DIFFICULT MORAL QUESTIONS
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Question 83: May pharmacists dispense pills to be used for ending human lives?
I am a pharmacist working in a large chain drugstore. Part of my job is to keep an eye out for circumstances in which there might be some reason for not filling a prescription, but otherwise I am expected to dispense whatever is prescribed. That includes birth control pills, although I reject contraception. Knowing that the pills have an abortifacient dimension, I have not liked doing this. But theologians usually faithful to the Church’s teaching have said it is acceptable material cooperation, and so I have done it. It would be virtually impossible to work as a pharmacist otherwise unless one owned the store. Today very few pharmacists can do that, and most, like me, are simply employees.
Still, I am worried about future developments. I feel sure that eventually abortion pills will be available by prescription, and probably suicide pills as well. In most ways, this does not seem to me to differ much from dispensing contraceptive pills, but my gut feeling is that it is much worse, and I cannot see myself doing it. What should I do if my fears are realized?
One other thing worries me. I know that prescriptions for birth control pills sometimes are being written with instructions regarding dosage and timing that make it clear they are being prescribed as morning-after pills. Physicians around here do not seem to be doing this, and up to now I have not been asked to fill such a prescription. But I expect I will be sooner or later. What should I do when that happens?
Analysis:
This question concerns problems of cooperation with wrongdoing, which must be treated by applying the usual criteria. Dispensing contraceptives is at odds with a pharmacist’s professional commitment rightly understood. In my judgment, a pharmacist who owns his or her own pharmacy engages in morally unacceptable cooperation in stocking and selling contraceptives or any other merchandise customers could want only for some objectively immoral use. However, when pharmacists who do not own their own business dispense drugs, even those that sometimes are abortifacient, for use as contraceptives, they can be engaging in morally acceptable material cooperation. The wrong of using abortion and suicide pills would be greater and more obvious than the wrong of using contraceptive drugs. Though pharmacists’ cooperation in the killing could remain strictly material, it would, in my judgment, be morally unacceptable even for employee-pharmacists. The very grave injustice of abortion grounds an especially cogent case against dispensing abortion pills. Dispensing contraceptive drugs for use as morning-after pills would involve material cooperation in their use with the twofold intention of preventing conception and preventing implantation—and so with a conditional intent to kill. This cooperation, in my judgment, would be morally similar to that involved in dispensing a drug specifically designed for killing. Rather than dispense either sort of drug, pharmacists should, I believe, give up their profession if necessary.
The reply could be along the following lines:
Serving alongside physicians, nurses, dentists, and so on, members of your profession make an important contribution to meeting people’s health care needs. That is why you rightly “keep an eye out for circumstances in which there might be some reason for not filling a prescription.” As your profession’s official ethics code makes clear, you have not undertaken merely to be a salesperson who dispenses drugs, while taking care to avoid mistakes, in order to make an honest living. You also have undertaken to help those you serve “achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.”266 Therefore, you should watch out for inappropriate or incompatible prescriptions and normally should do what you can to educate people who come to you, so that they will use prescribed drugs as directed and be alert for dangerous side effects. When possible, you also should offer prudent advice concerning nonprescription medications, discourage people from overmedicating with them, and try to offset excessive and misleading advertising claims.
Since at least some pills usually prescribed for contraception also can be used both in ways that certainly are morally acceptable and as morning-after pills, I shall first deal with cases in which you know the drug is being prescribed for use as a contraceptive, though it also sometimes acts as an abortifacient. Then I shall treat your question about dispensing drugs specifically designed for abortion and suicide when they are plainly prescribed for those purposes. Finally, I shall treat your question about dispensing contraceptive drugs for use as morning-after pills.
