Across the country, a disturbing trend is emerging that, if unchecked, will deny women access to legal, doctor-prescribed birth control. Women are being confronted with “pro-life pharmacists” who say they will not dispense birth control and/or emergency contraception because it violates their religious beliefs. Some even refuse to transfer prescriptions to another pharmacy or ask a pharmacist in their own store to serve the customer. Several women have reported that the pharmacist would not return the written prescription, forcing them to return to their doctor for another prescription. The refusing pharmacists claim they are acting because of their convictions that birth control pills are tantamount to abortion, a notion that is disputed by every major medical association and the U.S. Food and Drug Administration. These unethical refusals jeopardize women’s health and safety by placing them at risk for unintended pregnancy.
It is not clear just how many women have been denied their medications by pharmacists. Some women may be too embarrassed by the offending pharmacist to report the incident and others may not know how or wish to register a complaint. However, Planned Parenthood reports that refusals have been documented in California, Georgia, Illinois, Massachusetts, Minnesota, New Hampshire, New York, Ohio, Pennsylvania, Texas, West Virginia, and Wisconsin.(1)
Birth Control: Still Controversial?
In 1965, the Supreme Court ruled in Griswald v. Connecticut that a married couple had a right to privacy that included using contraception. The right was extended to unmarried couples seven years later in Eisenstadt v. Baird. Today, 95% of American women have used birth control at some point in their lives. Over 80% of women use oral contraceptives. Birth control enables women to plan for pregnancy when they and their family are emotionally, spiritually and financially ready. Without using contraception, the average woman could bear as many as 12 to 15 children in her lifetime.(2)
Women who take oral contraceptives or seek emergency contraception are actively trying to avoid a pregnancy. Birth control pills need to be taken at the same time every day to be the most effective. Emergency contraception, which is taken after occasions of unprotected sex, such as a broken condom, a missed birth control pill or sexual assault, should be taken as soon as possible after the incident of unprotected sex; the window of efficacy begins to close after 72 hours.
Emergency contraceptive pills are made of the same ingredients as the daily birth control pill and work by the same mechanisms. Neither form of contraception will affect an established pregnancy. Emergency contraception is different than the abortion pill, often called RU-486 or mifepristone, which is medically indicated to terminate an early pregnancy. RU-486 can only be distributed by a doctor and is not available in any pharmacy.
Pharmacists who refuse to dispense birth control pills and emergency contraception have claimed they believe the pills work as abortifacients. At issue is whether the pills prevent sperm and egg from meeting, or if they prevent a fertilized egg from implanting in the uterus. The Population Council’s International Committee for Contraception Research completed a study that showed the most popular type of emergency contraception, sold under the brand name Plan B, prevented a woman’s ovarian follicle from releasing an egg. The fertilization of an egg may not happen during intercourse, but can happen several days later. Sperm can live inside a woman’s body for up to five days, waiting for an egg to be released. An egg only lives for six to twelve hours.(3) By preventing the release of an egg, even after intercourse, emergency contraceptive pills act as a contraceptive.
There is a small chance that the medication changes the lining of the uterine wall and prevents the fertilized egg from implanting. The mainstream medical community agrees that pregnancy begins when a fertilized egg attaches to the uterine wall. There is no medical test to know if an egg has been fertilized until it implants into the uterus.
Religious Support For Family Planning
Women make the decision to use contraceptives because of their religious views. Most religions recognize that children fare far better when they are born into nurturing environments and families prepared for parenthood. In fact, many religions believe that family planning is a moral duty. Pharmacists who refuse access to contraceptives believe that their personal religious attitudes should prevail over the moral and religious rights and views of these women.
The Episcopal Church first approved of contraception for the purpose of family planning in 1930. In a 1994 resolution, it directed dioceses and agencies to “provide information to all men and women on the full range of affordable, acceptable, safe, and non‑coercive contraceptive and reproductive health care services.”
In 1954, the Evangelical Lutheran Church in America stated that “to enable them to more thankfully receive God’s blessing and reward, a married couple should plan and govern their sexual relations so that any child born to their union will be desired both for itself and in relation to the time of its birth.”
The Presbyterian Church (USA) supports “full and equal access to contraceptive methods.” In a recent resolution endorsing insurance coverage for contraceptives, the church affirmed that “contraceptive services are part of basic health care” and cautioned that “unintended pregnancies lead to higher rates of infant mortality, low birth weight, and maternal morbidity, and threaten the economic viability of families.”
