Refusing to Provide Contraception to Women: Whose ‘Right’ Is it Anyway?


The excellent blog, Midwife Connection, of the American College for Nurse Midwives (ACNM) published a thoughtful post the other day, “Should a pharmacist be able to refuse to fill a prescription?” on “pharmacist refusal” (ie, pharmacists refusing to fill prescriptions for emergency contraception because of a personal belief that contraception = murder). It was written by a certified nurse midwife in my home state of Washington. Midwives, of course, have a stake in this issue as CNMs can provide counseling about, information on, and prescriptions for contraception; a significantly important part of postpartum discussions with the women they serve. 

The post discusses a Washington state multi-year effort to ensure that pharmacists and pharmacies cannot discriminate against women who need a prescription for emergency contraception (EC) filled from their pharmacists. According to Midwife Connection:

Here in WA State, a prescription refusal issue is working its way
through the legal system. Many people are calling it “Refuse and Refer”
claiming that it is appropriate for a pharmacy or a pharmacist to
refuse to fill prescriptions to which they object on religious or moral
grounds, and refer clients elsewhere. A few claim they should be able
to refuse with no responsibility to refer at all.

In late October of this year, the Ninth Circuit Court of Appeals ruled in favor of "patients rights" in a case that,  according to Legal Voice, a legal advocacy organization in Seattle working on this issue, "involves a challenge brought by two pharmacists and a pharmacy to Washington State Board of Pharmacy rules requiring all licensed pharmacies to fill patients’ prescriptions, regardless of an individual pharmacist’s personal beliefs about a particular medication."

In other words, the Ninth Circuit reaffirmed an earlier decision that rules created by the Washington state Pharmacy Board "do not aim to suppress, target, or single out in any way the practice of religion, but, rather, their objective was to increase access to all lawfully prescribed medications."

Legal Voice Executive Director Lisa Stone, at the time, said, "This decision helps clear the way for the state to enforce its rules, ensuring that all pharmacies comply with the requirement that all patients get their medication needs met in a timely manner, without delay, and without harassment."

And hopefully that’s true.

But not everyone feels that way, of course. 

Someone posted a comment on Midwife Connection soon after the post was published:

But to the pharmacists in question, it is forcing them to participate in the murder of another human. Which should not be forced on anybody.


I responded to clarify that, in fact, Emergency Contraception (EC or, its brand name, Plan B) is not an abortifacient but a method of birth control. If one believes abortion is murder, that’s a separate issue (which I, of course, vehemently disagree with). This is about denying a woman her right to fill a prescription for a legal, FDA approved medication because you personally don’t “believe” in it.

I responded to the commenter:

 

I think you are mistakenly referring to RU-486 or the medication used for a medication abortion. The post above is about Plan B or emergency contraception. It is not the medication used for an abortion but, rather, it is a contraceptive method. You cannot get any sort of medication, from a pharmacist, that causes an abortion. This discussion is about whether or not pharmacists have the right to opt out of providing legal, safe, FDA approved birth control to the women of their community. There is no major, mainstream medical organization in this country that considers the results of using emergency contraception “the murder of another human.”

Do pharmacists, ultimately, have the right to discriminate against women by refusing to provide EC? Personally, I would say that if a pharmacist has an issue with the provision of birth control to women, they should probably find another line of work as 98% of American women use birth control at some point in their lives – 98%! That means that women who consider themselves pro-life, pro-choice, religious or not – we’re all using it. To deny services to women is unethical and, I believe, discriminatory.


The commenter then responded to me:

Actually, you can get Cytotec from a pharmacy, which does cause abortions.

But,
it depends on how you define the various terms. In the mid-60s,
obstetricians successfully redefined pregnancy as starting not with
conception (which was the time it historically was considered to have
started), but after the fertilized egg implanted, which meant that
anything that interferes with implantation is technically not
abortifacient — even though it stops a new developing human from being
able to live and develop further. But if life begins at conception,
then preventing that new life from implanting in the uterus, the sole
way this new life can continue to live, then, yes, it is interfering
with that, and causing the death of the genetically unique human.

