Prescriptions denied: pharmacy refusal clauses have become the latest battleground in the provision of safe and legal medical services.
IN JANUARY THIS YEAR, A MOTHER of six walked into a Walgreen's pharmacy in Milwaukee, Wis., to get a prescription filled for emergency contraception Emergency Contraception Definition
Emergency contraception or emergency birth control uses either emergency contraceptive pills (ECPs) or a Copper-T intrauterine device (IUD) to help prevent pregnancy following unprotected vaginal intercourse. (EC). The condom she and her partner were using had burst and she wanted to take precautions against pregnancy. However, when she handed the prescription over to the pharmacist, not only did the pharmacist refuse to fill it, but publicly humiliated hu·mil·i·ate
tr.v. hu·mil·i·at·ed, hu·mil·i·at·ing, hu·mil·i·ates
To lower the pride, dignity, or self-respect of. See Synonyms at degrade. her in the presence of other customers, calling her a "murderer" and "baby killer." When the woman spoke to the pharmacy manager she was informed that it was company policy to let the pharmacist decide whether or not to fill a prescription. Too traumatized by the whole incident to try filling it elsewhere, the customer left the store, and according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. a report in the Milwaukee Journal Sentinel The Milwaukee Journal Sentinel is a daily morning broadsheet printed in Milwaukee, Wisconsin, USA. It is the primary newspaper in Milwaukee, the largest newspaper in Wisconsin and is distributed widely throughout the state. , later had an abortion.
This scenario is becoming more common as part of a concerted assault on safe and legal reproductive health Within the framework of WHO's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene care services, seeking to enshrine en·shrine also in·shrine
tr.v. en·shrined, en·shrin·ing, en·shrines
1. To enclose in or as if in a shrine.
2. To cherish as sacred. the right to refuse a prescription into laws nationwide.
Standard refusal clauses are nothing new. Statutory barriers to women accessing legal reproductive health services proliferated across the country after the 1973 Roe v. Wade Roe v. Wade, case decided in 1973 by the U.S. Supreme Court. Along with Doe v. Bolton, this decision legalized abortion in the first trimester of pregnancy. decision. First, Congress enacted the Church Amendment in 1973, which stated that the receipt of federal funds Federal Funds
Funds deposited to regional Federal Reserve Banks by commercial banks, including funds in excess of reserve requirements.
These non-interest bearing deposits are lent out at the Fed funds rate to other banks unable to meet overnight reserve does not require health care providers to make abortion and sterilization sterilization
Any surgical procedure intended to end fertility permanently (see contraception). Such operations remove or interrupt the anatomical pathways through which the cells involved in fertilization travel (see reproductive system). services available. Since then, 46 states have passed laws modeling that legislation which allows certain medical professionals and entities to opt out of performing certain legal medical procedures, mostly, abortion.
The latest twist in the bat-tie over the provision of reproductive health services, commonly called "pharmacy refusals," has spawned legislative battles across the country. Often spurred on or heavily supported by either the US Conference of Catholic Bishops or local bishops' conferences, refusal dames have also received support from the Catholic Health Association (CHA). The CHA is the trade association of the Catholic health industry and, among other roles, represents the interests of Catholic health care providers on Capitol Hill and in local legislatures. It claims to be "the largest not-for-profit provider of health care services in the nation" and, according to its 2005-2006 advocacy agenda, the preservation of what it terms "conscience" clauses is deemed a priority.
THE BULLY PULPIT bully pulpit
An advantageous position, as for making one's views known or rallying support: "The presidency had been transformed from a bully pulpit on Pennsylvania Avenue to a stage the size of the world"
In Illinois, Chicago Auxiliary Bishop Thomas Paprocki vehemently opposed an emergency rule filed by Democratic Governor Rod Blagojevich on April 1 requiring pharmacies "that stock and dispense contraceptives to fill birth control prescriptions without delay." The order mandates that out-of-stock contraceptives must be ordered according to standard procedures and protects patients by requiring that, if unfilled, a prescription must be transferred to another local pharmacy or returned to the patient if the patient so desires. Since the governor's emergency rule will expire after 150 days, he filed for a permanent rule on April 18, 2005.
The order provoked Bishop Paprocki to single out the governor during a mass at St. Hyacinth's Basilica in April. "Mr. Governor, out of respect for Pope John Paul II Pope John Paul II (Latin: Ioannes Paulus PP. II, Italian: Giovanni Paolo II, Polish: Jan Paweł II) born , please respect his wishes ... rescind your order. Let our pharmacists be free to follow their faith," he said. (Washington Times, April 4, 2005) Governor Blagojevich has not backed down, but three challenges have since been filed against the order.
