tour of the Twenty-First-Century Moral Landscape (Miramax Books, 2004). In 2010, she was appointed by President Obama to the Presidential Commission for the Study of Bioethical Issues.
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Paul Rosenzweig
Paul Rosenzweig is a visiting fellow at the Heritage Foundation, a conservative Washington think tank.
He wrote a commentary arguing that, from the Pilgrims on, American history has been founded on freedom of conscience and that a pharmacist shouldn’t have to fill a prescription that violates his or her personal scruples but should provide an alternate source for the patient to receive the medication.
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David Luban
David Luban is a professor of law at the Georgetown University Law Center in Washington, D.C. He teaches about legal ethics and has written in an online blog that “pacifists should not join the Army, and people who do not wish to fill prescriptions should not become pharmacists.”
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Amitai Etzioni
Amitai Etzioni, a sociologist, is University professor at the George Washington University in Washington, D.C., and the author of From Empire to Community: A New Approach to International Relations (Palgrave Macmillan, 2004).
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James Trussell
James Trussell is a professor of economics and public affairs and faculty associate with the Office of Population Research at Princeton University in New Jersey. He has an expertise in abortion and advocates making emergency contraception widely available as a means of reducing unintended pregnancies and runs a website on the topic.
In the South
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Paige Johnson
Paige Johnson is director of public affairs of Planned Parenthood of Central North Carolina.
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Joseph Fink
Joseph Fink is a professor of pharmacy law and policy at the University of Kentucky College of Pharmacy. He has written about pharmacy law and ethics and is a founder of the American Society of Pharmacy Law. Contact [email protected].
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Heather Busby
Heather Busby is executive director of NARAL Pro-Choice Texas, which promotes reproductive choices for women.
In the Midwest
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Amy M. Haddad
Amy M. Haddad is a professor and director of the Center for Health Policy and Ethics and a professor of health sciences at Creighton University in Omaha, Neb. She is past chairwoman of the ethics special interest group of the American Association of Colleges of Pharmacy.
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R. Alta Charo
R. Alta Charo teaches law and bioethics at the University of Wisconsin law school. From 2015 to 2017, she was a member of the Human Genome Editing Initiative, a joint project of the National Academy of Medicine and National Academy of Sciences. She previously served on President Bill Clinton’s National Bioethics Advisory Commission.
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Matthew Murawski
Matthew Murawski is an associate professor of pharmacy administration at Purdue University in Indiana. He says pharmacists can face ethical concerns that go well beyond dispensing birth control – involving, for example, end-of-life issues and what medications are appropriate for children.
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Sandra Johnson
Sandra Johnson is a law professor emerita Saint Louis University. She has written about pain management, care of the dying and nursing homes, and can speak about the ethical challenges they present for health care workers.
In the West
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Lynn D. Wardle
Lynn D. Wardle, a law professor at the J. Reuben Clark Law School at Brigham Young University in Utah, has written a proposed draft of a conscience protection law that states generally that no health care provider should have to provide services that violate his or her moral or religious convictions.
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Daniel C. Robinson
Daniel C. Robinson is dean of the college of pharmacy at Western University in California.
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Ken Baum
Ken Baum, a lawyer in Santa Monica, Calif., argued for a balance between meeting the needs of patients and honoring pharmacists’ moral values in an article he co-wrote with his wife, Julie Cantor, also a lawyer and physician, for the Nov. 4, 2004, New England Journal of Medicine.
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Tom Van Hassel
Tom Van Hassel is the director of pharmacy at Yuma Regional Medical Center in Yuma, Ariz., and is president of the Arizona State Board of Pharmacy. He has also served on the board of the Arizona Pharmacy Alliance.
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Cathi Herrod
Cathi Herrod is director of policy for the Center for Arizona Policy. The center says it supports “pro-family laws and values.” Contact communications director Aaron Baer.
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Jennifer Kraska
Jennifer Kraska is executive director of the Colorado Catholic Conference.
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Erin Jemison
Erin Jemison is executive director of the Colorado Coalition Against Sexual Assault.
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Lorie G. Rice
Lorie G. Rice is associate dean of external affairs of the School of Pharmacy at the University of California at San Francisco, where she teaches courses in pharmacy law and ethics. She is also former executive officer of the California State Board of Pharmacy. Listen to an April 23, 2005, NPR interview in which Rice explains how she discusses ethical and moral issues with pharmacy students.
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Valerie J. Vollmar
Valerie J. Vollmar is a law professor at Willamette University College of Law in Salem, Ore. She can speak about how health professionals, including physicians and pharmacists, follow their consciences.
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Susan W. Tolle
Susan W. Tolle is director of the Center for Ethics in Health Care at Oregon Health & Science University in Portland.
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Don Downing
Don Downing is a clinical professor in the University of Washington School of Pharmacy. He has been involved with research about how pharmacists can improve women’s access to public health services, including contraception, and has trained pharmacists in Washington and across the U.S. to voluntarily prescribe emergency contraception, in states which allow that.