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Ensuring that Individuals are Able to Obtain Contraceptives at Pharmacies

  • Date: Nov 08 2006
  • Policy Number: 200611

Key Words: Condoms, Drugs, Ethics, Family Health, Family Planning, Pharmaceuticals

I. Background and Need for the Policy

The American Public Health Association (APHA) has long endorsed universal access to reproductive health care, including contraception, as an important public health measure.1-8 Indeed, the Centers for Disease Control and Prevention has declared family planning to be one of the 10 most significant public health achievements of the 20th century.9 This position paper concerns a specific emerging obstacle to contraceptive access not previously addressed by APHA policy.

Access to contraceptive information and services is critical to preventing unintended pregnancies and to enabling women to control the timing and spacing of their pregnancies.10 Use of contraceptives is widely accepted in the United States. The typical American woman, who wants to have only two children, uses contraceptives for about three decades. Research shows that 62 percent of American women ages 15 to 44 are using a contraceptive method, and 32 percent of those are using hormonal contraceptive pills.11

According to the Institute of Medicine, unintended pregnancy can have serious consequences for both women and infants, including late prenatal care, greater risks for the woman of depression and physical abuse, and increased incidence of low birthweight babies leading to higher risks of serious illness and even death in the first year of life.10 For some women, pregnancy can entail great health risks and even life endangerment, making access to contraception essential. Contraceptives often are prescribed for a range of medical purposes in addition to birth control, such as amenorrhea, dysmenorrhea and endometriosis.12

Accordingly, APHA notes with concern a number of reports of women being unable to fill prescriptions for hormonal contraceptives, including emergency contraception (EC), because of objections to contraception by individual pharmacists or pharmacies.13 In some instances, women have reported that pharmacists berated them about the use of contraceptives and/or refused to transfer the prescription to another pharmacy.14 The reason most often stated by objecting pharmacists for refusing to dispense contraceptives is the religious or moral belief that contraception (especially emergency contraception) is equivalent to "early abortion." Research indicates that this belief sometimes is based on pharmacists' confusion of emergency contraception with RU 486 (mifepristone, sometimes referred to as the "abortion pill"),15 and in other cases, is based on a conservative religious view of when pregnancy begins,16 which is at odds with the mainstream medical definition,17 and on an unproven hypotheses of contraceptives' mechanism of action.18;

While reports indicate only a minority of pharmacists are refusing to dispense contraceptives for religious or moral reasons, their actions nonetheless represent interference with patients' rights and the prescriber-patient relationship. This interference is especially harmful given the time sensitivity of all contraceptives, especially emergency contraception, and the fact that birth control pills are available only by prescription in the United States and emergency contraception is approved to be sold over-the-counter for people 18 and older with proper age identification.19 Birth control must be used on a regular schedule, and delayed or skipped doses can lead to unintended pregnancy. Emergency contraception is most effective when taken within the first 24 hours after unprotected intercourse, and has no demonstrated efficacy after 120 hours.20

Because of the time-sensitive nature of emergency contraception, APHA is among the more than 60 medical, public health and women's health organizations that had urged the U.S. Food and Drug Administration (FDA) to switch emergency contraception from a prescription-only medication to over-the-counter status.21 After a three-year regulatory review process, the FDA in August of 2006 approved the sale of Plan B emergency contraception without a prescription to people 18 and over who present required forms of identification with proof of age. This action will improve ease of access to emergency contraception for many women. However, women under 18 still will be required to present a prescription.19 Women with Medicaid coverage also currently need prescriptions, depending on state Medicaid regulations. This is because Medicaid coverage of over-the-counter drugs are at state option and, even when covered requires a prescription.22 The FDA action restricts sale of EC to pharmacies, and does not permit it in convenience stores or other locations where over-the-counter medications often are sold.19 Prior to the FDA's action, the APHA had supported interim efforts to make emergency contraception more readily available, such as through the adoption of state laws that permit pharmacists to directly dispense the medication to patients under collaborative practice agreements with physicians.21

APHA has also urged health systems to establish protocols to ensure that a patient is not denied timely access to emergency contraception based on the moral or religious objections of a health care provider.23 That position is at odds with public policies being sought in a number of states that would protect objecting pharmacists from any liability for refusing to fill contraceptive prescriptions based on pharmacists' personal beliefs, not medical judgment, and without provisions to ensure that patients are able to obtain needed medications in a timely manner.24 Four states, Arkansas, Georgia, Mississippi, and South Dakota permit pharmacists to refuse to dispense contraceptives, including emergency contraception. Other states are introducing bills or proposing regulations that permit pharmacists or pharmacies to refuse to fill prescriptions with inadequate or no patient protections.25,26

