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Pharmacists' Beliefs About Abortion and RU-486
Pharmacists' Beliefs About Abortion and RU-486 As abortifacients increasingly become an option in the United States) many pharmacists will need to reconcile practice with religious and ethical convictions. by Vincent Giannetti, PhD ANDRE LUCERO
Introduction The "political chemistry" of mifepristone (marketed for a decade in Europe as RU-486) led the Food and Drug Administration (FDA) in 1989 to declare a ban on the drug's import. Various groups had threatened a boycott of the drug's manufacturer and parent company, Hoechst-Roussel, if the drug was made available in the United States. l The ban on RU-486 was subsequently lifted in 1994, and the drug was licensed to The Population Council of New York City by the French pharmaceutical manufacturer Roussel Uclaf. Recently, the FDA advisory panel recommended approval for RU-486 for medical termination of pregnancy. The identity of the manufacturer of this drug has not been widely publicized. 2 Researchers have maintained that the import ban thwarted investigation of the potential value of RU-486 in treating Cushing's disease, meningioma, breast cancer, and viral infections, possibly depriving patients who are not seeking abortions of access to needed treatment. 3 While RU-486 may have potential therapeutic value for other conditions, the drug's main Use has been to induce abortion. RU-486 alone has been reported to be an effective abortifacient in 60% to 85% of cases for first-trimester pregnancies.4- 6 RU-486 combined With a prostaglandin administered within 49 days of the last menstrual cycle induces abortion in 95% to 99% of cases. According to the proponents of RU-486, its availability proVides the advantage of increased privacy, compensates for the decreasing availability of surgical abortion, and significantly reduces maternal morbidity and mortality associated with surgical abortion. 7,8 In France , Ru-486 is used in combination with a Prostaglandin for pregnancy termination up to the 49th day, and in that nation approximately one-third of women have chosen this regimen over surgical abortion. WorldVol. NS36, No. 12
December 1996
wide, approximately 120,000 women in 20 countries have received RU-486 together with a prostaglandin , resulting in a termination of 93% to 99% of these pregn ancies .9 In the United States, approximately 345 legal (surgical) ab ortions are performed per 1,000 live births, with 50% of abortio ns performed at or before eight weeks of gestatio n and 87% before the 13th week. In 1990 there were 1,429 ,577 abortions reported to the Centers for Disease Co n t ro l and Prevention. 10
Abstract The author conducted a survey of pharmacists ' beliefs regarding abortion and mifepristone (RU-486) to determine pharmacists' perceptions of the ethical dilemmas posed by the use of abortifacients in the United States and to determine whether and how these ethica l dilemmas affect practice. The sample was nonrandom and included religiously oriented pharmacists from a variety of practice settings, approximately two-thirds of w hom were women . The results indicated a plurality of beliefs about abortion rarely evident in the public debate. Alt hough the sample supported pharmacists' right to refuse to dispense abortifacients, slightly more than half (51 %) of the respondents stated that they themselves would not refuse to dispense abortifacients. Most responde nts (560/0) believed that abortion should remain a legal option, with slightly fewer respondents (50%) supporting the position that RU-486 should be made available in t he United States. Support for abortion was proportionate to the gravity of the reason underlying the decision to abort, with the sample tending to avoid absolutistic posit ions. These findings tend to dispel the stereotypes and myths regarding abortion beliefs in that two-thirds of the sample were Catholic and 96% of the sample rated rel igion as extremely or somewhat significant in their life.
journal of the American pharmaceutical Association
Pr p nents of the intr duction of R -486 into the United tat have predicted vigorous oppo ition to the use of this ag nt.11 If abortifacients become increasingly accepted or pre£ IT d as a method of inducing abortions, many pharmacists in th e nited States will fmd them elve facing, in their pracic , the same ethical i ue that society is grappling with. It is n t clear at this time whether community pharmacists would b involved in dispensing RU-486. For example, many community pharmacies lack a sufficiently private, confidential environment. Pharmacists working in clinical settings may be m o re likely to be involved in dispensing RU-486. 12 Although the political and moral issues surrounding abortion have led to a vigorous national debate, there has b een relatively little discussion of the topic in the pharmacy profession. While some professional organizations, such as the American Public Health Association and the National As ociation of Social Workers, have taken public stands on the issue of reproductive rights , professional pharmacy organizations have not done so. Moreover, little has been published in the pharmacy literature regarding the ethical dilemmas facing the pharmacist who has strong religious beliefs in opposition to abortion. However, Brushwood reviewed the legal literature regarding the right to assert a c onscientious objection to dispensing an abortifacient and indicated that conscience clauses in state laws and reliTable 1
Description of the Sample (n Median Age
= 120)
gious discrimination laws offer some legal b asis fOr refusal. 13 The purpose of this study was to survey pharmaCist~ beliefs about abortion, the dispensing of abortifacients, and the refusal to provide phannaceutical care on the basis of a conscientious objection to abortion.