I
agree that there is a double-standard in a pharmacy dispensing and
stocking standard birth control pills but not plan B, because BCPs can
also interfere with implantation. It’s not the primary method of
pregnancy prevention (supposedly), but it is one of the secondary or
tertiary methods — and the same with Plan B.
The only difference might be the percentage of the time that BCPs
prevent implantation as opposed to that of Plan B. For instance, if
Plan B worked to delay or prevent ovulation 10% of the time and prevent
implantation 90% of the time, that might make a difference in people’s
minds, as opposed to BCPs preventing ovulation 90% of the time and only
preventing implantation 10% of the time. [Hypothetical numbers.]

What
if euthanasia or "assisted suicide" were legal — would you suggest
that doctors be required to assist in ending the person’s life, though
s/he were morally or ethically opposed to it? After all, it’s a medical
condition — they are there to do what the patient wants, not play God.
What if any doctor in the state could be required to come and execute a
criminal by lethal injection, although s/he was opposed to the death
penalty, or thought the person to be convicted was not guilty? After
all, it’s a legal decision; what does ethics, morality or religion have
to do with it? What if a doctor felt that abortion was murder, but a
woman wanted to abort her 20-week fetus after finding out that the baby
was a girl, and not the boy she wanted? That’s a medical decision –
who cares if it’s discriminatory against infant women — they’re there
to perform a medical function for a paying customer — that’s all. It’s
a business — no room for morals or ethics in business, eh? Especially
in the business of medicine? (Which leaves me wondering why you find
ethicists in hospitals, helping to make decisions in hospital policy.)
Frankly, I think we need a heapin’ helpin’ of ethics particularly in
medicine!

I’ve met numerous people who never knew that chemical
birth control (not just pills, but all forms) could allow ovulation but
prevent implantation; many were upset that they were never told of that
possibility. Most stopped taking it after finding it out, because they
could not in good conscience use it. So, just because 98% of women use
it, it doesn’t mean that they were fully informed of the consequences
of it — especially if doctors and pharmacists don’t know (because of
the above definition of pregnancy and abortifacients).

To require people to assist in what they consider to be murder is unethical and most certainly discriminatory.

While I wanted to post the following comment on the ACNM blog, it was ridiculously long and have decided to post here instead. What follows is my response to the above commenter:

To your point about Cytotec: First off, while Cytotec (misoprostol) is used in medication abortion, it is not FDA approved for a physician to prescribe it as an abortifacient on its own. An abortion is a medical procedure that can only be offered by a qualifed medical provider. Cytotec is approved for ulcers, via a pharmacist. It is true that some women in this country are using it to induce an abortion, by themselves. But they are getting it from other women or the black market

If birth control results in the murder of a human being (which you have every right to believe, of course, and don’t need my permission for that!), and most women don’t know that, why aren’t anti-choice organizations and anti-choice politicians focusing on outlawing birth control as much as they are focused on criminalizing abortion? I would think that birth control would be considered a murder weapon. I assume, then, that women who do knowingly, with informed consent, use birth control or emergency contraception would be prosecuted under this scenario? 

I am not refuting your right to believe that contraception kills but the truth is I (and, again, all major mainstream medical organizations, most physicians, and most women who take birth control) do not agree with this assessment.

In addition, the World Health Organization and many of the world’s governments have agreed, via the Millennium Development Goals, that contraception is critical to saving women’s lives, raising the status of girls around the world, improving newborn health, improving the health and well-being of entire nations, actually!

I do agree, absolutely, that all women deserve to be fully informed about what birth control does and exactly how it works, so that they may make the best decisions for themselves, their lives, and their families.  I have worked in women’s health for over ten years now and I have not once heard anyone, except those who consider themselves religious fundamentalists, refute how important contraception is for women’s health, autonomy and equality – from the World Health Organization to UNFPA to the International Federation of Gynecology and Obstetrics, American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American Public Health Association. Even ACNM supports expanding access to EC. Are all of these experts wrong? Misguided? Misinformed?

