Pharmacists with No Plan B

Interesting piece from Christianity Today: Law or Free Market? Can a pro-life pharmacist be compelled to fill a prescription for a pill that goes against his or her religious beliefs? In full ...

On July 6, 2002, Neil Noesen found himself on the front line of the culture wars. Less than three days after taking a job as a pharmacist at a Kmart in Menomonie, Wisconsin, he received a refill request from University of Wisconsin-Stout student Amanda Renz for the contraceptive Loestrin.

Noesen, a devout Catholic, had always refused to dispense birth control. For six years previous, he had been willing to refer patients seeking contraception to another pharmacist, but a recent trip to Calcutta—where he realized anew that health care is about helping the suffering—had convicted him that this was wrong. "Finally, my conscience caught up to me," Noesen told CT. "I couldn't do it anymore. I felt like I was being used by the system, that I was becoming part of the problem rather than part of the solution."

Now back home in Wisconsin, he faced the first real test of his new policy. He told Renz he could not provide Loestrin.

The store's head pharmacist, who knew Noesen's concerns, had agreed to personally fill such prescriptions, but he was out of town for the weekend. Renz asked where else she could get the prescription filled. Noesen declined to tell her. Renz went to the local Wal-Mart, but when the pharmacist there attempted to transfer her prescription over the phone, Noesen refused.

The resulting deadlock put Noesen's name in newspapers around the country and brought the case to the attention of the Wisconsin Department of Regulation and Licensing (DRL). Though Noesen had violated no state law or administrative code, DRL's Pharmacy Examining Board looked into the matter. They found that Noesen was within his rights when he refused to fill the prescription, but that he had not served the public in a "minimally competent manner," because no procedure was in place to ensure that patients could fill prescriptions to which he objected.

On April 13, 2004, an administrative law judge agreed. She ruled that Noesen must take six credit hours of ethics courses and pay the full costs of the proceedings against him—around $20,000. Noesen's principled stand cost him dearly.

A Contested Right
Noesen's case is not an isolated incident. Since 2004, pharmacist refusals have made headlines across the country—and have often spurred local governments into action. In Denton, Texas, three pharmacists were fired from Eckerd after refusing to fill an emergency contraception prescription for a rape victim. Gene Herr told the Associated Press that he "went in the back room and briefly prayed about it" and decided that he could not in good conscience provide the pills, which he believes can cause an abortion. Similar refusals have been reported in Georgia, Alabama, New Hampshire, Missouri, Illinois, and Wisconsin.

Some states have already acted to limit such refusals. In response to reports that some Chicago pharmacists were refusing to fill certain prescriptions, Illinois Gov. Rod Blagojevich signed an emergency rule in early 2005 that ordered pharmacies to dispense drugs in a timely manner—no transfers or referrals allowed. Blagojevich argued that the state's Health Care Right of Conscience Act does not cover pharmacists. He later moved to make the rule permanent, saying there should be "No delays. No hassles. No lectures" (ct, June 2005, p. 29).

In 2005 alone, state legislatures considered more than 20 bills aimed at sorting out the situation. Some would force pharmacists to dispense all legal prescriptions, while others would allow pharmacists to refuse for any reason of conscience and prevent employers from taking action against them. Arkansas, South Dakota, Mississippi, and Georgia already have laws that give pharmacists the right to refuse, and many other states will decide one way or another in the next year.

The issue has exploded during the last five years, in part because of the recent availability of emergency contraception (EC). Both Preven (approved in 1998) and Plan B (1999) can be taken within 72 hours of unprotected sex. If properly used, they are more than 70 percent effective at preventing pregnancy. Though all forms of contraception raise ethical issues for Catholic pharmacists, EC raises the ante for Protestant pro-lifers as well, because some claim that the drug is an abortifacient.

"For pro-life pharmacists, this is a real bright line in the sand," David Stevens, executive director of the Christian Medical and Dental Associations, told CT. "There's a difference between dispensing EC and a birth-control pill."

The Religious Coalition for Reproductive Choice—a group that represents Episcopalians, Presbyterians (PCUSA), Conservative and Reform Judaism, United Methodists, and Unitarians, among others—argues that EC is little more than a potent birth-control pill of the kind that Christian women take routinely. It works the same way and contains the same ingredients as birth control (unlike the abortion pill, RU-486, which is not available in pharmacies), so it should pose no moral problems for pharmacists. The Rev. Carlton W. Veazey, the group's president, told CT, "People need to understand: The medical fact is that neither birth-control pills nor emergency contraception—a concentrated dose of these same birth-control pills—cause an abortion."

Defining Terms
So is this simply a case of some pro-life Christians refusing to look at the science? Not quite. As with many aspects of the abortion debate, defining terms is critical.

The American College of Obstetricians and Gynecologists (ACOG) defines conception (and therefore pregnancy) as beginning at the moment of implantation. "Conception is implantation," says ACOG, and therefore EC cannot, by definition, cause an abortion—even if it affects a fertilized egg. But, as Karen Brauer of Pharmacists for Life International told CT, "Our issue has to do with human life, not their definition of pregnancy." In her view, human life begins the moment that an egg is fertilized.

This difference in emphasis is crucial. According to its maker, Plan B "prevents pregnancy mainly by stopping the release of an egg from the ovary and may also prevent the fertilization of an egg. Plan B may also work by preventing it from attaching to the uterus." Though EC will do nothing to stop the growth of a developing fetus, it has the potential to prevent a fertilized egg from implanting in the uterine wall. To many pro-life pharmacists, this makes it an abortion-inducing drug, and its presence in the neighborhood pharmacy has caused them to fight for their right not to dispense it.

