A year ago a judge ordered the FDA to reconsider its behind-the-counter classification of emergency contraception. Nothing has happened, and these talking bunnies are (rightly) pissed off about it.
Apart from the added embarrassment of asking an old guy in a lab coat for that pill you take after having sex, there’s the additional risk that the pharmacist will refuse to hand over the goods on the grounds that actually giving you safe and legal medication violates his conscience, which, in my professional opinion, is totally dildos.
It’s irritating for two different reasons: first, the safe and legal part, as well as the idea that it’s part of a pharmacist’s job to hand over those sorts of medications; second, EC is not actually an abortifacient. In some cases it can prevent implantation of a fertilized egg, but that’s not the only way it can be effective, so what the pharmacist objects to is a role in a causal chain producing a chance at the prevention of implantation, which is not an abortion. Pharmacists can have moral scruples about this, of course, but that leads me to a broader point, namely, oversight of “conscientious objector” status. It’s bothersome to me that objecting to military service requires a lot of evidence of sincere commitment to pacifism (rather than moral objections to particular wars, as if these would be somehow less weighty) as well as other costs to the objector, while some pharmacists seem to be asserting the right to cost-free and scrutiny-free CO status. In general I like professional protections for people’s claims of conscience, but it’s a balancing act.
One easy fix: put the pills on the shelf.
The Edge of the American West 
36 comments
March 23, 2010 at 11:22 am
amy
I love a smart, scholarly blog that isn’t afraid to occasionally use the adjective “dildos.”
March 23, 2010 at 12:33 pm
elizardbreath
In some cases it can prevent implantation of a fertilized egg, but that’s not the only way it can be effective, so what the pharmacist objects to is a role in a causal chain producing a chance at the prevention of implantation, which is not an abortion.
To self-promotingly link to an old post from the blog I post at, my understanding is that there’s no evidence that it ever prevents implantation rather than blocking ovulation. Drug manufacturers have speculated that it might, and it’s in the package information as a possible effect, but there’s not much behind it.
Not that that changes anything important about your post.
March 23, 2010 at 12:52 pm
jvhillegas
I’m glad you brought this up. I’d never before equated the military’s CO status with some pharmacists’ assertions that they reserve the right to perform their professional duties on a case-by-case basis for purely subjective reasons.
Another wrinkle to think about with this issue are the kinds of professional services you compare. The U.S. military hasn’t had a draft in a while, which means that it is an “all-volunteer force.”* Similarly, going to pharmacy school is something that people do voluntarily. To the extent that things might be equal, it seems valid to me to expect that if one doesn’t want to kill other people (even potentially), one shouldn’t volunteer for the military, and if one doesn’t feel right about providing legal prescriptions to the full range of customers in one’s pharmacy, one shouldn’t volunteer to become a pharmacist.
If one gets into the military or the pharmaceutical profession and subsequently has a change of conscience, then — and speaking as a veteran who considered this option — there should be a clear and stringent set of hoops to jump through. This seems even more apropos for the military, because after the government has invested time and money during the training process, it has an understandable right to expect some kind of a return. Pharmacists, on the other hand, can just change professions.
In summary: Bollocks to pharmacists who assert their right to supersede the doctor-patient relationship, and to all the fundamentalist monotheists in their corner.
—-
* Scare quotes are intentional here. There are a host of valid arguments that illustrate why the U.S. military isn’t purely an all-volunteer force (in spite of what some might argue), often centering on issues of class, race, and geography that influence the range of available opportunities for young people, but that’s for another post.
March 23, 2010 at 7:49 pm
Tyler
1. A police officer who is unwilling, based on his/her personal opinions, to enforce certain laws should not be in the police force.
2. A lawyer who is unwilling, based on his/her personal opinions, to respect certain ethical and legal requirements of the practice of law should not be admitted to the bar.
I think those above statements are fairly uncontroversial. How about the following:
3. A pharmacist who is unwilling, based on his/her personal opinions, to dispense certain legal, FDA-approved drugs should not be licensed as a pharmacist.
How is the third statement different than the first two? Answer: it isn’t. The logic behind all three is the same.
March 23, 2010 at 9:33 pm
TF Smith
A public school history teacher who is unwilling, for example, to teach the state standards regarding the social sciences, needs to find another line of work as well.
March 23, 2010 at 9:56 pm
Jonathan Dresner
Or another state.
March 24, 2010 at 4:05 am
silbey
A resident of a state who is unwilling to live by the laws of that state should leave it.
(what was that MLK guy thinking, anyway?)