APHA has recognized the professional expertise of pharmacists and the important role pharmacists play in promoting public health, including ensuring safe medication use.27 The patient's welfare should be paramount in the performance of the pharmacist's professional responsibilities. As such, the Code of Ethics for Pharmacists adopted by the 53,000-member American Pharmacists Association (APhA) states that "a pharmacist places concern for the well-being of the patient at the center of professional practice" and "respects the autonomy and dignity of each patient."28

However, the APhA also supports an objecting pharmacist's refusal to dispense a medication for religious or moral reasons and the establishment of systems to ensure patient access in cases of such refusal.29 Some examples cited by the APhA of "systems" that could be used to ensure that patients receive needed medication include staffing the pharmacy so that another pharmacist in the same store can step in to fill the prescription, and referring or transferring a prescription to a different pharmacy. The APhA recommends that these systems be established "proactively- before a pharmacist is presented with a prescription to which they object," and should be seamless to the patient.29 In situations in which no local pharmacist is willing to dispense the medication, APhA further recommends that prescribers directly dispense the product and that prescribing health professionals proactively direct their patients to pharmacies that are known to carry the prescribed drugs.29

The patient's ability to obtain prescribed contraceptives promptly could nevertheless be compromised under such suggested systems. Some pharmacies do not have more than one pharmacist available at all times so there may be no alternative pharmacist available to step in for an objecting pharmacist when a prescription for contraceptives is presented. Referrals to other pharmacies may not be viable for women who must obtain their prescriptions from certain pharmacies that have contracted with their private or public health insurance plans.

Access to contraceptives for women in rural areas can be especially problematic if the only local pharmacy will not stock the medication, or if an objecting pharmacist is on duty alone for portions of the day. Overall, there are fewer health resources in rural communities, with almost 75 percent of rural counties having areas within them designated as Medically Under-served Areas.30 Pharmacists serving rural communities may be among the few available health care providers in a community, but they too can be scarce.31 Pharmacists are less available in rural areas, with a ratio of 66 pharmacists per 100,000 people in rural areas, compared with 78 pharmacists per 100,000 people nationwide in 1999.32 Rural area residents face additional challenges in obtaining health care, including higher poverty rates, geographic isolation, and lack of both public and personal modes of transportation.33 Until recently, Wal-Mart, which is the only pharmacy in some communities, refused to stock EC.34 Thus, the nearest alternative pharmacy to which a patient could be referred to fill an EC prescription (if under age 18 or on Medicaid) or to purchase EC may be located a considerable distance away, proving to be an insurmountable barrier for those with no ready access to transportation.

While it is possible for a woman in a rural area to contact a contraceptive prescriber over the Internet or by telephone, in most states, that prescriber still needs to phone the prescription into a pharmacy located near the patient, or ask the patient to pick up the medication at the prescribing clinic, which may be located hundreds of miles away. Moreover, most of these clinics do not operate 24 hours a day, or over the weekend, thus introducing delay into the process. One Planned Parenthood affiliate is shipping contraceptives to patients who have filled out assessment forms online or through a telephone interview. However, the administrator of that clinic stated this service is limited to residents of the same state and one neighboring state because of state regulations. In addition, the cost to the patient of obtaining the contraceptives is increased by the overnight shipping fees and the assessment of an on-line prescribing fee, and third-party payors (such as insurance plans) do not always cover these costs.35

Reproductive health and public health professionals, allied pharmacists and policy-makers have responded to the public health concerns raised by pharmacist refusals with a variety of approaches, including contacting state pharmacy oversight boards and seeking legislative or regulatory action. As a result of their refusals, pharmacies or pharmacists could be susceptible to disciplinary action under pharmacy oversight board complaint procedures. For example, the California Board of Pharmacy in June 2006 issued a citation and fined a pharmacist for violating California law when he obstructed a patient's access to emergency contraception by refusing to fill or transfer her prescription. The pharmacy board found that the violation constituted unprofessional conduct.36 The Wisconsin Pharmacy Examining Board reprimanded and limited the license of a pharmacist who failed to inform a young woman of her options for having her prescription for oral contraceptives refilled after he refused to dispense the contraceptive and also refused to transfer it to another pharmacy.36 A state court has upheld the pharmacy board's action.37

State pharmacy boards also have begun to issue policy statements to address this issue. For example, in May 2004 the Massachusetts Board of Registration in Pharmacy stated that Massachusetts licensed pharmacists are required to fill a prescription that has been determined by the pharmacist to be a valid prescription under state and federal laws and which has been subjected to a prospective drug review to determine issues such as drug allergy interactions. The Board noted that there are no statutory or regulatory exceptions for this requirement for any particular drug or class of drugs.38 Acting on this policy, the Board later required Wal-Mart to stock emergency contraception in all of its 44 stores in the state.39 Other states, such as North Carolina and Oregon, also have articulated policies to protect patient access.40,41

