As soon as the morning-after pill Plan B came
on the market several years ago, downstate-Illinois pharmacist
Peggy Pace knew that she’d never dispense it.
“It has the effect of ending the life
of an embryo,” she insists — flat-out rejecting the
drug’s classification as contraception: “A
contraceptive works by preventing ovulation or fertilization; this
doesn’t do either of those most of the time.”
Although Pace’s view of when pregnancy
begins is at odds with those of the medical establishment and the
U.S. Food and Drug Administration, she believes that the Illinois
Health Care Right of Conscience Act protects her religious beliefs
and her job as a medical professional. Working at a Walgreens in
Glen Carbon over the past two years, she has turned away two
prescriptions for Plan B — refusals that at the time were
condoned by her employer. In an earnest attempt to act
professionally, she says, she offered to call another pharmacy to
see whether they would fill the prescriptions, but both women took
them back and left.
In each of the two instances, Pace resisted
the temptation to preach about what she believes are the
drug’s consequences. “I know it’s not my
position,” she admits.
But if asked, either on or off the job,
she’ll tell.
“If they don’t have the full
story, how can they decide?” she wonders. “There is an
informed-consent issue that isn’t being addressed. A doctor
shouldn’t assume that a woman willing to use this drug
isn’t bothered by a postfertilization effect, isn’t
bothered that it will end the life of an embryo. They
shouldn’t assume women won’t care. A lot of women do
care.”
Pace is among a staunch group of pharmacists
who have been blocking prescriptions for emergency contraception
and, in some cases, birth-control pills as well.
But on April 1, their objections slammed into
the long arm of the law. That’s when Gov. Rod Blagojevich
issued an emergency executive order requiring pharmacies that carry
birth control to also fill prescriptions for the morning-after pill
— “no delays, no hassles, no lectures,” according
to Susan Hofer, spokeswoman at the state Department of Financial
and Professional Regulation, which licenses pharmacists and
pharmacies.
“The rule is a clarification of the
responsibility that pharmacists have to care for patients,”
she says.
This month, the governor revised the wording
of the edict on the basis of input gathered in writing and from a
standing-room-only public hearing in Chicago, Hofer adds. He has
now sent it on to a joint legislative committee with the request
that it become law, which will happen automatically late this
summer unless a three-fifths majority overturns it. Last month, the
committee fell three votes short of the eight votes needed to block
the governor’s original emergency order.
“You don’t have a right to pick
and choose who you’re going to provide prescriptions for and
which medication you’re going to fill,” says
Blagojevich spokewoman Abby Ottenhoff. “If you’re in
the business, you’ve made that choice.”
Pharmacies that disregard the edict are
subject to probation, suspension, or revocation of a license or
simply a fine or reprimand. Faced with the consequences and a
change in Walgreens policy warning pharmacists that they must
follow the state law, Pace became distraught and conflicted.
“I had a gnawing in my stomach,”
she recalls. She says she was nauseated and “stressed
out” before each shift, when a Plan B prescription might
appear at her counter, forcing her to disregard her moral beliefs or compromise her job. So far,
though, she says that has not happened.
Instead, Pace decided to fight back. She and
John Menges, a pharmacist living in Edwardsville, contacted the
American Center for Law and Justice. The legal group, founded by
religious broadcaster Pat Robertson, aided Terri Schiavo’s
parents in their bid to keep their brain-damaged daughter alive and
defends other religious-freedom cases, including one filed this
month against Eastern Illinois University on behalf of a nurse who
claims that she was denied a promotion after she admitted during an
interview that she would not dispense the morning-after pill.
The two pharmacists filed suit against
Blagojevich in state court and were later joined by four more
pharmacists from the Carbondale area. They have asked the judge to
declare the order invalid.
Their action may also force the first ruling
on whether pharmacists are covered as health-care personnel by the
state’s permissive Health Care Right of Conscience Act.
(Blagojevich insists that they are not.) In a separate suit, a
Chicago-area pharmacist is challenging the law with the assistance
of the Center for Law and Religious Freedom.
