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

The American College of Nurse-Midwives blog, Midwife Connection, poses the question, "Should a pharmacist be able to refuse to fill a prescription?" in response to "pharmacy refusal" policies currently making their way through Washington state courts.

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.

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.

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.]

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

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.