Their refusal got the attention of NARAL Pro-Choice America, which launched a campaign in March 2005 to pressure pharmacies and legislators. NARAL president Nancy Keenan said, "In 2005, it is appalling that women do not know whether their prescriptions will be filled. Pharmacies have no right to override a decision made by a woman and her doctor."

This move brought publicity to the debate about whether pharmacists should have the right to refuse any drug to any patient at any time. Most states passed "conscience clauses" years ago, but these were generally targeted at individual physicians, approved in the years following Roe v. Wade to allow doctors to opt out of performing abortions. The position of pharmacists has been more ambiguous. Few states have laws explicitly granting them the same conscience protection that doctors have.

Polls show that pharmacists want to be treated like true health care professionals, not automated pill dispensers. More than two-thirds of them want freedom to refuse to fill prescriptions, Glenn Kessler of HCD Research told CT.

The American Pharmacists Association, which represents more than 50,000 pharmacists across the country, has adopted a policy that supports a pharmacist "stepping away" from but not hindering a transaction. The association says that it "recognizes the individual pharmacist's right to exercise conscientious refusal and supports the establishment of systems to ensure [the] patient's access to legally prescribed therapy without compromising the pharmacist's right of conscientious refusal."

This right of refusal can take several forms. If at least two pharmacists are available, the one who objects may simply hand the prescription to the colleague. Or the pharmacist may refer the patient to another pharmacy.

Not all pharmacy chains find this an acceptable solution, however. Eckerd, CVS, and Kmart all have policies allowing pharmacists to refuse to fill prescriptions, but only when another pharmacist is available. When pharmacists work alone, they are generally expected to fill all prescriptions.

Fighting Words
Target, by contrast, allows its pharmacists to "refuse and refer" a patient to another pharmacy. This stand has earned Target the wrath of Planned Parenthood, which organized a nationwide protest against the retailer last December.

Though "refuse and refer" sounds moderate, it satisfies neither groups like Planned Parenthood nor some pro-life pharmacists. To Brauer, an Indiana pharmacist, giving a referral is like saying, "I don't kill people, but I can send you to a specific person who does."

Brauer believes that EC and some forms of birth control can cause abortions, and she was fired from a Kmart pharmacy in 1996 for telling a patient that the store was out of birth control (it was not). She went on to found Pharmacists for Life International, a group that represents about 1,500 members. The group's rhetoric is angry; members call their opponents names such as "Klan Parenthood" and "Slobodan Blagojevich," and they are on a mission to stop the work of "abortoholics" in this country.

Brauer's group can be uncompromising, but it's not the only one dishing out tough talk. On the other side, the Religious Coalition for Reproductive Choice argues that Christians working in public professions have no right to bring their views into the workplace. Those who want to do so should find a new job. "The pharmacist has a professional responsibility to fill prescriptions accurately and according to established standards, not to advocate personal or political views while on the job," says Veazey. "If the pharmacy is dispensing products the pharmacist objects to, then he or she should not be working there."

The public tends to side with Veazey. A 2005 poll by HCD Research found that 73 percent of Americans believe pharmacists should be required to fill all prescriptions despite religious objections. Responses of Catholics (70 percent) and Protestants (68 percent) were not much different from the general population, and among Orthodox Christians, the majority still sided with the patient (55 percent).

Advocates who oppose conscience clauses for pharmacists worry about the slippery slope. "Are we going to let the pharmacist ask for a marriage license?" Frances Kissling, head of Catholics for a Free Choice, told CT. "Are we going to allow them to deny prenatal vitamins to unmarried women because they shouldn't have gotten pregnant? How far does the right of conscience go?"

The discussion often comes down to one of rights: the right of pharmacists not to do something that violates their consciences versus the right of patients to obtain legally prescribed medications. Steve Aden, a lawyer at the Center for Law and Religious Freedom, has represented several pharmacists, including Noesen. Aden told CT that most pro-life pharmacists are not out to deny legal medications to anyone—they simply don't want to be forced to dispense them personally.

"In every case that I've ever heard of," he said, "a woman can get access to her contraceptive medication by alternative means if for some reason the nearest pharmacy doesn't have a pharmacist on duty who will dispense it."

Indeed, Amanda Renz, the young woman in search of Loestrin, got the contraceptive two days later and missed only a single dose.

But Kissling finds this scenario unacceptable. "I cannot in good conscience say that a woman who has been raped should shop around," she said, "before she finds [a pharmacy] that actually will fill the prescription."

Such overt refusals happen infrequently, especially when it comes to EC. Ron Stephens, a pharmacist who serves in the Illinois General Assembly, said Plan B is the least prescribed medication in the state. "I own parts of two pharmacies in downstate Illinois," he told CT. "We fill hundreds of thousands of prescriptions a year, and we've not seen one for the morning-after pill."

Kissling, however, said that's because many women don't know about EC.

Legislators Stepping In
Legislators at every level are attempting to settle the dispute. While bills introduced at the state level have varied widely, a consensus appears to be emerging within the federal government. Both the Access to Legal Pharmaceuticals Act (S.809) and the Workplace Religious Freedom Act (S.677) were introduced in 2005, and both take the same approach: They allow a pharmacist to refuse a prescription but make sure that another pharmacist can fill it. Everyone from John Kerry, D-Mass, to Rick Santorum, R-Penn, supports such legislation, but nothing has yet been passed. Until a federal bill is in place, both women and their pharmacists will remain uncertain about their rights and responsibilities.

Dilemmas like Noesen's will only multiply in the coming years. The last few decades have brought abortion, euthanasia, in vitro fertilization, and contraception. Newer technologies such as cloning and stem-cell research present similar challenges.

But this year, the main event is in the local pharmacy, and the outcome will define conscience rights in the public sphere for years to come. That's a prescription for battle.