Nationwide polls consistently show
that a wide majority of Americans believe that pharmacists ought to
fill prescriptions for the morning-after pill even if they are
morally opposed to it. One of the most recent, conducted in
mid-May, found that 74 percent of a sample of 1,200 Americans from
all major religions backed state laws requiring pharmacists to fill
prescriptions. That number jumped to 81 percent of those who
identified themselves as politically moderate and 87 percent of
liberals but slid to a still-substantial majority of 59 percent for
conservatives. By religious affiliation, 70 percent of Catholics
sided with patients’ rights over the moral conscience of
pharmacists; 68 percent of Protestants did so. The poll was
conducted by the Louis Finkelstein Institute for Social and
Religious Research in Flemington, N.J.
Two weeks ago, women’s-advocacy groups
celebrated the 40th anniversary of Griswold
v. Connecticut, the Supreme Court
ruling that legalized contraception for married couples.
“It seems to me amazing that we are
still struggling over this,” says Brigid Leahy, vice
president of Illinois Planned Parenthood Council, which backed
Blagojevich’s order, issued after a pharmacist refused to
fill a morning-after prescription at a Chicago Osco Drug in
February.
Says Leahy: “It’s legal; the FDA
says it’s safe and effective; women shouldn’t be denied
it.”
The extent to which women are still
struggling to get emergency contraception is impossible to
quantify, according to everyone involved. Blagojevich maintains
that even one woman denied is one too many, according to Hofer of
the IDFPR.
“We have anecdotal evidence it’s
happening throughout the state; there’s also evidence
it’s happening in every state of the Union,” she says.
“It should not happen at all, ever.”
Some fear that the problem is more pressing
for downstate women and those in rural areas, where there are fewer
pharmacies. Because the drug works best the sooner it is taken
after unprotected intercourse and must be used within 72 hours to
be effective at all, delays caused by having to shop around or find
transportation to another town could be disastrous, says nurse
practitioner Stephani Cox, director of patient services for Planned
Parenthood Springfield Area. Although she’s only had one
refusal since the governor’s order went into effect, she
claims that such occurrences used to happen frequently.
Cox is on the front lines of the prescription
war. She dispenses birth control and morning-after pills to
patients directly at the Planned Parenthood clinic during weekday
business hours. On weekends, however, she carries a pager and calls
in emergency-contraception orders directly to pharmacists.
“We’d have to call and ask,
‘Who’s on duty? Will they fill?’ ” Cox
recalls. “It happened often enough that it was a major
problem for us, and we ended up having to find a pharmacy that
would guarantee us that they would have pharmacists there to fill
it.”
Usually Cox could buffer patients by
screening pharmacists and working with them to find a substitute if
they didn’t specifically stock Plan B. High doses of regular
birth-control pills can used for the same effect, she explains.
But strident pharmacists have occasionally
engaged her in heated debate, refused a prescription, or worse: One
called a patient’s home directly instead of returning a call
to Cox, informing the woman that the prescription would kill her
baby.
“The patient called me back, hysterical
. . . she was trying to do the responsible thing,” Cox says.
“It took reeducation because people do look to pharmacists
for medical information, and when they put their beliefs over
medical fact, it’s really confusing for them.”
So what is the medical truth?
The FDA classifies morning-after pills such
as Plan B and Preven as contraceptives that prevent pregnancy, the
same as birth-control pills. They are not
“abortifacients” that end pregnancy, although some
pharmacists have used that term in the morning-after debate.
Abortifacients — or chemical abortion inducers such as
mifepristone (known as RU-486), methotrexate, and misoprostol — are never
dispensed by pharmacists; they’re given only under the
supervision of a clinic or physician.
Emergency contraception, on the other hand,
works by delaying or inhibiting ovulation, preventing
fertilization, or altering the lining of the uterus so that
implantation doesn’t occur, according to the FDA. Two recent
studies highlighted by Planned Parenthood show that morning-after
pills most often work by preventing ovulation or fertilization, not
by blocking implantation. Planned Parenthood also cites a 2003
study crediting the availability of morning-after pills for a 43
percent decrease in the number of abortions between 1994 and 2000.