In dispensing contraceptive pills and encouraging women to use them effectively, your colleagues who see nothing wrong with contraception doubtless think they are acting in accord with pharmacists’ professional commitment to the welfare of those they serve. However, like the use of abortion pills and suicide pills, the use of contraceptives is contrary to the good of human life. Of course, contraceptives sometimes are used to prevent pregnancies that should be avoided, and those who suppose that a good end can be a proportionate reason for choosing to prevent life judge that in such cases encouraging women to use contraceptives effectively really does promote their welfare. However, such judgments about welfare overlook the implications for human welfare adequately understood, which includes moral goodness, of choosing—and approving or sharing in others’ choices—to prevent human life or, more generally, to destroy, damage, or impede any good intrinsic to human persons. There can be no proportionate reason for making such a choice (see CMP, 141–71). And using contraceptives never effectively promotes anyone’s true welfare. So, providing contraceptives of any kind is not in accord, but rather at odds, with your professional commitment rightly understood. That is especially clear when you dispense contraceptive drugs that, though primarily meant to prevent conception, sometimes work as abortifacients. You are right to dislike doing this, for it not only reduces you to the role of a salesperson who dispenses drugs, but makes you reluctantly play a part in ending some incipient human lives.
What about the advice some theologians have given you—dispensing birth control pills is acceptable material cooperation for a pharmacist? I think a distinction should be made between pharmacists who own their own businesses and those who do not.
In my judgment, if you owned your own pharmacy, it would be wrong for you to dispense contraceptives or sell any other merchandise (such as pornographic magazines and books) that customers could want only for some objectively immoral use. Intending customers’ use of such products would be willing their wrongful acts, and the owner of a business usually promotes sales and always intends the use of whatever is promoted. Still, in filling prescriptions for contraceptives, a pharmacy owner might be able to avoid sharing the will that they be used, since he or she does not lead the purchaser to take the drug; that decision already has been made by the patient and the prescribing physician. But even if pharmacy owners who sell products they know will be put to a morally unacceptable use can avoid intending their use, they still should forgo such sales. Even their material cooperation is unjustifiable, not least because it inevitably tempts them to cooperate formally by promoting the use of such profitable products. Moreover, in dispensing birth control pills, as has been explained, the pharmacist acts at odds with his or her professional commitment and becomes a mere salesperson who dispenses drugs. Pharmacists who own their own pharmacies are less likely than those who are “simply employees” to be considered mere salespersons. So, their action in dispensing birth control pills is certain to undercut their witness to the truth that one should not use these drugs, and also is likely to cause scandal by contributing to users’ rationalizations.
In some places even pharmacists who do not own the business but are employees, as you are, can practice their profession without dispensing contraceptive drugs; either the employer has a policy of not stocking contraceptives or respects the consciences of employees who object to filling prescriptions for contraceptive drugs. In such a situation, a pharmacist should bear witness by refusing to dispense contraceptives. However, where there is no such opportunity, I think it possible that in dispensing contraceptives employee-pharmacists can avoid morally unacceptable cooperation.
Because employee-pharmacists normally have no responsibility for advertising and other forms of promotion, they avoid intending the use of the drugs they dispense more easily than owners do. Moreover, the material cooperation of employee-pharmacists who reluctantly dispense contraceptive drugs probably can be morally acceptable. If they clearly recognize the evil of using the drugs and wish to avoid wrongly cooperating, they are not likely to be tempted to cooperate formally. The risk of scandal also can be minimal, because the woman whose prescription is filled has already decided to use the pill and filling the prescription is hardly likely to lead anyone else to decide to use it. Then too, filling prescriptions for contraceptive pills is consistent with plausibly bearing witness to the evil of contraception, since people do not suppose that employee-pharmacists personally recommend or approve the use of everything they dispense. And refusing to dispense contraceptive pills so as to bear witness against their abortifacient dimension is hardly likely to be effective. Since the pills generally are not being used with the intention of causing abortion, their occasional, invisible abortifacient effect would not trouble most people, even if it were fully explained to them. Finally, the pill’s abortifacient dimension does not render the employee-pharmacist’s material cooperation with its use unfair to the unborn. Since most pharmacists dispense the pill and hardly anyone who uses it is likely to be concerned about its abortifacient dimension, refusing to dispense it is not likely to save lives.