March 24, 2010 at 4:36 am
ajay
If one gets into the military or the pharmaceutical profession and subsequently has a change of conscience, then — and speaking as a veteran who considered this option — there should be a clear and stringent set of hoops to jump through.
Hmm. But what if you don’t change, but your job does? I mean, it’s possible that someone joins the military while it’s doing generally acceptable things (national defence, peacekeeping, disaster relief) and then ten years later a different government gets in and starts getting all invadey. Or, you could argue, a pharmacist could get into the business before the invention of some ethically dubious pill. So the ethical conflict only arises later.
Same could apply to a police officer, or a lawyer or a doctor for that matter. If I get a job as a medical officer with the police, I can reasonably expect my duties to consist of patching up sick and injured police officers – entirely ethical. But what if I get told that it’s now also part of my job to sit in on enhanced interrogations and ensure that the suspect isn’t about to die? Is my only real option to resign?
March 24, 2010 at 4:54 am
dana
I don’t think that Tyler’s examples show what he wants. Cops often (for better or for worse) have a lot of discretion, and often are vocal critics of the laws they are supposed to enforce. A lawyer who never wants to defend a tobacco company isn’t thereby restricted from practicing law elsewhere. Doctors who don’t want to perform breast implants or oversee executions aren’t required to do them.
In other words, I doubt there’s a general principle along the lines of “if the state licenses a profession, those professionals give up all personal control over how they conduct their professional affairs.” I think conscience clauses over birth control pills are ridiculous, but I don’t think the solution is via recourse to that kind of principle.
March 24, 2010 at 5:19 am
Neddy Merrill
The reason I said it’s a balancing act is that, all other things being equal, it would be great if pharmacists with sincere moral misgivings could avoid EC dealings and patients who wanted EC could get it without hassle. In cases where someone else can hand over the pills without troubling the patient, great. (This is one reason why the lawyer analogy breaks down, since, as far as I know, one lawyer’s refusal to take a case rarely means that the would-be client goes without representation altogether, while there are famous cases of patients not getting EC during the window of effectiveness because of CO pharmacists.)
March 24, 2010 at 9:43 am
Charlieford
“It’s bothersome to me that objecting to military service requires a lot of evidence of sincere commitment to pacifism (rather than moral objections to particular wars, as if these would be somehow less weighty) as well as other costs to the objector, while some pharmacists seem to be asserting the right to cost-free and scrutiny-free CO status.”
Would the discrepancy be due to the differential in potential motivations for each class of claimants? Ie, there might be good reason to think all kinds of folk who aren’t actual pacifists would at certain moments want to claim CO status, whereas there might not be such evidence that insincere pharmacists are doing the same?
March 24, 2010 at 12:37 pm
Carl
“Apart from the added embarrassment of asking an old guy in a lab coat for that pill you take after having sex, there’s the additional risk that the pharmacist will refuse to hand over the goods on the grounds that actually giving you safe and legal medication violates his conscience, which, in my professional opinion, is totally dildos.”
First, agreed with Amy above about the dildos.
Asking any medical professional for any care related to the naughty bits is potentially embarrassing. I wasn’t excited about the old guy in the lab coat I talked with about my vasectomy, nor was I excited about the nurses who watched him perform it, or for that matter by his cheery play-by-play. Nor was I excited about looking deep into the eyes of a young nurse practitioner chaperone during my latest rectal exam by dear old Dr. Paine. But I had pleasant chats with all of them, because whatevs. I like the consequences of being that fragile way worse than the consequences of some awkward moments and worse still than those of not getting the care.
Beyond this, I’m a little unclear on the issue. Presumably the CO pharmacist is not deciding case-by-case whether to distribute the pill, she’s just not stocking it at all. In which case it’s just like any other commodity a store has or doesn’t have. With pharmacies on most corners and pharmacists of various moral persuasions staffing them, this does not seem like much of a barrier to access.
Still, I’m all for putting them in vending machines in the parking lot. However, a question might be what the consequences of easy at-will access might be, that is, what sorts of foreseeable misuses they might be put to. For example, they’re a big old dose of hormones. Probably not a good idea in the long run to substitute them for barrier contraceptives for regular use, but it sure would be convenient in the short run.
March 24, 2010 at 12:53 pm
dana
Two reasons I disagree with you, Carl. First, whether there’s lots of pharmacies around with responsible pharmacists is highly dependent on location; what’s true in a city or nice suburb might not be true in rural Alabama, and convenient access to them can also depend on cars (which means a wanker pharmacist hurts the bus-dependent more.) Second, emergency contraception works only within a short window of time. Imagine needing it, and needing to have time to visit all of the pharmacies in your area to try to get it, and having to do that around work/after borrowing a car from a friend/on the weekend, etc.