State legislative and regulatory bodies are weighing in on pharmacy refusals and patient access. For example, California adopted legislation that imposes a duty on pharmacists to fill all prescriptions, and permits pharmacist refusals based on ethical, moral or religious grounds only if the pharmacist has given advance notice in writing to his/her employer and if the pharmacy can accommodate that pharmacist's objections without undue hardship to the employer.42 In Illinois, the governor issued a regulation requiring pharmacies to ensure that prescriptions for contraception are filled without delay.43 On the federal level, Congress has introduced measures to require pharmacies to fill or order prescriptions for all medications, including contraceptives.44

The education of pharmacists about emergency contraception, particularly its time frame of effectiveness and mechanism of action, has also been identified as a critical need. Pharmacist confusion about the difference between emergency contraception and medication abortion (mifepristone) has been reported in several surveys.45,46,47,48,49,50 By contrast, pharmacists who have undergone training about emergency contraception have, as in the states of Washington and California, been more likely to work to expand women's access to that medication.51

Several national medical and health organizations have issued statements or policies addressing pharmacist refusals. The American Medical Association (AMA), for example, has a policy, "Preserving Patients' Ability to Have Legally Valid Prescriptions Filled."52 AMA trustee Peter W. Carmel, MD, issued a statement asserting that "Patients need reliable access to medications prescribed by their physicians without unnecessary delay or interference. The AMA will work with the pharmacists associations and state legislators so that neither patients' health, nor the patient-physician relationship, is harmed by pharmacists' refusal to fill prescribed medications."53

II. The Role of Pharmacists in Meeting Patients' Need for Contraceptives
When a health professional such as a physician or nurse practitioner has prescribed contraception,54 the patient must be able to obtain the contraceptive in a timely manner at a pharmacy, without interference from those pharmacists who have personal objections to contraception. Similarly, patients need timely access to non-prescription emergency contraception. Any delay in access can endanger the patient's health by increasing the risk of unintended pregnancy or exacerbating the other medical conditions for which contraceptives are sometimes prescribed.55,56

In a number of states, pharmacists have played an active role in improving patients' access to contraceptives. Pharmacists have worked with advocates to pass laws in nine states thus far -Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont and Washington- allowing participating pharmacists to dispense emergency contraception to women without a prior prescription under a collaborative practice arrangement with a physician or independent prescribing ability.57 In these states, the FDA's prescription requirement for females under 18 or patients without the required form of identification will not pose an obstacle because these patients will be able to obtain both the prescription and the medication at participating pharmacies. These arrangements can also be a way for women on Medicaid to obtain easier access to EC.

APHA recognizes pharmacists' professional responsibilities, and patients trust pharmacists to evaluate prescriptions for contraindications. APHA notes the objections of pharmacists and pharmacies to any mandate that they maintain all prescribed medications in stock.58 APHA also notes that while the vast majority of pharmacists have no objection to dispensing contraception, some pharmacists do profess deeply held personal objections, especially to the dispensing of emergency contraceptives. Those beliefs should be accommodated to the extent possible. However, the patient's right to timely access to contraceptives must not be sacrificed in order to accommodate such beliefs.

The practice of pharmacy is regulated by each state for the purpose of protecting public health. Accordingly, any public policies or professional standards that allow for individual pharmacists to refuse to dispense contraception must require pharmacies to protect the patients' ability to obtain prescribed contraceptives in a timely manner at their pharmacy.

III. APHA Recommendations
As the nation's oldest and largest public health organization, APHA has the responsibility and expertise to address this critical health access issue from the perspective of public health protection. Thus, APHA takes the position that the patient's health and well-being must come first in health care delivery and in the formulation of health policy. Therefore, APHA recommends that any policies or standards to address the desire of some pharmacists or pharmacy employees to refuse to dispense contraceptives should advance the following three principles:

