Most states have adopted conscience clauses since the Roe v. Wade paradigm in the 1970s; however, not all clauses are respective to pharmacists. The purpose of this report is to quantify the presence of conscientious objection among US states with respect to pharmacist’s right to refuse to dispense. Fifty Boards of Pharmacy administrative codes were consulted for review. If Web sites were ambiguous or undeterminable, E-mail requests were sent on active legislation per National Association of Boards of Pharmacy contact information. Eleven states have conscience clauses present in their pharmacy administrative code—nearly double than last published in 2006. Requirements vary throughout the states including drug-specific limitations, requirement in writing, or notification in advance. Some states alternatively require duty to dispense. Less than one-fourth of United States boards of pharmacy provide a conscience clause or similar intended language in laws or policies. Within those states, pharmacists have a right to refuse to perform certain services based on religious, ethical, or moral objections. Imprecise language throughout the nation allows the rights to vary widely.
Keywords: dispensing, ethics, human resources, managementIn 1973, the United States (U.S.) Supreme Court ruled in the landmark Roe v. Wade case that access to legal abortion is a constitutional right. 1 Since then, emphasis has been placed on patients’ rights to access healthcare services, particularly respective to women’s access to reproductive healthcare. Consequently, when laws are created to protect individuals seeking these medical needs, the question of how to avoid infringing on healthcare providers’ rights to their personal beliefs emerges. This is of particular concern for pharmacists as they are expected to dispense contraceptives or abortifacients; however, it is not limited to the community or retail setting. Health-system pharmacists, too, may encounter conscientious dilemmas. Situations that may be met include: do not resuscitate orders, blood administration, withdrawal of life support system, withdrawal of hydration and nourishment, use of experimental drugs, advanced directives, and iatrogenic fetal demise in an acute care setting. The growth of ambulatory and retail pharmacy presence within hospital and health-system pharmacy, too, creates greater probability of consideration in broader health-system pharmacy leadership. This is notable as many vignettes regarding pharmacists’ refusal have occurred within the retail pharmacy setting. Individual state pharmacy practice acts traditionally allow pharmacists to refuse to dispense if it is deemed harmful to the patient or if the validity is strongly questioned. To support healthcare individuals, including pharmacists, some states have developed healthcare law and policy to allow conscientious objection. These regulations have enabled pharmacists to honor their own reservations in the execution of their duties.
Conscientious objection is the refusal to perform a role or responsibility—including the provision of treatment—based on religious, ethical, cultural, or moral beliefs. 2 A conscience clause is a specific set of language found in healthcare law or policy that grants healthcare providers the right to conscientiously object. A 2006 summary published in Hospital Pharmacy cited only 5 states had conscience clauses with many others, at the time, considering its incorporation. 3
Professional organizations within pharmacy support conscientious objection. The American Society of Health System Pharmacists (ASHP) “recognizes the right of pharmacists, as health care providers, and other pharmacy employees to decline to participate in therapies they consider to be morally, religiously, or ethically troubling [and] supports the proactive establishment of timely and convenient systems by pharmacists and their employers that protect the patient’s right to obtain legally prescribed and medically indicated treatments while reasonably accommodating in a nonpunitive manner the right of conscience.” 4 Within the ASHP policy commentary, they suggest necessity for proactive notification by the pharmacist regarding therapies of concern. In congruence, the American Pharmacists Association (APhA) “recognizes the individual pharmacist’s right to exercise conscientious refusal [and] supports the establishment of systems to ensure patient’s access [. . .] without compromising the pharmacist’s right of conscientious refusal.” 5 This accommodation may fall on the pharmacy manager or owner to reconcile without creating undue hardship.
Pharmacists should be aware of the rights and responsibilities granted to them by the states in which they practice. Furthermore, it is of paramount importance that pharmacists-in-charge and administrative leaders recognize healthcare policies and laws in order to appropriately manage their employees while meeting patient needs. Our purpose is to provide an overview of U.S. states’ pharmacy law or policy regarding the presence of a conscience clause and identify key similarities and differences.
