Pharmacists’ Right to Refuse to Dispense Prescriptions Based on Moral Grounds: A Summary of State Laws and Regulations

Abstract

Although most states have laws that explicitly allow physicians to refuse to provide certain medical services, the policies pertaining to pharmacists are less clear. The purpose of this report is to determine which states have laws or regulations that address a pharmacist's right to refuse to dispense prescriptions based on moral grounds.
Fifty Boards of Pharmacy were contacted via phone or E-mail regarding regulations as well as active or pending legislation. Information was also solicited from various state Governors' legislative offices and Web sites.
Typically, individual state practice codes allow pharmacists to refuse to fill a prescription if in their professional judgment the prescription is outside the scope of practice of the prescriber; if the validity of the prescription is in question; or to protect the health and welfare of the patient. Only five states have a “conscience clause” that allows a pharmacist to refuse to fill or refill certain prescriptions, which he or she finds morally objectionable: Arkansas (contraceptives only), California, Georgia, Mississippi, and South Dakota (abortifacients and assisted suicide only). In contrast, Illinois, Massachusetts, North Carolina, and Pennsylvania have an emergency rule or regulation, which states or implies that all legal prescriptions must be dispensed or transferred. Seventeen states considered proposed bills during their respective 2005 legislative session
The rights of pharmacists to refuse to dispense certain prescriptions vary widely from state to state. The protection provided to an individual pharmacist may be very broad or very specific depending on the wording of the statute or regulation.

Full text

FEATURED ARTICLE
1176 Volume 41, December 2006
FEATURED ARTICLE
Pharmacists’ Right to Refuse to Dispense
Prescriptions Based on Moral Grounds:
A Summary of State Laws and Regulations
Denise Hopkins, PharmD, CDE* and Marsha Boss, RPh
†
Hospital Pharmacy
Volume 41, Number 12, pp 1176–1179
2006 Wolters Kluwer Health, Inc.
M
edia accounts of pharma-
cists refusing to fill or
refer prescriptions on
moral or religious grounds contin-
ue to gain national attention.
1,2
Although most states have laws
that explicitly allow physicians to
refuse to provide certain medical
services, policies pertaining to
pharmacists are less clear.
“Protection of conscience law
ensures that people cannot be
forced to facilitate practices or pro-
cedures to which they object for
reasons of conscience. These prac-
tices may include abortion, capital
punishment, contraception, steril-
ization, artificial reproduction,
euthanasia, assisted suicide,
human experimentation, torture,
etc….. Conscience clauses are usu-
ally less comprehensive than pro-
tection of conscience laws and
afford varying degrees of protec-
tion for conscientious objectors.
They appear in statutes or in the
policies of organizations or institu-
tions.”
3
Health policy 5.995 of the
American Medical Association
(AMA) House of Delegates states
“no physician or other profession-
al personnel shall be required to
perform an act violative of good
medical judgment. Neither physi-
cian, hospital, nor hospital person-
nel shall be required to perform
any act violative of personally held
moral principles. In these circum-
stances, good medical practice
requires only that the physician or
other professional withdraw from
the case, so long as the withdrawal
is consistent with good medical
practice.”
4
It is generally accepted that a
pharmacist has a duty to refuse to
fill a prescription if in their profes-
sional judgment the prescription is
outside the scope of practice of the
prescriber; if the validity of the pre-
scription is in question; or to pro-
tect the health and welfare of the
patient. Furthermore, the Drug
Enforcement Administration
*Assistant Professor of Pharmacy Practice, The University of Arkansas for Medical
Sciences, Little Rock, AR;
†
Critical Care Pharmacist, St. Vincent Health System, Lit-
tle Rock, AR.
Abstract — Although most states have laws that explicitly allow physi-
cians to refuse to provide certain medical services, the policies pertaining
to pharmacists are less clear. The purpose of this report is to determine
which states have laws or regulations that address a pharmacist’s right to
refuse to dispense prescriptions based on moral grounds.
Fifty Boards of Pharmacy were contacted via phone or E-mail regard-
ing regulations as well as active or pending legislation. Information was
also solicited from various state Governors’ legislative offices and Web
sites.
Typically, individual state practice codes allow pharmacists to refuse to
fill a prescription if in their professional judgment the prescription is out-
side the scope of practice of the prescriber; if the validity of the prescrip-
tion is in question; or to protect the health and welfare of the patient.
Only five states have a "conscience clause" that allows a pharmacist to
refuse to fill or refill certain prescriptions, which he or she finds morally
objectionable: Arkansas (contraceptives only), California, Georgia, Mis-
sissippi, and South Dakota (abortifacients and assisted suicide only). In
contrast, Illinois, Massachusetts, North Carolina, and Pennsylvania have
an emergency rule or regulation, which states or implies that all legal pre-
scriptions must be dispensed or transferred. Seventeen states considered
proposed bills during their respective 2005 legislative session
The rights of pharmacists to refuse to dispense certain prescriptions
vary widely from state to state. The protection provided to an individual
pharmacist may be very broad or very specific depending on the wording
of the statute or regulation.
Key Words — pharmacist conscience clause; right to refuse; state law
Hosp Pharm — 2006;41:1176–1179