Bishop Paprocki may have overplayed his hand. Using his pulpit to intervene in a political issue is not likely to earn him support from Catholics and further, Catholics overwhelmingly support family planning family planning
Use of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources. , including access to EC. A recent poll showed that 75 percent of US Catholics believe that the church should allow the use of contraception. (Baltimore Sun, April 10, 2005) Even the Ethical and Religious Directives governing Catholic health care facilities allow the provision of EC to women who have been raped. (USCCB USCCB United States Conference of Catholic Bishops (Washington, DC) , 4th Edition, 2001) Catholics in the US, like those in other countries, object to the pulpit being used to espouse political views. During the last election cycle, a full 70 percent of US Catholics did not believe the views of Catholic bishops were important in deciding for whom to vote. (Belden Russonello & Stewart poll for Catholics for a Free Choice Catholics for a Free Choice (CFFC) is a pro-choice political organization whose founders hold the belief that "the Catholic tradition supports a woman's moral and legal right to follow her conscience in matters of sexuality and reproductive health. , "The View from Mainstream America: The Catholic Voter in Summer 2004," July 2004)
AN UNFAIR FIGHT?
Public opinion on the issue of pharmacy refusals is solidly on the side of full access to prescribed pharmaceuticals. When Americans were asked whether or not pharmacists who personally oppose birth control for religious reasons should be able to refuse to fill an order for birth control, a full 80 percent say no. Only 16 percent believed that pharmacists should be able to refuse service. Even 74 percent of "prolifers" opposed giving pharmacists this power. (Lake Snell Perry Mermin/Decision Research poll for NARAL Pro-Choice America NARAL Pro-Choice America, founded in 1969 as the National Abortion and Reproductive Rights Action League, is a nonprofit organization that was formed primarily to maintain a woman's legal right to have an abortion. , June 6, 2005)
Despite this overwhelming public support, laws governing pharmacists vary considerably from state to state. According to the National Women's Law Center The National Women's Law Center (NWLC) is a Washington, DC-based non-profit organization. Through litigation and policy initiatives, the Center strives to improve the lives of women and their families in the areas of health, employment, family economic security, and education. , legislators in 28 states have filed bills that would allow pharmacists to refuse to fill prescriptions based on their personal beliefs. In just the first half of 2005, refusal clause bills were introduced in Arizona, Arkansas, California, Georgia, Indiana, Maryland, Michigan, North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. , Rhode Island Rhode Island, island, United States
Rhode Island, island, 15 mi (24 km) long and 5 mi (8 km) wide, S R.I., at the entrance to Narragansett Bay. It is the largest island in the state, with steep cliffs and excellent beaches. , South Dakota, Tennessee, Texas, Vermont, West Virginia and Wisconsin.
However, legislation has also been introduced in five states (California, Missouri, New Jersey, Nevada and West Virginia) to protect the rights of patients seeking legal, essential health care services.
In Arizona, Governor Janet Napolitano (D) vetoed a bill (HB 2541) that would have allowed pharmacists to refuse to fill a prescription for emergency contraception. Not surprisingly, this veto brought swift condemnation from the Arizona Catholic Conference: "With the veto of HB 2541, health care providers' inalienable Not subject to sale or transfer; inseparable.
That which is inalienable cannot be bought, sold, or transferred from one individual to another. The personal rights to life and liberty guaranteed by the Constitution of the United States are inalienable. civil rights are apparently deemed inconsequential.... [W]e are extremely disappointed that Governor Napolitano has rejected this important legislation." Napolitano, in her veto letter to lawmakers, said that pharmacies and other health care providers "have no right to interfere with the lawful personal medical decisions made by patients and their doctors."
Responsible governors understand that a pharmacist refusing to fill a prescription for EC will have a significant impact on public health. It is an incursion in·cur·sion
1. An aggressive entrance into foreign territory; a raid or invasion.
2. The act of entering another's territory or domain.
3. on patients' rights The legal interests of persons who submit to medical treatment.
For many years, common medical practice meant that physicians made decisions for their patients. This paternalistic view has gradually been supplanted by one promoting patient autonomy, whereby patients and to make personal and moral medical decisions. This is particularly the case for women in rural areas who may have a difficult time even getting to their local pharmacy--never mind having to choose amongst them for better service.
Soon, it is expected that Wisconsin Governor Jim Doyle, a Democrat, will face a bill already passed by the Wisconsin Assembly that will expand "conscience" clause protections to include pharmacists and medical school students. Doyle, who opposes the measure, will most likely veto the legislation if it reaches his desk.