  1. if the contraceptive is in stock the medication should be made available on the premises in the customary time frame, through such methods as having a non-objecting pharmacist or pharmacy employee step in to provide the medication; 
  2. if the contraceptive is not stocked by the pharmacy or is temporarily out of stock, the pharmacy should order the medication for the patient. Alternatively, the patient may be referred or a prescription transferred to another pharmacy that is known to have the medication in stock, if the referral or transfer would result in more prompt dispensing of the contraceptive and the patient prefers the referral or transfer; and 
  3. an objecting pharmacist or pharmacy employee should not be permitted to admonish patients about contraception or abortion, violate the patient's right to privacy, misrepresent whether the drug is in stock or can be ordered in a timely manner, or otherwise interfere with access to legally prescribed or marketed medications. 
Accordingly, APHA: 
  1. Urges pharmacist associations, pharmacies and schools of pharmacy to work with reproductive health and public health professionals to conduct ongoing educational programs for pharmacists about the dispensing of contraception, including emergency contraception, including: the time frame in which emergency contraception is effective and the latest research on its mechanism of action (including how it differs from medication abortion); the professional responsibilities of pharmacists to ensure that patients' needs are met; and the important role pharmacists can play in affording women timely access to contraceptives.
  2. Urges reproductive health and public health professionals to provide information and education to patients about what they should expect if and when they are trying to obtain contraceptives at their local pharmacies. Such information should include explanations of usual pharmacy protocols for dispensing contraceptives (especially emergency contraception, which is available both by prescription and over the counter), pharmacists options (if any) in a particular state for refusing to dispense contraceptives and their responsibilities for addressing patients' needs, and patients' rights to obtain contraceptives in a timely manner without interference from pharmacists or pharmacy employees who object on personal, moral grounds.
  3. Urges pharmacies to stock prescription and non-prescription contraceptives, including emergency contraception, and adopt protocols ensuring that women can purchase contraceptives on the premises in the customary time frame. Such protocols should attempt to accommodate those pharmacists who have expressed in advance their stated objections to filling contraceptive prescriptions, such as by having the prescription filled by another pharmacist or other pharmacy employee on duty. However, the protocol should not permit an objecting pharmacist to interfere with the patient's timely access to contraception or share personal beliefs about contraception. If the medication is not in stock, the patient should have the choice of having the medication ordered or being referred or having the prescription transferred to the nearest pharmacy where the medication is known to be available, if such a transfer or referral would not present a barrier to the patient and would result in quicker access to the medication.
  4. Urges state pharmacy boards to promulgate and enforce policies making pharmacies responsible for ensuring that contraceptive prescriptions are filled on the premises in the customary time frame and non-prescription emergency contraception can be purchased without delay or interference by objecting pharmacy employees. Individual pharmacist objections should be accommodated to the extent possible without interfering with the patient's timely access to medication or placing an undue hardship on the pharmacy. Any such policies should be consistent with the three principles outlined above.
  5. Encourages prescribing health professionals (e.g. physicians, physician assistants and nurse practitioners) to take pro-active steps to identify and inform patients about those pharmacies where contraceptive prescriptions can be filled without delay, including pharmacies that provide access to emergency contraception under collaborative agreements with authorized prescribers. Prescribing health professionals are also urged to report violations of patients' rights at pharmacies to state pharmacy boards.
  6. Urges state pharmacy boards, state legislators and health agency officials, family planning and community clinics, prescribing health professionals, drug suppliers and private and public (e.g. Medicaid) insurance entities to cooperate and devise policies and practices to facilitate timely access for women living in rural areas. Such action might include revising existing policies or regulations, as needed, to permit direct dispensing of emergency contraception by the prescribing providers, and overnight mail order shipping of contraceptives prescribed through internet and telephone contacts. These alternative modes of access should be covered by private and public insurance.
  7. Urges local, state and federal legislators and regulators to adopt laws, regulations, and policies requiring pharmacies to ensure that prescriptions for contraceptives are filled in a timely manner and non-prescription emergency contraception can be purchased without delay or interference by objecting pharmacists or pharmacy employees. Such policies should accommodate the objections of individual pharmacists to the extent possible without interfering with the patient's timely access to medication at their pharmacy or causing an undue hardship for the pharmacy. 
  8. Urges local, state and federal legislators and health agency personnel to adopt laws, regulations and policies to ensure that women whose public or private health insurance plans restrict their choice of pharmacies can obtain their contraceptives in a timely manner and without additional out-of-pocket costs if in-network pharmacies refuse to dispense the contraceptives. This objective could be accomplished by requiring out-of-network coverage for contraceptives or by contracting with pharmacies that will fill contraceptive prescriptions. APHA also urges state Medicaid programs to cover emergency contraception for enrollees, without the need for a prescription.
  9. Continues to urge the U.S. Food and Drug Administration to make emergency contraception available over the counter for patients of all ages, including those under 18 who are still required to obtain a prescription under the FDA's August 2006 ruling, so as to improve overall ease of patients' access to this medication. In the absence of FDA approval for non-prescription sales of emergency contraception for all individuals, the APHA continues to encourage and support state policies that allow women under 18, those without required forms of identification and women on Medicaid to obtain emergency contraception directly from pharmacists without previously seeing other health care providers via collaborative practice agreements or other mechanisms.59

