Conscience clauses, which allow pharmacists to opt out of providing the “morning after pill” without a prescription, risk unwanted pregnancies and undermine the principle of universal healthcare in the NHS, say pharmacists in the Journal of Medical Ethics.

These clauses should either be banned or enhanced so that pharmacists and patients know exactly where they stand, rather than the current “fudge”, which serves nobody well, the authors conclude.

Emergency hormonal contraception without a prescription became available from UK pharmacies in 2001 and the Republic of Ireland in 2011.

Built-in conscience clauses allow pharmacists to opt-out of provision on moral or religious grounds, providing they refer patients to other providers willing to prescribe the product.

The morning after pill has been the subject of a string of legal challenges, and those who believe it is wrong to provide it, often do so on the grounds that it could harm the developing embryo, say the authors.

But this ignores the principle of patient autonomy - “a core tenet of contemporary healthcare” - and arguably begs the question of why those with strong objections to carrying out a routine aspect of their profession should nevertheless opt for a job in which this is required, argue the authors.

“What pharmacists in such cases are demanding is the power of veto over the liberty of others, and over the implementation of public policy,” they write.

Under current regulations, pharmacists who hold religious and moral objections to providing the morning after pill must refer women to another appropriate source of supply. This opt out allows them to convince themselves that referral does not constitute supply, say the authors, but what of their professional duty to the patient?

What happens if no such alternative supply is available within the 72 hour time limit in which emergency hormonal contraception works - a particular issue for women in rural areas, for example - ask the authors?

There is nothing in the current legislation, or indeed professional guidance, which addresses that, they point out.

“Although the important distinction between objection and obstruction seems to be recognised by the regulatory bodies, they lack the impetus to follow their assertions through to their logical conclusion,” they write.

To be morally defensible and legally feasible, rules and regulations governing the supply of the morning after pill must be universally applicable, the authors contend.

“The current status quo is not satisfactory to either conscientious objectors or to those who must regulate them,” they write.

“Either [the professional regulators] must compel all pharmacists to dispense emergency hormonal contraception to all patients meeting the clinical criteria who request it….or the pharmacist must refuse both to supply [it] and to refer the patient to an alternative supplier,” they argue.

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Stephanie Burns
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BMJ-British Medical Journal