While Arizona and Illinois were success stories in terms of stopping the pharmacy refusal campaign, this was largely due to the fact that voters in those two states elected governors who are happy to use their power of a veto to protect the rights and consciences of women. States where voters have elected conservative chief executives do not have that luxury.
In June, the American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. passed a resolution in support of state and federal legislation that requires pharmacists to fill prescriptions without delay or to make an immediate referral to another pharmacy. If no other willing pharmacist can be found within 30 miles, they must fill it themselves.
On the federal level, legislation has been introduced in the United States Congress to address pharmacy refusals. At press time, the "Access to Legal Pharmaceuticals Act" is sponsored in the Senate by Senator Frank Lautenberg (D-NJ) and in the House by Representative Carolyn Maloney (D-NY). Additionally, there is the "Pharmacy Consumer Protection Act of 2005," sponsored by Senator Barbara Boxer (D-Calif.), and HR 1539, sponsored by Representative Carolyn McCarthy (D-NY), requiring pharmacies to fill prescriptions within four hours if one pharmacist refuses to fill it on grounds of conscience.
(While not refusal or pharmaceutical specific, the Workplace Religious Freedom Act The bipartisan Workplace Religious Freedom Act (WRFA) was introduced in the United States Senate by Senator Rick Santorum (R-Pennsylvania) and Senator John Kerry (D-Massachusetts) on March 17 2005, and in the House of Representatives by Representatives Mark Souder (R-IN), Carolyn , introduced by Senators Rick Santorum (R-PA) and John Kerry (D-Mass.) could conceivably offer workplace protection for pharmacists who refuse to fill a prescription with which they disagree if it is based on religion. The bill is currently opposed by Catholics for a Free Choice, Americans United for Separation of Church and State Americans United for Separation of Church and State (Americans United or AU for short) is a religious freedom advocacy group in the United States which promotes the separation of church and state, a legal doctrine seen by the AU as being enshrined in the Establishment and the American Civil Liberties Union American Civil Liberties Union (ACLU), nonpartisan organization devoted to the preservation and extension of the basic rights set forth in the U.S. Constitution. .)
It is unfortunate that some health care providers seek to withhold medical treatment or services from a patient who has already made the decision that the treatment is both morally and medically necessary medically necessary Managed care adjective Referring to a covered service or treatment that is absolutely necessary to protect and enhance the health status of a Pt, and could adversely affect the Pt's condition if omitted, in accordance with accepted and acceptable. In effect, these providers have decided that their consciences trump those of patients. While we do need to balance the rights of individual providers and patients, a pharmacy must make provisions so that if an individual pharmacist refuses to fill a prescription, the patient is still able to obtain the prescription they need in a reasonable time frame.
Pharmacists who refuse to fill prescriptions, who hold a prescription hostage or publicly berate a woman for asking for a prescription to be filled are not only denying women their basic health care rights, but are also disregarding the religious freedom of that woman to make her own decisions. This problem gets compounded for rural women who may not have the means to travel to a different pharmacy.
The systemic campaign in support of legislative obstacles to safe and legal public health services health services Managed care The benefits covered under a health contract is troubling. While we must recognize the right of individual medical professionals to decline to provide services they consider immoral, it goes too far to grant such rights to an institution or to permit individuals to refuse to refer the patient to another provider.
There will be times when the conscience of an individual doctor, nurse or pharmacist may conflict with the wishes or needs of a patient. There has, however, always been an ethical preference for ensuring that patients have the primary opportunity to act on their conscience.
In the case of refusal clauses, it is incumbent on the institution to ensure that the rights of both patients and providers are recognized and honored. The institution should be obliged to provide doctors and nurses and in these cases, pharmacists, who will provide services that patients deem moral and that are legal, while allowing those medical professionals who choose to opt out to do so.
When this is not possible, a reasonable ethical fall back is for the institution to provide the patient with "meaningful referral" that ensures that patients receive continuity of care without facing an undue burden, such as traveling long distances or encountering additional barriers.
State and federal legislators need to be mindful of and assimilate this ethical balancing act before they enshrine in law a system that does a disservice to both the medical profession and women seeking legal and necessary medical services.
Laws & Bills Governing Pharmacist Refusals
Most states in the US have statutes or regulations that implicitly impose a duty on the pharmacist to dispense all legally valid and medically appropriate prescriptions. However, several states have introduced, and some even enacted, measures that would permit pharmacists to refuse to fill prescriptions based on their personal beliefs.
ROGER J. LIMOGES is the senior policy analyst at Catholics for a Free Choice.