Refusing to supply emergency hormonal contraception undermines our profession — no pharmacist should do it

Pharmacists are no exception to the general public they serve. They hold a wide range of personal beliefs and values, with many religions practised among them, and we should recognise the positive impact this has on the care that they provide.

However, topics often thrown into the spotlight are faith and moral principles and how they are expressed at work. These fall under the so-called ‘conscience clause’ — the right of a healthcare professional to be able to exercise their personal values and beliefs at work and, on occasion, opt out of providing some services. In pharmacy, the most likely scenario in which a pharmacist could use this clause is in response to a request for an over-the-counter (OTC) supply of emergency hormonal contraception (EHC).

In England, EHC is available to buy OTC from most community pharmacies, and can be obtained for free in some. In a case reported in the British press in June 2019, a woman told of how she had pre-paid for EHC online but, when she visited a pharmacy in Brighton to collect it, she was unable to do so because of the beliefs of the pharmacist on duty^[1]
. The woman said she was advised to visit the nearest branch ten miles away or return the following day; reportedly she was “shocked” that the pharmacist had been able to “discriminate against women in this way”.

A few months later, in December 2019, the Royal College of Obstetricians and Gynaecologists (RCOG) published a report stating that although pharmacists generally provided a “non-judgemental service”, 7% of people were turned away for EHC and many women felt the consultation with the pharmacist left them “feeling uncomfortable, embarrassed or judged”^[2]
. The RCOG’s recommendation was that oral EHC should either be made free or reclassified to the General Sales List to allow it to be sold straight off the shelf without consultation.

Although I do not agree that scrapping pharmacist consultations is the right approach, these examples demonstrate the central questions the conscience clause raises about the professional role of the pharmacist. If a pharmacist refuses to provide a service that is available from their pharmacy, does that make them non-compliant with the professional standards for patient-centred care? Is it acceptable to direct a person to another pharmacy for a service when exercising one’s freedom of conscience?

Pharmacists have a duty to make employers aware of any circumstances where they are unable to provide any of the services available from the pharmacy

Looking at the General Pharmaceutical Council’s (GPhC’s) revised professional standards, published in 2017, there was a notable shift from previous standards towards patient-centred care being the priority, while still allowing pharmacy professionals to exercise their values and beliefs^[3]
. The document says that: “People receive safe and effective care when pharmacy professionals recognise their own values and beliefs but do not impose them on other people.”

In specific guidance on religion, personal values and beliefs, the GPhC is clear that religion and belief are “protected characteristics” and that pharmacy professionals “have the right to practise in line with their religion, personal values or beliefs, as long as they act in accordance with equalities and human rights law and make sure that person-centred care is not compromised”^[4]
.

It adds that this includes pharmacy professionals “thinking in advance about the areas of their practice which may be affected and making the necessary arrangements, so they do not find themselves in the position where a person’s care could be compromised”.

This clearly demonstrates that pharmacists have a duty to make employers aware of any circumstances where they are unable to provide any of the services available from the pharmacy.

The GPhC principles and standards for registered pharmacies also state that “the way in which pharmacy services, including the management of medicines and medical devices, are delivered safeguards the health, safety and wellbeing of patients and the public” and that pharmacy services should be “accessible to patients and the public”^[5]
. This also means employers must consider how to ensure a service can be provided consistently.

I would argue that this guidance implies that pharmacists should choose not to work in a place where they are unable to provide all services required, including EHC. Of course, this has wide-ranging implications for those individual pharmacists.

Before the implementation of the revised GPhC standards, religious group representatives expressed concerns around how the changes could make the position of some pharmacists unsustainable and discourage people from becoming a pharmacist if their faith meant they would not want to supply certain medicines^[6]
.

Our colleagues with strong personal convictions do not need to leave the profession

However, part of the process of choosing a role is to look for one that aligns as closely as possible with our range of interests, principles and ideology. There is a widening range of role opportunities for pharmacists and pharmacy technicians, including many that can accommodate personal beliefs without impacting on the people receiving pharmacy services. Our colleagues with strong personal convictions do not need to leave the profession.

I support the lead taken by the younger members of our profession. The British Pharmaceutical Students’ Association made the following addition to their policy statements in 2019: “This Association believes that all pharmacists in the UK should offer [EHC], regardless of their personal, ethical or religious beliefs”^[7]
. This demonstrates a clear commitment from our future pharmacists to deliver patient-centred care.

I would go further and encourage England to have the same relationship with the EHC service that exists in Scotland and Wales. In both countries, the service is free and has been recognised as a contributor to the overall reduction in the unintended pregnancy rate and, in Scotland, the remuneration rate for the clinical assessment and free of charge supply, when appropriate, has been increased from £25 to £30 per patient^[8]
. An advantage of having an EHC scheme as an NHS service is that there is a contractual requirement for pharmacy proprietors to provide it where clinically appropriate, which is not the case for OTC sale of EHC in England.

It is, of course, right for pharmacy professionals to be able to exercise their values and beliefs, but not at the expense of the patient experience. Provision of dependable, quality pharmacy-based services is an important factor for public and patient confidence in the profession of pharmacy, as is ensuring patient-centred care. Therefore, I believe it is unacceptable for any pharmacist to refuse a clinically appropriate EHC supply to a patient who requests it.