Methods An instrument that was originally developed by the Ameri· can Association for Marriage and Family Therapy to poll its members' attitudes concerning abortion was adapted to sur· vey pharmacists. 14 The resulting survey instrument assessed pharmacists' beliefs about abortion, public policy regarding abortion, continuing research on abortifacients, and the refusal to provide pharmaceutical care for patients who have had abortions. Using a "Yes-No-Undecided" response set, the survey was administered in 1994 and 1995 to 119 practic· ing pharmacists from a variety of practice settings. The sam· pIe consisted of pharmacists who attended continuing educa· tion sessions and volunteered to participate in the study. The respondents were made aware of the topic by the author of the survey before volunteering. The sample is a nonprobabili· ty sample, limited to western Pennsylvania and therefore prohibiting the ability to generalize results. Table 1 summarizes the demographic characteristics of the sample.
36 years
Gender Male (n = 45)
380/0
Female (n = 75)
620/0
Results
Practice Setting Hospital
450/0
Community
200/0
Long -term, managed care
300/0
Administration
20/0
Industry
30/0
Religious Affiliation Catholic
660/0
Protestant
220/0
Jewish
30/0
Agnostic
30/0
Other
60/0
Abortion Beliefs Pro-Choice
450/0
Pro-Life
430/0
Neither
120/0
Journal of the American Pharmaceutical Association
Table 2 shows the respondents' beliefs with respect to various justifications for abortion. The results indicate that over 80% of respondents could accept abortion when necessary to save a mother's life or prevent serious harm to the mother'S health; acceptance declined for reasons due to incest, rape. and birth defects (in that order). Respondents expressed little support for abortion in response to social constraints. unwanted pregnancy (without a reason), or sex selection. Table 3 describes respondents' beliefs about abortion policy. A majority of respondents believed that parents of minors seeking abortion should be notified (81.7%), that health care professionals should provide counseling about abortion as an option (7 1.3%), that a partner should be notified before a woman has an abortion (67%) , that abortion should remain a legal option (56.4%), and that government funds should no! be used for abortions (5 3.4%). Approximately 49% supported the use of tissues from aborted fetuses in some medical research. A public stance on reproductive rights by professional pharmacy organizations was opposed by 64.3%. December 1996
Vol. NS36, No. 12
Ta ble 4 ' unlmar ize ' Table 2 re 'ponden ts ' belief ' toward Justification for Abortion: Pharmacists' Beliefs abortifacients . Wh ile 5 .3% of the samp le state d t h at Approve Disapprove Undecided Belief pharmac ists h ad a rig h t to (% ) (%) (%) refuse p h a r maceu ti cal e r10.6 rices on th e basis of a con ci5.3 84. 1 Abortion is necessary to save a woman's life. (n = 113) entio us o bj ec ti o n to ab o rtion, 51 .3 % state d th at they 15.0 6.2 78.8 Woman's health is seriously endangered by pregnancy. (n = 113) themselves would n o t refuse to dispense an abo rtifacient. 14.0 15.8 70.2 Pregnancy is a result of incest. (n = 114) Thirty-eight p e rcent of th e 15.8 14.9 69.3 Pregnancy is a result of rape. (n = 114) sample believed that pharmacists had no right to refuse to 23.7 19.3 57.0 Strong probability of a birth defect. (n = 114) dispense an abortifacient on 15.9 69.0 15.0 Family cannot afford more children. (n = 113) ethical or moral grounds . More than 32 % stated that 14.9 19.3 65.8 Woman does not want more children. (n = 114) they would refuse to provide 4.4 1.8 93.9 Baby is not the sex desired by parents. (n = 114) pharmaceutical care , com63.2 23.7 pared with 29% who would Woman wants an abortion for whatever 13.2 reason. (n = 114) refuse to dispense an abortifacient on moral or ethical Note: n varies because some respondents did not answer all questions. grounds. Fifty percent of the sample believed that RU-486 and o ther abortifacients should be made available in the United States, and 42.5% beliefs in attitudes toward abortion, the Fisher Exact Test-a endorsed research to develop safe and effective chemothera- nonparametric statistic used for dichotomous data with small peutic means for abortion. More