But pharmacists such as Pace argue
that the FDA and the medical establishment have played around with
words, changing the definition of pregnancy from fertilization to
implantation so that Plan B and even intrauterine devices —
both capable of preventing implantation — cannot be said to
end a pregnancy.
“If it’s a birth-control pill,
then why do you take it after you have sex? It’s to prevent
whatever happened after you had sex from continuing,” says
Pace’s attorney Frank Manion, senior counsel at the ACLJ.
“If you believe that life begins at conception and
fertilization, then there are moral consequences that flow from
that belief.”
However, fertilization rarely occurs
immediately after intercourse. According to the Mayo Clinic’s
Web site: “During the time between intercourse and
conception, sperm continue to travel through the fallopian tube
until the egg appears. So, the ‘morning after’
isn’t too late to prevent pregnancy.”
Cox says Pace and others may choose to define
pregnancy as fertilization and fervently believe — against
considerable evidence — that morning-after pills only act
after fertilization. “That’s fine for their choice, but
it’s not medical fact,” Cox emphasizes. “Beliefs
and feelings don’t make it so.”
The Illinois Pharmacists Association stands
by its position that pharmacists are protected under the
state’s conscience clause. However, “the pharmacist
doesn’t have the right to lecture the person or withhold the
prescription or denigrate her,” clarifies executive director
Mike Patton. “We think the pharmacist should have the right
of conscience, but not at the expense of the patient.”
The association initially opposed the
governor’s order but now supports revised wording that
upholds a pharmacist’s right to check for drug-to-drug
interactions or an incorrect dosage and point such information out
to the patient or her physician, Patton says.
Regarding emergency contraception, Patton
wants the state to go further than state law allows and give
pharmacists the authority to dispense emergency contraception
directly to women. Such a move will save money by eliminating the
doctor visit and improve access to emergency contraception,
according to the IPA. Furthermore, the number of abortions declines
in states that have made it easier for pharmacists to dispense
morning-after pills, Patton says.
Such a position won’t help those
pharmacists who object to the pills on moral grounds. But Patton
believes that most stores that don’t stock Plan B do so for
business reasons: because there isn’t much demand. Those who
have religious objections are a “very, very small
minority,” he says.
Pace adamantly disagrees.
“In my immediate geographic area I know
of six pharmacies . . . and, in mine, 50 percent, or two out of
four, don’t dispense; in another there are two pharmacists
and both dispense; and in another there are three out of four staff
who will not dispense; in the next, four out of four will not
dispense; and in the furthest, two out of four will not
dispense,” she says. “I’ll give him that
we’re a minority, but a tiny minority is not true.
They’re just not speaking up but are defying the
governor’s order and waiting for it to be tested.”
Others say that pharmacists have acceded to
the new law and that pharmacies — particularly the national
chains — have gotten the message. Walgreens now requires
pharmacists in its 481 Illinois stores to fill all prescriptions in
accordance with the law, according to a spokeswoman. Wal-Mart
publicly says that it only stocks birth-control pills, not
emergency contraception such as Plan B. But according to a source
familiar with the pharmacy, the chain quietly began carrying
morning-after pills in Illinois locations last month in keeping
with the new law. Wal-Mart’s corporate-communications
department did not return phone calls seeking clarification.
But Cox maintains that aside from Plan B and
Preven, more than a dozen types of birth-control pills can be used
in varying doses to accomplish the same morning-after effect, and
Pace acknowledges that it’s likely she unknowingly has
dispensed birth-control pills for that purpose.
“For many years doctors have written
‘Take as directed,’ ” she concedes. “Well,
I’m out of the loop at that point, because that’s how
they write virtually every prescription for birth-control
pills.”
As for her professional duty as pharmacist to
patient, Pace believes she is obliged to deliver health care that
supports life, relieves suffering, and promotes health.
“I’m fulfilling my obligation by
not participating in what I see as harmful,” she insists.
“I’m not going to cross the line to harming human life,
and that’s a medical decision, it’s a moral decision,
an ethical decision, and a religious decision.”
This article appears in Jun 16-22, 2005.
