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Debate Club
DEBATE CLUB 4/25/05

Can Pharmacists Refuse to Fill Prescriptions?

David Boaz and Judy Waxman debate.

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Some pharmacists are refusing to fill prescriptions for birth control or emergency contraceptives, such as the "morning after" pill. The pharmacists say they are taking a moral stand and 11 states have enacted (or are in the process of enacting) laws that would protect them. Other states are considering bills that would require a pharmacist to fill any prescription that came across his counter.

Should pharmacists have the right to dispense only the medications they want to?


David Boaz is Executive Vice President of the Cato Institute and author of Libertarianism: A Primer. Judy Waxman is the Vice President and Director of Health and Reproductive Rights at the National Women's Law Center.

Boaz: 4/25/05, 12:22 PM
Freedom means freedom for everyone. In a free society, customers shouldn't be forbidden by law from purchasing products except in very restricted circumstances. And in a free society, proprietors and employers shouldn't be forced to sell any particular product. Government should not intrude into the conscience of citizens.

So the answer to the question is, Yes, pharmacists should be free to dispense and sell the products they choose. If you don't want to offer medical marijuana in states where it's legal, you shouldn't have to. Health food stores don't sell things they consider junk food. Some bookstores don't sell Bibles, or right-wing books, or pornography. I remember being at a conference at Williams College a few years ago, and a friend went to the local Williamstown pharmacy and asked for a bottle of the mega-vitamins he was used to taking. The pharmacist said he shouldn't take such a large dosage and refused to sell him tablets of that size. My friend was annoyed. But the pharmacist had a right to do what he thought best, just as my friend had a right to go to a different pharmacy.

Some pharmacists have moral objections to birth control and especially to morning-after pills. You might say they're conscientious objectors to what they see as murder. The New York Times reported on Patty Levin, a pharmacist for 22 years who works at Wender & Roberts in the north Atlanta suburb of Sandy Springs, who 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."

We may not agree with her, but we should not use the power of government to force her to do something that violates her conscience.

In a country of 290 million people and 14 million businesses, we should let these issues sort themselves out in the marketplace. Chances are that major drugstore chains like CVS and Walgreen's are going to insist that their stores fill all prescriptions. If they have more than one pharmacist on duty at a time, then they may be willing to tolerate pharmacists who avoid filling certain prescriptions. If they do insist that all pharmacists be prepared to fill any prescription presented by a customer, then pharmacists who can't accept such rules will have to look for jobs elsewhere.

And if customers encounter a pharmacist who won't give them what they want, then they will have to find another pharmacy.

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Waxman: 4/26/05, 02:05 PM
Pharmacists have a professional obligation to assure women access to prescriptions written for them by their doctors

Family planning is central to good health care for women. Access to contraception is critical to preventing unwanted pregnancies and to enabling women to control the timing and spacing of their pregnancies. Contraceptive use in the United States is virtually universal among women of reproductive age. Without contraception, the average woman would bear between 12 to 15 children in her lifetime. Also, women rely on prescription contraceptives for a range of medical purposes in addition to birth control, such as regulation of cycles and endometriosis.

Emergency contraception (EC) is, like birth control pills, approved by the FDA as contraception. Also known as the "morning-after pill," EC is an extremely time-sensitive drug that works for up to 72 hours, but is most effective if used within the first 12 to 24 hours following unprotected sex. Experts predict that access to EC could prevent as many as 1.7 million of the 3 million unplanned pregnancies that occur every year. This is something "pro-life" pharmacists should support.

These refusals to dispense prescription contraceptives are based on personal beliefs, not on legitimate medical or professional concerns. The same pharmacists who refuse to dispense contraceptives because of their personal beliefs often refuse to transfer a woman's prescription to another pharmacist or to refer her to another pharmacy. These refusals can have devastating consequences for women's health.

The laws and regulations in most states do not specifically speak to the issue of pharmacist refusals based on personal beliefs. States that provide general guidance about when pharmacists may refuse to dispense tend to limit the reasons for such a refusal to professional or medical considerations—such as potentially harmful contraindication, interactions with other drugs, improper dosage, suspected drug abuse or misuse and the like—as opposed to personal, moral, or religious judgments.

Many pharmacist associations note that while individual beliefs should be respected and accommodated where possible, the pharmacist ultimately has the responsibility to ensure timely patient access to legally prescribed medications—for example by either filling valid prescriptions or transferring them to another pharmacist who can. Pharmacists should not stand in the way of women getting their prescriptions.

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Boaz: 4/27/05, 09:54 AM
We seem to be talking past each other. I'm not challenging any of your arguments about the value of family planning and contraception. I'm just asking what we should do about people who disagree with you. I think people who have different moral or religious or medical views should not be forced by law to act against their consciences.

You say that "pro-life" pharmacists should be happy to distribute emergency contraception because it could prevent as many as 1.7 million unplanned pregnancies a year. And presumably the implicit point there is that EC would thus prevent some of those pregnant women from getting an abortion. But some pro-life pharmacists think that a morning-after pill is an abortion. Who should decide? I say each individual should be allowed to exercise her own conscience.

If you think that pharmacists should be required to dispense EC against their consciences, would you also say that every physician should be required to perform abortion if requested? Or every plastic surgeon required to perform breast implants if a woman shows up at the clinic requesting them? Or maybe you would say that women shouldn't be able to make the choice to get breast implants, and doctors shouldn't perform them. Either way, the question is: Who decides? Each individual, or the government?

