Pharmacists tend to believe that they provide dispassionate service and care for their customers who are, after all, patients. But in the 2000s, a passion-filled controversy is dividing pharmacists, engendering activity in Congress and dozens of state legislatures and creating questions about future practices in this field.

The crux of the matter: Should pharmacists have the right to refuse to dispense a medication if its use runs contrary to their moral or religious beliefs?

The issue could hardly be more divisive. Pharmacists in several states have refused to fill prescriptions for morning-after emergency contraceptives. In other cases, pharmacists have declined to dispense conventional birth-control pills, and some even refused to return the prescription to the patient. For pharmacists who exercise their conscience this way without legal protection, the consequences can be profound.

Both Sides Feel the Pressure

"Community pharmacists are under extreme pressure," says Karen Brauer, president of Pharmacists for Life International, which advocates for pharmacists' right to refuse and claims 1,500 members. "They're threatened with loss of jobs and possibly licenses for refusing to stop human life."

On the flip side, pharmacists who are handed prescriptions that a colleague has refused to fill may experience intense workplace stress.

The legal landscape is complex and unresolved. As of March 2009, seven states -- California, Illinois, Maine, Massachusetts, Nevada, New Jersey and Washington -- had passed laws requiring pharmacists to fill prescriptions, according to a report from the National Women's Law Center (NWLC) in Washington, DC.

Meanwhile, four states -- Arkansas, Georgia, Mississippi and South Dakota -- have passed laws explicitly permitting pharmacists to refuse to fill prescriptions based on personal beliefs. What's more, in the 2006 legislative session, 20 states considered such laws, according to the NWLC report. Various related bills are pending on the federal level.

Is There a Middle Ground?

Some in the industry are seeking a middle ground so pharmacists who refuse to fill contraceptive prescriptions can coexist with pharmacists who will, as most state boards of pharmacy require. "We like to say that we support pharmacists stepping away, not stepping in the way," says Kristina Lunner, director of federal government affairs at the American Pharmacists Association in Washington, DC.

Walgreens is one employer trying to steer such a middle course. The national drugstore chain said in a company statement that if one of its pharmacists refuses to fill a prescription, the order will be filled by another Walgreens pharmacist or by a nearby pharmacy.

But opponents of pharmacists' right to refuse say such policies are unworkable and unrealistic. "We don't think it's very likely that the majority of pharmacies across America will have the capacity" to transfer every refused prescription, says Rachel Laser, senior counsel at NWLC. Rural pharmacies, for example, often are staffed by just one pharmacist, and the next pharmacy may be towns away.

Others in the industry are remaining mum on this no-win topic. "We really don't know the details of store policies," says Michelle McKenna, a spokeswoman for the National Association of Chain Drug Stores. "We don't ask, and we don't track."

Big Issue for Pharmacy Students

Although the refusal to dispense has not been documented as widespread, both current and future pharmacists are paying close attention to the controversy. "For students, the issue is very much in the forefront," says Francis Palumbo, executive director of the Center on Drugs and Public Policy at the University of Maryland School of Pharmacy in Baltimore.

Some say student pharmacists should consider the issue early in their career planning. "If pharmacists have issues with a particular medication, there are different settings where they can choose to practice pharmacy," Lunner says.

That's the approach taken by Brauer, who is a third-shift pharmacist at an Indiana hospital that allows her to not dispense contraceptives. But this solution hasn't made her life simple. "I can't tell you where I work, because it would bring Planned Parenthood to my employer's door" to protest, claims Brauer, who was fired by an Ohio Kmart for refusing to fill birth-control prescriptions.

But others say the professional duty to dispense will ultimately prevail over pharmacists who feel they must refuse. "People considering a pharmacist career have to look hard inside and make sure they're comfortable with not obstructing access to particular drugs," Laser says.