References

  1. APHA, Providing Access to Emergency Contraception for Survivors of Sexual Assault, Pol. # 200316 (Nov. 18, 2003).
  2. APHA, Support of Public Education of About Emergency Contraception and Reduction or Elimination of Barriers to Access, Pol. #. 200315, (Nov. 18, 2003). 
  3. APHA, Support for Sexual and Reproductive Health and Rights in the United States and Abroad, Pol. # 200314 (Nov. 18, 2003). 
  4. APHA, Preserving Access to Reproductive Health Care in Medicaid Managed Care, Pol. # 200313 (Nov. 18, 2003). 
  5. APHA, Opposition to Coercion in Family Planning Decision Making, Pol. # 200122, (Jan. 1, 2001); APHA, Preservation of Reproductive Health Care in Hospital Mergers and Affiliations with Religious Health, Pol. # 9814 (Jan. 1, 1998); 
  6. APHA, Principles Regarding National Health Policy and Women's Health Care, Pol. # 7739(PP) (Jan. 1, 1977). 
  7. APHA, Policy Statement of Prevention, Pol. # 7633(PP) (Jan. 1, 1976). 
  8. APHA, Population: Family Planning as An Integral Part of Health Services, Pol. # 7518 (PP) (Jan. 1, 1975).
  9. CDC. Changes in the public health system. MMRW 1999; 48:1141-47 and CDC. Achievements in public health: family planning. MMWR 1999; 48:1073-1080.
  10. Institute of Medicine. The Best Intentions, New York: National Academy Press, 1995, and Brown SS and Eisenberg L, From the Institute of Medicine, JAMA 1995;274:1332. 
  11. Facts in Brief: Contraceptive Use, The Guttmacher Institute, 2006, citing to research conducted by the National Center for Health Statistics and Contraceptive Technology.
  12. See, e.g., Kaunitz. Oral contraceptive health benefits: perception v. reality. Contraception. 1999, 59:29S-33S and Sulak. Oral contraceptives: therapeutic uses and quality-of-life benefits - case presentations. Contraception 19;99; 59:35S-38S.
  13. National Women's Law Center. Pharmacy Refusals 101. Washington, D.C.: National Women's Law Center; November, 2005, stating that pharmacist refusals have been reported in a number of states, including California, Georgia, Louisiana, Illinois, Massachusetts, Minnesota, Missouri, New Hampshire, New York, North Carolina, Ohio, Rhode Island, Texas, Washington and Wisconsin; The Debate Over Plan B, segment of 60 Minutes program broadcast on November 27, which included a hidden camera interview with a Kentucky pharmacist who refused to fill a prescription for emergency contraception because she believes it is an abortifacient. "Anyone can walk in off the street and we can refuse to fill a prescription, the pharmacist said. Asked whether a prescription could be refused on religious grounds, the pharmacists said, On any grounds. Personal preference. Any reason, we can refuse to fill a prescription." CBS News.com, last visited March 13, 2006.
  14. Kaiser Family Foundation Daily Women's Health Report. Wisconsin pharmacy board reprimands, limits license of pharmacist who refused to refill oral contraceptive prescription. April 15, 2005; Johnson, A. Pharmacist wouldn't fill order for contraceptive. Milwaukee Journal Sentinel, May 10, 2005.
  15. Borrego, M., et all, New Mexico Pharmacists' Knowledge, Attitudes and Beliefs Toward Prescribing Emergency Contraception, J Am Pharm Assn 2006: 46(1): 33-43.
  16. The Pill: Contraceptive or Abortifacient? This document, prepared by Pharmacists for Life International, states that at the precise moment of conception, a woman is pregnant with a new individual and further states that the correct term to describe any interference with pregnancy after conception has occurred is abortifacient. Accessed on June 13, 2006, at http://www.pfli.org/faq_oc.html. Pharmacists for Life International President Karen L. Brauer, who was fired from Kmart pharmacy for refusing to fill birth control prescriptions, told the Washington Post that "Our group was founded with the idea of returning pharmacy to a healing-only profession. What's been going on is the use of medication to stop human life. That violates the ideal of the Hippocratic oath that medical practitioners should do no harm. Stein, R., Pharmacists' Rights at Front of New debate: Because of Beliefs, Some Refuse to Fill Birth Control Prescriptions. Washington Post March 28, 2005.
  17. The mainstream medical definition of when pregnancy begins is at successful implantation of a fertilized ovum on the wall of the uterus, not at fertilization. Trussell, J., Stewart, F., and Raymond, E., Emergency Contraception: A Cost-Effective Approach to Preventing Unintended Pregnancy, May 2006; Statement on Contraceptive Methods, Washington, D.C.: American College of Obstetricians and Gynecologists, July 1998; Hughes, EC (ed) Committee on Terminology, The American College of Obstetricians and Gynecologists, Obstetric-Gynecological Terminology, Philadelphia, PA, FA Davis Company, 1972.
