Refusal Clauses: A Threat to Reproductive Rights

Widespread Use of Contraception Can Reduce the Number of Unplanned Pregnancies

Ninety-five percent of American women use contraception at some point during their reproductive years. More than 50 percent of contracepting women use prescription methods. Approximately 27 percent use oral contraceptive pills (AGI, 2004a). Oral contraceptive pills (OCPs) and the dedicated product, Plan B^®, can be used for emergency contraception (EC). Emergency contraception, when started within 120 hours of unprotected intercourse, greatly reduces a woman's risk of pregnancy. It is more effective the sooner a woman starts taking it (Ellertson et al., 2003; "FDA Approves...," 1999;  Rodrigues et al., 2001).

Contraception Refusals by Pharmacists

OCPs and EC work by preventing ovulation and fertilization (ACOG, 1998; Hatcher et al., 2004). Despite this scientific fact, anti-choice organizations and individuals foment against women's access to safe, effective, and legal contraception by promoting false claims that OCPs and EC are abortifacients — that they interfere with pregnancy (ALL, 1997). These false claims are reflected in the arguments health care professionals — especially pharmacists — use to refuse the medications women need.

Pharmacists serve on the frontlines of the health care system. They are responsible for dispensing prescribed medication, educating patients on health promotion and disease prevention practices, and optimizing patients' "health-related quality of life" (APhA, 2004). From 60,000 to 120,000 prescriptions for EC are written annually (Kaufman, 2004). However, a 2003 study about the attitudes and knowledge base of Pennsylvania pharmacists, for example, found that 65 percent had negative feelings regarding EC, and that 13 percent believed that EC is an abortifacient (Bennett et al., 2003). Misinformation about the ways in which hormonal contraception works is the primary excuse for this nationwide campaign to refuse women:

• In Georgia, a pharmacist who doesn't believe in contraception refused to fill a prescription for OCPs. The prescription was eventually transferred and filled at a later date ("Our Opinions...," 2004).
• At an Eckerd's pharmacy in Texas, a pharmacist refused to dispense EC to a sexual assault victim on the grounds that it "violated his morals." The other pharmacists on duty also refused to fill the prescription. This woman was able to fill her prescription at a Walgreen's pharmacy later that evening. All three Eckerd's pharmacists were eventually fired for violating the patient's rights (Austin, 2004; Brown, 2004; Londono, 2004).
• A CVS pharmacist in Texas refused to dispense a prescription for birth control pills. The pharmacist told the patient and her husband that she did not "personally believe in birth control," birth control was not right, and "[birth control] pills cause cancer." The prescription was eventually filled the next evening and delivered to the patient's home (Brown, 2004).
• A woman in New Hampshire was denied EC by a Brooks pharmacist. The pharmacist claimed moral objections to both dispensing and transferring the prescription. By the time the managers at this Brooks Pharmacy resolved the situation, it was too late ("Pharmacist Denies Woman's...," 2004).
• A Kmart pharmacist in Wisconsin refused to fill and transfer a birth control prescription because he "did not want to commit a sin." The prescription was eventually filled by the pharmacy director two days later. This pharmacist is now on trial for violating the state's Regulation and Licensing Department's standards of care (Weier, 2004).
• Although the total number of pharmacist refusal incidents is unknown, reports of pharmacist refusal date back to 1991 (Cantor & Baum, 2004).

Contraception Refusals by Hospitals

Sexual assault survivors face similar obstructions to access to emergency contraception in hospital emergency rooms. An estimated 25,000 unintended pregnancies each year are a result of sexual assault. Approximately 22,000 of these pregnancies could be prevented if all women who were raped were provided with EC (Stewart & Trussell, 2000). Surprisingly, many hospitals overlook their responsibility to offer EC to sexual assault survivors.

A study of sexual assault survivors who were treated in emergency rooms found that fewer than half of the women who were at risk of pregnancy received EC (Amey & Bishai, 2002). Another study found that as many as 1,000 sexual assault survivors per year left New York State emergency rooms without having received EC (FPANYS, 2003).

