In July, Rachel Peterson’s OB-GYN called in a prescription to the Meijer pharmacy in Petoskey, Michigan, for misoprostol to treat her recent miscarriage. But about an hour later, Meijer pharmacist Richard Kalkman called Peterson and told her that because of his religious beliefs, he would not fill her prescription—nor would he call another pharmacist or transfer the prescription to another pharmacy. And with no law in Michigan explicitly protecting the rights of patients like Peterson from being denied health care and services because of another’s religious objection, Peterson was left with few options.

Peterson’s allegations are set forth in a letter sent by the American Civil Liberties Union (ACLU) of Michigan this week to Meijer on her behalf, demanding that the pharmacy address the kind of discriminatory behavior Peterson says she experienced.

According to the letter, just as she was leaving to go to the pharmacy, Kalkman called Peterson to tell her he would not fill her prescription. Given that misoprostol is sometimes used as part of medication abortion, Peterson claims Kalkman told her that “as a good Catholic male,” he could not fill the prescription because he believed she intended to use it to end her pregnancy. When Peterson explained that she had miscarried and needed the medication to manage that miscarriage, Kalkman said he did not believe her and ended the conversation.

Peterson eventually had to drive three-and-a-half hours to another pharmacy to get her prescription filled.

“If a man had shown up with the same prescription for an ulcer [another common use of misoprostol], I have no doubt that this physician would still fill the prescription without questioning him,” Merissa Kovach, policy strategist with the ACLU of Michigan, said in an interview with Rewire.News.

In response to a request for comment from Rewire.News, Meijer emailed a statement confirming it had received the letter and clarifying its corporate refusal policy: “A pharmacist may refuse to fill a prescription based upon religious beliefs. However, our procedure requires the prescription to then be filled by another pharmacist in the store. If no other pharmacist is available, the pharmacist must consult with the patient to arrange for the transfer of the prescription to another pharmacy that is convenient to them. This is consistent with the American Pharmacy Association and the Michigan Pharmacy Association guidelines. A pharmacist who fails to follow this procedure is in violation of our process.”

“Our practice is based upon our overwhelming concern for patient safety and care, balanced with the need to accommodate the religious beliefs of our employees,” the statement read. But as Kovach noted in her interview, that balance inevitably burdens patients more.

“Well, what’s the line here? What’s the definition of nearby? Even if it’s next door, you’re still burdening the patient,” Kovach pointed out. “In Michigan, we have a lot of rural areas. And what if it’s 30 minutes away, or what if it’s 45 minutes away?”

Kovach continued: “What were you telling that patient when you’re telling them they can’t get it filled there? Are you telling them why, that you disagree with the choices that they are making with their reproductive health? In that case, you’re shaming them and putting stigma around their health-care choices.”

Dr. Ghazaleh Moayedi, an OB-GYN in Texas and fellow with Physicians for Reproductive Health, told Rewire.News in an interview that misoprostol allows patients to manage miscarriages on their own terms. “The patient can somewhat control when they’re going to start bleeding and where they’re going to start bleeding,” Moayedi said. “They could be in their home for that rather than maybe they’re driving and all of the sudden start bleeding very heavily or working and all the sudden start bleeding heavily …. You could see that as a safety issue and certainly an autonomy issue.”

By contrast, Moayedi said, a delay in obtaining medication can cause additional costs and risks: “That can mean excessive time off of work. It could mean prolonged bleeding.”

Timely access to miscarriage medication also can prevent patients like Peterson from having to undergo surgery to remove the failed pregnancy, an option that can be complicated by state-level anti-abortion laws. “The surgical management of a miscarriage is actually the exact same procedure as a first-trimester surgical abortion. They are literally the exact same procedure, but that management through surgical means can vary widely depending on your region,” Moayedi said. “It is a procedure that can be done simply, quickly, effectively, and safely in the office of a physician or a nurse practitioner or a physician assistant or a nurse midwife. However, in that perfect scenario where it could be offered and that miscarriage could be managed surgically, really just depends on where that patient lives.”

“Unfortunately, in many parts of the country we either have outright bans on advanced practice commissions offering those services, whether it’s for miscarriage management or abortion, so that would mean bans on nurse midwives, nurse practitioners, nursing assistants doing the course of procedures,” Moayedi said. Michigan is one such state. “Or we don’t have providers who are trained in doing those procedures in the office setting. Patients are taken to the operating room when the procedure could be very quickly, easily, and safely done in an office setting. That delays care. It dramatically increases the cost of care too. It can also add risk to the procedure as well.”

The risk religious refusals of care pose to patients is not a hypothetical one. In 2010, a then-18 weeks pregnant Tamesha Means experienced a miscarriage and went to Mercy Health Partners in Muskegon, Michigan. Her water had broken and she was cramping. Mercy Health, a Catholic-affiliated facility, told Means that because her fetus still had a heartbeat there was nothing it could do for her and sent her home. Means, a mother of three, returned to Mercy the next day, in more pain and bleeding heavily. She was again told that because there was a fetal heartbeat, the course of action was to wait and see. It wasn’t until Means returned to Mercy Health a third time and with a significant infection as her miscarriage persisted untreated that Mercy even offered her aspirin. During that third hospital visit, Means eventually delivered a baby who died within hours of birth.

Means sued the U.S. Conference of Catholic Bishops, claiming the bishops’ anti-choice directives negligently affect the medical care delivered at Catholic-owned and -sponsored hospitals. A court later ruled that the bishops could not be sued and dismissed the lawsuit. Rewire.News has also reported on doctors in Wisconsin who had to wait for their miscarrying patients to sicken before being able to administer treatment at Catholic facilities.

And with regard to pharmacies, the infringement extends beyond miscarriage management as well. Recently a CVS pharmacy in Fountain Hills, Arizona, turned away a transgender woman trying to pick up hormone therapy treatments. CVS eventually issued an apology and said the pharmacist at issue had acted outside the company’s policy.

Arizona is one of six states that affirmatively allow pharmacists to deny health-care services with no protections for patients when that happens. More than half of states have no law directly addressing pharmacist refusals, leaving corporate policy like Meijer’s to determine patients’ access to the delivery of unbiased health care.

According to the ACLU, Peterson has said she does not want to pursue litigation against Meijer but rather hopes sharing her story can bring attention to religious refusals. “With Rachel’s story, what she wanted the most out of this is to make sure that this doesn’t happen to anyone else. She wanted to share her story in hopes that it might attract some attention to this, help woman navigate where they can go to get help more easily,” Kovach said.

On Thursday, Meijer stated in a response posted on Twitter that Kalkman had not been employed with the pharmacy since early July, but did not comment on the matter any further. The ACLU has asked the company to formally respond to its demand letter by October 29.