Morning-after pill | Conscientious objectors or dishonourable disobedience?

Pharmacists could be free to abstain from selling the morning-after pill on grounds of religious conscience, but ultimately the State is obliged to provide a legal alternative.

Amid controversy prompted by a judicial protest filed by the Women’s Rights Foundation and 102 women demanding the licensing of the MAP, the Chamber of Pharmacists has directed members to decide for themselves whether to dispense the emergency contraceptive or not.

Supporters of the MAP – which include political parties, women’s organisations and youth groups – are insisting that the pill is not abortive because it works by delaying ovulation, thereby avoiding pregnancy. Several health professionals have explained the MAP is classed as a hormonal contraceptive.

But the scientific community has been the least vocal on the MAP in a country that retains a general aversion towards anything that is potentially akin to ‘abortion’ in common parlance. The Chamber of Pharmacists’ ‘conchie’ directive only seems to further the perception that the MAP can be justifiably withheld in a country that retails condoms even inside supermarkets.

Pichon-Sajous

The classic case on conscientious objection in reproductive health is that of Bruno Pichon and Marie-Line Sajous, who owned a Bordeaux pharmacy and refused to sell contraceptives prescribed by doctors because they claimed it was against their religious beliefs.

The pharmacists claimed they were abiding by French law that prohibits the sale of substances that facilitate abortion.

The three women who were refused their prescriptions filed a complaint, and the Bordeaux Police Court decided that the law only concerned “abortifacients” and that “ethical or religious principles are not legitimate grounds to refuse to sell a contraceptive. There is no legislation which authorises pharmacists to refuse to supply contraceptives …”.

In 2001, the two owners took the French state to the European Court of Human Rights after their final appeal was dismissed by the  Court  of Cassation. Pichon and Sajous claimed their freedom to manifest their religious beliefs had been violated by the French state when it convicted them for refusing to sell the contraceptives.

The ECHR declared the case inadmissible, saying that Article 9 – which protects freedom of conscience and its expressions – does not always guarantee the right to practise this in public. The court said that given that contraceptives were legal and sold only with a prescription and only in pharmacies, pharmacy owners could not prioritise their beliefs over their professional obligations.

The question put to pharmacists is whether they believed that the Chamber had been fair in saying that they were right in refusing to dispense the morning-after pill, even if it is licensed for sale by the medicines authority.

And the answers have proved to vary drastically.

A pharmacist from Remedies Pharmacy, who did not wish to be named was unsure about her role in such a decision. “I don’t agree with the morning-after pill at all… [however] it’s difficult to say no. One needs to look at the misuse of the product.”

Others seemed to indicate that each pharmacist should get to decide for themselves whether to sell the morning-after pill or not. “It is really down to the pharmacist’s personal values,” Vanessa Sultana, from Gozo Chemist Pharmacy, said.

But one pharmacist told MaltaToday that it was her professional obligation to provide what doctors prescribe, and that ultimately the decision is not that of the pharmacist.

“The whole issue is one based on ethics. It’s not something I, as a pharmacist, can decide. It’s a decision to be taken between the woman and her gynaecologist,” the pharmacist from Ghaxaq’s Beta Pharmacy, who also wished to stay anonymous, said.

Another pharmacist from St Julian’s Pharmacy who also wished to remain unnamed, on the other hand, said she agreed with the morning-after pill, but that she supported her colleagues who would object to selling it on grounds of conscience.

“It is their right, as stated in the code of ethics, as long as they refer the patient to someone who will dispense it.”

Pharmacists cannot be pressured

Indeed it would seem that this is the prevalent spirit as laid down in a Council of Europe resolution on conscientious objection, which although non-binding, is politically significant.

It establishes that no person, hospital, or institution can be pressured, held responsible or discriminated against for refusing to perform, accommodate, or assist in certain treatment or the distribution of certain products.

But the same resolution emphasises the state’s responsibility to ensure that patients can access medical care in a timely manner.

In itself this echoes the more definite wording of a general recommendation from the Committee on the Elimination of Discrimination against Women (CEDAW committee) which established that it is “discriminatory for a state party to refuse to provide legally for the performance of certain reproductive health services for women… If health service providers refuse to perform such services based on conscientious objection, measures should be introduced to ensure that women are referred to alternative health providers.”

Critics of conscientious objection in reproductive healthcare are more zealous on the consequences of withholding the emergency contraceptive pill.

But even an ‘extreme’ opinion such as that of an abortion doctor, seems to make its own rational case  against objectors. Dr Christian Fiala, of the Gynmed Ambulatorium, says that since women are the vast majority of patients in reproductive healthcare, conscientious objection rises to the level of gender discrimination.

“It is a refusal to treat that should be seen as unprofessional. A just society and an evidence-based medical system should deem it as ‘dishonourable disobedience’, an ethical breach that should be handled in the same way as any other professional negligence or malpractice.”