While some emergency room physicians neglect to offer EC to rape survivors out of to sheer ignorance, others refuse to provide EC due to religious beliefs. Catholic hospitals are governed by the Ethical and Religious Directives for Catholic Health Care Services. The Directives state,

Compassionate and understanding care should be given to a person who is the victim of sexual assault. A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or to recommend treatments that have as their purpose of direct effect the removal, destruction, or interference with implantation of a fertilized ovum (USCCB, 2001).

The "testing" that the Directives call for does not exist. No medical tests exist that can detect the presence of a fertilized egg. Pregnancy tests only detect established pregnancies, which begin when implantation of the pre-embryo is complete. This does not occur until about 10-15 days after vaginal intercourse (Cunningham et al., 2001). At this point pregnancy is established and termination is only possible through abortion, which the Directives do not permit.

Women's access to reproductive health care diminishes as an increasing number of non-religiously affiliated hospitals are merging with Catholic hospitals.

• In June of 2000, it was found that 10 of the 20 largest not-for-profit U.S. hospital systems were operated by Catholic entities (Pawelko & Krishnamurthy, 2001).
• In the U.S., 13 percent of all hospitals with emergency rooms are Catholic. In many states, 30-40 percent of people who need emergency care visit a Catholic hospital (CFFC, 2002).

The History and Meaning of Refusal Clauses

Pharmacists, physicians, and other medical clinicians have professional and ethical responsibilities to their patients. Health-related decisions made between a provider and patient should be based on the personal welfare and health-care needs of the patient — not the morals or beliefs of the caregivers. Unfortunately, this isn't always the case.

• In June of 2004, nine Alabama State Health Department nurses quit their jobs rather than distribute EC to patients. In response to their decision, the department's chief of family planning stated that while he respected the nurses' right to their beliefs, he also had "an obligation to provide services to our clients. It's not appropriate...to dictate public policy based on personal beliefs" (Johnson, 2004).

Despite the needs of patients, many states and professional organizations have enacted refusal clauses that allow health care providers to refuse to provide medically needed treatments on the grounds that they conflict with the provider's religious belief. Refusal clauses limiting access to reproductive health care were initially established in the weeks following the January 1973 Roe v. Wade decision, which legalized abortion nationwide. In 1973, Congress passed the Church Amendment to allow health care providers to cite religious grounds in order to refuse to provide abortion or sterilization. Within five years, the majority of states adopted similar refusal clauses. Over time, refusal clauses have been extended to include assisted reproductive technologies, contraception and emergency contraception, human embryonic or fetal research, in vitro fertilization, and stem cell research (Sonfield, 2004).

Refusal clauses vary in terms of who they "protect," what services can be refused, and what justification an individual or institution may use to refuse to provide a service:

• Refusal clauses can apply to both medical and nonmedical individuals and institutions. These definitions include, but are not limited to, physicians, pharmacists, nurses, hospitals, clinics, universities, and insurance companies.
  
• Refusal clauses can cover a broad range of services including abortion, abortifacients, contraception, family planning services, and general reproductive health services. If the services are not specified, refusal clauses can be applied to other medications and procedures.
  
• Refusal of a service can be permitted on the basis of religion, personal conscience, moral conflict, or moral values. This broad definition permits individuals to refuse access on the basis of political ideology or bias, rather than genuine religious convictions.

The more broadly defined the refusal clause, the more dangerous it can be to a patient. All kinds of refusal clauses are in place across the country.

Forty-six states have existing refusal statues written into their state legislation, and federal legislation is being proposed to expand this.

• In 34 states, refusal statutes refer only to abortion. In 12 states they pertain to both abortion and contraception. Nine of these 12 states explicitly allow individuals to refuse birth control, contraception, and/or family planning. Four of these 12 states define "individual provider" broadly enough to include pharmacists (AGI, 2004b).
  
• A review of the online legal service database, Westlaw, showed that 14 states in 2004 introduced 37 bills to permit pharmacists and/or other health care providers to refuse to participate in abortion, or dispense abortifacients or other drugs on the basis of personal "moral" objections.
  
