When Two Fundamental Rights Collide at the Pharmacy: The Struggle to Balance the Consumer’s Right to Access Contraception and the Pharmacist’s Right of Conscience

Suzanne Davis, Paul Lansing

DePaul Journal of Health Care Law

Introduction:  The dangerous intersection between a pharmacist’s right of moral belief and a woman’s right of contraceptive use continues to be an important topic for debate across the nation. In fact, the area of contraceptive rights has been a controversial issue since the United States Supreme Court’s decision in Griswold v. Connecticut in 1965, which recognized a constitutional right of privacy in family planning decisions implicit within the meaning of the Bill of Rights. Now, over forty years since this landmark decision, courts continue to grapple with the notion of women’s rights and how contraceptive use should be protected.

New developments in pharmaceutical research and technology have resulted in the formation of new legal and ethical issues. The most recent dilemma faced by both federal and state courts features women who desire a recently FDA approved contraceptive drug called Plan B and pharmacists who are morally opposed to the mode of action of the drug. This newfound ability to prevent birth using a drug taken after sexual activity presents a scenario the Griswold Court would have never anticipated. Nonetheless, the precedent beginning with Griswold has created a necessary collision between these two fundamental rights.

Pharmacists are placed in a unique position in this controversy. Pharmacists are licensed by the state yet some believe that they cannot comply with state requirements due to their individual religious beliefs. As nearly all Americans are familiar, the right to religious belief has been protected since the drafting of the Bill of …


Davis S, Lansing P. When Two Fundamental Rights Collide at the Pharmacy: The Struggle to Balance the Consumer’s Right to Access Contraception and the Pharmacist’s Right of Conscience. 12 Depaul J. Health Care L. 67, 89-91 (2009)

Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise

Sean Murphy*

Conflicts of Conscience in Health Care: An Institutional Compromise

Lynch HF. Conflicts of Conscience in Health Care: An Institutional Compromise. Boston: The MIT Press; 2008. 368 p. ISBN: 9780262123051

Conflicts of Conscience in Health Care was published in 2008 as the 24th volume in the Basic Bioethics series from the Massachusetts Institute of Technology. It is an American book dealing with the American political and legal controversies over freedom of conscience in health care. However, the discussion of the American experience by Holly Fernandez Lynch is relevant elsewhere, since the United States has the most extensive and varied network of protection of conscience legislation in the world.

While acknowledging that freedom of conscience is of concern to all health care workers and institutions, Fernandez Lynch focuses exclusively on physicians. This carefully and deliberately restricted focus is one of the strengths of the book.

After a preface and introduction, discussion and argument occupy about 260 pages, supplemented by 53 pages of end notes, many of which offer expanded comment on the text. A good 12 page index has been included, as well as four pages of cited statutes and cases. The earliest source found in a list of 300 references is from 1951; the rest date from 1972 to 2007.

Goal

The author introduces her subject with a statement from Pope John Paul II:

. . . to refuse to take part in committing an injustice is not only a moral duty, it is also a basic human right. Were this not so, the human person would be forced to perform an action intrinsically incompatible with human dignity, and in this way human freedom itself, the authentic meaning and purpose of which are found in its orientation to the true and the good, would be radically compromised.

Fernandez-Lynch does not argue from a Catholic or even religious perspective. Nonetheless, she describes this as “a powerful statement about the nature of conscience, complicity in morally objectionable actions, and avoidance of injustice.” She adds that it is generally acceptable to religious and nonreligious people alike, regardless of their political views.

This reflects the spirit in which she pursues her project. As the subtitle of the book indicates, she is seeking a compromise that will provide “maximal liberty for all parties.” She believes that freedom of conscience for physicians and the provision of legal medical services are both important social goals, and that they are not incompatible. Thus, she rejects “all-or-nothing” strategies that seek “total victory.” Ultimately, quoting the Protection of Conscience Project, she affirms that all legitimate concerns can be met by “dialogue, prudent planning, and the exercise of tolerance, imagination and political will.”

Context of the discussion

The author recognizes that she writes with the abortion controversy more or less continuously in the background. But she insists – correctly, in the Project’s view – that “limiting the debate to tired abortion rhetoric could be quite dangerous if it prevents meaningful discussion” of broader issues. Referring to a number of other controversial issues and the impact of ongoing technological developments, Fernandez Lynch predicts that these, combined with “increasing diversity of health-care providers” have “the potential to create a perfect storm.”

Overview

The shape of the compromise proposed by Fernandez Lynch can be outlined while describing the book’s structure. It consists of three main parts.

The first reviews American protection of conscience laws and examines four paradigms of medical professionalism. The author selects one of these paradigms – physician as gatekeeper – as most suited to the compromise she seeks.

In Part II, Fernandez Lynch explains what she believes to be the source of the current controversy. Applying the professional model of physician as gatekeeper, she observes that an objecting physician may sometimes be the only available “gatekeeper” who can open the gate to a desired service. Her solution: tell patients about other gates and gatekeepers, redistribute them, and, if necessary, provide more gates and more gatekeepers. Or, to paraphrase anti-euthanasia activists, if access is the problem, eliminate barriers to access, not objecting physicians.

To accomplish this, the author suggests that a designated institution ensure access to services through effective distribution of health care resources and connect patients with willing physicians. Hence, the subtitle of the book: an institutional compromise. Fernandez-Lynch identifies state licensing boards as the institutions best placed to accomplish this. The last two thirds of the book describes how the compromise might be implemented in practice. It includes a model statute and extended discussions about calculating patient demand and meeting it through the supply of willing physicians. . .