Jewish traditions have a long history of support for family planning, dating to the 1929 Reform resolution noting that birth control contributes to social stability. In a pioneering 1935 resolution, Women of Reform Judaism expressed support for lifting bans on the dissemination of information about birth control.
The Southern Baptist Convention, the nation’s largest Protestant denomination, supports the use of some forms of family planning by married couples. According to Dr. Richard Land, President of the denomination’s Ethics and Religious Liberty Commission, “….in terms of regulating the number of children and how far apart they are, we would leave that as a moral decision for the couple, as long as they used means of birth control that prevented conception from taking place.”
Unitarian Universalists consider the use of contraception to be a human right. The 1987 General Assembly opposed “any move to deny or restrict the distribution of government funds as a means of restricting access” to contraception in the U.S. or abroad.
The United Church of Christ General Synod, in affirming God as “the source of life—our life, all life, life to the full,” recognizes that “He has called us to share the work of creation with him, giving us the privileges and responsibilities of fellowship in this family and the wide units of society.”
The United Methodist Church, the nation’s second largest Protestant denomination, says that “each couple has the right and the duty prayerfully and responsibly to control conception according to their circumstances.” Its Resolution on Responsible Parenthood states that in order to “support the sacred dimensions of personhood, all possible efforts should be made by parents and the community to ensure that each child enters the world with a healthy body, and is born into an environment conducive to realization of his or her potential.” To this end, the United Methodist Church supports “adequate public funding and increased participation in family planning services by public and private agencies.”
Eighty-eight percent of Roman Catholic women in the United States have used the pill or other commonly used contraceptive at some point in life.(4) The Catholic Church teaches that modern birth control is “intrinsically evil” and that contraception is “rooted in a hedonistic mentality unwilling to accept responsibility in matters of sexuality.”(5) Most Catholics in American disagree with the church’s position, yet some Catholic pharmacists refuse to be involved even if a woman and her doctor decide birth control pills are medically appropriate for her.
Accommodating pharmacists without compromising care
State laws and pharmacy boards govern the practice of pharmacy and the laws and regulations vary greatly from state to state.
State Laws Protecting Prescriptions
The pharmacy boards of North Carolina and Massachusetts have indicated that “pharmacists who impede patients’ access to prescription medications will be met with disciplinary action under existing state laws and regulations.”(6) The governor of Illinois issued an emergency rule that requires pharmacies to stock emergency contraception if they stock other types of contraception and also requires the pharmacy to ensure a patient receives valid prescription medications “without delay.” In California, a pharmacist must either dispense a lawful prescription or provide an “appropriate referral” so that a patient receives his or her medication in a timely manner.
Other states specify the situations when a pharmacist may refuse to dispense a drug. These states require a pharmacist to refuse to fill a prescription if it will interact with a drug the patient is already taking, if the prescription has been forged, if there is an error in the dosage or if there is reason to believe the drug is being abused.(7) Since there is no mention of religious or moral reasons for refusing to fill, those reasons are implicitly prohibited.
State Laws Favoring Refusals
Four states have laws in place that allow the judgments of pharmacists to take precedence over the health needs of women. Since 1973, Arkansas protects a “physician, pharmacist, or any other authorized paramedical personnel from refusing to furnish any contraceptive procedures, supplies, or information.”(8) The Georgia Code of Professional Conduct states that “it shall not be considered unprofessional conduct for any pharmacist to refuse to fill a prescription based on his or her ethical or moral beliefs.”(9) In Mississippi, any health care worker can refuse to provide any medical services. South Dakota permits a pharmacist to reject a prescription if there is any reason to believe the medication will cause an abortion or destroy the life of an unborn child. However, every major medical organization and the U.S. Food and Drug Administration classify emergency contraceptives as preventing pregnancy – not as abortifacients. These regulations do not require that the prescription be referred to a pharmacist who will dispense the medication, and a woman may have her prescription confiscated.
Legislators in Georgia, Illinois, Michigan, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Tennessee, Vermont, Washington and Wisconsin have introduced bills in 2006 that affect access to prescribed medication. Politicians in New Jersey, New York and Pennsylvania have proposed laws that a pharmacist may not refuse to dispense a prescription solely based on philosophical, moral or religious beliefs.(10)
Proposed Federal Laws
Endangering the Most Vulnerable Women
If a pharmacist refuses to fill a time-sensitive prescription such as emergency contraception, many women do not have the luxury of shopping around for a drugstore that will accommodate their medical needs.
- In rural parts of the United States, a single pharmacy may serve the entire community. The next closest pharmacy could be many miles away.
