Pharmacies Balk on After-Sex Pill and Widen Fight in Many States
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By Monica Davey and Pam Belluck
The New York Times
Tuesday 19 April 2005
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"The governor is trying to make a decision that must be left to the pharmacy," said Senator Watson, whose family business, Watson's Drug Store in Greenville, Ill., does not stock the pill. "It's an infringement on a business decision and also on the pharmacist's right of conscience."
Senator Watson, the Republican leader of the Senate, and Governor Blagojevich, a Democrat, are the latest combatants in a growing battle over emergency contraception. In at least 23 states, legislators and other elected officials have passed laws or are considering measures in a debate that has attracted many of the same advocates and prompted much of the same intensity as the fight over abortion.
In some states, legislators are pushing laws that would explicitly grant pharmacists the right to refuse to dispense drugs related to contraception or abortion on moral grounds. Others want to require pharmacies to fill any legal prescription for birth control, much like Governor Blagojevich's emergency rule in Illinois, which requires pharmacies that stock the morning-after pill to dispense it without delay. And in some states, there are proposals or newly enacted laws to make the morning-after pill more accessible, by requiring hospitals to offer it to rape victims or allowing certain pharmacists to sell it without a prescription.
Some of the bills could become moot if the Food and Drug Administration approves the morning-after pill for over-the-counter sale by pharmacists, something advocates for women's reproductive rights and several Democratic senators have pressured the agency to do.
If over-the-counter sales are allowed, experts on the issue say, pharmacists who do not want to provide the pill on moral grounds could simply decide not to stock it, which current state laws already allow them to do. If a large drugstore chain decided to stock it, but an individual pharmacist in the chain objected, such a dispute might be governed by the employment agreements between the chain and the pharmacist.
But the bills may also lay the groundwork for pharmacists' actions regarding future controversial medications. And both sides in the debate may consider the publicity generated by any proposed legislation to be beneficial to their cause.
"This is going to be a huge national issue in the future," said Paul Caprio, director of Family-Pac, a conservative group that urged pharmacists in Illinois to ignore Governor Blagojevich's rule. "Pharmacists are coming forward saying that they want to exercise their rights of conscience."
Nancy Keenan, the president of Naral Pro-Choice America, said she believed the issue was blocking women in many parts of the country from getting morning-after prescriptions filled, though she had no firm statistics. "It's difficult to get the hard numbers because there's not a mechanism for women to report this," she said. "But we have heard about cases from Beverly Hills to Wisconsin, Massachusetts, Chicago - it seems to be all over the country."
In Illinois, Governor Blagojevich enacted his emergency rule after hearing of two women who said a pharmacist had refused to fill their morning-after pill prescriptions at a drugstore downtown this year. Penalties against a pharmacy can range from a fine to revocation of its license to dispense drugs.
Since April 1, officials at the governor's office say, two more people have filed complaints to an emergency hot line about similar situations. On Monday, Governor Blagojevich submitted paperwork to try to make his emergency rule permanent.
On the other side of the debate, two pharmacists from downstate Edwardsville, Ill., filed suit against the governor and his emergency rule last week, saying it infringed on their right to weigh their own "conscientious convictions" while carrying out their work. A third pharmacist filed a similar suit on Friday.
But pharmacists and many of their advocates argue that, in reality, only a small number of pharmacists have found themselves in standoffs with customers over the issue.
"There's so much of a spotlight on those very few cases," said Susan C. Winckler, of the American Pharmacists Association, a Washington-based group that represents about 52,000 pharmacists. "This has left some people seeming to say that a pharmacist is nothing more than a garbage man, and that's not what the average pharmacist wants to hear."
The association supports a position that pharmacists should be allowed to "step away" from dispensing items they oppose, while still finding a way to ensure that the customer has access to the items some other way - another pharmacist or another store, for example.
While a few doctors and pharmacists have for years declined to prescribe or sell birth control pills for religious reasons, the objections of some to the morning-after pill are more vehement because they consider it to be more akin to abortion.
The reason the morning-after pill has touched off such debate hinges on the way each side sees the drug, which is also known as Plan B or the emergency contraceptive pill.
Abortion rights advocates and most physicians say the pill, unlike the French drug RU-486, is not an abortion drug because it does not destroy an embryo. Instead, the pill prevents ovulation or fertilization, or blocks a fertilized egg from becoming implanted in the uterus.
