Pharmacists and Emergency Contraception
http://www.100md.com
《新英格兰医药杂志》
To the Editor: We commend Cantor and Baum for calling attention to the problem of pharmacists' refusals to dispense emergency contraception (Nov. 4 issue).1 However, the authors' recommendation for resolving this problem by means of a notice or referral policy is unrealistic. First, because emergency contraception is most effective when used within 12 to 24 hours after intercourse, a policy permitting notice or referral in lieu of dispensation fails to meet this urgent health need. A delay could mean that a woman will be faced with the pregnancy she is trying to prevent. Second, referral is an unworkable solution, because pharmacists who refuse to dispense emergency contraception often also categorically refuse to refer patients to another pharmacy or to transfer the prescription on the basis of the same personal objections. Indeed, pharmacists across the country have already prevented women from accessing not only emergency contraception but also birth control pills by refusing to dispense, refer, or transfer prescriptions for contraception. We encourage pharmacies to reject this impractical compromise and ensure the provision of contraception — a basic and critical health care need for women — to all with a valid prescription.
Judy Waxman, J.D.
Rachel Laser, J.D.
National Women's Law Center
Washington, DC 20036
The National Women's Law Center receives financial support from foundations, individuals, and some corporations, including some pharmaceutical companies; contributions from pharmaceutical companies are less than 2 percent of the overall budget.
References
Cantor J, Baum K. The limits of conscientious objection -- may pharmacists refuse to fill prescriptions for emergency contraception? N Engl J Med 2004;351:2008-2012.
To the Editor: Cantor and Baum present the major arguments for and against a pharmacist's right to refuse to dispense emergency contraception. We agree that health professionals have the right to conscientious objection but do not have the right to obstruct access to legal health services. However, the authors go too far in suggesting that pharmacists are obligated to provide referrals to other pharmacies or to organizations such as Planned Parenthood. Their argument in favor of such referrals, which is based largely on the premise of professional and ethical obligation, is overstated and without legal precedent. Like other health professionals who refuse to provide certain health services with regard to reproductive control, pharmacists should be afforded the same right without fear of retribution or retaliation. Pharmacists are not morally or legally compelled to assist except in circumstances in which withholding such services would pose immediate health risks to the patient. We propose an alternative touchstone — although pharmacists do not have the right to obstruct, they should not be coerced into being passive participants in practices they deem morally objectionable.
Karim Anton Calis, Pharm.D., M.P.H.
14302 Woodcrest Dr.
Rockville, MD 20853
Frank Pucino, Jr., Pharm.D.
135 W. Main St.
New Market, MD 21774
Maria L. Restrepo, M.D.
8955 Edmonston Rd.
Greenbelt, MD 20770
To the Editor: The opinion of Cantor and Baum that a pharmacist has the right to object but not the right to obstruct is consistent with the official policy of the American Society of Health-System Pharmacists (ASHP)1: "ASHP recognizes a pharmacist's right to conscientious objection to morally, religiously, or ethically troubling therapies and supports the establishment of systems that protect the patient's right to obtain legally prescribed and medically indicated treatments while reasonably accommodating the pharmacist's right of conscientious objection." In our journal, Pentel et al.2 recently noted that it is the consensus of "the World Health Organization, the Food and Drug Administration, the American College of Obstetricians and Gynecologists, the Association of Reproductive Health Physicians, the American Public Health Association, and the American Medical Association" that emergency contraception is just that, not abortion. Although people may have diverse beliefs with regard to the definition of pregnancy and arbitrary opinions on the precise beginning of life, they should not have the right to impose those beliefs on others.
Henri R. Manasse, Jr., Ph.D., Sc.D.
American Society of Health-System Pharmacists
Bethesda, MD 20814
References
Conscientious objection by pharmacists to morally, religiously, or ethically troubling therapies. In: Best practices for hospitals and health-system pharmacy: positions & guidance documents of the ASHP. Bethesda, Md.: American Society of Health-System Pharmacists, 2004-2005.
Pentel PR, Nelson B, Wikelius N, et al. Hospital-based emergency contraception. Am J Health Syst Pharm 2004;61:1773-1774.
The authors reply: We agree with Waxman and Laser that reproductive control is crucial to women's health. As we argued, the refusal to fill prescriptions for emergency contraception is ethically indefensible, laws requiring referral (and, in rural areas, possibly also dispensation) are appropriate, and blanket immunity for pharmacists, recently proposed in Texas,1 is unwise. However, because emergency contraception is efficacious for hours, not minutes, we analyzed the legal problem as one of medical urgency, not emergency. Referral is perhaps inconvenient, but it is not unrealistic, especially if sanctions loom. Advance provision of the drug, as we noted, could also alleviate the time pressure.
