Abstract In Stormans, Inc. v. Selecky, a group of Washington pharmacists contended their religious beliefs precluded them from dispensing the drug Plan B, a post-coital emergency contraceptive. They based their argument on rights conferred by the Free Exercise Clause of the First Amendment to the United States Constitution. A United States District Court found in the pharmacists’ favor and enjoined enforcement of rules issued by the Washington State Board of Pharmacy requiring pharmacies to deliver medications. The Ninth Circuit reversed, finding that the district court erroneously applied a heightened level of scrutiny to a neutral law of general applicability. Interestingly, the pharmacists did not bring a claim under the Washington State Constitution, a document that has been interpreted to confer greater protection for free exercise rights than the U.S. Constitution. This Comment argues that even under the Washington State Constitution’s heightened protection of free exercise, the pharmacists’ position in Stormans would ultimately fail. The Board’s rules protect public health and accommodate individual religious objections, thereby satisfying the Washington State Supreme Court’s strict scrutiny test.
Karen B. Farris, Daniel Ashwood, Jennifer McIntosh, Natalie A. DiPietro, Nicole Monastersky Maderas, Sharon Cohen Landau, John Swegle, Orod Solemani
Journal of the American Pharmacists Association
Abstract Objectives: To review the literature regarding pharmacists’ roles in preventing unintended pregnancy, review the relevant laws and policies in the United States to describe pharmacists’ and/or pharmacy’s role in policy development related to unintended pregnancy, and identify partners who pharmacists can work with in this public health area.
Data sources: A systematic review was conducted focusing on the role of pharmacists in unintended pregnancy. For practice, articles were identified in Medline through July 1, 2009, using MeSH and keywords. For policy, two authors examined the current status of access issues related to over-the-counter (OTC) status and collaborative practice agreements. Partners were identified in the reviews and authors’ experiences.
Data extraction: English-language, U.S.-based articles that contained either qualitative or quantitative data or were review articles addressing pharmacist interventions, pharmacists’ knowledge and attitudes regarding contraception, and pharmacists’ comfort and ability to counsel on preventing unintended pregnancy were included.
Data synthesis: Some improvements to emergency contraception (EC) access in pharmacies have occurred during the previous decade. Studies focused on counseling, pharmacist provision of depot reinjection, and pharmacist initiation of oral contraceptives were positive. No studies linked increased contraceptive access in pharmacies to lower pregnancy rates. In terms of policy, the literature described three access-related areas, including (1) EC and conscience clauses, (2) collaborative practice agreements, and (3) changes in prescription to OTC status. Pharmacists’ partnerships may include physicians/clinicians, local health departments, family planning organizations, nongovernmental organizations, and colleges of pharmacy.
Conclusion: Currently, pharmacists may increase access to contraceptives primarily via EC and use of collaborative practice agreements to initiate and/or continue hormonal contraceptives. New practice models should be implemented in community or clinic practices as allowed by collaborative practice regulations in each state. We encourage researchers and practitioners to consider a community approach in their endeavors by working with numerous types of primary care providers and organizations to explore ways to increase contraceptive access.
Extract Conclusion This Comment analyzes the PCR, which is currently under review by the Obama Administration. As currently written, the PCR promises to have devastating effects on the healthcare system. . .
Commenters have predicted that the PCR will be used to discriminate against patients based on their sexual orientation. 196 And because reproductive healthcare remains so controversial in this country, women will be disproportionately disadvantaged by the PCR, which now allows almost all employees-not only the doctor, but potentially the nurse, the pharmacist, the pharmacist’s assistant, the receptionist, the ambulance driver, and the janitor-to have a say in whether she can access her chosen healthcare without interference.
The PCR brought the ongoing debate over conscience clauses into the national spotlight. . . .this Comment argues that any analysis of conscience clauses must recognize that what is at stake is access to healthcare services, and that reduction of healthcare access can be accomplished not only explicitly, for example through the explicit redefining of the term “abortion,” but also through “strategic ambiguity.” . . .