respondents (39%) disap- expected values-was calculated. Since both the number of proved of further research on abortifacients than disapproved nonreligiously oriented persons and the responses in the of making RU-486 available in the United States (32%) . Table 3 The personal significance Abortion Policy: Pharmacists' Beliefs of religious beliefs and the extent of clinical experience Belief Yes Undecided No with patients seeking abor(%) (0/0) (0/0) tions can influence beliefs Abortion should remain legal. (n = 117) 56.4 29.1 13.7 regarding abortifacients. Fiftyseven percent of the sample Government should make public funds available 27.6 19.0 53.4 of pharmacists rated the sigfor abortion. (n = 116) nificance of religious beliefs Parents of minors should be notified when children 81.7 8.7 9 .6 in their lives as very signifiseek an abortion. (n = 115) cant, 39% as somewhat signif67.0 Partner should be notified before a woman has 28.7 4.3 icant, and 4% as not signifian abortion. (n = 115) cant at all. Thirty percent of 71.3 18.3 10.4 Health care professionals should counsel regarding the sample reported having the option of abortion. (n = 115) delivered pharmaceutical 48.7 22.6 28.7 Fetal tissue from aborted fetuses should be used care (not specifically defmed for treatment of Alzheimer's disease and other in the survey) to abortion patients. (n = 115) patients, and 70% stated that 12.2 23.5 64.3 Professional pharmacy organizations should take a they have never had the public stand regarding reproductive rights/ Opportunity to provide care abortion. (n = 116) to abortion patients. Note: n varies because some respondents did not answer all questions. To analyze the effect of the ignifi cance of religious Vol. NS36, No. 12
December 1996
journal of the American Pharmaceutical Association
Table 4
Abortifacients: Pharmacists' Beliefs Belief
Ves
No
Undecided
(%)
(%)
(%)
RU- 486 and other abortifacients should be made available in the United States. (n = 114)
50.0
31.6
18.4
Research should be conducted to discover safe and effective chemotherapeutic means for abortion. (n = 113)
42.5
38.9
18.6
Does a pharmacist have a right to refuse pharmaceutical services to abortion patients on ethical or moral grounds? (n = 116)
54.3
37.9
7.9
Would you refuse to dispense RU -486 if the drug was intended to terminate pregnancy? (n = 115)
28.7
51.3
20.0
Would you refuse to provide pharmaceutical care to patients seeking an abortion on ethical or moral grounds? (n = 117)
32.5
53.0
14.5
cance of religiou s belief upon beliefs about abortion policy. No statistically significant difference was found for the effect of religious beliefs on the support for abortion as a legal option. However, the significance of religious beliefs did differentiate among those respondents who would refuse to provide pharmaceutical care and who would refuse to dispense RU-486 , and those who opposed the availability of RU-486 or opposed further research on abortifacients.
Note: n varies because some respondents did not answer all questions.
Conclusion und u
id d at
ory w r low, th r were not sufficient val11 t p rform a chi quar analysis with a threentin ncy tabl acc unting for the nonreligious id d at f th
1 r p nd nt m a uring th
The purpose of this article is not to advocate any position, but to present some limited data regarding pharmacists' beliefs about abortifacients and to use the data to raise questions that the profession and individual pharmacists may need to address as RU-486 becomes available in the United States. The results of this survey indicate that a majority of respondents could accept abortion in limited cases where serious negative consequences for the health of the mother or continTable 5
Pharmacists' Beliefs on Abortifacients and the Personal Significance of R ligious Beliefs Religious Beliefs
Abortifacient Beliefs Would refuse to provide pharmaceutical care to abortion patients. (n = 22)
Extremely Significant (n)
Somewhat Significant (n)
Ves
Ves
No
No
p
10
5
0
7
.005
9
5
0
7
.01
4
9
6
1
.05
Support further research on abortifacients. (n = 19)
3
9
7
0
.003
Abortion should remain a legal option. (n = 21)
5
9
6
Would refuse to dispense RU -486. (n Support availability of RU -486. (n
= 21)
= 20)
.06
Note: n varies because some respondents did not answer all questions.