The analysis by Calis and colleagues is puzzling. Offering information is not passive participation. Even if it were, society mandates active participation in endeavors some consider objectionable. The Civil Rights Movement could be viewed that way. Notably, the state of Washington requires hospitals with religious affiliations to offer emergency contraception to rape survivors, regardless of objections.2 Some states require abortion providers to pay for and distribute government-sponsored pamphlets about fetal development, even if the providers disagree with the views in them.3 Federal courts, including the Supreme Court, have held that such laws do not violate the health care providers' constitutional rights.4 Referral reasonably accommodates nondispensing pharmacists, and the courts agree that health care providers and civil servants who refuse reasonable accommodations can be fired.5,6 Furthermore, the standard of "immediate health risks" is not a recognized ethical or legal doctrine. It would also allow pharmacists to impose their morality on patients — exactly the imposition they decry. Calis et al. concede that pharmacists may not obstruct access. But stonewalling is obstruction, and a culture of obstruction cannot be tolerated.
Extreme positions alienate, and holding fast to them achieves little. We sought middle ground. Our idea, like the ASHP policy quoted by Dr. Manasse, balances society's diverse views with health care professionals' obligations. We envisioned a compassionate, tolerant, and responsible society whose time may not have come. The divergent opinions in these letters — that we went too far, that we did not go far enough — indicate the intractable nature of this conflict.
Two stopgap solutions emerge. First, consider physicians' distribution of emergency contraception. The current system may be nonsensically slow, especially if encounters at pharmacies are more frustrating than fruitful. Distribution by physicians would streamline the process. Alternatively, we may need to extricate both pharmacists and physicians from the process. These letters lend strong support to granting over-the-counter status to emergency contraception. This change would make pharmacists' objections moot. It would also leave a very private decision with the individual — which is precisely where it belongs.
Julie Cantor, J.D.
Yale University School of Medicine
New Haven, CT 06510
Ken Baum, M.D., J.D.
Wiggin and Dana
New Haven, CT 06511
References
An Act relating to the right to object to participation in an abortion procedure or to the dispensing of an emergency contraceptive. 2005 Bill text, Tex. H.B. 16.
Wash. Rev. Code (ARCW) 70.41.350 (2004).
Ky. Rev. Stat. 311.725 (2004).
Eubanks v. Schmidt, 126 F. Supp. 2d 451, 457 (D. Ky. 2000), citing Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833, 884 (1992).
Shelton v. Univ of Medicine & Dentistry, 223 F.3d 220 (3d Cir. 2000).
Endres v. Ind. State Police, 349 F.3d 922 (7th Cir. 2003), cert. denied, 158 L. Ed. 2d 493 (2004).
Judy Waxman, J.D.
Rachel Laser, J.D.
National Women's Law Center
Washington, DC 20036
The National Women's Law Center receives financial support from foundations, individuals, and some corporations, including some pharmaceutical companies; contributions from pharmaceutical companies are less than 2 percent of the overall budget.
References
Cantor J, Baum K. The limits of conscientious objection -- may pharmacists refuse to fill prescriptions for emergency contraception? N Engl J Med 2004;351:2008-2012.
To the Editor: Cantor and Baum present the major arguments for and against a pharmacist's right to refuse to dispense emergency contraception. We agree that health professionals have the right to conscientious objection but do not have the right to obstruct access to legal health services. However, the authors go too far in suggesting that pharmacists are obligated to provide referrals to other pharmacies or to organizations such as Planned Parenthood. Their argument in favor of such referrals, which is based largely on the premise of professional and ethical obligation, is overstated and without legal precedent. Like other health professionals who refuse to provide certain health services with regard to reproductive control, pharmacists should be afforded the same right without fear of retribution or retaliation. Pharmacists are not morally or legally compelled to assist except in circumstances in which withholding such services would pose immediate health risks to the patient. We propose an alternative touchstone — although pharmacists do not have the right to obstruct, they should not be coerced into being passive participants in practices they deem morally objectionable.
Karim Anton Calis, Pharm.D., M.P.H.
14302 Woodcrest Dr.
Rockville, MD 20853
Frank Pucino, Jr., Pharm.D.
135 W. Main St.
New Market, MD 21774
Maria L. Restrepo, M.D.
