Every pharmacist in the U.S. takes an oath to make "the welfare of humanity and relief of human suffering" their primary concern. Apparently, the "welfare of humanity" has different meanings to different pharmacists.
In several recent incidents, pharmacists have refused to fill prescriptions for birth control pills or "morning-after" pills, citing conflicts with their religious beliefs. Now, legal wrangling at the state and federal level is focused on the question of whether pharmacists' personal moral codes should trump their professional duties.
In the most recent example, two Illinois pharmacists have a preliminary court hearing today in an attempt to halt an emergency rule by Gov. Rod Blagojevich requiring pharmacies that stock the morning-after pill to dispense it "without delay."
Their lawyer says the issue is one of religious freedom.
"Prior to the rule, their employer respected their choice not to dispense medications that violate their religious beliefs," said Frank Manion of the American Center for Law and Justice, a conservative legal group. "There's nothing in this rule that allows employers to accommodate employees' religious beliefs."
The controversy leaves pharmacists defending their need for autonomy and places them at the center of the abortion debate.
While many agree that legally prescribed and clinically viable prescriptions should be filled regardless of personal religious stances, they are wary of laws that would require them to dispense. To some, a legal mandate would turn them into nothing more than prescription vending machines.
"You don't need a pharmacist at all if you're going to just require them to dispense medications. That takes away their clinical role," said Susan Winckler, vice president of policy and communications for the America Pharmacists Association, which counts about 200,000 pharmacists as members.
The pharmacy industry does not police ethical behavior, and state agencies enforce legal infractions. The consequences for refusing to dispense medicine are often murky, and many states are trying to clarify the issue.
According to Planned Parenthood Federation of America, three states -- Arkansas, Mississippi and South Dakota -- already have laws that give pharmacists the right to refuse to fill prescriptions. Ten other states are considering similar laws.
Four states -- California, New Jersey, West Virginia and Missouri -- are evaluating laws that would require pharmacies to fill all legally prescribed medications. And Democratic lawmakers gathered in Washington recently to tout a plan for a federal law that would stop pharmacies from denying the sale of prescribed medications.
Then there's the Illinois rule, pushed through on April 1 after two incidents in Chicago involving a pharmacist who refused to fill contraceptive prescriptions. The emergency rule will be in place for 150 days, and Blagojevich is expected to push for its permanent adoption.
The Illinois pharmacists, one a Catholic and one a Baptist, have sued the governor, saying the rule violates their First Amendment right to religious freedom. Both are career pharmacists who are uncomfortable dispensing the morning-after pill.
"Both of them had been dispensing birth control pills for many years. It's only with the advent of the morning-after pill that this has become an issue," said Manion.
The Food and Drug Administration is considering an application that would make the morning-after pill available over the counter. Some of the politicking could become moot if the FDA approves it, but for now the controversy is heating up.
Also known as emergency contraception, the morning-after pill is essentially a mega dose of birth control hormones that is effective for up to five days after sexual contact, but is most effective the earlier it is used. It works by preventing female ovulation or the fertilization of an egg by sperm or by interfering with the implantation of a fertilized egg into the uterus.
Abortion opponents believe this is tantamount to preventing human life. Supporters of the morning-after pill say it is simply another form of contraception.
The supporters, such as Planned Parenthood, where the movement to allow pharmacists to reject prescriptions is known as "pharmacist refusal," say the denial or delay of contraceptive medication is an infringement on patient rights.
"The point is that women need to have their birth control when they need it, with no delay," said Karen Pearl, interim president of Planned Parenthood.
Pharmacists say their expertise in evaluating prescriptions is a necessary part of the medicating process, and the pharmacy industry believes these questions can be answered without a legal mandate to fill prescriptions.
Frank J. Ascione, dean of the University of Michigan's College of Pharmacy, said the hope is that pharmacists with religious or moral concerns will avoid jobs where contraception prescriptions are an issue.
"If they're going to be working in a community pharmacy, they're going to be dispensing oral contraceptives. If they can't administer oral contraceptives for whatever moral reasons, they have every right not to work there," he said.
Winckler of the APhA said pharmacists should have the right to refuse. But the APhA also supports the creation of a system that would ensure patients can access legally prescribed medicine in cases of refusal, such as a referral to another pharmacy.
For customers forced to drive around to various pharmacies, this would be an inconvenience. But Manion said creating an inconvenience is not the same as violating patients' rights.
"They're saying that freedom of religion and access to contraception are both fundamental liberties," Manion said. "If that's true, when two fundamental liberties collide, you don't just throw one out in favor of the other, you balance them. And I'm sure you don't balance them by telling pharmacists: 'You have no rights.' "