In introducing the Workplace Religious Freedom Act, Sen. John Kerry said, "No American should have to face the choice between practicing their faith or working at their job, it's that simple." He wants a law that would require employers to make accommodations for their employees' religious beliefs. I'm sympathetic to that concern, but I don't think government should be making such requirements. I'm opposed to his bill to force new rules on millions of employers, and I'm also opposed to the bills—which some of the same people may well support—to force a different set of rules on pharmacies. What happens if both laws pass? Then a pharmacy would be required to fill all prescriptions and also required to accommodate employees who don't want to do that. That's why it's better to let each business make its own rules and let us all sort ourselves in a dynamic and diverse marketplace, rather than trying to impose one rule on everyone.

Pharmacists should not stand in the way of women getting their prescriptions. But neither should government stand in the way of a professional exercising her conscience.

Waxman: 4/27/05, 06:58 PM
The pharmacist holds a unique position within the health care system. The patient has a relationship with a doctor, but to carry out a treatment plan, the patient must often depend on another professional—the pharmacist. Many statutes spell out a duty of care between patients and pharmacists. The pharmacist cannot be equated with a book store or health food store owner deciding whether or not to stock Penthouse or potato chips. The training required to practice pharmacy, and the state regulation of the profession come with both rights and responsibilities.

Some pharmacists use these rights and responsibilities as a basis for refusal and say that they should be allowed to refuse to fill prescriptions just as doctors are permitted to refuse to perform abortions. According to our government's Food and Drug Administration (FDA), both birth control pills and "the morning after pill" are contraception. The only FDA approved medication to induce abortion (Mifepristone), can not be sold at pharmacies, and is available only from doctors who order it directly from the manufacturer. The objection to contraception is rooted in personal religious belief, and not professional training, science, medicine or the law.

While not exactly on point (since the vitamins were presumably an over-the-counter medication and not prescreened and regulated by the FDA) the pharmacist that refused megadoses of vitamins to the friend you mentioned on Monday was indeed acting within the boundaries of the profession. That pharmacist used his professional judgment and not his personal moral or religious belief. There was a medical and scientific basis for his refusal, based on his education, training, and professional determination that such doses could be harmful to the patient. I agree with the many state laws and regulations list factors a pharmacist should review before dispensing, including dosages, contraindications with other medications, or potential abuse, just to name some considerations.

The National Women's Law Center opposes WRFA as it is currently drafted because it fails to provide assurances that customers and patients will have their needs met when an employee asserts a religious objection. As in many areas where individual rights and liberties are in conflict, this is not a problem that can be solved by the market. Government "intrusion" was needed to desegregate lunch counters and allow women access to opportunities in employment and education; and it is needed now to secure access to basic health care.

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Boaz: 4/28/05, 11:49 AM
Well, I guess we've joined the issue now. You say that pharmacists should not be able to act on their own consciences. I say they should. I say the law should not force people to violate their consciences without some overriding reason. If you believe in a woman's right to choose birth control or abortion, you should also believe in a woman's (or a man's) right to choose whether to be the provider of that service.

You know, this is an example of how one state intervention generates the demand for additional interventions. We say you can't be a pharmacist unless you get a state license, and now you want to say that that license should empower the state to impose morally offensive obligations on those who were required to get the license.

Similarly, we require a prescription to get many drugs, including some forms of contraception. Why should a woman need a prescription for contraception? Why not just grant access to contraception by allowing it to be sold over the counter? Here we've created one intervention—the requirement that people get a prescription from a licensed doctor, which they must take to a licensed pharmacist—and it has led to a situation you don't like, in which some tiny number of pharmacists are refusing to dispense a particular prescription. So you say we should have another rule, another regulation, another intervention. Let's just let women buy the contraceptives they choose.

Until we do that, though, women should have the right to choose, and so should pharmacists. We're all less free if the state forces our neighbors to act against their consciences.

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Waxman: 4/29/05, 07:56 AM
As it stands, we have a system of laws, regulations, and licensing requirements that are intended to protect the public. The practice of pharmacy is not subject to regulation because of the potential harms to the pharmacist, but to the public served by the pharmacist.

David, you believe all intervention is bad, while I do not. All intervention is not created equal. There is intervention based on facts, science, professional training, and considerations authorized by the law. And then there is intervention based on personal moral and religious views that are beyond the boundaries of the profession. Given the balance of rights and responsibilities, once we infuse morality into the practice of pharmacy, there can be no bounds to what might be subject to non-medical considerations. Should a pharmacist who sees a person buying Oreo cookies then refuse to fill that person's prescription for a diabetes medication? Should a pharmacist refuse to provide a person with AIDS medication because the pharmacist believes the individual's life style is immoral? If a new drug is developed for Alzheimer's disease through stem cell research, should the pharmacist be permitted to refuse to dispense it?

Pharmacists knowingly enter a profession where they serve the public, subject to regulation. The system regulating the profession should not allow pharmacists to act on their individual religious or moral beliefs at the expense of that public. Ideally, such beliefs could be accommodated, but we know that these systems often fail. Often, objectors are not willing to participate in any suggested accommodation. For example, the head of Pharmacists for Life objects to referring contraception prescriptions to another pharmacist or drugstore. In her opinion, providing a referral for birth control would be tantamount to her doing an "abortion" herself. Given the real possibility that some pharmacists will prevent women from obtaining access to necessary health care, regulators should assure women that pharmacists will not be able to stand in the way of women securing contraception.

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