8955 Edmonston Rd.
Greenbelt, MD 20770
To the Editor: The opinion of Cantor and Baum that a pharmacist has the right to object but not the right to obstruct is consistent with the official policy of the American Society of Health-System Pharmacists (ASHP)1: "ASHP recognizes a pharmacist's right to conscientious objection to morally, religiously, or ethically troubling therapies and supports the establishment of systems that protect the patient's right to obtain legally prescribed and medically indicated treatments while reasonably accommodating the pharmacist's right of conscientious objection." In our journal, Pentel et al.2 recently noted that it is the consensus of "the World Health Organization, the Food and Drug Administration, the American College of Obstetricians and Gynecologists, the Association of Reproductive Health Physicians, the American Public Health Association, and the American Medical Association" that emergency contraception is just that, not abortion. Although people may have diverse beliefs with regard to the definition of pregnancy and arbitrary opinions on the precise beginning of life, they should not have the right to impose those beliefs on others.
Henri R. Manasse, Jr., Ph.D., Sc.D.
American Society of Health-System Pharmacists
Bethesda, MD 20814
References
Conscientious objection by pharmacists to morally, religiously, or ethically troubling therapies. In: Best practices for hospitals and health-system pharmacy: positions & guidance documents of the ASHP. Bethesda, Md.: American Society of Health-System Pharmacists, 2004-2005.
Pentel PR, Nelson B, Wikelius N, et al. Hospital-based emergency contraception. Am J Health Syst Pharm 2004;61:1773-1774.
The authors reply: We agree with Waxman and Laser that reproductive control is crucial to women's health. As we argued, the refusal to fill prescriptions for emergency contraception is ethically indefensible, laws requiring referral (and, in rural areas, possibly also dispensation) are appropriate, and blanket immunity for pharmacists, recently proposed in Texas,1 is unwise. However, because emergency contraception is efficacious for hours, not minutes, we analyzed the legal problem as one of medical urgency, not emergency. Referral is perhaps inconvenient, but it is not unrealistic, especially if sanctions loom. Advance provision of the drug, as we noted, could also alleviate the time pressure.
The analysis by Calis and colleagues is puzzling. Offering information is not passive participation. Even if it were, society mandates active participation in endeavors some consider objectionable. The Civil Rights Movement could be viewed that way. Notably, the state of Washington requires hospitals with religious affiliations to offer emergency contraception to rape survivors, regardless of objections.2 Some states require abortion providers to pay for and distribute government-sponsored pamphlets about fetal development, even if the providers disagree with the views in them.3 Federal courts, including the Supreme Court, have held that such laws do not violate the health care providers' constitutional rights.4 Referral reasonably accommodates nondispensing pharmacists, and the courts agree that health care providers and civil servants who refuse reasonable accommodations can be fired.5,6 Furthermore, the standard of "immediate health risks" is not a recognized ethical or legal doctrine. It would also allow pharmacists to impose their morality on patients — exactly the imposition they decry. Calis et al. concede that pharmacists may not obstruct access. But stonewalling is obstruction, and a culture of obstruction cannot be tolerated.
Extreme positions alienate, and holding fast to them achieves little. We sought middle ground. Our idea, like the ASHP policy quoted by Dr. Manasse, balances society's diverse views with health care professionals' obligations. We envisioned a compassionate, tolerant, and responsible society whose time may not have come. The divergent opinions in these letters — that we went too far, that we did not go far enough — indicate the intractable nature of this conflict.
Two stopgap solutions emerge. First, consider physicians' distribution of emergency contraception. The current system may be nonsensically slow, especially if encounters at pharmacies are more frustrating than fruitful. Distribution by physicians would streamline the process. Alternatively, we may need to extricate both pharmacists and physicians from the process. These letters lend strong support to granting over-the-counter status to emergency contraception. This change would make pharmacists' objections moot. It would also leave a very private decision with the individual — which is precisely where it belongs.
Julie Cantor, J.D.
Yale University School of Medicine
New Haven, CT 06510
Ken Baum, M.D., J.D.
Wiggin and Dana
New Haven, CT 06511
References
An Act relating to the right to object to participation in an abortion procedure or to the dispensing of an emergency contraceptive. 2005 Bill text, Tex. H.B. 16.
Wash. Rev. Code (ARCW) 70.41.350 (2004).
Ky. Rev. Stat. 311.725 (2004).
Eubanks v. Schmidt, 126 F. Supp. 2d 451, 457 (D. Ky. 2000), citing Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833, 884 (1992).
Shelton v. Univ of Medicine & Dentistry, 223 F.3d 220 (3d Cir. 2000).
Endres v. Ind. State Police, 349 F.3d 922 (7th Cir. 2003), cert. denied, 158 L. Ed. 2d 493 (2004).