Journal of the American Pharmaceutical Association
December 1996
Vol. NS36, No. 12
ued pregnancy due to incest or rape could be avoided. The results for birth defects were slightly more equivocal. The acceptance of abortion for reasons that appeared less compelling to respondents, such as fmancial constraints, not wanting more children, sex selection, or for no reason given, declined significantly, with the majority of respondents disapproving of abortion in these cases. These findings indicate that when respondents consider specific situations that they believe involve the prevention of serious harm, they are more likely to accept abortion as an option. When asked the general question of whether abortion should remain a legal option without qualification, only 56% of the sample agreed. Respondents did not express support for professional pharmacy organizations taking a public stand on abortion or making government funds available for abortion. These results were obtained with two-thirds of respondents identifying themselves as Catholic and 57% of all respondents rating religious beliefs as highly significant in their lives. Pharmacists in this sample supported the responsibility to counsel on the option of abortion while endorsing parental and partner notification. While there was support for pharmacists' right to refuse to dispense abortifacients, more than half the respondents stated that they themselves would not refuse. The 29% who would refuse to dispense an abortifacient is consistent with the survey in Drug Topics reporting that 28% of pharmacists in the eastern United States would refuse to dispense an abortifacient. The overall national rate of refusal in the Drug Topics survey was 36%, with pharmacists in the South having the highest rate of refusal (44%).15 However, a greater percentage of pharmacists in this study would refuse to provide pharmaceutical care than would refuse to dispense. This difference may indicate the perceived increased responsibility for patient care outcomes implied in the concept of pharmaceutical care. The act of simply dispensing a medication implies less involvement with patients and outcomes than the counseling, mOnitoring, and advocacy that forms the basis of pharmaceutical care. While the pharmacists who rated religious beliefs as extremely significant tended more often to object to offering pharmacy services to patients considering abortion and to oppose further availability of and research on abortifacients, they did not significantly differ from other respondents regarding abortion remaining a legal option. Although this study used a small, geographically restricted (western Pennsylvania), nonrepresentative sample of religiously oriented pharmacists, the fmdings demonstrate a complexity of attitudes toward abortion rarely captured by the
Vol. NS36, No. 12
December 1996
media or evident in public debates. Ethical and policy issues will become increasingly important for the profeSSion of pharmacy if abortifacients become universally available. Will the profession's organizations and regulations support the legal and ethical right of pharmacists to refuse to provide pharmaceutical services in abortion cases? What if the refusal results in a lack of availability of pharmaceutical services to patients? What position should the pharmaceutical industry take toward the production and research of abortifacients? As the public debate over reproductive rights and abortion continues, should the profession take a public stand concerning abortifacients? Hopefully, with the introduction of RU-486 in the United States, the pharmacy profession will be able to discuss these issues and accommodate the diverse values and interests in this divisive and extremely complex ethical issue in contemporary health care. Vincent Giannetti, PhD, is professor ofpharmaceutical administration, Duquesne University, Pittsburgh, Pa.
References 1. Hodgen G. Antiprogestins : the political chemistry of RU-486. Fertil Steril.1991 ;56(3):394-5. 2. Rxtra Facts. Supplement to Drug Facts and Comparisons. St. Louis: Facts and Comparisons;1996;1(1). 3. Regelson W, Luce R, Ralimi M. Beyond abortion: RU-486 and the needs of the crisis constituency. JAMA. 1990;264(8):1026-7. 4.
Birgerson L, Odlind V. The antiprogestational agent RU-486 as an abortifacient in early human pregnancy: a comparison of three dose regimens. Contraception. 1988;38(4):391-9.
5. Coyzinet B, LeStrat N, Ulmann A. et al. Termination of early pregnancy by the progesterone antagonist RU-486 (mifepristone). N Engl J Med. 1986;315(25):1565-70. 6. Cameron IT, Baird DT. Early pregnancy termination: a comparison between vacuum aspiration and medical abortion using prostaglandin or the anti progestin RU-486. Br J Obstet Gynecol. 1988;32( 1):95,275-6. 7. Peyron R, Aubeny C, Targosy V, et al. Early termination of pregnancy with mifepristone (RU-486) and the orally active prostaglandin misoprostol. N EnglJ Med.1993;328(1) :1509-13. 8. Averch 0, Golan A, Weintraub Z, et al. Mifepristone (RU-486) alone or in combination with a prostaglandin analogue for termination of early pregnancy: a review. Fertif Steril. 1991;56(3):385-93. 9. Spitz I, Bardin CWoMifepristone a modulation of progestin and glucocorticoid action. N Engl J Med. 1993;329(6):404-11. 10. Koonin LM, Smith JC, and Merrell R. Abortion Surveillance US 1990. In: CDC Surveillance Summaries December 1993. MMWR. 1993;42(S86):29-57. 11 . Rosenfield A. Mifepristone (RU-486) in the United States. N Engl J Med.1993;328(21):1560-1. 12. RU-486 to bypass pharmacies. Am Pharm. 1995;NS 35(2): 7-8. 13. Brushwood DB. Conscientious objection and abortifacient drugs. Clin Therapeut. 1993; 15( 1):204-12. 14. AAMFT adopts statement on reproductive rights . Family Therapy News. 1991;22(2). 15. What pharmacists are saying about hot topics. Drug Topics . 1995;139(10):46-8.