  18. Recent research has shown that emergency contraception works primarily by inhibiting ovulation or interfering with fertilization. It has been hypothesized, but not been scientifically proven, that it may occasionally work in a third way, by interfering with the implantation of a fertilized ovum. Emergency Contraception's mode of action clarified, Population Briefs, 2005, 11:3, accessed on June 13, 2006, at http://www.popcouncil.org/pdfs/popbriefs/pbmay05.pdf
  19. FDA Approves Over-the-Counter Access for Plan B for Women 18 and Older; Prescription Remains Required for Those 17 and Under press release issued by the U.S. Food and Drug Administration, August 24, 2006, accessed at http://www.fda.gov/bbs/topics/NEWS/2006/NEW01436.html on October 31, 2006. Also, Reproductive Health Technologies Project. Plan B OTC: what will it look like? Washington, D.C. Reproductive Technologies Project, Oct. 27, 2006, accessed at http://www.rhtp.org on October 31, 2006.
  20. Piaggo, G., von Hertzen, H., Grimes, D.A., Van Look, P.F.A. Timeline of emergency contraception with Levonorgestrel or the Yupze Regimen. Lancet. 1999; 359 (9154):721;Ellertson, C., et al, Extending the time limit for starting the Yupze Regimen of emergency contraception to 120 hours. Obstetrics and Gynecology 2003; 101:1168-1171.
  21. APHA, Support of Public Education About Emergency Contraception and Reduction or Elimination of Barriers to Access, Pol. # 200315 (Nov. 18, 2003).
  22. National Health Law Program. FDA's approval of Plan B: women still have no sure access to over-the-counter emergency contraception. Los Angeles: National Health Law Program, November 2006, accessed at www.healthlaw.org on Nov. 5, 2006. 
  23. APHA, Support of Public Education About Emergency Contraception and Reduction or Elimination of Barriers to Access, Pol. # 200315 (Nov. 18, 2003).
  24. Pharmacists for Life International, Pharmacist's Model Conscience Clause, adopted 1988, posted at http://www.pfli.org/main.php?pfli=modelpharmacistcc, last visited March 13, 2006; Pharmacists for Life International, Why A Conscience Clause is a Must- Now!, posted at http://www.pfli.org/main.php?pfli=conscienceclausefaq, last visited March 13, 2006, which states: "A pharmacist by virtue of properly understood conscience cannot be licitly compelled to cooperate," in a patient's use of contraception by referring her to a pharmacist who will fill her prescription.
  25. Guttmacher Institute. State policies in brief: refusing to provide health services. May 1, 2006.
  26. National Women's Law Center. Pharmacy Refusals 101. Washington, D.C.: National Women's Law Center, Nov. 2005. and Diaz, E. 'Conscience' bill for pharmacists vetoed. The Arizona Republic. April 14, 2005, posted at www.azcentral.com/arizonarepublic/news/articles/0414pharmacists14.html, last visited March 13, 2006. Legislatures in two states (Arizona and Wisconsin) approved the measures. "Pharmacies and other health care service providers have no right to interfere in the lawful personal-medical decisions made by patients and their doctors," Arizona's governor declared in vetoing that state's proposed pharmacist refusal law in April of 2005. The measure had no requirement to refer a patient to another pharmacist or pharmacy, and so was opposed by the Arizona Pharmacy Association and the Arizona Public Health Association; Kaufman, M. Plan B Battles Embroil States. Washington Post. Feb. 27, 2006, stating that "more than 20 other states will consider bills that give pharmacies the right not to stock [Plan B] and pharmacists the right not to dispense it, even to women with valid prescriptions."
  27. APHA Policy 8024, The Role of the Pharmacist in Public Health; Cain, RM, Kahn JS. The pharmacist as a member of the health team. Am J Public Health 1971; 61:2223-9.
  28. American Pharmacists Association, Code of Ethics for Pharmacists. adopted October 27, 1994, posted at http://www.aphanet.org/AM/Template.cfm?Section=Search&template=/CM/HTMLDisplay.cfm&ContentID=2903, last visited March 13, 2006. 
  29. MacLean, LG. American Pharmacists Association. Testimony before the Small Business Committee, U.S. House of Representatives, on Freedom of Conscience for Small Pharmacies, July 25, 2005, referencing policy 1998 adopted by APhA's House of Delegates, as amended in 2004, Pharmacist Conscience Clause (1998/2004).
  30. Kaiser Commission on Medicaid and the Uninsured. The Uninsured in Rural America. April 2003.
  31. Knapp KK, Paavola FG, Maine LL, Sorofman B, Politzer RM. Availability of primary care providers and pharmacists and pharmacists in the United States. J Am Pharm Assoc Sep.-Oct. 2000; 40:580.
  32. Rural Assistance Center. Pharmacy and prescription drugs frequently asked questions, accessed on June 2, 2006, at http://wwwraconline.org/info_guides/pharmacy/pharmacyfaq.php, citing to J. Am. Pharm. Assoc. Mar.-Apr. 1999; 39:127-35.