Laura A.Davidson, Clare T.Pettis, Amber J.Joiner, Daniel M.Cook, Craig M.Klugmand
Social Science & Medicine
Abstract Some US states allow pharmacists to refuse to dispense medications to which they have moral objections, and federal rules for all health care providers are in development. This study examines whether demographics such as age, religion, gender influence 668 Nevada pharmacists’ willingness to dispense or transfer five potentially controversial medications to patients 18 years and older: emergency contraception, medical abortifacients, erectile dysfunction medications, oral contraceptives, and infertility medications. Almost 6% of pharmacists indicated that they would refuse to dispense and refuse to transfer at least one of these medications. Religious affiliation significantly predicted pharmacists’ willingness to dispense emergency contraception and medical abortifacients, while age significantly predicted pharmacists’ willingness to distribute infertility medications. Evangelical Protestants, Catholics and other-religious pharmacists were significantly more likely to refuse to dispense at least one medication in comparison to non-religious pharmacists in multinomial logistic regression analyses. Awareness of the influence of religion in the provision of pharmacy services should inform health care policies that appropriately balance the rights of patients, physicians, and pharmacists alike. The results from Nevada pharmacists may suggest similar tendencies among other health care workers, who may be given latitude to consider morality and value systems when making clinical decisions about care.
Eileen P Kelly, Aimee Dars Ellis, Susan PS Rosenthal
Employee Responsibility and Rights Journal
Abstract Advances in technology have resulted in medical procedures and practices that were unthought-of in previous generations. Embryonic stem cell research, abortifacients, birth control, and artificial insemination are just a few examples of these technological advances. While many individuals readily embrace such medical advances, others find them morally objectionable. A contentious national debate is now occurring over whether employee pharmacists have the right to refuse to fill legal prescriptions for emergency contraception because of conscientious objections. In the United States, existing public policy is somewhat muddled in both protecting and encroaching on the employee pharmacist’s right of refusal. This article discusses the legal and ethical nature of that controversy, as well as the clash of interests, rights and responsibilities between employers, employee pharmacists and customers from a U.S. perspective.
Abstract Legal scholarship in this area debates the fairness of conscience clauses. The debate appears to be at an impasse and is, in any event, unsatisfying. This Article proposes the application of welfare economics as the guiding principle in policy determinations and presents an alternative approach to the current debate surrounding pharmacist conscience clauses. The theoretical application of welfare economics demonstrates that pharmacist conscience clause legislation may not maximize individuals’ well-being. A common law approach, whereby a pharmacist may be held liable for refusing to fill a prescription for a non-medical reason, most likely can reach the appropriate balance to minimize total social costs. If however, states refuse to repeal pharmacist conscience clause legislation or states continue to pass pharmacist conscience clause legislation, duty-to-fill legislation, which places a statutory duty on pharmacies or pharmacists to fill valid prescriptions, may be needed. If this is the case, duty-to-fill legislation should include a provision that pharmacies cannot refuse to carry any FDA approved medication due to any religious or personal objections. Importantly, duty-to-fill legislation does not alter any of the professional responsibilities and gatekeeper functions of a pharmacist. The pharmacist’s job to ensure the prescription is valid and legal remains. The expertise required for drug allergies or interactions is still a critical component of the profession. Interesting to note in this debate is that the word science is within the word conscience.
Extract Conclusion In conclusion, we think that the marketplace of ideas should be allowed to function on this issue. So long as consumers have access to distribution channels for emergency contraception and to information regarding where the drug is available, there is no reason why the market would fail to reconcile this dilemma. However, if Wilson is correct that governments will not be able to fight the urge to take an active role in this dispute, then freedom of conscience should be the paramount fundamental right. This determination is necessary to provide the proper balance of rights because placing an affirmative duty on pharmacists to dispense a drug negates the basic premises on which our nation is built and only avoids a slight inconvenience to consumers who desire emergency contraception. Finally, it is important for governments to recognize that there are sound arguments on both sides of this legal debate and that an in depth analysis of the ethical and public policy ramifications of regulation on this issue is absolutely necessary.
