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Pharm Stand
By Deirdre Fulton

Anti-abortion pharmacists opposed to all forms of artificial contraception are seeking the power to interfere with women’s everyday lives

The majority of women, whether they support abortion rights or not, are more familiar with the look and feel of their local drugstore than they are with the inside of an abortion clinic. An estimated 95 percent of women use some form of artificial contraception at some point during their childbearing years, while statistics from the New York–based Alan Guttmacher Institute show that at current rates, about 35 percent of American women will have an abortion during their reproductive years. We certainly can do more to continue reducing the abortion rate, but the fact remains, many more women are preventing unwanted pregnancies than are terminating them.

So, when the religious right enters pharmacies and emergency rooms to undermine access to contraception—“a very important part of women’s basic health care,” as Massachusetts ACLU lobbyist Norma Shapiro says—the intrusion is not abstract. By expanding their opposition to reproductive rights beyond the context of abortion, a growing movement of anti-choice extremists in the pharmacy profession is messing with women’s everyday lives.

Some religiously conservative pharmacists affiliated with organizations such as Pharmacists for Life International have long objected to synthetic birth control, such as the pill. In the past, many have quietly passed such prescriptions on to colleagues unfettered by such qualms. These days, however, technical refinements to the “morning-after pill,” or emergency contraception—a highly concentrated form of birth control that works within five days after unprotected sex to prevent ovulation, fertilization, or, in very few cases, implantation of an egg in the uterus—along with efforts to expand access to and awareness of it, have prompted conservative pharmacists to mount organized opposition to all forms of artificial birth control.

No doubt emboldened by right-wing political rhetoric and an increasingly anti-choice climate, these pharmacists are seeking protection through what are called “conscience clauses,” which allow health-care providers to bow out of providing services that conflict with their moral or religious beliefs. That may sound reasonable enough. Trouble is, there is every indication that, in today’s political climate, activist pharmacists are unwilling to settle for conscience clauses alone.

Four states already have laws on the books that permit pharmacist refusals; now, 12 more are considering similar legislation. Only some require pharmacists to refer (to another pharmacist or a different drugstore entirely) a prescription they refuse to fill. Meanwhile, just four other states are considering legislation that would do the opposite by requiring pharmacists to fill prescriptions.

With several states, including New York and Massachusetts, considering expanding EC access, and the federal Food and Drug Administration weighing the benefits of over-the-counter access to the drug, the drugstore battles are bound to heat up even further.

George W. Bush’s reelection sounded a wake-up call to reproductive-rights advocates across the country. With conservatives controlling two branches of government—and ready to pounce on a third as soon as a Supreme Court seat opens up—women’s-rights organizations prepared for an onslaught of federal and state legislative attacks on reproductive rights. Their concern was not misplaced. During Bush’s first four years, right-wingers launched a series of incursions into reproductive rights—passing anti-abortion legislation; de-funding international health-care agencies that merely offer information about abortion; nominating extreme religious conservatives to key positions, such as the failed attempt to name David Hager head of the Food and Drug Administration’s Committee on Reproductive Health; and promoting abstinence-only rather than comprehensive sex education in public schools.

After November’s elections, the anti-choice movement gained momentum. Just last week, the House passed a bill that would make it illegal for an adult other than a parent or guardian to transport a minor across state lines (presumably to a state with less-stringent parental-notification laws) to get an abortion. Women’s-rights groups say the measure places undue strain on young women and families, and argue that it’s just one more angle from which to chip away at abortion rights. The bill, and its Senate counterpart, are on the GOP’s top-10 list of legislative priorities this session.

In Arkansas, Georgia, Mississippi, and South Dakota, state laws or pharmacy-board regulations already allow pharmacists to refuse to fill prescriptions, including those for birth control, if doing so conflicts with their personal beliefs. (Mississippi’s statute passed in 2004; the others have been on the books for years.) As of April, legislators in 12 other states (including Rhode Island, Vermont, Texas, and West Virginia) had filed similar legislation for the current session. More legislation likely will lead to increased public acceptance, and then, more refusals.

