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Pharmacists' Conscience Rights: When Is It OK to Refuse to Fill a Prescription

Pharmacy Practitioners' Objections to Some Therapies Are Protected

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Emergency contraceptive Plan B (levonorgestrel) raises conscience issues for many pharmacists.

Laws in several states and policy statements from some pharmacy associations affirm pharmacists' rights to refusal to fill prescriptions on moral, ethical or ethical grounds.

Photo courtesy of DailyMed

Two pharmacists in Illinois on Sept. 21, 2012, won their seven-year court battle for recognition of their rights to refuse to fill prescriptions for emergency contraceptives. The community pharmacists claimed that their religious beliefs led them to understand that life begins at contraception and, therefore, they could not in good conscience dispense medications like Teva Women's Health's Plan B (levonorgestrel), the so-called "morning after pill," that adversely affected a fertilized ovum.

The pharmacists originally sued the state government after then-governor Rod Blagojevich issued an executive order compelling all pharmacists licensed in Illinois to fill and dispense lawful contraceptive prescription orders. His successor kept the order in force on the grounds that all patients should have access to all health care services in all appropriate settings. State officials seemingly saw patients' rights as more important than pharmacists' rights.

The pharmacists' victory may prove short-lived if state officials file an appeal, but the case has the potential to stand as an important affirmation of pharmacy professionals' rights to apply their ethical, moral and religious beliefs to their health care practice.

Legal Conscience Clauses

"Potential" is a key word for understanding the import of the Illinois appellate court ruling. It applies only to the plaintiff pharmacists. Other challenges to the state law will be needed to extend full conscience rights to other pharmacy practitioners.

Currently, 14 states have laws guaranteeing some refusal to fill rights for pharmacists. Eight of these laws, which are generally called "conscience clauses," are written broadly enough to protect conscience rights for student pharmacists and pharmacy technicians. Summarizing those laws is beyond the scope of this article, but the National Conference of State Legislatures provides brief descriptions and links on its website.

Pharmacy Associations and Conscience Rights

Professional organizations have also come to the defense of pharmacy professionals with objections to filling and dispensing certain prescriptions. The strongest of these conscience clause statements was adopted by members of the American Pharmacist Association in 1998.

Specifically, APhA "recognizes the individual pharmacist's right to exercise conscientious refusal and supports the establishment of systems to ensure [a] patient's access to legally prescribed therapy." Key to this policy is having policies in place in every pharmacy setting to ensure that one practitioner's refusal to fill does not leave a patient without a needed medication. In practice, this means that a pharmacist who has religious objections to emergency contraception must be willing and able to refer a woman to an easily accessible pharmacy colleague who will dispense a prescription for the treatment.

Legal Implications of Refusal to Fill

Pharmacists, students and technicians who simply tell patients "no" leave themselves liable to malpractice lawsuits. The Healthcare Providers Service Organization, which offers professional liability insurance for pharmacy professionals, notes in an article on its website that conscience issues arise with more than contraceptives, extending to potentially lethal doses of narcotics for terminally ill patients and participating in the supply chain for lethal injection drugs. Again, though, HPSO emphasizes that no pharmacy professional can outright deny patients the ability to have a legitimate prescription order filled.

The Special Case of Plan B

The hormonal contraceptive at the heart of the pharmacist conscience clause case in Illinois is likely to continue stirring controversy. Uniquely, Plan B has dual prescription-OTC status in the same dose and for the same indication. Women and teenagers older than 17 can purchase the medication over the counter without first visiting a doctor or nurse. Younger teens must present a prescription and receive a patient information sheet and an offer of counseling. Certainly when working with younger patients, filling and dispensing a Plan B prescription is a face-to-face health care interaction that can be fraught for even pharmacists with no objections to birth control.

The reality, though, is that Plan B proves problematic for many simply because it is a medication that prevents pregnancy. Although it is not an abortifacient, it often gets described in the same terms as Danco Laboratories' Mifeprex (mifeprex), which is most popularly known as RU-486 and which does end a pregnancy in progress. Add to that mischaracterization of all hormonal birth control medications as abortion drugs the largely Catholic Church-led campaign to exempt employer-provided health insurance plans from federal requirements to cover women's contraceptives without requiring co-pays, and conscience issues are sure to remain unresolved on any level beyond each pharmacist, student and technician deciding what practices best accord with his or her own moral, ethical and religious beliefs.

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