The culture wars have already seeped into hospices, movie theaters, and the Super Bowl. Now, even the corner drugstore has become a battleground.
From rural Texas to Chicago, more instances are cropping up of pharmacists refusing to fill prescriptions for oral contraceptives and the morning-after pill. As a result, politicians around the country are stepping into the fray.
It's a debate that weighs personal morals against professional responsibility. It pits religious rights against patients' rights and raises the question of just where pharmacists stand on the spectrum of health-care professionals.
Many pharmacists point to the "conscience-clause" exceptions that nearly every state has in place for doctors, allowing them to recuse themselves from performing abortions or other procedures they object to. They believe they should have similar protection.
Critics point out that filling a prescription is a very different job from writing one, and question whether pharmacists can deny a legal drug on moral grounds. And the patients who have been denied are simply angry to see their prescriptions become fodder for a public debate - especially when the prescriptions they wanted filled were for something as time-sensitive as emergency contraceptives, often known as the morning-after pill.
"Most observers seem to say it [refusing to give out contraceptives] is picking up, and there seems to be a more organized campaign to allow pharmacists to refuse," says Adam Sonfeild, an analyst with the Alan Guttmacher Institute, which tracks reproductive health issues.
And as the issue gets more attention, politicians are weighing in - on both sides:
• In Illinois, Gov. Rod Blagojevich (D) last week issued an executive rule clarifying his view of state law: Any pharmacy that sells contraceptives must promptly fill a woman's prescription for them.
• Four states, including California and New Jersey, are considering laws that would require pharmacists to fill prescriptions despite any religious or moral objections, unless they could find an alternative that doesn't inconvenience the patient.
• Thirteen states are considering giving pharmacists the kind of conscience-clause outs that doctors have, allowing them to refuse to fill some prescriptions that go against their personal beliefs. (Four already have such laws on the books.)
• In a related issue, Colorado Gov. Bill Owens (R) exercised a rare veto this week, for a bill that would have required all hospitals - including Catholic ones - to inform rape victims about the availability of emergency contraceptives. Among other concerns, he questioned the constitutionality of forcing religious institutions to engage in speech counter to their principles.
With the pharmacist battles, it's principles of individuals, rather than institutions, that come into play. While no hard numbers are available, anecdotes have cropped up with increasing frequency.
Two pharmacists at a drugstore in Texas refused to fill a prescription for an emergency contraceptive for a woman said to be a rape victim. They were later fired. In Wisconsin, a judge reprimanded Neil Noesen this year for not only refusing to fill a college student's prescription for birth-control pills, but for balking at transferring the prescription to a pharmacist who would fill it.
Governor Blagojevich's ruling was prompted by a pharmacist at a downtown drugstore who refused to give emergency contraceptives to two women. "The governor said that there seems to be a pattern here, and it was important to take action quickly to make sure pharmacies in Illinois know they have an obligation to ensure a woman's access to health care," says Abby Ottenhoff, an aide to the governor.
Public opinion tends to come down in favor of the patient. In a November New York Times poll, just 16 percent of respondents said they believed a pharmacist should be able to refuse to dispense birth-control pills for religious reasons. Among white evangelical Christians, that number grew to just 24 percent.
But many pharmacists believe it's possible to accommodate their consciences and still ensure a patient gets her prescription. "We support the pharmacist stepping away, but we don't support them stepping in the way," explains Susan Winckler of the American Pharmacists Association, which adopted a policy calling for conscience protections, as long as the pharmacy had an alternative system in place - another pharmacist on duty, for instance, or an agreement with a neighboring pharmacy. The issue first arose not because of contraceptives, she says, but over pharmacists in Oregon concerned about taking part in assisted suicide.
Ms. Winckler is concerned about the order in Illinois, which she says has caused many drugstores to reverse their policies and doesn't take into account that pharmacists may refuse to fill a prescription due to health concerns as well as moral objections. She's also worried about proposed laws that give too much weight to either the pharmacist's rights or the patient's rights, instead of considering them both.
Still, in a conflict, the patient's rights should win, say some medical ethicists. "For the past few years now, pharmacists have wanted to model their relationship with the patient on the physician-patient relationship, which is not really appropriate," says Evelyne Shuster, a medical ethicist at the University of Pennsylvania.
Others wonder about the implications down the road: A pharmacist only agreeing to give contraceptives to married clients, for instance. Defenders of the conscience clause dismiss such fears as ridiculous, and contend that pharmacists - who have an obligation to look out for their clients' interests when it comes to, say, adverse side effects or potential allergies - are healthcare professionals who should have the same protections as doctors do.
"We intervene and stop prescriptions and make doctors change prescriptions," says Karen Brauer, a pharmacist in Lawrenceburg, Ind. The pharmacy she works at refuses to stock contraceptives - a fact she explains if people come in looking for them - but she feels that workers at any pharmacy need to be able to follow their conscience.
Ms. Brauer, along with some other pharmacists, has a particular problem with emergency contraceptives because they work by inhibiting ovulation, fertilization, or implantation. While most medical professionals define pregnancy as beginning with implantation in the uterus, she and some others consider a fertilized egg, even before implantation, to be human. "We should be free to opt out of killing humans at any stage of development," she says. "If women really want this drug, they are going to have to find a willing provider."
Others voice more tempered views, but still feel that allowing a right of conscience shouldn't have to keep a patient from being serviced. "We don't force doctors to perform abortions, and we shouldn't force pharmacists to dispense contraceptives," says Steven Aden of the Center for Law and Religious Freedom.
He doesn't buy the argument that referring a client elsewhere can be too burdensome or cause delays that threaten the effectiveness of the morning-after pill. "You don't force somebody to do something they think is morally wrong because somebody can't get into a car or a bus and access healthcare."
Reproductive-rights advocates note that keeping a woman from the morning-after pill can cause more unwanted pregnancies - and potentially abortions - than making it available. But above all, they say the issue comes down to discrimination that no woman should have to face at the pharmacy. "A pharmacist's job is to dispense medication," says Steve Trombley, president of Planned Parenthood Chicago. "Not moral judgment."