Proponents feel it is critical for many pharmacists to offer the morning-after pill because women have only a small window of time after sex in which to obtain and use it. The pill is effective up to three to five days after intercourse, and it is most effective when taken immediately.
Advocates also argue that the pill will lead to fewer abortions.
"This is one of the safest medicines we have available, and it can prevent unplanned pregnancies," said Dr. Karen Lifford, the medical director of the Planned Parenthood League of Massachusetts, who testified at a public hearing last week on a bill being considered by the Massachusetts legislature. "We're trying to reduce the number of pregnancies and abortions, and people of different religious views can agree that this is a good thing to do."
But many abortion opponents believe the morning-after pill ends a human life and is therefore tantamount to abortion.
"Emergency contraceptive pills can be abortifacient if they are taken after ovulation has occurred," Dr. Gertrude Murphy, a retired physician who worked at a Catholic hospital in Boston and is currently on the board of Massachusetts Citizens for Life, testified at the hearing. "An abortifacient is defined here as any medication or device that causes the death of the developing human after fertilization."
Around the country, in at least 12 states, including Indiana, Texas and Tennessee, so-called conscience clause bills have been introduced, which would allow pharmacists to refuse to dispense contraceptives if they have moral or religious objections. Four states already have such laws applying specifically to pharmacists: Arkansas, South Dakota, Mississippi and Georgia.
Proposals in three states - California, Missouri and New Jersey - would have the opposite effect, compelling pharmacies to fill any legal prescription.
In California, West Virginia and a few other states, there is a legislative tug of war, with both types of bills pending in the legislature. In Arizona last week, Gov. Janet Napolitano, a Democrat, vetoed a bill that would have allowed pharmacists to refuse to dispense such drugs.
On the federal level, bills requiring all legal prescriptions to be filled have been introduced in recent days by Senator Barbara Boxer of California and Senator Frank R. Lautenberg of New Jersey. A House version of the Lautenberg bill has been sponsored by Representatives Carolyn B. Maloney of New York and Debbie Wasserman-Schultz of Florida, both Democrats, and Representative Christopher Shays, Republican of Connecticut, among others. The bills are not expected to get very far.
Senator John Kerry, Democrat of Massachusetts, and Senator Rick Santorum, Republican of Pennsylvania, have introduced the Workplace Religious Freedom Act, which would allow a pharmacist to refuse to dispense certain drugs as long as another pharmacist on duty would.
In other states, the battle has less to do with pharmacists' moral beliefs than with efforts by advocates to make emergency contraception more widely available.
Six states - California, Alaska, Hawaii, Maine, New Mexico and Washington - already have laws that skirt the lack of F.D.A. approval of over-the-counter sales of Plan B. These laws, called collaborative practice measures, allow pharmacists to dispense the morning-after pill if they have received training or certification from the state and are working in collaboration with a physician. Eight other states, including New York and Massachusetts, are considering similar laws.
The Massachusetts law would also require hospitals to inform rape victims about the pill, something Catholic hospitals, in particular, object to. Colorado's governor, Bill Owens, a Republican and a Catholic, vetoed such a bill this month, saying in his explanation, "it is one of the central tenets of a free society that individuals and institutions should not be coerced by government to engage in activities that violate their moral or religious beliefs."
As the debate grows among lawmakers, a quieter debate is taking place behind the counters of many drugstores.
"As far as being a health care professional, I don't think I should be injecting my moral values on other people," Rod Adams, a pharmacist at the Colorado Pharmacy in Denver, said in an interview last week. "Obviously a morning-after pill is a personal choice that someone has to make. They've already made that choice when they come in here, and I don't think - I'm not a counselor - I don't really think that's my job."
But Patty Levin, a pharmacist for 22 years who works at Wender & Roberts in the north Atlanta suburb of Sandy Springs, said that she had never been asked to fill a prescription for the morning-after pill.
"I would be opposed to dispensing that particular product," she said. "It's basically an early abortion, is basically what it is. I would just hand it to the other pharmacist here," she said, adding, "If I'm not filling it, it doesn't involve me."
Monica Davey reported from Chicago for this article, and PamBelluck from Boston. Ariel Hart contributed reporting from Atlanta, Mindy Sink fromDenver and Katie Zezima from Boston.