As for morals and ethics in businesses, no one is saying one shouldn’t have morals and ethics. But what about the morals and ethics of the woman? A pharmacist has every right to abide by his or her own belief system, as long as a woman has a legal right to access the birth control she’s been prescribed by her doctor or that she requests on her own. And, yes, a legal right supersedes ones’ personal belief system, often, in this society. We do not allow those who may hold a personal/moral belief system, however repugnant, that African-Americans are inferior to Caucasians, to discriminate. We legislate discrimination against those who are differently abled and against those of a certain age. Why would we allow pharmacists to discriminate based on a personal belief system? For a pharmacy to refuse to fill a prescription to all women because a pharmacist on duty doesn’t "believe in it" is discrimination. If birth control is outlawed, then we can have this discussion again. We’re talking about safe, FDA approved, physician prescribed contraception, however.

What about women and adolescents who take contraception for other reasons? To regulate ones’ cycle, for example? Is that morally offensive to some pharmacists? Do women need to stand up at the counter and justify their reasons for needing a certain medication so that it jibes with the pharmacists belief system?

Do you, then, also agree that it is okay for a pharmacist who is homophobic or whose religious beliefs compel her/him to believe that homosexuality is wrong, to refuse to fill physician prescribed medication to a gay person? How about a pharmacist who hates Jews? Can they refuse to prescribe medication to Jewish people because they believe it is immoral to live as anything but a Christian? Is it based on the action one would take with the medication? What about Viagra, then? What if your religious or personal belief system is such that you believe sex outside of marriage is immoral? Do you then get to refuse to prescribe Viagra to a man unless you know he would be using it with his wife?

If a pharmacist believes that legal birth control is immoral and cannot perform part of his or her duties because of this belief system, the pharmacy should then either always have another pharmacist on duty who believes otherwise or the pharmacist in question should open his or her own business, and state clearly that they refuse to service the women of their community who need or want birth control. The community may still protest and try and shut them down because that’s our right in a democracy. But at least the pharmacist can try and peddle his/her morality with a certain amount of freedom.

One has the right, in a free society, to wholeheartedly believe with faith, that birth control is a murder weapon, preaching their belief system in order to convince others of their stance. But, again, in a democratic society, others with different religious, moral and ethical belief systems have the right to believe that birth control and family planning are ethical, loving, moral tools whose usage is supported by solid evidence via organizations like the World Health Organization, our best scientific and medical minds, and, well women themselves.

Finally, as I mentioned above, I am committed to making sure all women know exactly how birth control works. I have made it my life’s mission to ensure that women have the access to information and tools, around the world, to live as healthily and happily as possible. I challenge all of us to commit to this ideal.

If women themselves decide that contraception is murder,  and have as many babies as they will, over the course of a lifetime, because it’s their choice, then I support that. But we see that when women are given options, choice and information – full information – about birth control, women chose control, autonomy, safety and equality. 

Pharmacies, as private businesses, should not allow the pharmacists they employ to engage in discriminatory behavior because of a personal belief system. If a pharmacist belives that certain drugs are murderous, he or she should likely become a full time agent of change, rather than a pharmacist whose job it is to fill prescriptions for legal medication.

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  • kerewin21

    Thanks for this thoughtful commentary. If a health care professional finds legal medical procedures or medications abhorrent in his or her personal set of morals, he or she needs to figure out a way that the procedures and medications are always available with no barriers even if patients have the misfortune of needing services from that provider, or they need to find another job. Period.

  • crowepps

    Since the idea that hormonal birth control MAY cause failure to implant is entirely speculative, and there is actually no scientific evidence whatsoever to support it, the percentages which this person uses are also entirely speculation. Considering the extremely high failure rate of Plan B (or The Pill if a couple day’s dose are skipped), the percentage of instances in which failure to implant a healthy zygote might happen are more likely to be on the order of ‘stops ovulation/99.9999% – causes failure to implant .0001%’.

  • princess-rot

    Like you, I could write a thousand well-reasoned, scientifically-based treatises on why all this (I call it “breeder mentality”) is a load of horse apples, but I know it wouldn’t go anywhere because practicality is not as appealing as romanticism.