JOurna1 of the American Phannaceutical Association
Introduction The "political chemistry" of mifepristone (marketed for a decade in Europe as RU-486) led the Food and Drug Administration (FDA) in 1989 to declare a ban on the drug's import. Various groups had threatened a boycott of the drug's manufacturer and parent company, Hoechst-Roussel, if the drug was made available in the United States. l The ban on RU-486 was subsequently lifted in 1994, and the drug was licensed to The Population Council of New York City by the French pharmaceutical manufacturer Roussel Uclaf. Recently, the FDA advisory panel recommended approval for RU-486 for medical termination of pregnancy. The identity of the manufacturer of this drug has not been widely publicized. 2 Researchers have maintained that the import ban thwarted investigation of the potential value of RU-486 in treating Cushing's disease, meningioma, breast cancer, and viral infections, possibly depriving patients who are not seeking abortions of access to needed treatment. 3 While RU-486 may have potential therapeutic value for other conditions, the drug's main Use has been to induce abortion. RU-486 alone has been reported to be an effective abortifacient in 60% to 85% of cases for first-trimester pregnancies.4- 6 RU-486 combined With a prostaglandin administered within 49 days of the last menstrual cycle induces abortion in 95% to 99% of cases. According to the proponents of RU-486, its availability proVides the advantage of increased privacy, compensates for the decreasing availability of surgical abortion, and significantly reduces maternal morbidity and mortality associated with surgical abortion. 7,8 In France , Ru-486 is used in combination with a Prostaglandin for pregnancy termination up to the 49th day, and in that nation approximately one-third of women have chosen this regimen over surgical abortion. WorldVol. NS36, No. 12
December 1996
wide, approximately 120,000 women in 20 countries have received RU-486 together with a prostaglandin , resulting in a termination of 93% to 99% of these pregn ancies .9 In the United States, approximately 345 legal (surgical) ab ortions are performed per 1,000 live births, with 50% of abortio ns performed at or before eight weeks of gestatio n and 87% before the 13th week. In 1990 there were 1,429 ,577 abortions reported to the Centers for Disease Co n t ro l and Prevention. 10
Abstract The author conducted a survey of pharmacists ' beliefs regarding abortion and mifepristone (RU-486) to determine pharmacists' perceptions of the ethical dilemmas posed by the use of abortifacients in the United States and to determine whether and how these ethica l dilemmas affect practice. The sample was nonrandom and included religiously oriented pharmacists from a variety of practice settings, approximately two-thirds of w hom were women . The results indicated a plurality of beliefs about abortion rarely evident in the public debate. Alt hough the sample supported pharmacists' right to refuse to dispense abortifacients, slightly more than half (51 %) of the respondents stated that they themselves would not refuse to dispense abortifacients. Most responde nts (560/0) believed that abortion should remain a legal option, with slightly fewer respondents (50%) supporting the position that RU-486 should be made available in t he United States. Support for abortion was proportionate to the gravity of the reason underlying the decision to abort, with the sample tending to avoid absolutistic posit ions. These findings tend to dispel the stereotypes and myths regarding abortion beliefs in that two-thirds of the sample were Catholic and 96% of the sample rated rel igion as extremely or somewhat significant in their life.
journal of the American pharmaceutical Association
Pr p nents of the intr duction of R -486 into the United tat have predicted vigorous oppo ition to the use of this ag nt.11 If abortifacients become increasingly accepted or pre£ IT d as a method of inducing abortions, many pharmacists in th e nited States will fmd them elve facing, in their pracic , the same ethical i ue that society is grappling with. It is n t clear at this time whether community pharmacists would b involved in dispensing RU-486. For example, many community pharmacies lack a sufficiently private, confidential environment. Pharmacists working in clinical settings may be m o re likely to be involved in dispensing RU-486. 12 Although the political and moral issues surrounding abortion have led to a vigorous national debate, there has b een relatively little discussion of the topic in the pharmacy profession. While some professional organizations, such as the American Public Health Association and the National As ociation of Social Workers, have taken public stands on the issue of reproductive rights , professional pharmacy organizations have not done so. Moreover, little has been published in the pharmacy literature regarding the ethical dilemmas facing the pharmacist who has strong religious beliefs in opposition to abortion. However, Brushwood reviewed the legal literature regarding the right to assert a c onscientious objection to dispensing an abortifacient and indicated that conscience clauses in state laws and reliTable 1
Description of the Sample (n Median Age
= 120)
gious discrimination laws offer some legal b asis fOr refusal. 13 The purpose of this study was to survey pharmaCist~ beliefs about abortion, the dispensing of abortifacients, and the refusal to provide phannaceutical care on the basis of a conscientious objection to abortion.