The movement, meanwhile, is not content merely with pushing for conscience clauses. Reflecting the extreme social conservatism of its deceased founder, Sam Walton, Wal-Mart refuses even to stock EC (and given the behemoth superstore’s market share, it’s sure to be the only pharmacy serving many rural areas). There are also reports of pharmacists flat-out refusing to transfer a prescription to a more-cooperative colleague. Even more disturbing are scattered accounts of pharmacists offering lectures in lieu of prescriptions.

“If it’s about conscience, that’s one thing,” says Judy Waxman, vice president for health and reproductive rights at the Washington, D.C.–based National Women’s Law Center. However, she adds, the pharmacy isn’t a pulpit. “If it’s about extremists trying to get in the way of women’s health care, it’s inappropriate.”

Especially since, like most other women’s-health issues, this one has the potential for a disproportionately harsh effect on women who are poor or young, or live in rural areas. These women will have more difficulty traveling to fill a referred prescription at a different pharmacy. In addition, studies show that poor women and minorities are less likely even to know about emergency contraception. Unaware of the drug, or of how and when to obtain it until the last minute, women seeking EC might arrive at a pharmacy later in the five-day window of the drug’s effectiveness—with less time to waste dealing with moralizers and bureaucracy.

In Massachusetts, pharmacists who refuse to fill a prescription are violating the state’s policy, which contains “no morals clauses or conscience clauses,” says Donna Rheaume, spokeswoman for the Massachusetts Department of Public Health. “The Board of Pharmacy expects that all prescriptions will be filled by pharmacists,” unless there’s a medical reason (such as drug interactions) why one shouldn’t be.

New York, likewise, has no conscience clause for pharmacy practice, says Selig Corman, director of professional affairs for the Pharmacists Society of the State of New York.

Unfortunately, that doesn’t mean it can’t happen here. Places like Wal-Mart avoid legal problems by not stocking EC at all. “If an item is not in stock, you can’t very well dispense it,” says Corman. “You can’t force someone to stock something.”

It’s not just Wal-Mart, however. Beth Quinn, a columnist for the Times Herald-Record out of Middletown, wrote on May 2 about a friend who had a prescription for regular birth-control refused in Sullivan County, “complete with a lecture on morals.”

Quinn has launched an online survey collecting stories of other refusals. She has not published the full results yet, but she reports that along with the expected problems at Wal-Mart pharmacies, she has received several complaints about an Eckerd pharmacist refusing to fill EC prescriptions. (This is not a chain-wide policy. In fact, last year, three pharmacists at an Eckerd pharmacy in Texas were fired for refusing to fill an emergency contraception prescription.)

Planned Parenthood League of Massachusetts also reports hearing of a handful of refusals; the organization is in the process of confirming the nine official complaints it has received in the past year and a half. “Sometimes it’s not even a refusal, it’s a lecture,” says PPLM spokeswoman Erin Rowland. “It’s the same imposition of ideology on a patient who’s very vulnerable.”

In one publicized case last year, a CVS pharmacist in Amherst refused to fill the regular birth-control prescription of a University of Massachusetts sophomore, the school’s Daily Collegian reported in December 2004.

Of course, aside from Wal-Mart, these are isolated incidents. New York has 19,000 registered pharmacists, half of whom work in the state’s 4,400 community pharmacies. Massachusetts has 9,940 state-licensed pharmacists who work in 1,044 pharmacies. Most of the industry is on record as supporting expanded access to EC. Extreme pharmacists’ refusals have been “raised to such a high level of visibility, and I think it really represents a very small fraction of pharmacists that are practicing,” says Doctor of Pharmacy Daniel Robinson, dean of Northeastern’s Bouvé College of Pharmacy and Health Sciences.

