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Abortion debate spreads to pharmacy counter

By Marie McCullough
March 28, 1999

Pharmacy counters are becoming a new front in the nation's bitter battle over abortion.

The reason is emergency contraception -- the so-called morning-after pill.

Increased demand for the emergency method has created a crisis of conscience for some pharmacists who view it as a form of chemically induced abortion. Isolated cases of pharmacists' refusing to fill prescriptions for emergency contraception are popping up around the country. The emergency method isn't new. It consists of a slight overdose of ordinary birth-control pills taken within three days of sex to help prevent pregnancy. But awareness has grown with the promotion of the method by women's-health advocates and the debut of Preven, an emergency contraception kit that hit the market late last year.

"I am not stopping anybody from getting Preven or whatever they want to get; I'm just not involved in it," said Andy Cocco, who has made up his mind not to fill any such prescriptions should they come his way.

He works at a chain drugstore in Boothwyn, Delaware County, and belongs to Pharmacists for Life International.

"This is a difficult balance to achieve," said Todd Andrews, a spokesman for CVS Corp., "because we don't want pharmacists to do anything against their conscience. We also have an obligation to dispense medications."

Pharmacist associations in Pennsylvania, New Jersey, and numerous other states have responded to concerns about emergency contraception, as well as the specter of assisted-suicide drugs and the abortion pill RU-486, by adopting "conscience-clause" guidelines that affirm pharmacists' right to refuse to fill prescriptions on moral, ethical or religious grounds. They also have pushed for legislation to protect druggists from retribution.

Abortion-rights activists agree that pharmacists have a right to follow the dictates of their conscience, just as doctors do. But there is sharp dispute over how obstructionist pharmacists are entitled to be: Must a pharmacist who won't dispense a drug help a patient find one who will?

The Pennsylvania Pharmacists Association and the New Jersey Pharmacists Association have adopted the stance of the 48,000-member American Pharmaceutical Association, which supports "the establishment of systems to ensure patient access" to medications. That could mean leaving a prescription to a partner, giving it to another store, or handing a patient a toll-free hotline number, such as one set up by proponents of emergency contraception.

Pharmacists for Life International opposes that approach, saying any accommodation amounts to cooperation in abortion.

Connecticut pharmacist Robert Tendler, who recently launched Pharmacists for Choice, said, "It's difficult to find the wording to satisfy both prochoice and prolife people. "I certainly understand there are people who are against abortion and birth control. But I believe when a patient comes to your pharmacy, you have an obligation to fill the prescription."

Scientists say emergency contraception works by preventing ovulation, fertilization or implantation of a fertilized egg. It is that third action that is anathema to pharmacists who believe that life begins at conception.

Pharmacists for Life urges its 1,500 members to refuse to fill not only emergency contraception but all birth-control prescriptions -- pills, implants, injections and intrauterine devices -- because of the chance, no matter how remote, of disrupting implantation of a fertilized egg.

Rumblings of conscientious refusal began to be heard in 1997, after the Food and Drug Administration proclaimed emergency contraception safe and effective, leading to the launch of Preven by Gynetics Inc. of Belle Mead, N.J.

"The morning-after pill is what really made it nuts," said Karen Brauer, a Lawrenceburg, Ind., pharmacist who says she was fired for refusing to dispense a particular birth-control pill.

"Preven has just brought this out. I think there is a lot of angst about it," said Boothwyn pharmacist Cocco.

"The recent refusal of a handful of pharmacists to fill prescriptions for emergency contraception has caught women and reproductive-health-care providers off guard," said Alexander C. Sanger, president of Planned Parenthood of New York City and grandson of birth-control pioneer Margaret Sanger.

Nancy Yanofsky, president of the ProChoice Resource Center in Port Chester, N.Y., said the refusal to dispense is "the newest wrinkle" in the evolution of conscience clauses for health-care providers.

"It's a sleeper issue that has . . . snuck up on the prochoice community," she said.

Gynetics founder and CEO Rod Mackenzie sees his product as a way to prevent pregnancy and avoid abortion.