Murphy S. Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise. Protection of Conscience Project; 2009 Dec 17.

Conscientious Objectors Behind the Counter: Statutory Defenses to Tort Liability for Failure to Dispense Contraceptives

Jennifer E. Spreng

Journal of Health Law & Policy

Introduction:  The United States Food and Drug Administration’s decisions in the past decade to approve both RU-486 and Plan B have created crises of conscience for some religious pharmacists. RU-486 induces abortion in the first trimester of pregnancy without surgical intervention and Plan B is a two-pill “emergency contraceptive” regimen that may have abortifacient properties. Some religious pharmacists prefer not to dispense the drugs because their religious scruples forbid them from participating in abortions.  Some also object to dispensing daily oral contraceptives6 on the same basis.


Spreng JE. Conscientious Objectors Behind the Counter: Statutory Defenses to Tort Liability for Failure to Dispense Contraceptives. 1 St. Louis U. J. Health L. & Pol’y 337, 337-40 (2008)

Achieving transparency in implementing abortion laws

Rebecca J. Cook, Joanna N. Erdman, Bernard M. Dickens

International Journal of Gynecology & Obstetrics

Abstract: National and international courts and tribunals are increasingly ruling that although states may aim to deter unlawful abortion by criminal penalties, they bear a parallel duty to inform physicians and patients of when abortion is lawful. The fear is that women are unjustly denied safe medical procedures to which they are legally entitled, because without such information physicians are deterred from involvement. With particular attention to the European Court of Human Rights, the UN Human Rights Committee, the Constitutional Court of Colombia, the Northern Ireland Court of Appeal, and the US Supreme Court, decisions are explained that show the responsibility of states to make rights to legal abortion transparent. Litigants are persuading judges to apply rights to reproductive health and human rights to require states’ explanations of when abortion is lawful, and governments are increasingly inspired to publicize regulations or guidelines on when abortion will attract neither police nor prosecutors’ scrutiny.


Cook RJ Erdman JN, Dickens BM. Achieving transparency in implementing abortion laws. Int J Gynaecol Obstet. (2007) 99, 157-161

The Fallacies of Objections to Selective Conscientious Objection

Amir Paz-Fuchs, Michael Sfard

The Fallacies of Objections to Selective Conscientious Objection

Abstract

This paper critically analyzes the theoretical and pragmatic arguments raised against the refusal of individuals to serve in a specific military campaign that they view as immoral. The Israeli Supreme Court case of Zonshein v Judge-Advocate General will serve as an axis of the discussion, as it combines two related facets: first, the Court’s decision touches upon most of the difficult issues in the field of conscientious objection. And second, the development leading up to the decision was accompanied by an exceptional clash of academics, each side summoning expert opinions in support of its claim.

Courts worldwide have accepted that a categorical distinction exists between universal and selective conscientious objection. The combination of the Zonshein decision and the accompanying academic debate presents the opportunity to reexamine the theoretical and pragmatic reasons that are offered as support for distinguishing the two ‘types’ of conscientious objection. Close scrutiny finds them wanting.


Paz-Fuchs A, Sfard M. The Fallacies of Objections to Selective Conscientious Objection. Israel Law Review, Special Issue: Refusals to Serve – Political Dissent in the Israel Defense Forces. 2002 Fall; 36(3);111 – 143. DOI: https://doi.org/10.1017/S0021223700017994.

Reproductive health services and the law and ethics of conscientious objection

Bernard M. Dickens

Medicine and Law

Abstract: Reproductive health services address contraception, sterilization and abortion, and new technologies such as gamete selection and manipulation, in vitro fertilization and surrogate motherhood. Artificial fertility control and medically assisted reproduction are opposed by conservative religions and philosophies, whose adherents may object to participation. Physicians’ conscientious objection to non-lifesaving interventions in pregnancy have long been accepted. Nurses’ claims are less recognized, allowing nonparticipation in abortions but not refusal of patient preparation and aftercare. Objections of others in health-related activities, such as serving meals to abortion patients and typing abortion referral letters, have been disallowed. Pharmacists may claim refusal rights over fulfilling prescriptions for emergency (post-coital) contraceptives and drugs for medical (i.e. non-surgical) abortion. This paper addresses limits to conscientious objection to participation in reproductive health services, and conditions to which rights of objection may be subject. Individuals have human rights to freedom of religious conscience, but institutions, as artificial legal persons, may not claim this right.


Dickens BM. Reproductive health services and the law and ethics of conscientious objection. Med Law. 2001;20(2):283-93.

Some legal and ethical issues in assisted reproductive technology

Bernard M. Dickens, Rebecca J. Cook

International Journal of Gynecology & Obstetrics

Abstract: The potential and actual applications of reproductive technologies have been reviewed by many governmental committees, and laws have been enacted in several countries to accommodate, limit and regulate their use. Regulatory systems have nevertheless left some legal and ethical issues unresolved, and have caused other issues to arise. Issues that regulatory systems leave unresolved, or that systems have created, include disposal of embryos that remain after patients’ treatments are concluded, and multiple implantation and pregnancy. This may result in risks to maternal, embryonic and neonatal life and health, and the contentious relief that may be achieved by selective reduction of multiple pregnancies. A further concern arises when clinics must or choose to publicize their success rates, and they compete for favorable statistics  by questionable patient selection criteria and treatment priorities.


Dickens BM, Cook RJ. Some legal and ethical issues in assisted reproductive technology. Int J Gynaecol Obstet. 66 (1999) 55-61