Thursday, 27 May 2010

Pharmacists can refuse to sell the pill...

This week the General Pharmaceutical Council is completing a consultation on their new draft guidance to pharmacists. It is a useful document full of clear, sensible and well laid out instructions and principles. It promotes a client/patient-centred approach to dispensing; calling on pharmacists to be respectful of patients, to put quality care before any personal considerations etc...kind of what you’d expect from professionals who are an essential part of community health care in this country.

There is one glitch. It’s quietly buried amongst the good stuff, but screamed off the page at me...Pharmacists who have a personal objection to providing a particular medication can opt out of doing so. It is not named in the guidance, but we all know it’s referring to emergency hormonal contraception – the ‘morning after pill’. Ten years ago or even five it would have been inconceivable that a pharmacist would have been given the right to ‘conscientiously object’ to providing a legally available medication or treatment. Now it seems that we might be going the way of the US where pharmacists are routinely refusing to fill women’s prescriptions for the contraceptive pill and emergency hormonal contraception, or Plan B – the US brand name.

The arguments about conscientious objection are complex. They don’t divide us simply down liberal (small L) and conservative (small C) lines like so many issues seem to. Many people may argue that the individual should have the right to live by their own beliefs and that might mean not co-operating in the provision of services that go against those beliefs. On the flip side people may think that professional commitment comes before personal preferences and you shouldn’t take on a job if you’re not willing to carry out all aspects of it.

Whatever our abstract philosophical beliefs about conscientious objection we do need to worry about the women on the end of these ideas. Maybe it’s because I’ve spent the last ten years travelling around the country training nurses and hearing their anecdotes that I find myself rooted not in the abstract, but in the prosaic, the every day, the real. When I think of a pharmacist refusing to give someone the ‘morning after pill’ I don’t imagine someone standing at the Boots counter in Oxford Street, where another three pharmacists are available to step in. I see a 16 year old on a chilly Monday morning in rural North Yorkshire. Let’s call her Rachel. She’s walking into the only chemist shop in the village 36 hours after she had sex, and she’s being refused the emergency contraceptive pill she desperately wants and needs to prevent her from getting pregnant. She hasn’t got the bus fare into town where the nearest alternative chemist is – and anyway the bus is sporadic at the best of times. School starts in ten minutes and so she shrugs her shoulders and walks out of the shop feeling sick with anxiety because she knows that by the time she can get to town at the weekend it’ll be too late. She’s also feeling a bit shabby because she must have asked for something bad – and by extension be bad – if the pharmacist has refused to sell her what she wants. Nothing for it now but to cross her fingers and hope she gets her period...

There is nothing in the guidance to pharmacists that deals with this situation. No protocol for medication that is time-sensitive and urgent such as emergency hormonal contraception. No acknowledgement that all the good client-centred principles are wiped out at one stroke when a pharmacist can say ‘I know better than you what you can put in your body. I am willing to refuse you this prescription and take the risk that YOU will become pregnant against your will.’

When the right to conscientiously object was written into the 1967 Abortion Act, it recognised that someone who didn’t agree with abortion in principle shouldn’t have to physically get involved in the very practical and visceral experience of carrying out abortion. As time has gone on a small, but significant proportion of GPs have taken this to mean they don’t have to refer women for abortion if they object to it. Now it seems that pharmacists need not even help a woman to prevent a pregnancy if they don’t believe in hormonal contraception. I’ve never liked that expression “thin edge of the wedge”, but you have to wonder...condoms next?


  1. If you want pharmacists to be gatekeepers, you can't complain when they keeping gate.

    If you believe individuals are more competent to decide that a pharmacist put drugs in supermarkets and cut the pharmacist out of the loop.

    Medicine in the UK (like many things) is completely over-regulated - instead of adding more regulations (more guidance, more training, more protocols, more, more, more) try cut, cut, cut instead.

  2. We think pharmacists are competent to advise on the risks and side effects of drugs and how to take medication properly. There may be medical contraindications to use of some medicines and in that case a pharmacist would have to act as a 'gatekeeper'. However, they are not appointed as moral arbiters of people's decisions or gatekeepers of particular drugs. They certainly do not have the magical skills to know what is best for a woman requesting EHC. In relation to over-regulation, a guideline that says your political or moral position should not interfere with patient/customer care, doesn't seem too onerous.

  3. The patient should always come first. So if a pharmacist feels unable to provide all services they shouldn't take a job where they'll be working alone. Unfortunately the GPC seems to think that a pharmacist's career prospects come first and that having a conscientious objection shouldn't have any cost to the holder.