- A woman may not have transportation to another pharmacy, or may not be able to take the time off of work to search for a pharmacist who will fill her prescription.
- A woman’s health insurance may only allow her to fill prescriptions at certain pharmacies. The pharmacy that ultimately fills her prescription may not be approved by her insurance, and she will be forced to pay full retail price for a covered medication.
- Young women may not look for another drugstore for fear of another judgmental rejection.
- Victims of sexual assault who were not offered emergency contraception in the emergency room may be further traumatized by a pharmacy refusal.
Three bills have been introduced by Congress to protect consumers seeking lawful prescriptions from religious refusals by pharmacists or pharmacies. The Pharmacy Consumer Protection Act, introduced in the U.S. Senate by Barbara Boxer (D-CA), will require a pharmacy that accepts payments from the government for Medicare and Medicaid to fill all valid prescriptions without unnecessary delay or interference. Congresswoman Carolyn McCarthy (D-NY) introduced a bill in the U.S. House of Representatives that requires a pharmacy that participates in interstate commerce to fill all lawful prescriptions. Both of the above-mentioned bills require that if one pharmacist refuses to fill a prescription for religious or moral reasons, another must fill the prescription. The Access to Legal Pharmaceuticals Act, introduced in the U.S. House by Carolyn Maloney (D-NY) and the U.S. Senate by Frank Lautenberg (D-NJ), requires a pharmacy to ensure that any in-stock prescription that one pharmacist refuses to fill on the basis of a personal belief is filled by another pharmacist without delay. All three bills state that a pharmacist may not refuse to return or transfer a prescription.
These proposed federal laws do not force pharmacists to dispense a drug that they feel violates their religious beliefs, but rather require a pharmacy to ensure patients have access to prescribed medication. Pharmacies can accommodate pharmacists who refuse to dispense birth control by having more than one pharmacist on duty at a time or by having a pharmacist on call to dispense birth control. If these steps are financially impractical, other methods can be devised that ensure the availability of time-sensitive medications.
Arrangements such as these are only effective if the refusing pharmacist agrees to refer the patient to another pharmacist. The group Pro-Life Pharmacists International advocates refusing to hand back a prescription and states that “it is not an inconvenience to refuse to refer such a client since the pharmacist is doing the woman and her preborn child a favor in terms of physical and spiritual health.”(11) Attitudes and actions such as these flagrantly disrespect the moral decisions of the woman who seeks to use contraception for family planning.
The policy of the American Pharmacists Association, the largest professional association of pharmacists in the United States, is that the patient should not be aware of a pharmacist refusal because he or she was not inconvenienced. “Whether another pharmacist on duty completes the prescription or patients are proactively directed to pharmacies where certain therapy is available, or even different systems are set up, the patient gets the medication, and the pharmacist steps away from the activity – with no intersection from the two.”(12)
Respecting Patients’ Rights
A patient’s health should be paramount in any health care facility. Pharmacists who work in a secular business and serve the public should not be allowed to impose their personal beliefs about health care on entire communities. They have a duty to provide comprehensive prescription care to all patients.
In keeping with our constitutional right to practice our religious beliefs without government interference, individuals should not have to perform services to which they are religiously or morally opposed. However, the responsibility of the pharmacy is to the consumer. A pharmacy must ensure that full access to FDA-approved and doctor-prescribed medication is available to all patients.
(2)National Women’s Law Center, Pharmacy Refusals 101, p. 1, 11/29/05.
(3)Population Briefs, Population Council. May 2005, Volume 11, Number 2.
(4)A World View, “Catholic Attitudes on Sexual Behavior and Reproductive Health.” http://www.catholicsforchoice.org/topics/reform/documents/2004worldview.pdf
(6)Don’t Take “NO” For an Answer, A guide to Pharmacy Refusal Laws, Policies and Practices, National Women’s Law Center. P 5.
(7)Don’t Take “NO” For an Answer, A guide to Pharmacy Refusal Laws, Policies and Practices, National Women’s Law Center. P 5.
(11)Pro-Life Pharmacy News Jul/Aug/Sept 1997 AD, http:www.pfli.org/begin104.html
(12) American Pharmacists Association, 2004 House of Delegates, Report of the Policy Review Committee (2004), at 10 (retaining 1998 Policy).
The Religious Coalition for Reproductive Choice, founded in 1973, is the national organization of pro-choice people of faith. The Religious Coalition—comprising Protestant, Jewish, and other denominations and faith groups, the Clergy for Choice Network, and state affiliates throughout the country—works to ensure reproductive choice through the moral power of religious communities.
Perspectives #1: March 1, 2006