In dispensing contraceptive pills, however, if you have reason to think pointing out the possibly abortifacient mode of action of a prescribed contraceptive might deter a particular purchaser from using it, you should point out and explain the language in the package insert indicating that possibility. Moreover, you must never fulfill the pharmacist’s usual responsibility of encouraging effective use of the drug. In this case, you cannot have such a responsibility, for you could not encourage effective use of contraceptive pills without intending that they be used effectively, and that intent, being contraceptive, would be evil. But you should keep an eye out, as usual, for contraindications the prescribing physician may have overlooked, and alert purchasers to side effects that may require the physician’s attention. When you can do so without risking your job, you also should throw away or put out of sight displays and other materials advertising contraceptives and promoting their use.
Someone might suggest that, rather than filling the prescription for a drug you know is being prescribed for contraception, you should contact the prescribing physician, just as you would about any other prescription of a drug likely to harm the user and perhaps even kill her unborn child. Unless you thought the physician had made a mistake, however, contacting him or her would be pointless, since the moral question that concerns us does not trouble the prescribing physician.
I believe you are right in thinking that dispensing abortion or suicide pills would be similar in important respects to dispensing contraceptive drugs. Your cooperation would differ in similar ways from the cooperation of the physician prescribing the drugs, and, as an employee-pharmacist, you could easily avoid formal cooperation. Moreover, I believe that your material cooperation would be no more likely to tempt you to cooperate formally. But I also think your gut feeling is right—dispensing abortion or suicide pills would be worse than dispensing contraceptives.
Though the wrong involved in contraceptives’ use (the evil of contraception and the risk of an abortifacient effect) is grave, it is less obvious and less certain than the wrong involved in using abortion or suicide pills (the evil of intending to kill and the virtual certainty that the drug will be effective). While the limited material cooperation of the employee-pharmacist in the former evil can be morally acceptable, that is hardly the case with similar material cooperation in the latter, more obvious and more certain evil. Dispensing drugs specifically designed to kill would be plainly contrary to a pharmacist’s proper role and professional commitment. Therefore, dispensing abortion and suicide pills would more likely convey the pharmacist’s approval and undercut his or her prolife witness.
Moreover, even if most pharmacists will dispense pills specifically designed to kill, with the result that people who want them will be able to get them elsewhere, refusing to fill prescriptions for these drugs would bear significant witness to the truth about them. Their sole intended effect will be to kill, and clearheaded users will have that intention. Pointing out the evil of using them, and if necessary sacrificing one’s livelihood to do so, will call those planning to use them to repent and those tempted, to resist. At least with respect to abortion pills, bearing witness in this way will be, in my judgment, a strict obligation for pharmacists. Putting oneself in the place of innocent and defenseless unborn persons, one can hardly deny the duty to do what one can to save at least a few of their lives. And putting oneself in the place of potential suicides, who might die in mortal sin, one can hardly doubt that Christian mercy calls for considerable sacrifice to save at least some of their souls.
When drugs usually used for contraception are prescribed for genuinely therapeutic purposes, your moral responsibility is determined by the drug’s use rather than by its pharmacological characteristics. Similarly, when you are asked to dispense drugs usually used for contraception prescribed as morning-after pills, your moral responsibility will be determined by the precise intention with which they are prescribed and used. But while the phrase, morning-after pills, indicates that the drug is to be used after intercourse, it does not specify whether the intention is to prevent pregnancy by preventing conception (as contraceptive pills generally do) or by preventing either conception or the implanting of the early embryo in the uterus, as the case may be. Even if some slight chance that the drug might prevent implantation is accepted by the prescribing physician and/or user, pills to be taken after intercourse with the reasonable expectation and intention of preventing conception would not, in my judgment, pose for you a problem different from that posed by the common use of the contraceptive pill.267 However, the medical literature and discussion in the mass media may make it clear that physicians who prescribe morning-after pills and women who use them typically mean to do whatever is necessary to prevent pregnancy, and so act with a twofold intention: to prevent conception when that is possible and, if it is too late, to prevent the implantation of the early embryo.268 That, I take it, is the situation you anticipate and ask about toward the end of your question. In that situation, you will have to assume that any prescription presented to you for a morning-after pill will pose the problem of helping implement an abortifacient intention.
