Some pharmacists across the country are refusing to fill prescriptions for birth control and morning-after pills, saying that dispensing the medications violates their personal moral or religious beliefs.
The trend has opened a new front in the nation's battle over reproductive rights, sparking an intense debate over the competing rights of pharmacists to refuse to participate in something they consider repugnant and a woman's right to get medications her doctor has prescribed. It has also triggered pitched political battles in statehouses across the nation as politicians seek to pass laws either to protect pharmacists from being penalized — or force them to carry out their duties.
Growing wave of drug-counter disputes
"This is a very big issue that's just beginning to surface," said Steven H. Aden of the Christian Legal Society's Center for Law and Religious Freedom in Annandale, which defends pharmacists. "More and more pharmacists are becoming aware of their right to conscientiously refuse to pass objectionable medications across the counter. We are on the very front edge of a wave that's going to break not too far down the line."
An increasing number of clashes are occurring in drugstores across the country. Pharmacists often risk dismissal or other disciplinary action to stand up for their beliefs, while shaken teenage girls and women desperately call their doctors, frequently late at night, after being turned away by sometimes-lecturing men and women in white coats.
"There are pharmacists who will only give birth control pills to a woman if she's married. There are pharmacists who mistakenly believe contraception is a form of abortion and refuse to prescribe it to anyone," said Adam Sonfield of the Alan Guttmacher Institute in New York, which tracks reproductive issues. "There are even cases of pharmacists holding prescriptions hostage, where they won't even transfer it to another pharmacy when time is of the essence."
That is what happened to Kathleen Pulz and her husband, who panicked when the condom they were using broke. Their fear really spiked when the Walgreens pharmacy down the street from their home in Milwaukee refused to fill an emergency prescription for the morning-after pill.
"I couldn't believe it," said Pulz, 44, who with her husband had long ago decided they could not afford a fifth child. "How can they make that decision for us? I was outraged. At the same time, I was sad that we had to do this. But I was scared. I didn't know what we were going to do."
Supporters of pharmacists' rights see the trend as a welcome expression of personal belief. Women's groups see it as a major threat to reproductive rights and one of the latest manifestations of the religious right's growing political reach — this time into the neighborhood pharmacy.
"This is another indication of the current political atmosphere and climate," said Rachel Laser of the National Women's Law Center in Washington. "It's outrageous. It's sex discrimination. It prevents access to a basic form of health care for women. We're going back in time."
The issue could intensify further if the Food and Drug Administration approves the sale of the Plan B morning-after pill without a prescription — a controversial step that would likely make pharmacists the primary gatekeeper.
Hippocratic oath invoked
The question of health care workers refusing to provide certain services first emerged among doctors, nurses and other health care workers over abortions. The trend began to spread to pharmacists with the approval of the morning-after pill and physician-assisted suicide in Oregon, with support from such organizations as the U.S. Conference of Catholic Bishops and Pharmacists for Life International, which claims 1,600 members on six continents. Its members are primarily in the United States, Canada and Britain.
"Our group was founded with the idea of returning pharmacy to a healing-only profession. What's been going on is the use of medication to stop human life. That violates the ideal of the Hippocratic oath that medical practitioners should do no harm," said Karen L. Brauer, president of Pharmacists for Life, who was fired from a Kmart pharmacy in Delhi, Ohio, for refusing to fill birth control prescriptions.
No one knows exactly how often that is happening, but cases have been reported across the country, including in California, Washington, Georgia, Illinois, Louisiana, Massachusetts, Texas, New Hampshire, Ohio and North Carolina. Advocates on both sides say the refusals appear to be spreading, often surfacing only in the rare instances when women file complaints.
Push for 'conscience clause' laws
Pharmacists are regulated by state laws and can face disciplinary action from licensing boards. But the only case that has gotten that far involves Neil T. Noesen, who in 2002 refused to fill a University of Wisconsin student's birth control pill prescription at a Kmart in Menomonie, Wis., or transfer the prescription elsewhere. An administrative judge last month recommended Noesen be required to take ethics classes, alert future employers to his beliefs and pay what could be as much as $20,000 to cover the costs of the legal proceedings. The state pharmacy board will decide whether to impose that penalty next month.
"He's a devout Roman Catholic and believes participating in any action that inhibits or prohibits human life is a sin," said Aden of the Christian Legal Society. "The rights of pharmacists like him should be respected."
Wisconsin is one of at least 11 states considering "conscience clause" laws that would protect pharmacists such as Noesen. Four states already have laws that specifically allow pharmacists to refuse to fill prescriptions that violate their beliefs. At the same time, at least four states are considering laws that would explicitly require pharmacists to fill all prescriptions.
The American Pharmacists Association recently reaffirmed its policy that pharmacists can refuse to fill prescriptions as long as they make sure customers can get their medications some other way.
"We don't have a profession of robots. We have a profession of humans. We have to acknowledge that individual pharmacists have individual beliefs," said Susan C. Winckler, the association's vice president for policy and communications. "What we suggest is that they identify those situations ahead of time and have an alternative system set up so the patient has access to their therapy."
Delicate balance between rights
The alternative system can include making sure another pharmacist is on duty who can take over or making sure there is another pharmacy nearby willing to fill the prescription, Winckler said. "The key is that it should be seamless and avoids a conflict between the pharmacist's right to step away and the patient's right to obtain their medication," she said.
Brauer, of Pharmacists for Life, defends the right of pharmacists not only to decline to fill prescriptions themselves but also to refuse to refer customers elsewhere or transfer prescriptions.
"That's like saying, 'I don't kill people myself but let me tell you about the guy down the street who does.' What's that saying? 'I will not off your husband, but I know a buddy who will?' It's the same thing," said Brauer, who now works at hospital pharmacy.
Large pharmacy chains, including Walgreens, Wal-Mart and CVS, have instituted similar policies that try to balance pharmacists' and customers' rights.
"We obviously do have pharmacists with individual moral and ethical beliefs. When it does happen, the pharmacist is asked to notify the manager that they have decided not to fill the prescription, and the manager has the obligation to make sure the customer has access to the prescription by another means," said Tiffany Bruce, a spokeswoman for Walgreens. "We have to respect the pharmacist, but we have to also respect the right of the person to receive the prescription."
'A slap in the face,' advocates say
Women's advocates say such policies are impractical, especially late at night in emergency situations involving the morning-after pill, which must be taken within 72 hours. Even in non-urgent cases, poor women have a hard time getting enough time off work or money to go from one pharmacy to another. Young women, who are often frightened and unsure of themselves, may simply give up when confronted by a judgmental pharmacist.
"What is a woman supposed to do in rural America, in places where there may only be one pharmacy?" asked Nancy Keenan, president of NARAL Pro-Choice America, which is launching a campaign today to counter the trend. "It's a slap in the face to women."
By the time Suzanne Richards, 21, finally got another pharmacy to fill her morning-after pill prescription — after being rejected by a drive-through Brooks Pharmacy in Laconia, N.H., one late Saturday night in September — the 72 hours had long passed.
"When he told me he wouldn't fill it, I just pulled over in the parking lot and started crying," said Richards, a single mother of a 3-year-old who runs her own cleaning service. "I just couldn't believe it. I was just trying to be responsible."
In the end, Richards turned out not to be pregnant, and Pulz was able to obtain her prescription last June directly from her doctor, though she does not think she was pregnant, either.
"I was lucky," Pulz said. "I can sympathize with someone who feels strongly and doesn't want to be involved. But they should just step out of the way and not interfere with someone else's decision. It's just not right."