Protection of Conscience Project
Protection of Conscience Project
Service, not Servitude

Service, not Servitude

Healthcare without Conscience - Unconscionable!

The Annals of Pharmacotherapy
2007 November, Volume 41
Reproduced with permission

Gene Rudd MD *
Senior Vice President, Christian Medical & Dental Associations

Protecting right of conscience for pharmacists means protecting this right for everyone. . . .Once we breach this most fundamental line, there will be another issue and another class of citizens who will not be allowed to follow their convictions. Either we defend this liberty, or we will not have it.

The governor of Illinois has told pharmacists to check their conscience at the door. They are not to allow their personal convictions to alter their professional activities. Specifically, pharmacies are to fill all legal prescriptions, even if doing so is contrary to deeply held moral or religious beliefs of the pharmacists. More recently, the Washington State Board of Pharmacy, under pressure from its governor, crafted new rules increasing pressure on pharmacists to fill prescriptions for which there may be moral objection.1 Soon we may see help wanted signs saying, "Pharmacists who wish to exercise conscience need not apply."

While some are sympathetic to the pharmacists' dilemma, the governor of Illinois and others seemed more compelled by the story of a patient who was embarrassed at the counter when the pharmacist refused to fill her prescription. The story was also presented in the context of the patient being denied access to health care.

Pharmacists are currently on the front line in the battle for right of conscience, but they are not alone. Skirmishes have occurred with nurses and physicians, most notably related to abortions. Court cases have generally sided with the healthcare professional, protecting his or her right to refuse to participate in activities they deem morally objectionable. However, recent legislative and legal actions involving pharmacists challenge these precedents. Perhaps pharmacists are seen as soft targets for changing the paradigm.

Federal and state governments are scurrying to respond. The 2005 Federal Weldon Amendment came to the support of individuals and organizations that refuse to perform abortions.2 It was subsequently upheld in courts. According to, at least 9 states were considering new right of conscience legislation in 2006 (an up-to-date, detailed list of state laws and legislation can be found [here]) and 46 states have laws protecting some healthcare professionals in certain situations.3 Medical journals are also addressing the issue.4, 5,6 The controversy is far from resolved. A Supreme Court case seems likely.

What Perspective Should Guide Our Law-Making?

Our founding fathers would not equivocate. They established a precedent that has guided our culture for 200 years by writing the First Amendment in the Bill of Rights: "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof…." While the phrase "right of conscience" is not mentioned, it is clearly what they had in mind. James Madison penned the first draft: "The Civil rights of none shall be abridged on account of religious belief or worship.…"

Madison went on to say, "Religion, or the duty which we owe our Creator, and the manner of discharging it, can be directed only by reason and conviction, not by force and violence; and therefore all men are equally entitled to the free exercise of religion, according to the dictates of conscience."7 Thomas Jefferson wrote, "[O]ur rules can have authority over such natural rights only as we have submitted to them. The rights of conscience we never submitted, we could not submit. We are answerable for them to our God."8

Preserving Right of Conscience Is Critical to Our Social Order

Protecting right of conscience for pharmacists means protecting this right for everyone. Said differently, if this right can be taken away from pharmacists, it can be taken away from anyone. Once we breach this most fundamental line, there will be another issue and another class of citizens who will not be allowed to follow their convictions. Either we defend this liberty, or we will not have it.

Since conscience is intimately wrapped in character and integrity, what will health care become if we undermine these ideals? Do we really want our pharmacists and physicians to check their consciences at the door-to simply be facilitators of whatever the patient wants? This would have the effect of turning healthcare professionals into vending machines. Edmund Pellegrino and David Thomasma remind us that all medical ethics finally rest on the physician's or pharmacist's moral character.9 In those moments of clinical decision, when no one is watching, the physician's or pharmacist's character is the patient's last safeguard.

But What About Patient Rights?

Do not those in health care have an obligation to meet the patient's expectations regardless of their own moral convictions?

Rights conflicts are inevitable. Reason and experience have taught us to protect the more fundamental right. It was no accident that the writers of the Declaration of Independence listed the inalienable rights in order of their priority: "life, liberty and the pursuit of happiness." Life rights should trump liberty rights, and liberty rights should trump pursuit rights. Requiring pharmacists to dispense every prescription results in the patient's pursuit rights trumping the pharmacist's liberty rights. While the patient has the right to pursue her care, she cannot do it at the cost of liberty to a fellow citizen. Patient pursuit and preference should not trump the liberty of others. Making exceptions of healthcare professionals makes them second-class citizens.

Moreover, we should consider whether patients are truly being denied access. Public reports have indicated that only a few patients have been inconvenienced or embarrassed. Accessing prescriptions via in-town competition or Internet pharmacies with overnight deliveries are preferable alternatives to passing laws that coerce professionals to participate there are moral objections. Neither do we need coercive laws to remedy the problem of patients' being offended. While patients should not be treated rudely, we can find better solutions for unbecoming professional conduct than sabotaging the fundamental right of conscience. Additionally, if concern over patient access were truly the motivation of those who would deny pharmacists their right of conscience, they are better advised to deal with the economic inaccessibility of pharmaceuticals affecting a large number of our fellow citizens.

Surely our society is resourceful enough to provide a means by which patients can acquire legal prescriptions (or other healthcare services) without forcing healthcare professionals to be complicit against their will. Pharmacies can clearly post their policies. Patients can seek alternatives. There need be no awkward encounters.

Do the Pharmacists' Objections Have to Be Popular to Be Defended?

Many of us may not embrace the particular conviction that compels some pharmacists to refuse to fill certain prescriptions. However, lack of popular support for a conviction should not be the criteria for denying the right to act on that conviction. If so, public whim would soon place in question all fundamental rights.

We stand at a crossroads. Some advocate compromise- a balancing of these rights. The result, however, would be an erosion of something precious to all of us. Dr. Farr Curlin summarizes, "Acting conscientiously is the heart of the ethical life, and to the extent that physicians give it up, they are no longer acting as moral agents. … Conscientious practice in a pluralistic world is messy even when peaceable. Yet the alternative is a society in which physicians are required to forfeit conscience in order to join the profession. Patients will not be well served by moral automatons who shape their practices, without struggle or reflection, to the desires of patients and the dictates of whatever regime is currently in power."10

Gene Rudd MD, Senior Vice President, Christian Medical & Dental Associations,
2604 Highway 421, PO Box 7500, Bristol, TN 37621
Fax 423/844-1017,
Reprints: Dr. Rudd

1. Washington State Pharmacy Association. Legislative items. (accessed 2007 Jul 24)

2. Div. F, Title V, 508(d), Pub. L. 108-447.

3. American Medical Association. Broader conscience clauses would expand physicians' right of refusal. (accessed 2007 Jul 24).

4. Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2004;356:593-600.

5. Cantor J, Baum K. The limits of conscientious objection-may pharmacists refuse to fill prescriptions for emergency contraception? N Engl J Med 2007;351:2008-12.

6. Genuis SJ. Dismembering the ethical physician. Postgrad Med J 2006;82:233-8. DOI 10.1136/pgmj.2005.037754

7. Hutchinson WT, Rachal WME, eds. The papers of James Madison. Vol. 1. Chicago and Charlottesville: University Press of Virginia, 1962-1991:175.

8. Peden W, ed. Notes on the State of Virginia, Query 17. Chapel Hill, NC:University of North Carolina Press, 1954:159.

9. Pellegrino ED, Thomasma DC. The virtues of medical practice. New York: Oxford University Press, 1993.

10. Curlin F. Religion, conscience, and controversial clinical practices (letter). N Engl J Med 2007;356:1889-92.