Corman, whose organization represents 3,000 New York pharmacists and who himself supports both expanded access to EC and an individual’s right not to dispense it, gets very touchy at the implication that pharmacist refusal is common. “It absolutely has not been much of a problem in New York state,” he says, cautioning that most reports are anecdotal. “I don’t believe that there are any pharmacists that I know that would verbally abuse a women for presenting the prescription. If it has happened, it’s one of these one-in-a-million type things.”

But the more legislative support they have, the more bold the anti-birth- control pharmacists might become. One tool they could soon have at their disposal is the proposed Workplace Religious Freedom Act, a federal bill cosponsored by Sen. John Kerry (D-Mass.). The bill would reinforce existing protections offered by Title XII of the Civil Rights Act of 1964 by ensuring freedom of religious expression on the job—concerning such matters as religiously appropriate clothing and leave time during religious holidays—as long as it doesn’t affect the employer’s bottom line. Combined with its bizarre and unpalatable cosponsor (Pennsylvania’s homophobic Republican Sen. Rick Santorum), the bill worries some women’s-rights advocates, who fear it could give pharmacists greater legal latitude to refuse to fill birth-control prescriptions.

“The bill is broad and vague,” Judy Waxman says. “It maybe could be interpreted to allow a pharmacist to actually obstruct a woman’s ability to get the drug.” The National Women’s Law Center has shared its concerns with the bill’s co-sponsors, and “they have been listening to us,” Waxman says.

Meanwhile, Sens. Barbara Boxer (D-Calif.) and Frank Lautenberg (D-N.J.) have proposed bills that would ensure contraceptive access at pharmacies across the nation. They acknowledge individual decisions of conscience, while placing the burden on pharmacies to make sure a woman gets served in a timely manner.

Women’s-rights advocates like to illustrate how absurd pharmacist refusals would sound under different circumstances. What if a pharmacist decided to stop filling prescriptions for diabetes medications, asks Aaron Payson, a Unitarian Universalist minister in Worcester who served as president of the Religious Coalition for Reproductive Choice. Or scrips for Viagra, Rowland asks. Or those for Retin-A, offers Shapiro: “Does the pharmacist say, ‘Gee, I don’t approve of women who want to get rid of their wrinkles?’ Where do you draw the line?”

Locally, Family Planning Advocates of New York State, while saying that pharmacist refusal to dispense birth control or EC is “egregious wherever it happens,” is focused on increasing access to EC more broadly by supporting the “Pharmacy Access bill,” which would allow physicians write non-patient-specific EC prescriptions for the pharmacies to keep on file, allowing patients to obtain EC without a personal prescription. This is partially possible, says JoAnn Smith, president of Family Planning Advocates, because the drug is so safe that there are practically no contraindications.

“What it means is that there are less delays for women in getting emergency contraception,” says Smith. “One of the most important things about emergency contraception is it’s time sensitive. You really want a woman to be able to get it within 72 hours. . . . We really like if women can get it within 12 hours even.”

Maine, California, Alaska, Washington, New Mexico, and Hawaii have enacted similar legislation. Because the choice to allow EC to be sold over-the-counter would be a federal decision, says Smith, the non-patient-specific prescriptions are what the states can do to increase access. “We’ve done a lot of really good work in New York state with pharmacists and their groups,” says Smith. “And we’re working closely with pharmacists’ groups on the pharmacy-access bill.” The bill passed the Assembly by a wide margin in January. The Senate version, S3661, was referred to the Higher Education Committee in March.

A similar bill is before the state Legislature in Massachusetts. That “EC Bill” also would require all hospital emergency rooms, including those in Catholic hospitals, to offer information about EC to sexual-assault victims. New York passed a law requiring that two years ago.

Both of these measures are good steps for women, Robinson says. “Every one of them, in their community, have access and are served by a pharmacy 365 days a year—and that’s the beauty of getting a pharmacy involved. They’re already there, they’re available, they’re strategically located, and they’re there holidays, weekends, anytime that would be needed by a woman in need of EC.”