Beyond that, it’s safe. There aren’t a whole lot of misuses it could be put to; I don’t underestimate human ingenuity but it won’t harm an existing pregnancy, and it doesn’t have pleasant side effects, so it’s less fun than, say, Nyquil.
March 24, 2010 at 1:05 pm
Carl
Fair enough – like I said, I’d be fine with vending machines. I’m not entirely comfortable in principle with a model of distributive prudence where others have to stand ready to cover my ass, hurry hurry, when I find myself in a foreseeable and mostly avoidable pickle. But having found myself in that very pickle several times in the days before this particular expedient and escaped it only by good fortune, I sure know how principles break down in practice.
I wonder how we’re categorizing these things. Are they rights? Affordances? Commodities? Duties? Luxuries?
March 24, 2010 at 2:21 pm
Vance
Carl, if I understand you right, that’s pretty repugnant. Suffice it for now to say that this particular argument isn’t about entitlement. There’s a safe and legal drug, and a customer who needs it, and an individual who is in a Maxwell’s-Demon-like position, able to choose whether the transaction goes forward or not. The question is about the extent of his freedom to act.
March 24, 2010 at 2:34 pm
dana
when I find myself in a foreseeable and mostly avoidable pickle.
… which might lead someone to want emergency contraception in order to avoid pregnancy responsibly? How is expecting, like other people who sometimes need drugs, to be able to procure a safe and legal drug from an establishment that has a license on the sale of them making others cover my ass?
March 24, 2010 at 2:59 pm
Carl
Vance, I’m assuming there’s a discussion here. If we all just want to chorus about foregone conclusions there are churches for that. So although I’d personally like people to have easy access to any damn thing they want, pills, stem cells, kidneys, guns, shark fins, whatever, because I find regulating myself hard enough without trying to regulate others, I note that there can be circumstances in which sound minds disagree about the practical and moral costs of various items on our shopping lists. So no, the issue is not settled by the mere legality or safety of the drug, nor by the customer’s need for it, compelling though I personally find those arguments in the current instance.
So OK, we’ve got a situation in which this safe, legal and needful item has been placed, by the same law that made it legal, behind an arbitrary gatekeeper. Presumably this is because some fraction of the votes needed to get the former could only be purchased with the latter. We can see the gatekeeper then as the collectively-empowered proxy for that fraction of our political culture that is just barely on board with the notion that the item is legitimately needed (safe is a medical question of fact). This is one frame within which to think about the extent of the Demon’s freedom to act. I could see thinking this is a damn poor way to do democracy, right up until I was in the minority thus empowered against a majority tyranny.
March 24, 2010 at 3:57 pm
chingona
We can see the gatekeeper then as the collectively-empowered proxy for that fraction of our political culture that is just barely on board with the notion that the item is legitimately needed (safe is a medical question of fact). This is one frame within which to think about the extent of the Demon’s freedom to act. I could see thinking this is a damn poor way to do democracy, right up until I was in the minority thus empowered against a majority tyranny.
And you don’t find it remotely worth interrogating why this is the only medical decision in which we give people who aren’t you (excuse me, you, if you were female) or your doctor a veto? Why this, of all the medical decisions with actual public health consequence, is the one that is subject to the political process at all?
You have been very careful to construct your argument in the most neutral, abstract terms possible, but we are not about to see the day when a pharmacist refuses to fill your Lipitor prescription because you should eat better and exercise more. Though I’m sure we could summon up some fraction of our political culture that is just barely on board with the notion that the item is legitimately needed.
March 24, 2010 at 5:32 pm
bitchphd
EC is not actually an abortifacient
You don’t say.
March 24, 2010 at 6:02 pm
dana
So no, the issue is not settled by the mere legality or safety of the drug, nor by the customer’s need for it, compelling though I personally find those arguments in the current instance.
It is sufficient in the case of other drugs. As chingona noted, I can’t imagine someone writing that it was acceptable for a pharmacist to refuse to sell a fever reducer to the parents of an infant who needed it following a vaccination on the grounds that he thought vaccinations were immoral. Nor would we find it convincing if he pointed out that the parents should have known that infant fevers were likely and could have stocked up ahead of time or driven around to other stores, and so it can’t be counted as a burden and that it’s not society’s job to shield you from the results of your point choices.. We don’t normally expect the pharmacist’s personal morals to come into play; we don’t expect that some won’t fill our hydrocodone prescription so we can learn the value of pain and a stiff upper lip following a root canal. (“Well, if you’d taken care of your teeth and planned ahead you wouldn’t need to hustle, so why should we cover your ass?”) We don’t call the pharmacist an enabler if he fills that Lipitor prescription, or if he fills a Paxil prescription.
