SAAHIP Position Paper on the Pharmacist’s Role
in Termination of Pregnancy

Since the implementation of the Choice on Termination of Pregnancy Act in February 1997, many pharmacists have been confronted with a new ethical dilemma – whether or not they can or should be involved in the provision of the services made possible by the Act. The need for this position paper arose from a request by a SAAHIP member who brought to the attention of the National Executive an apparent anomaly in the way State-employed pharmacists were directed to act. However, this issue is not peculiar to State pharmacists, and could as easily apply to those in the employ of any organisation, whether public or private.

The bare facts of the issue are as follows: the Choice on Termination of Pregnancy Act, while guaranteeing access to the procedure for women, specifically allows health workers (including pharmacists) to exercise their rights to conscientious objection, based on religious or moral grounds. That should, in the case of State employees, be interpreted together with the stipulation in the Code of Conduct of the Public Service that requires civil servants to "loyally" execute the policies of the government of the day, but with the proviso that these should be in line with "all statutory and other prescripts". A direct contradiction might be apparent here, in that on the one hand the rights of the health worker are vouchsafed by the Act, but the intention of the Public Service is clearly to enable government to provide the services made possible by its policies. Whether the policy is correct or not is beyond the scope of the present deliberation.

This position paper does not, in addition, concern itself with the equally vexing question of "off-label" use of drugs, such as misoprostol. That topic, which relies to a greater extent on purely legal arguments, deserves attention in its own right, divorced from the contentious issue of abortion.

One possible answer to the problem would be to take a simple legalistic view of the issue. Thus it could be argued that, while the "policy" of the government of the day is to allow patients the choice to terminate their pregnancies under certain conditions, the specific "statutory" provision allows for health workers to disassociate themselves from this practice. The Code of Conduct should therefore not be seen as allowing coercion of health workers. It remains to be seen whether this issue will be pursued with new applicants as opposed to those already in the service. The employment policy of the State might be to ask applicants in advance to specify their views on such contentious issues, and to restrict employment to those willing to comply with government policy.

The very nature of ethical conundrums is that they are not amenable to simplistic solutions, and this question is no exception. Russell and Butler, in a series of articles in Modern Pharmacy (January and March 1995) characterised ethical questions as "inherently perplexing", involving "conflicts of values", but also as having a "profound and far-reaching effect on several areas of human concern".

This question would seem to fit the bill. It represents a conflict between two apparently irreconcilable viewpoints. On the one hand are those who believe that life begins at conception and that the foetus has a morally significant claim to life. At the other extreme are those who believe that the foetus is not a person, that life begins at birth. In between are those who see the foetus as a potential person, with life beginning sometime during pregnancy. They would see the foetus and the mother as having rights, the weight of each changing as the pregnancy proceeds.

The question also represents the collision of two approaches to ethics. Those who might be portrayed as pro-choice utilise a consequentialist or utilitarian approach to ethics, in that they seek to maximise the good consequences of their actions and are guided by consideration of the effects (or consequences) of their choices. In contrast, pro-life pharmacists might see their view as justified by a deontological approach to ethics. They would point to the existence of a categorical imperative, a cast-iron rule, which guides their actions, such as a religious belief in the sanctity of all life. It is important to note that the two options do not represent a rationalist versus unthinking dichotomy - both are logical taken from their point of reference.

Medical ethics would seem to lean towards the consequentialist model. Russell and Butler give the example of triage in a casualty unit as showing the application of this approach. Various ethical pronouncements in the medical world also show the move towards a more utilitarian approach. The 1968 Declaration of Geneva was adamant in stating "I will maintain the utmost respect for human life, from the time of conception". In contrast the 1970 Declaration of Oslo recognised the growing conflict in medical circles regarding abortion, and stated "This is a matter of individual conviction and conscience". The Act in question upholds that view.

That leaves us with the uncomfortable situation of putting in stark opposition the right of the woman to access a service which is legal, and the legal right of the health worker to refuse to participate. The Bill of Rights in South Africa guarantees the rights of the individual, for example rights of access to health care services. This right has been expanded upon in the SA Health Rights Charter, launched by the Progressive Primary Health Care Network in December 1997. This details 24 specific rights, including access to care, confidentiality, treatment, and most crucially in this regard, choice and information. A California law case might give us some pointers in this matter. The case, reviewed by Brushwood in the American Journal of Hospital Pharmacy in 1990 (volume 47, pp 395-6), revolved around the right of a rape victim to information regarding emergency contraception when she sought attention at a Catholic hospital. While the case was finally decided on the issue of whether such treatment really constituted abortion, the court did express itself on the issue of the patient’s as opposed to the health worker’s rights. It stated that an adult of sound mind has "the right, in the exercise of control over her body, to determine whether or not to submit to lawful medical treatment". Brushwood interprets the ruling as suggesting that "in general, care givers have a duty to provide patients with objective information about therapies, even if the care giver believes that giving the information is morally wrong. But there is no duty to provide the treatment itself. The patient’s right is to be fully informed so that she can decide on treatment options, unconstrained by the personal beliefs of the healthcare provider". This can be seen as entirely consistent with the basic ethical principle of patient autonomy. As Russell and Butler put it: "Respect for the autonomy of the patient is the cornerstone of a patient-centred view of health care".