• Rep. Dave Weldon (R- FL) successfully tacked a so-called "Abortion Non-Discrimination Act" onto the federal government's 2005 budget. The Weldon Amendment allows health care institutions to refuse to comply with federal and state regulations regarding a range of abortion-related services, including pharmacist referrals (Feldt, 2004). This legislation, signed into law on December 8, 2004, overrides Title X guidelines that require women to be referred for abortions upon their request. As we go to press, the State of California has already taken action to challenge this legislation.

Refuse and Refer

According to professional organizations, refusal clauses that allow an expression of religious beliefs can be considered acceptable if they provide an adequate plan for referral (APHA, 2003). Health care must not be disrupted or obstructed by either untold delay or barrier. Under the view of these organizations

• Professionals who object to providing a service need to do so consistently and provide forewarning to their employers and clientele.
  
• All prescription referrals must be directed to a local pharmacist or pharmacy that is within a reasonable distance.
  
• "Should the alternate means provided by the employer fail to operate...in a timely fashion...then the pharmacist has a duty to the patient to dispense the medication" (APhA, 1998).

Planned Parenthood Federation of America believes in the right of every individual to have access to reproductive health care services, including family planning services and products. We believe it is an act of discrimination to refuse to provide legal and medically prescribed OCPs or EC. Individuals who have medications prescribed for them by their health care providers should be able to have their prescriptions filled without delay. While we firmly believe that all people have the right to their own opinions and moral beliefs, it is unethical for health care providers to stand in the way of a woman's access to safe, effective, legal, and professional health care.

Cited References

AGI — Alan Guttmacher Institute. (2004a, accessed 2004, October 10). Facts in Brief: Contraceptive Use. [Online]. http://www.guttmacher.org/pubs/fb_contr_use.html

_____. (2004b, December 1, accessed 2004, December 6). State Policies in Brief: Refusing to Provide Health Services, November 1, 2004. [Online]. http://www.guttmacher.org/statecenter/spibs/spib_RPHS.pdf

ACOG — American College of Obstetricians and Gynecologists. (1998, July). Statement on Contraceptive Methods.

ALL — American Life League. (1997, accessed 2004, November 15). Emergency Contraception: The Morning-After Pill. [Online]. http://www.all.org/issues/bc05.htm

Amey, Anette & David Bishai. (2002). "Measuring the Quality of Medical care for Women who Experience Sexual Assault with Data from the National Hospital Ambulatory Medical Care Survey." Annals of Emergency Medicine, 39(6), 631-8.

APhA — American Pharmacists Association. (1998, accessed 2004, October 6). 1997-1998 Policy Committee Report: Pharmacist Conscience Clause. [Online]. http://www.aphanet.org/lead/committee2.html

_____. (2004, accessed 2004, October 18). Principles of Practice for Pharmaceutical Care. [Online]. http://www.aphanet.org

APHA — American Public Health Association. (2003, accessed 2004, October 6). Preservation of Reproductive Health Care in Medicaid Managed Care. [Online]. http://www.apha.org/private/2003_Proposed_Policies
/12_Reproductive_Heath_Care.pdf

Austin, Liz. (2004, February 21). "Friend Recounts Rape Victim's Search for Morning-After Pill." The Associated Press.

Bennett, Wendy, et al. (2003). "Pharmacists' Knowledge and the Difficulty of Obtaining Emergency Contraception." Contraception, 68, 261-7.

Brown, Angela K. (2004, March 30). "Woman Said Pharmacist Denied Her Birth-Control Prescription." The Associated Press.

Cantor, Julie & Ken Baum. (2004). "The Limits of Conscientious Objection — May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?" New England Journal of Medicine, 351(19), 2008-12.

CFFC — Catholics for a Free Choice. (2002, accessed 2004, October 10). Hospital Mergers in the USA. [Online]. http://www.cath4choice.org/healthmergers.htm

Cunningham, F. Gary, et al. (2001). Williams Obstetrics: 21st Edition. New York: McGraw — Hill.