A review of states’ board of pharmacy statutes, regulations, and policies was conducted for all 50 states as of May 2020. First, statutes and regulations linked within each state’s board of pharmacy website were reviewed using the search terms conscience, refuse, refusal, decline, religious, religion, moral, and ethical. If no relevant results populated, an email inquiry was sent to the contact information located on the National Association of Boards of Pharmacy website (https://nabp.pharmacy/boards-of-pharmacy/). Data collected in each state included: (1) which jurisdictions maintain a conscience clause (or similar language) within their pharmacy law or policy, (2) which jurisdictions explicitly require statements of conscientious objection in writing, (3) additional requirements such as provisions mentioned to protect patients’ access to health services, (4) explicit language referencing abortion/contraception, and (5) statutory language.
Table 1 displays the results of the review. 6 -16 A conscience clause or similar intended language was present in the pharmacy laws and policies in 11 of the 50 jurisdictions reviewed (22%). New York, North Carolina, Oregon, Pennsylvania, and Rhode Island regulations urge pharmacists who intend to conscientiously object to notify employers in advance (45.5%; n = 11). Rhode Island explicitly requires a statement of objection in writing (9.1%; n = 11). Delaware, New York, North Carolina, Oregon, Pennsylvania, and Rhode Island include language intended to protect patients’ rights to access healthcare services (54.5%; n = 11). Kansas, North Carolina, and South Dakota maintain statutes that explicitly apply to abortion and/or emergency contraception (27.3%; n = 11).
Summary of Pharmacy Conscience Clauses by State.
| State | Citation | Explicitly requires statement in writing | Urge employer notification in advance | Additional requirements/caveats | Statutory language a |
|---|---|---|---|---|---|
| Delaware (2009) | Delaware Code Regs. 24 2500 §3.1.2.4 | No | No | PIC must establish procedures within operation that maintain standard of practice as it relates to a pharmacist’s refusal to dispense based on religious, moral, or ethical beliefs | Only mentioned in the context of PIC responsibilities |
| Georgia (2001) | Georgia Admin. Code §480-5-.03(n) | No | No | . . . | Not considered unprofessional conduct for a pharmacist to refuse to fill any prescription based on professional judgement or ethical or moral beliefs |
| Kansas (2012) | Kansas Statutes § 65-443 | No | No | Explicitly applies to abortion | Shall not be required to perform, refer for, or participate in procedures or in prescription or administration of any device or drug resulting in termination of pregnancy |
| New York (2005) | Lawrence H. Mokhiber “Policy Guideline Concerning Matters of Conscience” | No | Yes | Professional obligation to take steps to avoid abandoning or neglecting a patient; when beginning practice, take steps to notify owner or supervisor of beliefs that will limit drug products he or she will dispense | Owner or supervising pharmacist should make accommodations that respect the pharmacist’s choice while ensuring delivery of services to patients |
| North Carolina (2005) | “Conscience Concerns in Pharmacist Decisions” | No | Yes | Explicitly applies to emergency contraception; resolve questions prior to employment; must not obstruct a patient’s right to obtain such medication and has an obligation to get the patient and prescription to a pharmacist who will dispense | Pharmacist has the right to avoid being complicit in behavior that is inconsistent with his or her moral or ethics |
| Oregon (2005) | “Statement Regarding Considering Moral and Ethical Objections” | No | Yes | PIC should adopt written policies and procedures to address issues of pharmacists’ moral, ethical, and professional responsibilities; pharmacist must inform PIC in advance in order to make accommodations | Pharmacists have a choice whether or not to participate in activities they find morally or ethically objectionable |
| Pennsylvania (2007) | Pennsylvania Cons. Title 49 § 27.103 | No | Yes | Notify owner or pharmacist-manager when beginning practice; owner or pharmacist-manager should devise accommodations for both pharmacists and patients in need; professional obligation to take steps to avoid the possibility of abandoning or neglecting the patient | May decline to fill or refill due to religious, moral, or ethical objection |
| Rhode Island b | Rhode Island Code § 216-40-15-1 Pharmacy Regulations 1.165.2 “Violations and Sanctions” | Yes | Yes | Pharmacy owner must, without creating undue hardship, provide reasonable accommodation of the objection | May decline to dispense a drug or device on ethical, moral, or religious grounds |
| South Carolina (2002) | S.C. Ann Code 40-43-86(E)(6) | No | No | . . . | Nothing abridges the right of a pharmacist to refuse to fill or refill a prescription |
| South Dakota (1998) | SDCL 36-11-70 | No | No | Explicitly applies to abortion and euthanasia | No pharmacist may be required to dispense a medication if reason to believe it would be used for these purposes; refusal not basis for damages or disciplinary or discriminatory action |
| Texas (2017) | Texas Occupations Code § 551.006 | No | No | . . . | Pharmacist has exclusive authority to determine whether or not to dispense a drug |
Our findings indicate the number of states in which a conscience clause is present has increased in the last 15 years. With respect to pharmacy law, the number of states has nearly doubled since the summary published in 2006. The results indicate there is not uniform application of the conscience clause or similar intended language throughout the U.S. Less than one-quarter of U.S. states include it within their pharmacy law or policies. Some states require notification in advance and/or in writing. These key obligations are requisite to consider for pharmacy managers and administrators with direct oversight of pharmacy personnel.
