Pharmacists Grapple With Questions, Confusion Around Abortion Access

Abortion has been a major topic of discussion among health care providers and the general public in recent years, particularly following the June 2022 US Supreme Court decision in Dobbs v Jackson Women’s Health Organization, which upended decades of precedent holding that there was a constitutional right to abortion in the United States.¹ The decision led to a multitude of questions, including legal debates around access to drugs commonly used in medication abortion, access to contraception, and unintended consequences for women’s health.

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As of October 2023, abortion was banned in 14 states and 1 state had limited abortion to less than 12 weeks’ gestation. Abortion was still legal beyond 22 weeks’ gestation in 25 states and Washington, DC, while 9 states had limits between 15 and 22 weeks’ gestation.²

Many of these questions directly involve pharmacists, who are grappling with their responsibilities for patients vs legal implications. Understanding these nuances and knowing where to go for questions is crucial for pharmacists looking to provide the best possible patient care.

MEDICATION ABORTION

Mifepristone has been approved by the FDA in a regimen with misoprostol to end an intrauterine pregnancy through 10 weeks’ gestation (70 days or less since the first day of a patient’s last menstrual period) under a Risk Evaluation and Mitigation Strategy (REMS) program.³

The goal of the mifepristone REMS program is to mitigate the risk of serious complications associated with mifepristone when used for medical termination of pregnancy through 10 weeks’ gestation by, among other things, requiring that prescribers have the necessary qualifications to assess whether patients are appropriate candidates for the drug and to provide necessary intervention in case of complications (or have made plans to provide such care through others). The program ensures that mifepristone is dispensed only by certified pharmacies or under the supervision of certified prescribers and requires that patients be informed of the risks of the treatment regimen.³

Following the Supreme Court decision in 2022, the US Department of Health and Human Services (HHS) released a guidance for pharmacies specifying that as recipients of federal financial assistance, including Medicare and Medicaid payments, pharmacies are prohibited under law from discriminating based on race, color, national origin, sex, age, and disability in any programs and activities, including supplying and prescribing medications.⁴ In an update on September 29, 2023, HHS clarified that pharmacies are not required to fill prescriptions for medication for the purpose of abortion given the differing state regulations.⁴

State laws banning or restricting surgical or procedural abortion may also apply to medication abortion. As the legal landscape of medication abortion is changing rapidly, pharmacists should consult their state boards of pharmacy; local, state, or national associations; and state law to determine the legality of medication abortion as it applies to them.

CONSCIENTIOUS OBJECTION

Conscientious objection has been a topic of intense debate within health care communities, including pharmacy, for decades. Conscientious objection is defined as a practitioner’s refusal to engage in or provide a service primarily because the action would violate their deeply held religious, moral, or ethical values about right and wrong.⁵

Australia has minimized the complexities of managing the pharmacists’ right to conscientious objection by initiating an “opt-in” registration system.⁵

There have been several interesting case studies surrounding this issue.

In July 2002, a student at the University of Wisconsin-Stout went to a Kmart store to fill her prescription for oral contraceptives. The pharmacist, Neil Noesen, PharmD, asked if she intended to use the prescription for contraception. When she said she did, he refused to fill the prescription because it would be against his religious beliefs as a Roman Catholic. He also refused to transfer the prescription to another pharmacy or tell her how she could otherwise get it filled, because he believed this would constitute participation.⁶

The woman filed a complaint with the Wisconsin Department of Regulation and Licensing’s Pharmacy Examining Board. The judge said that the ordinary standard of care “requires that a pharmacist who exercises a conscientious objection to dispensing of a prescription must ensure that there is an alternative mechanism for the patient to receive his or her medication.”⁶

In another case, Andrea Anderson filed a lawsuit against a pharmacist, George Badeaux, claiming he violated the Minnesota Human Rights Act when he would not fill her prescription for the morning after pill in 2019. A jury ruled that Badeaux, who refused to fill her prescription based on his beliefs, did not discriminate, but awarded her $25,000 for the emotional harm caused.⁷

BARRIERS

Pharmacists are available for counseling and are highly accessible to patients. Pharmacists can be crucial team members for patients seeking abortion or information on the procedure, but barriers to care must be addressed, including legal questions.