Ellertson, Charlotte, et al. (2003). "Extending the Time Limit or Starting the Yuzpe Regimen of Emergency Contraception to 120 Hours." Obstetrics & Gynecology, 101, 1168-71.

"FDA Approves Progestin-Only Emergency Contraception." (1999). The Contraception Report, 10(5), 8-10, 16.

Feldt, Gloria. (2004, October 8, accessed 2004, October 8). "Whose Conscience?" TomPaine.common sense. [Online]. http://www.tompaine.com/print/whose_conscience.php

FPANYS — Family Planning Advocates of New York State. (2003, accessed 2004, October 10). "Survey Shows Gap in NY Hospital Treatment for Sexual Assault Survivors." [Online]. http://www.fpaofnys.org/mediacenter/1272003.html

Grimes, David A. (1997). "Emergency Contraception: Expanding Opportunities for Primary Prevention." New England Journal of Medicine, 337(15), 1078-9.

Guillebaud, John. (1998). "Commentary: Time for Emergency Contraception with Levonorgestrel Alone." The Lancet, 352(9126), 416.

Hatcher, Robert A., et al. (2004). Contraceptive Technology, 18th Revised Edition. New York: Ardent Media, Inc.

Hughes, Edward C., ed. (1972). Obstetric-Gynecologic Terminology. Philadelphia: F.A. Davis Company.

Johnson, Bob. (2004, June 29). "Nurse Quits Job To Avoid Distributing "Morning-After" Pills." The Associated Press.

Kaufman, Marc. (2004, May 7). "Plan B Won't Be Sold Over Counter; FDA: Contraceptive Needs More Testing." The Washington Post.

KFF — Kaiser Family Foundation. (2001, accessed 2004, October 10). "HRET Employer Health Benefits: 2001 Annual Survey." [Online]. http://www.kff.org/content/2001/3138/EHB2001-fullrpt.pdf

Londono, Vanessa. (2004, February 3, accessed 2004, February 4). "Protesters Fight Pharmacy: Groups Target Eckerd's for Violating Rights." North Texas Daily. [Online]. http://www.ntdaily.com/vnews/display.v/ART/2004/02/03/401f3ebb7558e

"Our Opinions: The 50 States of Denial; Pharmacists' Ability to Reject Prescriptions on Personal Grounds Violates Consumers' Rights." (2004, October 14). The Atlanta Journal — Constitution, p. 18A.

Pawelko, Ronnie & Kalpana Krishnamurthy. (2001). Mergers & You: The Physicians' Guide to Religious Hospital Mergers. New York: Physicians for Reproductive Choice and Health and the Education Fund of Family Planning Advocates of New York State.

"Pharmacist Denies Woman's Request for Morning-After Pill". (2004, September 27). The Union Leader, p. C7.

Rodrigues, Isabel, et al. (2001). "Effectiveness of Emergency Contraceptive Pills Between 72 and 120 Hours After Unprotected Sexual Intercourse." American Journal of Obstetrics and Gynecology, 184(4), 531-7.

Sonfield, Adam. (2004). "New Refusal Clauses Shatter Balance Between Provider 'Conscience,' Patient Needs." The Guttmacher Report, 7(3), 1-3.

Stewart, Felicia & James Trussell. (2000). "Prevention of Pregnancy Resulting from Rape: A Neglected Prevention Health Measure." American Journal of Preventive Medicine, 19(4), 228-9.

USCCB — United States Conference of Catholic Bishops. (2001, accessed 2004, October 10). Ethical and Religious Directives for Catholic Health Care Services, Fourth Ed. [Online]. http://www.nccbuscc.org/bishops/directives.htm

Weier, Anita. (2004, October 12). "Rx License Is On the Line In Abortion Fight: Pharmacist Refused Pill Order Due To Faith." The Capital Times, p. 1A.

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Lead Author — Deborah Friedman, MPH

Published: 12.17.04 | Updated: 12.17.04

Published by the Katharine Dexter McCormick Library

©2004 Planned Parenthood^® Federation of America, Inc.
All rights reserved.


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