Methods An instrument that was originally developed by the Ameri· can Association for Marriage and Family Therapy to poll its members' attitudes concerning abortion was adapted to sur· vey pharmacists. 14 The resulting survey instrument assessed pharmacists' beliefs about abortion, public policy regarding abortion, continuing research on abortifacients, and the refusal to provide pharmaceutical care for patients who have had abortions. Using a "Yes-No-Undecided" response set, the survey was administered in 1994 and 1995 to 119 practic· ing pharmacists from a variety of practice settings. The sam· pIe consisted of pharmacists who attended continuing educa· tion sessions and volunteered to participate in the study. The respondents were made aware of the topic by the author of the survey before volunteering. The sample is a nonprobabili· ty sample, limited to western Pennsylvania and therefore prohibiting the ability to generalize results. Table 1 summarizes the demographic characteristics of the sample.
36 years
Gender Male (n = 45)
380/0
Female (n = 75)
620/0
Results
Practice Setting Hospital
450/0
Community
200/0
Long -term, managed care
300/0
Administration
20/0
Industry
30/0
Religious Affiliation Catholic
660/0
Protestant
220/0
Jewish
30/0
Agnostic
30/0
Other
60/0
Abortion Beliefs Pro-Choice
450/0
Pro-Life
430/0
Neither
120/0
Journal of the American Pharmaceutical Association
Table 2 shows the respondents' beliefs with respect to various justifications for abortion. The results indicate that over 80% of respondents could accept abortion when necessary to save a mother's life or prevent serious harm to the mother'S health; acceptance declined for reasons due to incest, rape. and birth defects (in that order). Respondents expressed little support for abortion in response to social constraints. unwanted pregnancy (without a reason), or sex selection. Table 3 describes respondents' beliefs about abortion policy. A majority of respondents believed that parents of minors seeking abortion should be notified (81.7%), that health care professionals should provide counseling about abortion as an option (7 1.3%), that a partner should be notified before a woman has an abortion (67%) , that abortion should remain a legal option (56.4%), and that government funds should no! be used for abortions (5 3.4%). Approximately 49% supported the use of tissues from aborted fetuses in some medical research. A public stance on reproductive rights by professional pharmacy organizations was opposed by 64.3%. December 1996
Vol. NS36, No. 12
Ta ble 4 ' unlmar ize ' Table 2 re 'ponden ts ' belief ' toward Justification for Abortion: Pharmacists' Beliefs abortifacients . Wh ile 5 .3% of the samp le state d t h at Approve Disapprove Undecided Belief pharmac ists h ad a rig h t to (% ) (%) (%) refuse p h a r maceu ti cal e r10.6 rices on th e basis of a con ci5.3 84. 1 Abortion is necessary to save a woman's life. (n = 113) entio us o bj ec ti o n to ab o rtion, 51 .3 % state d th at they 15.0 6.2 78.8 Woman's health is seriously endangered by pregnancy. (n = 113) themselves would n o t refuse to dispense an abo rtifacient. 14.0 15.8 70.2 Pregnancy is a result of incest. (n = 114) Thirty-eight p e rcent of th e 15.8 14.9 69.3 Pregnancy is a result of rape. (n = 114) sample believed that pharmacists had no right to refuse to 23.7 19.3 57.0 Strong probability of a birth defect. (n = 114) dispense an abortifacient on 15.9 69.0 15.0 Family cannot afford more children. (n = 113) ethical or moral grounds . More than 32 % stated that 14.9 19.3 65.8 Woman does not want more children. (n = 114) they would refuse to provide 4.4 1.8 93.9 Baby is not the sex desired by parents. (n = 114) pharmaceutical care , com63.2 23.7 pared with 29% who would Woman wants an abortion for whatever 13.2 reason. (n = 114) refuse to dispense an abortifacient on moral or ethical Note: n varies because some respondents did not answer all questions. grounds. Fifty percent of the sample believed that RU-486 and o ther abortifacients should be made available in the United States, and 42.5% beliefs in attitudes toward abortion, the Fisher Exact Test-a endorsed research to develop safe and effective chemothera- nonparametric statistic used for dichotomous data with small peutic means for abortion. More