"We are not aware of a single prescription for Preven being refused because of a moral objection," he said. "No one has been able to come up with a valid moral argument against something that could potentially stop 800,000 abortions a year."

The magnitude of druggists' objection is hard to gauge. Pharmacy Today magazine recently conducted an informal survey: Of the 381 responses, 80 percent said pharmacists had a right to refuse to dispense emergency contraception; 57 percent saw no obligation to refer patients. The results, however, may have been skewed, because the antiabortion pharmacy group urged members to respond.

Another unscientific survey, of 120 pharmacists, published in late 1996 in the Journal of the American Pharmaceutical Association, found that 29 percent would not be willing to dispense RU-486, which is expected to receive FDA approval this year. But RU-486 has a different mechanism than emergency contraception: The drug disrupts pregnancies that are weeks along.

It's also hard to gauge the impact of conscientious refusal on women's health care, because few patients have complained publicly about being denied emergency contraception.

In 1997, Michelle Crider, then a 28-year-old mother of a 2-year-old, was refused emergency pills by a chain-store pharmacist in Temecula, Calif. Although the prescription was readily filled at a nearby supermarket, she was angry.

"Without knowing my situation, he could have affected a huge part of my life. What if there had been no other pharmacy to go to?" Crider said at the time.

Abortion-rights activists fear that, in remote places, women could face more than inconvenience. Last year, in New Mexico, the National Abortion and Reproductive Rights Action League called every pharmacy with a phone-book listing and found that 28 of 192 pharmacies -- about 15 percent -- wouldn't dispense emergency contraception. The survey was prompted when a 32-year-old woman told the league that she had been refused the pills at a pharmacy in Silver City.

"The scary thing was if it had been Sunday night . . . we would have had to drive 75 miles to find another open pharmacy," said the woman, who did not want her name used. "You think about a poor rural woman with no car; it would have been a real bad deal."

So far, drugstore chains seem to be responding case-by-case to customer complaints.

"We have discussed the possibility of creating some kind of policy statement to provide pharmacists guidance on this matter," Andrews of CVS said. "But the instances where this has come up have been extremely rare."

Dan Jarvis, a spokesman for Kmart, said the company has no "hard-and-fast rule." Although Kmart does not want its pharmacists to turn away business, "we are not taking a stance that if a pharmacist doesn't fill this prescription, we will fire him. . . . We'll look for an alternative and work with them," he said.

But Brauer, the Indiana pharmacist, says Kmart gave her no alternative when she was fired in 1996. She refused to consent to a disciplinary document, which she has since posted on her Web site, because it required her to promise to fill all legally written prescriptions "regardless of my feelings or beliefs." (Kmart would not comment on her case.)

Brauer acknowledged that she did something that could be viewed as unethical: She lied. She said she was out of the birth-control brand that she couldn't in good conscience dispense, hoping to avoid tension. The customer later discovered the lie.

Daniel Hussar, a professor at Philadelphia College of Pharmacy and an outspoken supporter of the right of refusal, said: "I do not condone lying. It's a breach of integrity. There are courteous ways of handling a delicate situation."

South Dakota recently passed a law protecting pharmacists from retribution for conscientious refusal to dispense drugs that they believe would cause an abortion or be used for assisted suicide or mercy killing.

Pennsylvania Rep. Tom Tangretti of Armstrong, Westmoreland County, intends to introduce protective legislation this year. He believes that pharmacists should be shielded from reprisals even if they decline to provide referrals.

Many pharmacists cite assisted-suicide drugs and RU-486 as evidence that their ethical predicaments are sure to multiply.

But RU-486 will be provided directly to doctors through a special distribution system, according to the Danco Group, which is licensed to market the drug in the United States.

And if Oregon's trailblazing approach to physician-assisted suicide is a model, lethal drugs will be dispensed only by pharmacists who volunteer to do so.

Conflicts over conscientious refusal, however, could get even hotter. Manufacturers are developing at least two emergency contraceptive products that would be more effective and have fewer side effects.