General Articles

Prescriptions Denied: Refusal Clauses Affect Women’s Access to Legally Prescribed Medications

A number of recent reports suggest that pharmacists across the country are refusing to fill prescriptions for hormonal contraception. These pharmacists are basing their decisions on "refusal clauses," a combination of federal, state, and private pharmacy policies that give pharmacists the right to refuse legally prescribed medications based on their personal convictions. Advocates of reproductive and sexual health argue that women’s health and private medical decisions are taking a back seat to individuals’ religious beliefs.

Examples from Texas

In a recently reported case, a woman who was visiting her mother in Fabens, Texas, tried to have her prescription filled at the local Medicine Shoppe, a private pharmacy in Fabens. She was stunned to find that the pharmacist behind the counter refused to fill her prescription. According to the El Paso Times who reported the incident, the pharmacist holds strong religious beliefs and was influenced by a radio show that described birth control pills as "abortifacient." The pharmacist explained, "I fill some prescriptions for the pill, as long as it is used for menopause or other medical reasons besides birth control."1

Another incident occurred in North Richland Hills, Texas, when a second-grade teacher and mother of two was denied her birth control prescription at CVS because of the pharmacist’s "personal belief." A CVS spokesperson responded, "We recognize that, in very limited circumstances, a pharmacist may have a deeply held personal belief regarding a certain medication, and we would respect their belief in that particular instance. . . However, our pharmacists have a responsibility to ensure that our customers are able to obtain their medications."2

Hormonal Contraceptives Widely Accepted

Hormonal contraceptives, or the pill, as it is most commonly known, was approved as a family planning method by the U.S. Federal Drug Administration in 1960 and is currently used by an estimated 12 million women in the United States.3 Today the pill is covered in over 95% of employment-based insured health plans (up from 59% in 1993.)4

Despite the medical safety and mainstream acceptance of the pill, advocates say that some pharmacists seem newly emboldened to act on their "moral principals" by refusing to dispense this and other medications. According to The Guttmacher Report, "this campaign to expand refusal rights threatens the ability of governments, communities and private organizations to protect patients’ access to information and care."5

Refusal Clauses

Pharmacists who refuse to fill prescriptions based on their own personal beliefs are protected by refusal clauses that were first established 30 years ago. After Roe v. Wade recognized a woman’s right to make the private decision as to whether or not to terminate a pregnancy, anti-choice advocates began state-level campaigns to erode the constitutional right to choose. One tactic was to establish refusal clauses that allow doctors and health institutions who do not want to perform or provide abortions to deny women the medical service if they held personal or religious convictions against the procedure.

This right to refuse medical attention based on one’s personal beliefs has expanded over the years and now includes the right to refuse to provide sterilization and contraceptive services. According to The Alan Guttmacher Institute’s State Policies in Brief, "almost every state has a policy explicitly allowing some health care professionals or institutions to refuse to provide or participate in some types of reproductive health care, such as abortion, contraceptive services or sterilization services."6 Twelve states are currently cited as having specific state laws allowing health care providers to deny contraceptive services.7

Refusal clauses are also being expanded on the federal level. In July, Representative Dave Weldon (R-FL) proposed an amendment to the Fiscal Year 2005 Labor-HHS-Education Appropriations bill that would broaden the current right of doctors and hospitals to refuse to provide abortions for moral or religious reasons. The amendment, which is included in the House-passed version of the appropriations bill, states that funding for federal, state, or local programs that support any health care entity (including doctors, hospitals, and insurers) will be ended if the program "discriminates" against health care providers by requiring them to "provide, pay for, provide coverage of, or refer for abortions." In other words, states that protect access to abortion could be found guilty of discrimination and thus would forfeit all federal funds available through the FY 2005 Labor, Health and Human Services and Education Appropriations bill.

The National Women’s Law Center explains that, "anti-choice extremists could argue that ‘abortion’ includes various forms of contraception, such as the birth-control pill, IUD and emergency contraception, despite the conclusion of both the scientific and medical communities that these forms of birth control do not cause abortion, and thus argue that ‘health care institutions’ can refuse to provide or cover them as well."8

SIECUS is also concerned about these new laws, Bill Smith, director of public policy explained, "Yet again, women’s basic, fundamental health care and decision-making is being judged and subjugated by individuals’ personal, religious beliefs."


  1. D. W. Valdez, "Fabens pharmacist won’t fill orders for birth control pills," El Paso Times. July 29, 2004.
  2. B. Tinsley, "Pharmacist Refuses Birth Control Prescription in North Richland Hills, Texas," The Miami Herald. March 31, 2004.
  3. C. Bollinger, "Access Denied," Prevention Magazine. July 2, 2004.
  4. A. Sonfield et al., "U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002," Perspectives on Sexual and Reproductive Health, 2004, 36(2):72-79. It should be noted that employment-based insured health plans make up roughly half of the private-sector, employer sponsored insurance market. This study does not include "self-insure" employer coverage, where employers pay directly for employee health care.
  5. A. Sonfield, "New Refusal Clauses Shatter Balance Between Provider ‘Conscience,’ Patient Needs," The Guttmacher Report, Vol. 7, No. 3. August 2004.
  6. State Policies in Brief: Refusing to Provide Health Services, (New York, NY: The Alan Guttmacher Institute, August 1, 2004).
  7. Ibid. The twelve states are: Arkansas, Colorado, Florida, Illinois, Maine, Massachusetts, Mississippi, New Jersey, South Dakota, Tennessee, Virginia, and Washington.
  8. The Federal Refusal Clause Amendment: An Attack on Hard-Won Federal and State Protections Preserving a Woman’s Right to Choose, (Washington, DC: The National Women’s Law Center, August 2004).