Last November a Planned Parenthood nurse in
Idaho rang a local pharmacist and asked for methergine — a drug used to
prevent bleeding after childbirth or an abortion. Considering the source of the
request it is quite likely to have been the latter, and the pharmacist, who has
a conscientious objection to abortion, asked whether that was the case. The
caller refused to say, citing federal privacy law, and the pharmacist refused
to fill the prescription. The caller then asked for a referral to another pharmacy
and the pharmacist hung up on her.
For a year now, conscience
legislation has been extended to Idaho pharmacists, giving them the right
to refuse to provide any health care service or dispense any drugs that violate
their conscience. The freedom to decline services applies to abortion,
emergency contraception, stem cell treatment, and end of life care and
treatment. It is a right not meant to restrict or limit, in any way, health care services.
Yet there are some who wish that conscience
protection laws could be abolished, and this incident has helped their cause.
Planned Parenthood has complained to the state about the pharmacist, alleging
that she was not covered by the law. Whether she acted legally is not for me to
decide but for the proper tribunal. My concern is with the ethics of refusing
to dispense methergine in those circumstances.
Reports of the case portray the pharmacist as having acted
in an uncaring, unprofessional, and discriminatory manner — behaviour which is
never justified. And yet this is the sort of mess any healthcare provider could
get herself into if she has only got as far in her ethical reasoning as,
“abortion is evil and I don’t want anything to do with it”.
So, what are the broad ethical principles that underpin decision making in these fraught
In order for a healthcare provider to make
a good moral decision, there is an obligation to be familiar with the relevant
facts and recent research on a given issue, as well as the obligation to work
out beforehand the practical consequences of one’s beliefs. I call this
First the facts. Did the pharmacist not
know what the drug was for? After all, methergine is not used as an
abortifacient but is meant to stop post-partum or post-abortion bleeding. If it
was a drug she was unfamiliar with, did she not have easy access to the drug
company website or other information source? If so, she could have
readily asked the nurse to wait while she did a quick search.
Next, the application of principles to the
situation. Wesley Smith has done an excellent exercise of this on his blog, Secondhand Smoke
In his analysis, he surmises that the
pharmacist thought the patient had an abortion. She found that morally
repugnant. But refusing the prescription for that reason, he explains, is
no more acceptable than refusing to dispense cancer treatment medications to a
lung cancer patient or the anti bleeding medication for a bank robber who was
shot. “Such moral judgments about patients are unacceptable. It is
the procedure that must be objectionable.”
In the Idaho case there certainly appears
to be a lack of understanding as to what cooperation with the act of abortion
entails. Even assuming that the drug were a necessary part of an abortion
protocol, without which no abortionist would dare to proceed, the ethical
principle of double effect would come into play, meaning that the pharmacist
intends to prevent harm to the mother should haemorrhaging occur, even though
she foresees that providing the drug will have the unintended effect of
enabling the abortion to go forward.
The care offered to the sick can never be
judgmental in nature. In the case of HIV, a person may have contracted
this virus via an immoral lifestyle or by accident but we do not distinguish
between causes when we give them medication or care. We do not reject the
person who has acquired the disease through IV drug use or sexual promiscuity —
although we would certainly be showing care for the person if we offered
counselling against such poor lifestyle choices. The most telling application of this principle
is the fact that the Catholic Church cares for one in four people living with
HIV around the world.
But what if I refuse to sell the morning
after pill to a woman in my pharmacy? Am I not then breaking my own rules
of preventing harm and not judging the person?
To this I answer that not dispensing the
drug in this case is more in keeping with my mission statement of first doing
no harm than would be dispensing it. The judgement I make is not based on
the values or behaviour of the woman, but on my own ethical values, which
proscribe participation in a potential abortion at its earliest stages — even
before the woman is aware that she may be pregnant.
Furthermore, the assumption that not
dispensing the wanted drug is harmful to the patient is based on social
considerations, not her health. The case is quite different to refusing a
drug that stops haemorrhaging. If I refuse to dispense the morning after
pill a woman’s health will not be harmed. On the contrary. To
dispense a potent dose of steroids for the purpose of eradicating a new life at
its earliest stage can also turn out to harm women in ways we had not fathomed, not taking into
account some little-explored benefits of motherhood,
even when unplanned.
While I cannot force a woman to carry her
child, neither will I be forced to help her terminate. Once again, not
providing the morning after pill is a million miles away from refusing to
provide a lifesaving drug.
Returning to the Idaho incident, I agree with Wesley Smith that it does not
appear to be a proper conscience clause case. The pharmacist was undoubtedly
well-intentioned, but not sufficiently informed at the ethical level. In
another way, the incident as reported — ending with the pharmacist hanging up
on the caller — seems to have more to do with a rude reaction to a request;
whether sparked by professional incompetence or panic reflex, I cannot judge.
But I do think it was a lost opportunity.
After all, it’s not every day a principled pharmacist gets to deal with a
renowned abortion provider.
Alarcon is a Vancouver pharmacist and writer. She holds a Masters in Bioethics.