What is a legitimate reason that EC is the one case where the pharmacist’s person morals are relevant? I grant that there’s a belief that EC is immoral, but why should I think that over-rules the patient’s right, when it doesn’t seem to in lots of other circumstances?
March 24, 2010 at 6:26 pm
Carl
Chingona (thank you for the awesome screen name), what I find remotely worth interrogating and what I can fit into blog comments short enough to capture the medium’s characteristic attention-span are dramatically different thangs. For efficiency’s sake and because I’m easily bored by the obvious therefore I skip over the stuff everyone hereabouts knows and amply agrees upon, such as the embedding of patriarchal gender politics in moralistic wedge issues targeted at women. Back in the old days it took me whole semesters to interrogate this issue with a batch of students. Nowadays the young’uns are steeped in the cultural unconscious of the second wave and the work is done in a swift fifty minutes. Not that they all agree on conclusions, of course, for various reasons, which is where I thought it might be more interesting to go with the conversation.
Dana, granting that there’s a belief that EC is immoral answers the question. That makes it a place where not just health or formal law is at stake, but the nature of the sacred. My thing is that on the same grounds I accept and support liberal women’s self-empowering moral claim to control their own bodies, and applaud chemistry and law that supports that, I also see and appreciate conservative women’s (patriarchically) self-empowering claim to a sacralized image of motherhood. Nothing like that is at stake with Lipitor.
March 24, 2010 at 8:12 pm
chingona
Nothing like that is at stake with Lipitor.
Given the amount of moral shaming that goes into our discourse around diet, obesity, health, will power and personal responsibility, I wouldn’t say “nothing like that” is at stake. And yet … we don’t see doctors refuse to prescribe it or pharmacists refuse to fill the prescriptions. So glad it takes just one class period to dispense with such a boring subject. I, too, find it boring at times, but I don’t have the luxury of playing devil’s advocate with my own bodily autonomy.
March 25, 2010 at 12:02 am
Baaaa
So here’s what I don’t get: morals are supposed to regulate the way I choose to live my life (within the bounds of the law, of course), and the decisions I make in my life. I don’t get to enforce *my* morals on you. For instance, let’s say I am a strict vegetarian, and my morals lead me to believe that meat is murder. Would I then get to decide that no one else gets to eat meat ever again?
No.
I get to decide that *I* don’t get to eat meat.
And that I shouldn’t work in a butcher’s shop, or at a Steakhouse where I would feel obligated to scream at the patrons about eating tortured baby cows when they order veal.
I say if a pharmacist wants to come between me and my doctor, I should get to come between him and his grocer. Or, the person they refuse EC to should be able to make loud judgments about every decision the pharmacist makes throughout the day, and then they might have a taste of what it’s like to have a total stranger judge you about things that are NONE of their business. Gah.
Do we then let Scientologist pharmacists not hand out medications for mental disorders because they don’t believe in them? Can a pharmacist decide to not hand over fertility drugs because they don’t believe in “playing God” in that way? My aunt believes very strongly that people who can’t reproduce on their own shouldn’t be parents- can she police fertility drugs now?
Look, you are free to live your beliefs and follow your religion. That also means I am free to live by my beliefs, and you don’t have to live by my morals and I don’t have to live by yours either. Nose in your own business and all that.
March 25, 2010 at 4:15 am
Jonathan Dresner
A resident of a state who is unwilling to live by the laws of that state should leave it.
(what was that MLK guy thinking, anyway?)
Silbey: this raises interesting potentials regarding Texas, but there’s a difference between an individual and a movement. (Or an insurgency, if you take Grimsley’s definition)
An individual who is unwilling to live by the laws and guidelines governing their profession may well choose to violate them, but there should be consequences. If they succeed in convincing enough people that the consequences are inappropriate, things may change.
On the other hand, if the vast majority of people in a state believe that, for example, substituting Schweikart’s Patriot’s History for Kennedy, et al’s American Pageant represents bad teaching, perhaps they have a case and that teacher should move to Texas.
March 25, 2010 at 4:41 am
silbey
Silbey: this raises interesting potentials regarding Texas, but there’s a difference between an individual and a movement. (Or an insurgency, if you take Grimsley’s definition)
Sure, but I remain uncomfortable with a blanket announcement that people have to adhere to externally-imposed professional norms, no matter what.