No factual evidence or philosophical argument provides reasonable grounds for denying that the new human individuals who sometimes will be intentionally killed by morning-after pills are tiny persons. The Church clearly and most firmly teaches that such an individual must be regarded as a new human being, whose “rights as a person must be recognized, among which in the first place is the inviolable right of every innocent human being to life.”269 So, when contraceptive pills are used as morning-after pills, one of their intended effects is to kill an individual who must be regarded as a person, and those who prescribe and use them with the twofold intention explained above intend what should be considered homicide. Therefore, if you dispense morning-after pills, you will knowingly help people commit intentional homicide.
What, then, should you do if you are asked to dispense them? You should, in my judgment, draw the line at this and refuse. Though those acting with the conditional abortifacient intention will be unaware of the instances in which the condition is fulfilled, their wills will be morally similar to those of people who prescribe and use drugs specifically designed to kill. Thus, there is the same possibility and need for witness to the truth about the morning-after pill as about drugs specifically designed to kill, and the duty to try to save lives also is similar.
Someone might object that, even if dispensing morning-after pills is similar in the way explained to dispensing pills specifically designed for abortion, filling a prescription for morning-after pills could be morally acceptable material cooperation. The argument would be that the woman taking the pill seldom will be pregnant, never will know that she is, and very often either will not understand that taking the pill will prevent the implantation of a new individual or will not agree that the new individual is a person. But these subjective factors in no way affect the fact that whenever the morning-after pill prevents implantation a tiny person dies. Moreover, the very factors that might prevent or lessen guilt for the killing also facilitate rationalization and self-deception, which can impede repentance for doing something confusedly recognized as gravely wrong. Thus, witness to the truth about morning-after pills is no less morally required—and perhaps even more so—than is witness to the truth about drugs specifically designed to kill. Therefore, the differences between the two do not imply that the material cooperation with killing involved in dispensing morning-after pills can be morally acceptable.
You may be able to avoid dispensing pills specifically designed to kill and morning-after pills by finding employment in a pharmacy whose owner either will not stock them or will respect a conscientious objection to dispensing them. If not, you must, in my judgment, refuse to dispense them, explain why, and, if necessary, give up your profession.
Since that plainly would be a great sacrifice, you should try to organize other pharmacists to work together—and in cooperation with other health care professionals—to obtain provisions in relevant laws, governmental regulations, and codes of professional ethics to exempt individuals who regard intentional killing as wrong from cooperating in this growing evil.270 I do not believe that this effort’s objective should be the kind of conscience clause that would wrongly suggest that some special moral or religious ground is needed to justify refusing to participate in killing the innocent. Rather, the objective should be language guaranteeing the full freedom of anyone and everyone to choose not to participate in any way in such killing (see q. 79, above). Morally speaking, that freedom requires no justification, and those who rightly desire to exercise it should resist demands to offer any.
Considering the great need for such protections, you and other health care professionals have a serious and urgent responsibility to work for them. Do not delay in getting to work. I hope your effort will be successful.
266. American Pharmaceutical Association, Code of Ethics for Pharmacists (27 Oct. 1994), I.
268. See, e.g., Leon Jaroff, “Rx: ‘Morning After’ Pills,” Time, 148:4 (15 July 1996): 59.
269. John Paul II, Evangelium vitae, 60, AAS 87 (1995) 469, OR, 5 Apr. 1995, xii; cf. LCL, 495–98.
270. On the right to opt out, see Evangelium vitae, 74, AAS 487–88, OR, xiv.