respondents (39%) disap- expected values-was calculated. Since both the number of proved of further research on abortifacients than disapproved nonreligiously oriented persons and the responses in the of making RU-486 available in the United States (32%) . Table 3 The personal significance Abortion Policy: Pharmacists' Beliefs of religious beliefs and the extent of clinical experience Belief Yes Undecided No with patients seeking abor(%) (0/0) (0/0) tions can influence beliefs Abortion should remain legal. (n = 117) 56.4 29.1 13.7 regarding abortifacients. Fiftyseven percent of the sample Government should make public funds available 27.6 19.0 53.4 of pharmacists rated the sigfor abortion. (n = 116) nificance of religious beliefs Parents of minors should be notified when children 81.7 8.7 9 .6 in their lives as very signifiseek an abortion. (n = 115) cant, 39% as somewhat signif67.0 Partner should be notified before a woman has 28.7 4.3 icant, and 4% as not signifian abortion. (n = 115) cant at all. Thirty percent of 71.3 18.3 10.4 Health care professionals should counsel regarding the sample reported having the option of abortion. (n = 115) delivered pharmaceutical 48.7 22.6 28.7 Fetal tissue from aborted fetuses should be used care (not specifically defmed for treatment of Alzheimer's disease and other in the survey) to abortion patients. (n = 115) patients, and 70% stated that 12.2 23.5 64.3 Professional pharmacy organizations should take a they have never had the public stand regarding reproductive rights/ Opportunity to provide care abortion. (n = 116) to abortion patients. Note: n varies because some respondents did not answer all questions. To analyze the effect of the ignifi cance of religious Vol. NS36, No. 12
December 1996
journal of the American Pharmaceutical Association
Table 4
Abortifacients: Pharmacists' Beliefs Belief
Ves
No
Undecided
(%)
(%)
(%)
RU- 486 and other abortifacients should be made available in the United States. (n = 114)
50.0
31.6
18.4
Research should be conducted to discover safe and effective chemotherapeutic means for abortion. (n = 113)
42.5
38.9
18.6
Does a pharmacist have a right to refuse pharmaceutical services to abortion patients on ethical or moral grounds? (n = 116)
54.3
37.9
7.9
Would you refuse to dispense RU -486 if the drug was intended to terminate pregnancy? (n = 115)
28.7
51.3
20.0
Would you refuse to provide pharmaceutical care to patients seeking an abortion on ethical or moral grounds? (n = 117)
32.5
53.0
14.5
cance of religiou s belief upon beliefs about abortion policy. No statistically significant difference was found for the effect of religious beliefs on the support for abortion as a legal option. However, the significance of religious beliefs did differentiate among those respondents who would refuse to provide pharmaceutical care and who would refuse to dispense RU-486 , and those who opposed the availability of RU-486 or opposed further research on abortifacients.
Note: n varies because some respondents did not answer all questions.
Conclusion und u
id d at
ory w r low, th r were not sufficient val11 t p rform a chi quar analysis with a threentin ncy tabl acc unting for the nonreligious id d at f th
1 r p nd nt m a uring th
The purpose of this article is not to advocate any position, but to present some limited data regarding pharmacists' beliefs about abortifacients and to use the data to raise questions that the profession and individual pharmacists may need to address as RU-486 becomes available in the United States. The results of this survey indicate that a majority of respondents could accept abortion in limited cases where serious negative consequences for the health of the mother or continTable 5
Pharmacists' Beliefs on Abortifacients and the Personal Significance of R ligious Beliefs Religious Beliefs
Abortifacient Beliefs Would refuse to provide pharmaceutical care to abortion patients. (n = 22)
Extremely Significant (n)
Somewhat Significant (n)
Ves
Ves
No
No
p
10
5
0
7
.005
9
5
0
7
.01
4
9
6
1
.05
Support further research on abortifacients. (n = 19)
3
9
7
0
.003
Abortion should remain a legal option. (n = 21)
5
9
6
Would refuse to dispense RU -486. (n Support availability of RU -486. (n
= 21)
= 20)
.06
Note: n varies because some respondents did not answer all questions.