Hospital Pharmacy 1177
Pharmacists‘ Right to Refuse to Dispense Prescriptions: Summary of State Laws
(DEA) rule in the Code of Federal
Regulations states that a pharma-
cist has violated the law if a pre-
scription is filled that is for a use
that is not in the ordinary course of
treatment.
5
What is less clear is
whether a pharmacist has the right
to refuse to dispense medications
because of personal beliefs. The
purpose of this report is to summa-
rize which states have laws or reg-
ulations that address this right.
METHODS
In May 2005, 50 State Boards
of Pharmacy were contacted by
the authors via phone or E-mail
and asked the following question:
“Does your state have a law or
regulation, active or pending,
that addresses a pharmacist’s
right to refuse to fill certain pre-
scriptions?” If no answer was
received from a Board of Pharma-
cy, the respective state Governor’s
legislative office was contacted.
Legislative Web sites were
checked in December 2005 for
any new or recently passed relat-
ed legislation.
RESULTS
Typically, individual state
pharmacy practice acts, found in
pharmacy regulations, allow phar-
macists to refuse to fill a prescrip-
tion if in their professional judg-
ment it would be harmful to the
recipient or if the validity of the
prescription is in question. Howev-
er, five states have a conscience
clause that allows pharmacists to
refuse to fill or refill certain pre-
scriptions which they find morally
objectionable: Arkansas (contra-
ceptives only), California, Georgia,
Mississippi, and South Dakota
(abortifacients and assisted suicide
only).
In contrast, four states; Illinois,
Massachusetts, North Carolina
and Pennsylvania, have an emer-
gency rule or regulation that states
or implies that all legal and binding
prescriptions must be dispensed or
transferred.
Seventeen states considered
proposed bills addressing pharma-
cists refusal to fill or refer prescrip-
tions on moral or religious grounds
during their 2005 legislative ses-
sion: Arizona, Arkansas, Califor-
nia, Georgia, Indiana, Maryland,
Michigan, Missouri, New Jersey,
North Carolina, Rhode Island,
South Dakota, Tennessee, Texas,
Vermont, West Virginia, and Wis-
consin.
6,7
Some of these bills man-
dated dispensing by pharmacists or
pharmacies (California, Missouri,
New Jersey, West Virginia) while
others allowed refusal by pharma-
cists or pharmacies (Arizona,
Arkansas, California, Georgia,
Indiana, Maryland, Michigan,
North Carolina, Rhode Island,
South Dakota, Tennessee, Texas,
Vermont, West Virginia, Wiscon-
sin). At the time of this study, Cal-
ifornia and West Virginia were
considering bills in both cate-
gories. Figure 1 shows the current
status of each state as of January
1, 2006. Of all the states men-
tioned above, only California was
successful in enacting legislation
related to this issue in 2005.
DISCUSSION
Conscience Clause Defined
The concept of a medical
“conscience clause” arose to pro-
tect health care professionals who
did not wish to participate in
reproductive-health services after
the Roe v Wade decision in 1973.”
8
The American Pharmaceutical
Association (APhA) first adopted a
conscience clause in 1997. The
APhA pharmacist conscience
clause states, “APhA recognizes
the individual’s right to exercise
conscientious refusal and supports
the establishment of systems to
ensure patient access to legally pre-
scribed therapy without compro-
mising the pharmacist’s right of
conscientious refusal.”
9
This policy,
while not legally binding, was reaf-
firmed in 2002. While the APhA
supports the right of pharmacists
to excuse themselves from certain
Figure 1. Conscience clause status as of January 1, 2006.