  33. Kaiser Commission on Medicaid and the Uninsured. The Uninsured in Rural America. April 2003. 
  34. Editorial, Moralists at the pharmacy. NY Times. Apr. 3, 2005; Katie Fairbank, Pharmacists' refusal to fill contraception prescriptions a question of choice. Dallas Morning News. Apr. 29, 2005 (stating that there are 10 towns in Texas in which Wal-Mart is the only pharmacy).
  35. Telephone interview on June 14, 2006, with David Greenberg, President and CEO of Planned Parenthood of Columbia-Williamette in Oregon, which ships contraceptives to residents of Oregon and Washington. 
  36. In re Becker-Ellison, Citation No. CI 2005 31291 (Cal. Bd. Of Pharmacy, Dep't of Consumer Affairs, June 30, 2006)(citation and fine).
  37. In Re Neil T. Noesen, No. LS0310091PHM (Wisc. Pharmacy Examining Board, April 13, 2005)(final decision & Order); Kaiser Family Foundation Daily Women's Health Report, Wisconsin Pharmacy Board Reprimands, Limits License of Pharmacist Who Refused To Refill Oral Contraceptive Prescription, Kaiser Family Foundation Daily Women's Health Report, April 15, 2005. Also, Noesen v. WI Dept. Reg. & Lic. Pharmacy Examining Board, No. 05 CV 212 (Wis. Cir. Ct., Feb. 3, 2006) (In denying the pharmacist's appeal and upholding the Pharmacy Examining Board's decision to reprimand, the County Circuit Court stated that "the state has a compelling interest in ensuring that patients are able to access the medications that have been prescribed to them.")
  38. Letter from James T. DeVita, President, Mass. Board of Registration in Pharmacy, to Dianne Luby, President/CEO, MA Planned Parenthood (May 6, 2004).
  39. Kaiser Daily Reproductive Health Report. Mass. pharmacy board orders Wal-Mart to fill EC prescriptions; company says it will comply, review nationwide policy. Feb. 15, 2006.
  40. North Carolina Board of Pharmacy, Frequently Asked Questions for Pharmacists on Conscience Clause, posted at http://www.ncbop.org/Conscience%20Clause.asp, last visited March 13, 2006 (stating that pharmacists should discuss and resolve any questions about emergency contraception prior to employment,- "take proactive measures so as not to obstruct a patient's right to obtain such medication" if they object on moral or ethical beliefs alone, and have "an obligation to get the patient and the prescription to a pharmacist who will dispense that prescription in a timely manner"). 
  41. Oregon State Board of Pharmacy, Policy No. 386: Pharmacy Services: Considering Moral and Ethical Objections, published in the board's newsletter, November 2005, Vol. 26, No. 4. advising that "interference with a patient's right to receive timely, professional prescription services and information may be considered unprofessional conduct and could lead to disciplinary action by the Board."
  42. Cal. Bus. & Prof. Code §§733, 4314, 4315 (2005).
  43. Illinois Office of Governor, Press Release, State Commission Gives Permanent Approval to Gov. Blagojevish's Emergency Ruling Protecting Illinois Women's Right to Birth Control (Aug. 16, 2005); Ill. Dept. Financial and & Professional Reg., Guidance Regarding the Emergency Rule (April 7, 2005), http://www.idfpr.com/emergencyruleguidance.asp, last visited March 13, 2006.
  44. On April 13, 2005, Sen. Barbara Boxer introduced S. 778, Pharmacy Consumer Protection Act of 2005, which would require pharmacies participating in Medicare and Medicaid to fill all prescriptions, including contraceptives, without unnecessary delay or interference. 
  45. Bennett, W., et al. Pharmacists' knowledge and the difficulty of obtaining emergency contraception. Contraception 2003; 68:261-267, which reported on a survey of a sample of 315 pharmacists in Pennsylvania. Among its findings were that only one third of the pharmacists accurately stated the time frame in which emergency contraception is effective and 13 percent incorrectly stated that emergency contraception would cause an abortion. 
  46. Planned Parenthood of Connecticut, Inc., & NARAL Pro-Choice Connecticut Foundation, Connecticut Pharmacists' Knowledge of EC: A Telephone Survey. Summer 2005. The survey contacted 445 pharmacies in Connecticut, or 76.7 percent of the total. Of those, 203 agreed to participate in the survey. Of those pharmacists questioned, 43.4 percent agreed with the incorrect statement that emergency contraception can cause an abortion of an implanted fetus, 43.4 percent disagreed and 13.2 percent were unsure.
  47. Espey, E., et al. Emergency contraception: pharmacy access in New Mexico. Obstetrics and Gynecology 2003:102:918-21, reporting on the results of researchers' visits to 89 pharmacies in Albuquerque, New Mexico, presenting a prescription for emergency contraception. Only 11 percent of the pharmacies had the medication in stock, and in 42 percent of the pharmacy visits, the pharmacy provider was rated to be "unhelpful" in explaining how the researchers could obtain the product elsewhere. The majority of the pharmacists were found to lack "a positive approach to helping women with a need for medication with time-limited effectiveness."