While all pharmacists, and in particular those in hospital and institutional practice, would agree with a dedication to a patient-centred approach consistent with the Pharmaceutical Care philosophy, this might not help in resolving the dilemma of the conscientious objector. Mason and McCall Smith (Law and Medical Ethics, Butterworths, 1983) put it this way: "The great majority of what has been written on the subject of abortion is directed to a comparison of the rights of the mother and the foetus – comparatively little attention is given to those who participate as third parties". They detail a legal challenge by the Royal College of Nursing in 1981 which sought to counter the view that the dominant choice in the matter lay with the responsible medical practitioner. The case was lost in the High Court, won in the Court of Appeal and finally lost again in the House of Lords. The authors maintain that "abortion, no matter how it is performed, is a team effort and is no different in this respect from any other form of treatment". They note that five out of nine judges involved in the various stages of the case supported the view of the nurses. Where does that leave the pharmacist who is required to supply the wherewithal for the termination? The authors offer no panaceas, only pointing to the dearth of material on this problem.

The intention of the Department of Health is clear. It will make every effort to provide women with the rights to which they are legally entitled. At the same time, the passage of the Act has enshrined the rights of conscientious objection. However, the Department sees this objection as being based in many instances on a lack of insight or information. As a response to such views, a number of bodies have embarked on so-called "Values Clarification workshops" to address what they consider as misconceptions. The Department of Health, together with outside funders, has also supported the publication Barometer, produced by the Reproductive Rights Alliance. This national alliance of 30 organisations promotes a pro-choice agenda. The Alliance gathers and disseminates data on the implementation of the service to date. For example, the September 1997 issue (vol 1, issue 2) shows that nationally 64.5% of terminations are being performed in the first trimester, with 82.6% of woman who use the service being over the age of 18. The vast majority classify themselves as single. They also document a considerable degree of difficulty experienced by many women in accessing services, particularly in areas like the Northern Province and rural areas of KwaZulu-Natal, where one of the contributory factors is the unwillingness of practitioners to perform terminations.

The response from one KZN Medical Superintendent can be of use in resolving this issue for SAAHIP members. Noting the fact that doctors employed at his hospital were not willing to perform terminations, he stated that "steps would not be taken by the hospital to influence the moral stand points of conscientious objectors". Significantly, he stated that "the hospital is willing to accommodate a mobile termination of pregnancy team (based elsewhere) on their premises should such a team be formed". Let us examine that response, together with a comment from the Vryburg Hospital in the same publication, which stated: "Health care providers at the hospital are committed to providing the service and creative solutions are urgently needed to ensure that women in the North-West have access to a safe, legal procedure". As health workers we should at all times resist the temptation to make paternalistic choices for patients, but rather respect their autonomy as independent adults. As pharmacists we have repeatedly committed ourselves to a practice approach which seeks to put the patient first, which recognises the covenantal relationship between patient and pharmacist, and which eschews any notion of dominance of the patient by the decisions or viewpoints of the pharmacist. Klugman has outlined just such a "rights framework for practitioners" in regard to women’s health (SAMJ 1997; 87: 1496-9). She traced the evolving human rights backing for the crucial issues in women’s health, including reproductive health, through such recent events as the United Nations International Conference on Population and Development in Cairo and the Platform of Action of the 4^th World Conference on Women in Beijing. She concludes that: "The increased interest in promoting gender equality is impacting on the research and service agenda demonstrating the need to increase the diversity of reproductive health services and provide for a wider range of women’s health needs through fully integrated primary health care services. Most importantly, it challenges the general practitioner, the nurse and the gynaecologist to put human rights first: the right to dignity, to privacy, to equality, to information, to freedom from fear". To that list we would add the pharmacist.

The need for a clear statement on the supremacy of human rights was also well put by Redman, a nursing professor, who in examining the challenges facing pharmacy leadership pointed to a nursing struggle which we would share, "the constant battle to support patients to make their own decisions in a system that feels it knows what is best" (Am J Health-Syst Pharm 1995; 52: 2099-104). She concluded that "ethical leadership is nothing more than a brave willingness to take risks in favor of the core values of your profession and an intelligent ingenuity in finding ways to realize them".

In summary therefore, the key ethical dilemma facing the pharmacist who wishes to exercise his/her legal right to conscientious objection is how to reconcile that right with the arguably pre-eminent right of the woman in question to self-determination and autonomy, rights enshrined in our Bill of Rights and expressly so in the Health Rights Charter. Where can the "intelligent ingenuity" of the pharmacist be exercised?

SAAHIP’s position is thus that, while it respects the rights of its members to take advantage of their legal rights in respect of the termination of pregnancies, the exercise of these rights should not deny women their rights under the same law and as expressly stated in our Constitution. SAAHIP would thus urge members to find pragmatic ways of avoiding compromising the ability of their institutions to provide the service as laid down in the Act. This can take many forms, from co-operation with external mobile teams to the use of intermediaries for the distribution of drugs to termination units within their hospitals. For example, some hospitals handle the requisite drugs as schedule 5 items. Direct supply from a central store to the clinic/ward involved is another option. While these measures can be construed by those who hold strong views as constituting avoidance of the issue or unprincipled behaviour, they represent the only tenable answers. Absolutist options cannot be helpful in an arena of human debate that is fraught with contradictions and conundrums. What we can lean on however, is the firm indication across a range of issues from patient consent, the compliance versus concordance debate and on to the issues of euthanasia, that Pharmacy as a profession is firmly supportive of the primacy of patient autonomy – this is one of our core values. The two opposing viewpoints on termination of pregnancy cannot be reconciled, but pharmacists can and must find ways of operating in a society which celebrates diversity. Pharmacists who experience difficulties in regard to this or any related issue are urged to contact the Association for guidance.