To that end, Planned Parenthood and other experts are training pharmacists across the state to dispense EC. “I can’t tell a pharmacist what to believe, but I can sit them down and talk to them and educate them,” says Kristyn Napoli, a Neponset Health Center pharmacist who leads continuing-education EC programs for colleagues. “We don’t know where that patient is coming from. We’re not there to judge her, we’re there to give her timely access to health care.”

Because the arrangements would be voluntary, any pharmacist uncomfortable with dispensing the contraception would not have to do so. But that doesn’t placate the Massachusetts Catholic Conference. They have seized on the emergency-room portion of the bill, claiming that it violates their religious freedom.

“It would mandate certain actions in Catholic hospitals which we could be opposed to,” says Maria Parker of the MCC. “It’s kind of a nuanced thing. Contraceptives can act as a true contraceptive or as an abortifacient. And when it acts as an abortifacient, that is problematic, because now you are jeopardizing the life of a human being. And that is opposed to our Catholic position.”

Nuanced indeed. If a woman is pregnant, EC doesn’t have an effect. It cannot induce abortions, and is entirely separate from RU-486, the medical-abortion drug. Their so-called abortion objection, therefore, refers only to the few cases in which EC prevents a fertilized egg from implanting in the uterus. Official Catholic teaching supports EC for rape victims if it is unlikely that they have a fertilized egg, something that is difficult to test. Different hospitals interpret this doctrine differently.

A 2003 Catholics for a Free Choice study found that across 47 states and Washington, D.C., only 28 percent of Catholic hospitals would dispense EC to rape victims, and many hospital staff were unaware of their hospital’s protocols. But in New York, although some Catholic organizations did oppose the bill, Smith says her organization’s surveys found that even before it was required, Catholic hospitals were doing about the same as secular hospitals at providing EC. (It was the small hospitals that were the problem, she says.) And now, she says, their follow-ups indicate that all hospitals are following the law.

Nonetheless, if anyone has a problem with either a hospital or a pharmacist, says Smith, “There is an e-mail, conduct@mail.nysed.gov. That’s where you would e-mail to file a complaint against any professional licensed by the state education department. If anyone feels they got inappropriate care, we urge people to contact them right away.”

 

For More Information

These four sites are clearinghouses for political and medical updates on birth control and pharmacists. They also offer information and assistance to women trying to access contraception through local pharmacies. Each has its own niche: Go2EC (www.go2ec.org) offers comprehensive facts, figures, and state profiles on EC access; EC-Help (www. ec-help.org) offers direct connections with pharmacies that dispense EC; Pharmacy Access, (www.pharmacy access.org) is geared toward professionals hoping to learn more; Health Step, (www.healthstep.org) is specifically for women who use Depo Provera, the “birth-control shot.”

Then there’s Planned Parenthood (www.plannedparenthood.org), Planned Parenthood League of Massachusetts (www.pplm.org) and Family Planning Advocates of New York State (www.fpaofnys.org). At these sites, you can get involved in women’s-health activism, read about reproductive rights and family-planning options, find the nearest Planned Parenthood clinic, or order birth control or emergency contraception online (if you’re a PP client).

At Catholics for a Free Choice (www.catholicsforchoice.org) and Religious Coalition for Reproductive Choice (www.rcrc.org), learn more about those who have reconciled their faith with their support for women’s reproductive rights.

Pharmacists for Life International (www.pfli.org) wouldn’t talk to the Phoenix for this story, so visit their Web site to learn more about this organization—the “only pharmacy association which is exclusively pro-life, something no other pharmacy organization can say (or would have the courage to say!)”

In New York state, if you have had problems with a pharmacist or hospital refusing to fill a prescription, contact the state Education Department (which licenses pharmacists) at (800) 442-8106 or conduct@mail.nysed.gov.

 

Deirdre Fulton is a staff writer at the Boston Phoenix, where a version of this article first appeared. She can be reached at dfulton@phx.com. Miriam Axel-Lute contributed reporting to this version.


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