1178 Volume 41, December 2006
Pharmacists‘ Right to Refuse to Dispense Prescriptions: Summary of State Laws
activities, the organization also
endorses “the establishment of
alternative systems to ensure that
the patient gets clinically safe,
legally prescribed therapy”
10
in
keeping with the duties of the
APhA Pharmacist’s Code of
Ethics.
11
The American Society of
Health-System Pharmacists
(ASHP) has also developed a posi-
tion statement on this issue. This
policy, last reviewed in 2002,
states, “ASHP recognizes a phar-
macist’s right to conscientious
objection to morally, religiously, or
ethically troubling therapies and
supports the establishment of sys-
tems that protect the patient’s right
to obtain legally prescribed and
medically indicated treatments
while reasonably accommodating
the pharmacist’s right of conscien-
tious objection.”
12
State Conscience Clause Excerpts
Following are excerpts from
the four state laws (Arkansas, Cal-
ifornia, Mississippi, South Dakota)
and one state regulation (Georgia)
that allow a pharmacist’s right of
conscientious refusal.
Arkansas Code 20-16-304:
“Nothing in this subchapter
shall prohibit a physician, pharma-
cist, or any other authorized para-
medical personnel from refusing to
furnish any contraceptive proce-
dures, supplies, or information.”
13
California Senate Bill 644,
Section 2 Section 733 (3):
“A licentiate may decline to
dispense a prescription or device
on the basis only if the licentiate
has previously notified his or her
employer, in writing, of the drug or
class of drugs to which he or she
objects and the licentiate’s employ-
er can, without creating undue
hardship, provide a reasonable
accommodation of the licentiate’s
objection. The licentiate’s employ-
er shall establish protocols that
ensure that the patient has timely
access to the prescribed drug or
device despite the licentiate’s
refusal to dispense the prescription
or order.”
14
Note that only the California
bill, which became law, effective
January 1, 2006, stipulates that
protocols must be established to
ensure timely delivery of the drug
to the patient if a pharmacist
chooses not to fill a prescription.
Georgia Code 480-5-.03:
“It shall not be considered
unprofessional conduct for any
pharmacist to refuse to fill a pre-
scription based on his/her profes-
sional judgment or ethical or moral
beliefs.”
15
Mississippi Code 41-107-5:
“Health care providers
(including pharmacists and phar-
macy employees) have the right not
to participate in a health care ser-
vice that violates their conscience.
However, this subsection does not
allow a health care provider to
refuse to participate in a health
care service regarding a patient
because of the patient’s race, color,
national origin, ethnicity, sex, reli-
gion, creed or sexual orienta-
tion.”
16
South Dakota Code 36-11-70:
“No pharmacist may be
required to dispense medication if
there is reason to believe that the
medication would be used to (1)
Cause an abortion; or (2) Destroy
an unborn child as defined in sub-
division 22-1-2(50A), (Author’s
note: subdivision 22-1-2(50A)
defines “unborn child” as begin-
ning at fertilization); or (3) Cause
the death of any person by means
of assisted suicide, euthanasia or
mercy killing.”
17
Duty to Dispense
On April 1, 2005, Governor
Rod R. Blagojevich of Illinois
issued an emergency rule requiring
pharmacists whose pharmacies sell
contraception to dispense birth
control without delay to women
with valid prescriptions.
18
The
Governor’s emergency rule was
made permanent the following
August by the Illinois Joint Com-
mittee on Administrative Rules.
19
This policy appears to negate the
Illinois Health Care Right of Con-
science Act that allows for individ-
uals or organizations to refuse to
participate in health care services
which are “contrary to their con-
science or conscientious convic-
tions.” (745 ILCS 70/2, eff. 1-1-
98)
20
While there is no doubt
regarding the intent of the Illinois
Governor’s rule, which mandates
dispensing, some state regulations
only imply a duty to dispense.
Pennsylvania’s Standard of Prac-
tice Code, Board Regulation Sec-
tion 27.18(p)(2) states, “A phar-
macist shall offer complete phar-
maceutical service by compound-
ing or dispensing prescriptions
which may reasonably be expected
to be compounded or dispensed by
pharmacists to meet the needs of
persons who would usually
attempt to utilize the services.”
21
The Code of Professional Conduct
for Massachusetts’s pharmacists is
worded a bit stronger: 247 CMR
9.01(16) states, “A pharmacist
shall not refuse to compound cus-
tomary pharmaceutical prepara-
tions except upon extenuating cir-
cumstances.”
22
(Author’s note:
“extenuating circumstances” is not
defined in this regulation.)
In January 2005, the North
Carolina Board of Pharmacy clari-
fied its position on pharmacists’

Hospital Pharmacy 1179
Pharmacists‘ Right to Refuse to Dispense Prescriptions: Summary of State Laws
refusals with the following state-
ment, “The Board notes that
although pharmacists have a right
to avoid moral or ethical conflict,
they do not have a right to obstruct
otherwise legitimate prescription
dispensing or delivery solely on the
basis of conscientious objection.”
23
CONCLUSIONS
The rights of pharmacists to
refuse to dispense certain prescrip-
tions vary widely from state to
state. The protection provided to
an individual pharmacist may be
very broad or very specific depend-
ing on the wording of the statute
or regulation. It is not surprising
that attempts to modify these poli-
cies are frequent. Every pharmacist
is encouraged to review the law in
their respective state and keep
abreast of new developments.
As this subject is evolving,
please follow up with the National
Conference of State Legislature site
at: www.nesl.org/programs/
health/conscienceclauses.htm.
ACKNOWLEDGEMENT
The authors wish to acknowl-
edge Kimberly R. Watson, PharmD
for her assistance with data collec-
tion.
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