Journal Extract It has been 40 years since the seminal papers on pharmacy’s status as a profession sparked debate about the pharmacist’s role in health care, yet the questions they raised are just as poignant today as they were then. The issue of pharmacy’s status as a profession and its role in health care has again been brought into question, albeit in a roundabout manner, through discussions over the pharmacist’s right to refrain from dispensing emergency contraception. The key to understanding the contemporary pharmacist’s role as part of the health care team, as well as the pharmacist’s alleged right to refrain from dispensing emergency contraception, is to examine a situation that almost every contemporary pharmacist experiences.
Abstract Pharmacy, like other health care professions, is both a knowledge-based and a value-based profession. However, the values that inform practice activities are rarely made explicit. We sought to identify the values drawn on by UK pharmacists through qualitative interviews on day-to-day practice activities focused around practitioners’ conceptions of ‘the good pharmacist’, good practice and their experiences of ethical issues and dilemmas. The study was based upon loosely structured, one-to-one interviews of 38 selected practitioners reflecting a range of practice roles and settings. The interviews were recorded, transcribed and analysed following the principles of grounded theory. The accounts of practice (of self and colleagues) in the data showed pharmacists to be very dedicated and conscientious. Practice was predominantly discussed and presented by practitioners drawing upon a scientific mode of rationality. Value and ethical judgements were typically presented within this mode, with more open-ended and complex discussion of values and ethics appearing quite rarely. Two core values generally drawn on in reported practice emerged from the analysis – these were, ‘the patient’s best interests’ and a value we labelled ‘respect for medicines’. Common dilemmas arose from conflicting values, for example competing obligations to different parties, sometimes brought to a head by the conflicting demands of ‘rules’ of various sorts. Reported dilemmas related to rule breaking, resource allocation, patient communication and teamwork. There was a tendency for practitioners to ‘fall back’, often unreflectively, on their own personal value judgements when addressing these dilemmas. However, in the main, the values and dilemmas reported clearly show the socially embedded nature of professional ethics and, thereby, contribute to the social science re-theorisations of professional ethics needed if work on ethics development is to be realistic.
Abstract BACKGROUND: For over 30 years, pharmacists have exercised the right to dispense medications in accordance with moral convictions based upon a Judeo-Christian ethic. What many of these practitioners see as an apparent shift away from this time-honored ethic has resulted in a challenge to this right.
OBJECTIVE: To review and analyze pharmacy practice standards, legal proceedings, and ethical principles behind conflicts of conscientious objection in dispensing drugs used for emergency contraception.
DATA SOURCES: We first searched the terms conscience and clause and Plan B and contraception and abortion using Google, Yahoo, and Microsoft Networks (2006-September 26, 2008). Second, we used Medscape to search professional pharmacy and other medical journals, restricting our terms to conscience, Plan B, contraceptives, and abortifacients. Finally, we employed Loislaw, an online legal archiving service, and did a global search on the phrase conscience clause to determine the status of the legal discussion.
DATA SYNTHESIS: To date, conflicts in conscientious objection have arisen when a pharmacist believes that dispensing an oral contraceptive violates his or her moral understanding for the promotion of human life. Up to this time, cases in pharmacy have involved only practitioners from orthodox Christian faith communities, primarily devout Roman Catholics. A pharmacist’s right to refuse the dispensing of abortifacients for birth control according to moral conscience over against a woman’s right to reproductive birth control has created a conflict that has yet to be reconciled by licensing agents, professional standards, or courts of law.
CONCLUSIONS: Our analysis of prominent conflicts suggests that the underlying worldviews between factions make compromise improbable. Risks and liabilities are dependent upon compliance with evolving state laws, specific disclosure of a pharmacist’s moral objections, and professionalism in the handling of volatile situations. Objecting pharmacists and their employers should have clear policies and procedures in place to minimize workplace conflicts and maximize patient care.