  48. NARAL Pro-Choice Wisconsin. Telephone survey of 256 Wisconsin pharmacies. 2005, reporting that 40 of 154 pharmacists interviewed in depth gave medically inaccurate information about emergency contraception, including confusing it with the abortion pill.
  49. ACLU of Kentucky Reproductive Freedom Project. Kentucky pharmacists' knowledge and difficulty of obtaining EC: a 'Mystery Shopper' telephone survey. Fall 2005. The survey contacted 309 pharmacies, or 28 percent of all Kentucky pharmacies, with samples selected from each of Kentucky's 120 counties. Of the 250 pharmacies that responded to the question, 60 percent stated that Plan B was an abortion pill. Thirty-one percent stated it was not an abortion pill but a form of contraception, and 9 percent did not know or could not decide.
  50. Riper, KK, Hellerstedt, WL, Emergency contraception pills: dispensing practices, knowledge and attitudes of South Dakota Pharmacists. Perspectives on Sexual & Reproductive Health March 2005; 37:19-24.
  51. Downing, D., RPh, clinical associate professor, University of Washington Department of Pharmacy, personal communication; Letter from Gans, J.A., Executive Vice President, American Pharmacists Association, to James Oliphant, Editor-in-Chief, Legal Times, August 22, 2005, posted at www.aphanet.org, last visited March 13, 2006. 
  52. American Medical Association. D-120.975 Preserving Patients' Ability to Have Legally Valid Prescriptions Filled, posted at http://www.ama-assn.org/apps/pf_new/pf_online?f_n=resultLink&doc=policyfiles/DIR/D-120.975.HTM&s_t=pharmacist&catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/DIR&&nth=1&&st_p=0&nth=15&, last visited March 13, 2006.
  53. American Medical Association. Press release: AMA passes new policies to reduce health care disparities, ensure patient access to prescribed medications, June 20, 2005, posted at http://www.ama-assn.org/ama/pub/category/15253.html, last visited March 13, 2006. 
  54. Depending on state law, non-physician health professionals such as physician assistants, nurse practitioners, and midwives, in addition to physicians, can prescribe emergency contraception for a present need or for future use. Center for Reproductive Rights. Emergency contraception: common legal questions about prescribing, dispensing, repackaging and advertising. Briefing Paper. April 2002.
  55. Institute of Medicine. The Best Intentions, New York: National Academy Press, 1995, and Brown SS and Eisenberg L, From the Institute of Medicine, JAMA 1995;274:1332. 
  56. Kaunitz. Oral contraceptive health benefits: perception v. reality. Contraception. 1999, 59:29S-33S and Sulak. Oral contraceptives: therapeutic uses and quality-of-life benefits - case presentations. Contraception 19;99; 59:35S-38S.
  57. Gardner, J.S., Hutchings, J., Fuller, T.S., Downing, D. Increasing access to emergency contraception through community pharmacies: lessons from Washington State. Family Planning Persp July/Aug. 2001; 33:172-175 and Richardson, C., Advocates again look to states to promote eased access to emergency contraception. Guttmacher Policy Rev. Spring 2006; 9:11-14. 
  58. Some large pharmacy chains' policies are to stock and dispense emergency contraception. For example, Wal-Mart, noting requirements in Illinois and Massachusetts to stock emergency contraception and pressure building in other states, has announced that beginning on March 20, 2006, Wal Mart pharmacies will stock emergency contraception. However, Wal-Mart will maintain its "conscientious objection" policy that allows "any Wal-Mart or SAM'S CLUB pharmacy associate who does not feel comfortable dispensing a prescription to refer customers to another pharmacist or pharmacy." Wal-Mart. Press Release: Wal-Mart to Carry Plan B Emergency Contraception, Mar. 3, 2006; Walgreens, Rite Aid, Costco, CVS, Target and K-Mart all are reported to stock EC in their stores. Canedy, D. Wal-Mart Decides Against Selling Contraceptives. NY Times. May 14, 1999; Leingang, M. "Morning after" pill may not need Rx. Cincinnati Enquirer. April 29, 2004. However, the chains have varying policies on how to ensure access to patients when individual pharmacists refuse to fill prescriptions. See, e.g., Stevens, A. Target at center of battle over Plan B. Women's E-News. Jan. 15, 2006, posted at http://www.womensenews.org/article.cfm/dyn/aid/2602/context/archive, last visited March 13, 2006.
  59. APHA, Support of Public Education About Emergency Contraception and Reduction or Elimination of Barriers to Access, Pol. #. 200315, Nov. 18, 2003.

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