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Thursday, June 16, 2005 10:58 pm

Right of refusal

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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.”

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