In data from one study, published in Contraception in January 2023, researchers found that even in states with supportive abortion policies, patients encounter multiple barriers. The study focused on Los Angeles, California, and recruited 17 participants for structured interviews. Participants had visited 3 or more clinics and/or waited more than 2 weeks between seeking and obtaining their abortion.⁸

According to the findings, participants described 3 primary barriers: insurance coverage or authorization, inadequate screening resulting in multiple appointments, and challenges with timely referrals to appropriate clinics. Participants also reported fatigue from facing “layers of resistance” during the process. The findings illustrate that even in states that have maintained or expanded abortion access in recent years, patients face multiple challenges.⁸ These are often compounded for patients in states with restricted access, where patients seeking abortions must often take time off work, travel long distances, and pay travel costs in order to obtain abortion care.

Researchers have found that 90% of counties in the United States do not have a single clinic offering abortion care, and barriers such as those mentioned above disproportionately impact low-income families.⁹ To address these concerns, some researchers have proposed novel models, including provision of medication abortion in pharmacies, with pharmacist-prescribed medications. Although this is not currently legal in the United States, research findings published in May 2023 investigated pharmacists’ attitudes toward such a proposal.⁹

The findings, published in BMC Health Services Research in May 2023, found several major themes among respondents. These included the need for pharmacist provision of medication abortion as well as pharmacists’ perception of this as an acceptable model if anticipated barriers are addressed. Barriers identified in the study included personal, religious, and political beliefs of pharmacists and a lack of space and systems to support the model. Adequate staffing in pharmacies willing to participate, private spaces built in the pharmacy, adequate time for counseling, follow-up procedures, training, and reimbursement mechanisms are all necessary to facilitate such a model.⁹

CONCLUSION

Although such a model is not legal in the United States, pharmacists are dedicated to providing the best possible care for their patients. Legislators on the state and federal levels must work to clarify lingering questions around both surgical and medication abortion procedures so that pharmacists can provide that crucial care and counseling to their patients. As long as these questions remain, pharmacists should check with their state boards of pharmacy as well as local, state, or national organizations in order to understand their responsibilities and options.

ABOUT THE AUTHOR

Kathleen Kenny, PharmD, RPH, earned her doctorate from the University of Colorado Health Sciences Center. She has more than 25 years of experience as a community pharmacist and works as a clinical medical writer based in Homosassa, Florida.

REFERENCES

1. Expert discusses long-term implications of Roe v Wade decision for pharmacists, contraception access. Pharmacy Times. June 30, 2022. Accessed October 18, 2023. https://www.pharmacytimes.com/view/expert-discusses-long-term-implications-of-roe-v-wade-decision-forpharmacists-contraception-access
2. Abortion policy tracker. KFF. Reviewed June 6, 2023. Accessed October 18, 2023. https://www.kff.org/other/state-indicator/abortion-policy-tracker/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
3. Information about mifepristone for medical termination of pregnancy through ten weeks gestation. FDA. Updated March 23, 2023. Accessed October 18, 2023. https://www.fda.gov/drugs/postmarket-drug-safetyinformation-patients-and-providers/information-about-mifepristonemedical-termination-pregnancy-through-ten-weeks-gestation
4. Guidance to nation’s retail pharmacies: obligations under federal civil rights laws to ensure nondiscriminatory access to health care at pharmacies. US Department of Health and Human Services. Updated September 29, 2023. Accessed October 18, 2023. https://www.hhs.gov/civilrights/for-individuals/special-topics/reproductive-healthcare/pharmaciesguidance/index.html#:~:text=This%20guidance%20supersedes%20and%20revises,pharmacies%20to%20fill%20prescriptions%20for
5. Isaac S, Chaar B. Should pharmacists be allowed to conscientiously object to medicines supply on the basis of their personal beliefs?. Can J Hosp Pharm. 2018;71(2):149-151.
6. Mclean MR. Markkula Center for Applied Ethics. A pharmacist refuses to fill a prescription for birth control: an ethics case study (podcast). November 3, 2011. Accessed October 18, 2023. https://www.scu.edu/ethics/focus-areas/bioethics/resources/conscientious-refusal/
7. Scribner H. Jury rules pharmacist who denied patient morning after pill did not discriminate. Axios. August 5, 2022. Accessed October 18, 2023. https://www.axios.com/2022/08/05/minnesota-pharmacist-morning-afterpill-case
8. Jung C, Fiastro A, Cornell A, Steward R, Rible R, Gipson JD. Patient perspectives on barriers in obtaining timely abortion care in Los Angeles, California. Contraception. 2023;117:50-54. doi:10.1016/j.contraception.2022.08.003
9. Sandoval S, Chen G, Rafie S, Rabin B, Mody S, Averbach S. A qualitative analysis of pharmacists’ attitudes towards provision of medication abortion. BMC Health Serv Res. 2023;23(1):557. doi:10.1186/s12913-023-09543-z