Journal of the American Pharmaceutical Association
December 1996
Vol. NS36, No. 12
ued pregnancy due to incest or rape could be avoided. The results for birth defects were slightly more equivocal. The acceptance of abortion for reasons that appeared less compelling to respondents, such as fmancial constraints, not wanting more children, sex selection, or for no reason given, declined significantly, with the majority of respondents disapproving of abortion in these cases. These findings indicate that when respondents consider specific situations that they believe involve the prevention of serious harm, they are more likely to accept abortion as an option. When asked the general question of whether abortion should remain a legal option without qualification, only 56% of the sample agreed. Respondents did not express support for professional pharmacy organizations taking a public stand on abortion or making government funds available for abortion. These results were obtained with two-thirds of respondents identifying themselves as Catholic and 57% of all respondents rating religious beliefs as highly significant in their lives. Pharmacists in this sample supported the responsibility to counsel on the option of abortion while endorsing parental and partner notification. While there was support for pharmacists' right to refuse to dispense abortifacients, more than half the respondents stated that they themselves would not refuse. The 29% who would refuse to dispense an abortifacient is consistent with the survey in Drug Topics reporting that 28% of pharmacists in the eastern United States would refuse to dispense an abortifacient. The overall national rate of refusal in the Drug Topics survey was 36%, with pharmacists in the South having the highest rate of refusal (44%).15 However, a greater percentage of pharmacists in this study would refuse to provide pharmaceutical care than would refuse to dispense. This difference may indicate the perceived increased responsibility for patient care outcomes implied in the concept of pharmaceutical care. The act of simply dispensing a medication implies less involvement with patients and outcomes than the counseling, mOnitoring, and advocacy that forms the basis of pharmaceutical care. While the pharmacists who rated religious beliefs as extremely significant tended more often to object to offering pharmacy services to patients considering abortion and to oppose further availability of and research on abortifacients, they did not significantly differ from other respondents regarding abortion remaining a legal option. Although this study used a small, geographically restricted (western Pennsylvania), nonrepresentative sample of religiously oriented pharmacists, the fmdings demonstrate a complexity of attitudes toward abortion rarely captured by the
Vol. NS36, No. 12
December 1996
media or evident in public debates. Ethical and policy issues will become increasingly important for the profeSSion of pharmacy if abortifacients become universally available. Will the profession's organizations and regulations support the legal and ethical right of pharmacists to refuse to provide pharmaceutical services in abortion cases? What if the refusal results in a lack of availability of pharmaceutical services to patients? What position should the pharmaceutical industry take toward the production and research of abortifacients? As the public debate over reproductive rights and abortion continues, should the profession take a public stand concerning abortifacients? Hopefully, with the introduction of RU-486 in the United States, the pharmacy profession will be able to discuss these issues and accommodate the diverse values and interests in this divisive and extremely complex ethical issue in contemporary health care. Vincent Giannetti, PhD, is professor ofpharmaceutical administration, Duquesne University, Pittsburgh, Pa.
References 1. Hodgen G. Antiprogestins : the political chemistry of RU-486. Fertil Steril.1991 ;56(3):394-5. 2. Rxtra Facts. Supplement to Drug Facts and Comparisons. St. Louis: Facts and Comparisons;1996;1(1). 3. Regelson W, Luce R, Ralimi M. Beyond abortion: RU-486 and the needs of the crisis constituency. JAMA. 1990;264(8):1026-7. 4.
Birgerson L, Odlind V. The antiprogestational agent RU-486 as an abortifacient in early human pregnancy: a comparison of three dose regimens. Contraception. 1988;38(4):391-9.
5. Coyzinet B, LeStrat N, Ulmann A. et al. Termination of early pregnancy by the progesterone antagonist RU-486 (mifepristone). N Engl J Med. 1986;315(25):1565-70. 6. Cameron IT, Baird DT. Early pregnancy termination: a comparison between vacuum aspiration and medical abortion using prostaglandin or the anti progestin RU-486. Br J Obstet Gynecol. 1988;32( 1):95,275-6. 7. Peyron R, Aubeny C, Targosy V, et al. Early termination of pregnancy with mifepristone (RU-486) and the orally active prostaglandin misoprostol. N EnglJ Med.1993;328(1) :1509-13. 8. Averch 0, Golan A, Weintraub Z, et al. Mifepristone (RU-486) alone or in combination with a prostaglandin analogue for termination of early pregnancy: a review. Fertif Steril. 1991;56(3):385-93. 9. Spitz I, Bardin CWoMifepristone a modulation of progestin and glucocorticoid action. N Engl J Med. 1993;329(6):404-11. 10. Koonin LM, Smith JC, and Merrell R. Abortion Surveillance US 1990. In: CDC Surveillance Summaries December 1993. MMWR. 1993;42(S86):29-57. 11 . Rosenfield A. Mifepristone (RU-486) in the United States. N Engl J Med.1993;328(21):1560-1. 12. RU-486 to bypass pharmacies. Am Pharm. 1995;NS 35(2): 7-8. 13. Brushwood DB. Conscientious objection and abortifacient drugs. Clin Therapeut. 1993; 15( 1):204-12. 14. AAMFT adopts statement on reproductive rights . Family Therapy News. 1991;22(2). 15. What pharmacists are saying about hot topics. Drug Topics . 1995;139(10):46-8.
JOurna1 of the American Phannaceutical Association