An emphasis on conscientious objection is present worldwide. Piecuch et al 17 surveyed attitudes of community pharmacists toward a conscience clause in Poland. Ninety-two percent of respondents stated they had never refused to dispense a prescription due to their beliefs. Two-thirds of respondents stated they would not exercise conscientious objection even if enacted in law. Interestingly, 74% of respondents think that pharmacists should not have the right to conscientious objection. Regarding reproductive healthcare, The European Court of Human Rights suggests pharmacists should not allow their personal convictions and beliefs to be superior to their professional responsibilities and goal. 18 Within the Code of Ethics for Pharmacists, the American Pharmacists Association 19 emphasizes the importance of respect for autonomy and dignity for each patient. In all cases, they stress deference to personal and cultural differences based on moral obligations and virtues.
Emergency or hormonal contraceptives including intrauterine devices, following medical abortion, were indicated as the most common products that might invoke a pharmacist’s conscientious objection. 20 Within our results, 3 of the 11 states with conscience clause or similar intended language were specific to abortion and/or contraception (27.3%). One state, South Dakota, additionally emphasized euthanasia in its administrative code. Other areas of potential contention cited include sterilization, vaccines, end-of-life care, and care of LGBTQ patients.
Our research also determined some states, on the contrary, maintain duty to dispense clauses. These require the provision of care to avoid the possibility of abandoning or neglecting the patient. For example, New Jersey Code 45:14-67.1, places emphasis on practice sites to properly dispense lawful prescriptions without undue delay despite employee conflicts (eg, moral, philosophical, or religious beliefs). Other states may necessitate similar dispensing practices.
A final observation, albeit unintentional, is many states include conscience clauses within their broader health policy or law. While the intended research focused on pharmacy statutes, the authors discovered a significant presence of similar intended language within broader state regulations. Almost every state has a conscience clause or similar intended language that can be found in either its pharmacy law or general health law. 21 For example, Alabama, Arizona, Arkansas, California, and Mississippi include similar language in their general health laws. The challenge is the applicability and interpretation of such laws within the pharmacy realm. As one instance, Alabama defines “healthcare provider” in its state law surrounding conscientious objection; their definition includes pharmacists. Arizona general health law mentions pharmacists, too. Arkansas and California, for example, do not mention pharmacists but explicitly mention “dispensing medications”. Other states’ policies, such as in Mississippi, may refer to providers but not necessarily include pharmacists in their definition. This adds complexity to the issue—especially if compromising scenarios are encountered in routine pharmacy practice. Furthermore, the absence of pharmacy technicians within the identified regulations prohibits consideration of their right to refuse.
Limitations of this review include the potential for change of legislation. Additionally, our data review is subject to misinterpretation of legislation. Some states’ conscience clauses are detailed and possess stipulations that minimize disruption in patients’ access to care, while other states’ clauses remain indistinct. This document can serve as an updated tool for pharmacy advocacy professionals to benchmark conscience clause inclusion throughout the United States.
One ethical dilemma remains. What if the states do not have a policy or law regarding conscientious objection? The vast majority do not. Are pharmacists then unable to refuse in such states? This remains a quandary for pharmacists practicing in such states and may pose dilemmas for frontline practitioners and pharmacy administrators alike.
Less than one-fourth of United States boards of pharmacy provide a conscience clause or similar intended language in laws or policies; thereby, recognizing, to varying standards, that pharmacists have a right to refuse to perform certain services based on religious, ethical, or moral objections. There remains an absence of similar intended language for pharmacy technicians. Imprecise language throughout the nation allows the rights to vary widely.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Thomas S. Achey https://orcid.org/0000-0002-2456-7875
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