An individual who is unwilling to live by the laws and guidelines governing their profession may well choose to violate them, but there should be consequences. If they succeed in convincing enough people that the consequences are inappropriate, things may change.
You mean they might get a law passed saying that pharmacists don’t have to pass out drugs that the use of which they don’t support?
March 25, 2010 at 4:46 am
dana
Dana, granting that there’s a belief that EC is immoral answers the question.
I don’t think it does. At least, there are plenty of drugs some people believe are immoral: anti-depressants, fertility drugs, birth control pills, etc. The question of why it’s this case where the pharmacist’s beliefs are thought to count as relevant is interesting.
March 25, 2010 at 5:20 am
Jay C
The question of why it’s this case where the pharmacist’s beliefs are thought to count as relevant is interesting.
Simple – because it involves sex. And issues about sex (although usually cloaked as issues over “reproduction”) are the easiest sort for God-bothering moralists to push to the front of public-policy discussions/political debate. Mainly because for EC, unlike a lot of other health concerns, there is a well-defined moral/religious/ideological framework for what is considered “right” and “wrong” (outdated, illiberal and hugely misogynistic, but well-defined nevertheless), and thus a nice cheap way to make a “moral” point – i.e. exert social control – in a policy affecting the public.
March 25, 2010 at 6:03 am
chingona
At least, there are plenty of drugs some people believe are immoral: anti-depressants, fertility drugs, birth control pills, etc.
There have been cases where pharmacists have refused to fill scrips for birth control pills because they believe they are abortifacients. Or refused to fill scrips for unmarried women because, I suppose, they think it’s their business. So, uh, points for consistency?
March 25, 2010 at 6:45 am
matt w
Presumably the CO pharmacist is not deciding case-by-case whether to distribute the pill, she’s [sic] just not stocking it at all.
Why presume this? I don’t think most pharmacists own their own shops, so most of them don’t get to decide what to stock — but under this policy, they do get to decide whether to hand it out to someone with a valid prescription.
For instance, a small chain of stores you might have heard of, as of 2006, stocked EC but maintained a policy that if an individual pharmacist was enough of a misogynist slut-shamer (I’m really not interested in a polite discussion of whether there’s any other reason to refuse to prescribe EC; there isn’t), that pharmacist could tell the patient to find another pharmacist, and if she couldn’t find one, get an abortion.
March 25, 2010 at 8:29 am
Carl
“(I’m really not interested in a polite discussion of whether there’s any other reason to refuse to prescribe EC; there isn’t)”
March 25, 2010 at 9:19 am
bitchphd
granting that there’s a belief that EC is immoral answers the question.
Why is that something worth discussing, but the embedding of patriarchal gender politics in moralistic wedge issues targeted at women is boring and not really worth talking about? Everyone knows that some people think EC is immoral. That’s not the issue.
March 25, 2010 at 9:36 am
Neddy Merrill
refuse to prescribe
Not a big point, but the pharmacist isn’t even prescribing, since OC is BTC but not by-prescription-only.
Other miscellany: the time-sensitivity of EC matters a lot, since inability to access the pills might well mean a choice between an unwanted child and an abortion. Since there are great many people who have moral qualms about abortion without having moral qualms about EC, this is a big deal even from a moral point of view, regardless of the extra time/expense of abortion.
March 25, 2010 at 10:09 am
Carl
“Why is that something worth discussing, but the embedding of patriarchal gender politics in moralistic wedge issues targeted at women is boring and not really worth talking about?”
In the context of a community, e.g. this blog, where everyone who sticks around for more than two minutes is already down with second-wave doctrine, the repetition of what everyone already knows ceases to have analytical value and becomes a corporate ritual of belonging. Complete with shun-the-unbeliever responses for anyone who doesn’t intone the Pledge of Allegiance in chorus. But I’m laughing at myself because what did I expect? I’m the one who wanted to peer over the fence at the other faith community, after all, which is always bad form when the sacred is in play.
March 25, 2010 at 11:56 am
dana
Complete with shun-the-unbeliever responses for anyone who doesn’t intone the Pledge of Allegiance in chorus.
Neddy’s always out of harmony.
March 25, 2010 at 12:00 pm
Jason B.
Neddy’s always out of harmony.
Only because he sings in that weird Mohammedan tonality.
March 29, 2010 at 6:12 am
Barry
(identity unknown, because the comments are poorly formatted in IE):
“In which case it’s just like any other commodity a store has or doesn’t have. ”
No, it’s a commodity that a pharmacist or the store has deliberately decided not to stock, due to them having rather gerrymandered ethics.
Or a commodity that a pharmacist doesn’t give out, depending on whether or not he likes that person.