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Susanne Koestner was 32 years old, just out of graduate school, and about to start a new job when an unexpected turn of events at her local pharmacy transformed her from a customer into a patient advocate.
Koestner wanted to refill a birth control prescription in her hometown of Albuquerque, New Mexico. She had been on birth control since her late teens, and didn't expect to encounter any problems.
But the Walgreens pharmacist refused to fill her prescription — due to his religious beliefs.
"I was shocked and emotional, because it's quite frightening to think that someone has the power to take your legally prescribed medication and not give it you," Koestner said. "It's really frightening that someone who has no knowledge of the situation can just decide, 'I don't want to do this,' and they're making a judgment based on no information."
The incident happened in June 2012, when Koestner had been married to her high school sweetheart for five years. The couple were waiting to have kids, especially given that Koestner had just completed her degree in mental health counseling and was just about to begin her career as an adviser and social worker at a nearby community college.
Koestner ended up getting the prescription from another Walgreens about five miles away, but was determined to do whatever she could to help other women from feeling as judged as she did. She filed a complaint through the American Civil Liberties Union alleging sex discrimination, and Walgreens ultimately agreed to a company-wide policy so customers would get prescriptions in a timely matter, even if pharmacists had personal objections to the medication.
But the case highlighted a gray area that many patients have no idea even exists when they go to pick up a prescription.
And in the past month, two similar instances have come to light, both out of Arizona. In the first, a woman who was having a miscarriage was denied a pregnancy-terminating drug at a Walgreens in Peoria; in the second, a transgender woman was denied hormones her doctor had prescribed for her by a CVS in Fountain Hills.
After Nicole Arteaga, the Peoria woman, was denied her prescription, Walgreens said in a statement that it has a policy that allows pharmacists to step away from filling a prescription for which they have a moral objection.
But it added: "It's important to note in that situation, the pharmacist also is required to refer the prescription to another pharmacist or manager on duty to meet the patient's needs in a timely manner."
CVS has a similar policy.
Experts say instances of pharmacists refusing to fill valid prescriptions from doctors on account of personal beliefs are rare, but in some cases, may be legal.
"The pharmacies are governed by state law and state boards, and the pharmacies themselves often have their own policies," said Gretchen Borchelt, vice president for reproductive rights and health at the National Women's Law Center.
Less than half of all states have something on the books about pharmacist refusals. Six states, including Arizona, have laws or regulations that allow pharmacists to refuse to dispense medication for religious or moral reasons without any obligation to the patient, such as transferring the prescription to another pharmacist or pharmacy, according to the National Women's Law Center.
Eight other states explicitly require pharmacists to provide medication to patients even if there are objections, and seven others allow pharmacists to refuse but prohibit them from obstructing access to the medication, the National Women's Law Center says.
The rest, including New Mexico, have no legislation on the matter.
The laws — referred to as "conscience clauses" — can be trumped by corporate policy, meaning even if a pharmacist is in a state that allows for a refusal, they should still pass the prescription to another pharmacist, if the company that employs them requires them to.
It's a protocol that Sunny Linnebur, a professor of clinical pharmacy at the University of Colorado School of Pharmacy, encourages her students to follow if they ever find themselves in a moral dilemma over a legally prescribed medication.
"There is an obligation that the pharmacist has to the patient, even if that means referring them to another pharmacy or pharmacist."
"They have a duty to the patient," Linnebur, who was a practicing pharmacist at a Target store for 10 years, said. "There is an obligation that the pharmacist has to the patient, even if that means referring them to another pharmacy or pharmacist."
While pharmacist refusals may come as a surprise to patients, not everyone thinks there should be more laws related to them.
"The government doesn't need to get involved in this. They should stay out of it. These are personal decisions that pharmacists have to make," Rep. Buddy Carter, R-Ga., the only pharmacist serving in Congress, said, adding that he always respected his pharmacists' beliefs, but "wouldn't leave the patient hanging" if they needed a drug.
Others are concerned about the message that conscience clauses send.
"If a woman is told no at the pharmacy, she can't get the medication, know that that threatens her health but it also can leave her feeling ashamed and judged," Borchelt, of the National Women's Law Center, said. "It's both a health issue but also a dignity issue."
The American Pharmacists Association, which represents more than 62,000 pharmacists and pharmacy technicians, would not comment, but pointed to its policy on conscience clauses, which recognizes an individual pharmacist's right to refuse while supporting systems that ensure the patient's access to legally prescribed medication.
Douglas Hoey, CEO of the National Community Pharmacist Association, which represents about 22,000 independently owned pharmacies, said such refusals are not common.
"I think it's extremely, extremely rare," he said, citing the 4 billion prescriptions that are dispensed every year.
If a patient does encounter a pharmacist who won't fill their prescription, experts say the patient should ask for another pharmacist at the store to fill it for them, or if there isn't one, get their prescription slip back so they can have it filled elsewhere. Each state has its own board of pharmacy, which reviews complaints, if a patient feels their rights has been violated.
Koestner, the New Mexico woman who was denied birth control in 2012, is now taking time off from her career to raise her 2-year-old son, Evan. She was dismayed by the recent cases of other women being denied medication, and wondered how often patients don't even realize why they have been denied.
"People might think maybe there's a problem with their insurance," she said. "They don't really understand that what's going on is you're being denied service based on someone else's opinion of your medication."