    Every time I see some woolly-headed pro-life twit banging on about on about the special snowflakeness inherent in human zygotes I get an irrational urge to hoof said twit in the junk. It’s just gotten that tiring, having to constantly point out that it’s all love and human rights and acceptance right up to the point it’s discovered you have a double X chromosome and you aren’t co-operating with what the dominant paradigm thinks you should do with your private parts. It’s all free speech until you actually have the ability to speak for yourself, in which case you should toe the line or risk having your humanity revoked for doing nothing other than acting like you have bodily autonomy, a reality men take for granted.

    It’s really not wonderful to live in a world that applies humanity on a sliding scale, one that you’re always at the bottom of. A world thinks a zygote has more humanity than you do, because you are just an annoying, willful and selfish life support system for the next generation, whom they hope will be marginally more silent and compliant with each increment of forced idealogy.

    Why, yes, I am cynical.

  • wendy-banks

    "Every time I see some woolly-headed pro-life twit banging on about on about the special snowflakeness inherent in human zygotes I get an irrational urge to hoof said twit in the junk."

    I coundn’t agree with you more Princess Rot!

    Unfornuately, One of the Pharmacists at my local CVS insists that Plan B causes abortion– I got in to it with him that ‘no implantation equals no pregnacy’ but he’s a far-right winger so the point is moot… At least CVS will not allow him to refuse to give it out– That’s something.  Boy, am I glad I’m ‘spayed’ and don’t need to deal with birth control anymore.

  • herchoice

    I have long held that if someone chooses a profession that is responsible for delivering a type of health care, that person cannot stand in the way of a patient obtaining a legal treatment just because the provider or dispenser does not agree with it.
    If certain pharmacists do not wish to be involved with birth control, they should not have become pharmacists. That is the job of a pharmacist.

  • amie-newman

    because physicians are free to provide whatever services they wish, if they are in an independent practice. As well, there are refusal clauses that allow doctors and pharmacists to essentially opt-out of providing services with which they do not agree based on religious principles. However, they cannot stand in the way of women accessing that treatment or service elsewhere.  But, of course, I have never heard of these refusal clauses (‘conscience’ clauses) being applied to ANYTHING but reproductive health services – and not just reproductive health care but women’s reproductive health care. I think it’s a travesty and utter prejudice against women. I have no interest in forcing a doctor to provide abortions, in an independent practice. But all health and medical centers should have, in their employ, physicians who can and will provide abortions and birth control; and an informed, robust, thoughtful referral system in place to ensure that all women who need or want services have easy access to said services. If a pharmacy hires a pharmacist who cannot perform his or her job with half of the population, by refusing to fil prescriptions for birth control to women, then he or she should never be allowed to work alone; there needs to always be a pharmacist on duty who can and will fill prescriptions.

    Amie Newman

    Managing Editor, RH Reality Check

  • carolyn-marie-fugit

    It always amazes me how someone can be morally opposed to specific medications and refuse to give it out. Perhaps you could advertise it? I know of a few vegetarians and vegans who work in food service that includes serving meat. Can they moralize to patrons about the evils of eating meat and refuse to serve beef? Or is that behavior only acceptable when it deals with women’s reproduction and autonomy?

  • crowepps

    Remember how Islamic cabdrivers were refusing the carry passengers who had liquor?  Remember how they didn’t want ‘unclean dogs’ in their cabs?  Remember the claims of "right of conscience" by color-coding alcohol free cabs and "freedom of religion"?  Remember the screams of anguish from people who didn’t think anybody should be able to impose their religion on others?

     

    The state agency that licenses cab drivers prohibits discrimination against passengers unless the driver feels his life is in danger.

    "This is a public access issue," says Chuck Samuelson, of the American Civil Liberties Union of Minnesota, "Bottom line is we are a secular society, and that’s the way it is."

    Minnesota’s Muslim American Society had offered a compromise measure last year to color code cabs that would not transport alcohol, but the airport commission turned the proposal down.

    http://abcnews.go.com/International/story?id=2827800&page=1

     

  • catseye71352

    These pharmacists are the moral equivalent of hard-core vegans taking jobs at Burger King and refusing to serve meat, and expecting not to get fired. Tf these quacks won’t do their jobs, FIRE THEM AND BLACKLIST THEM!

    Catseye  ( (|) )