As someone who has been associated with colleges of pharmacy as student or professor for 25 years, I feel compelled to weigh in on the debate raging in the US between a pharmacist’s right of conscientious objection to filling certain prescriptions and their responsibilities as a licensed health professional of the state. I originally intended this discussion to target the emergency contraceptive, Plan B. However, today’s post by Tara about a pharmacist refusing to fill a Vicodin prescription for a relative after breast surgery reminds me of the slippery slope we face in permitting health professionals to reject the duties of their profession.
Should a pharmacist have a right to refuse filling a prescription on religious or moral grounds?
I argue “no,” with the exception of extremely rare circumstances.
If you care to read more on both sides of this issue, I direct you to Cantor and Baum’s 2004 NEJM paper (NEJM 2004; 351:2008-12) and Hepler’s 2005 paper in the Journal of the American Pharmacist’s Association (JAPhA 2005; 45:436-438, also available at Medscape with free reg.)
The arguments are as follows: on one side, pharmacists reserve the right to deny filling prescriptions they deem morally wrong. This argument most often relates to the filling of prescriptions for emergency contraception. On the other side, pharmacy is a profession that puts the rights of the patient and their autonomy ahead of the pharmacist’s personal views. This argument holds that if a therapy is approved by the US Food and Drug Administration, a pharmacist has a professional duty to provide access to the therapeutic when accompanied by a valid prescription.
First, let us dispense with the rhetoric that Plan B is an abortifacient (i.e., induces abortion). This is untrue. Plan B is an emergency contraceptive that prevents ovulation and/or implantation, just like daily oral contraceptives. As pointed out by Dr Henri Manasse, Jr, of the American Society of Health-Systems Pharmacists, Pentel and colleagues have reported that it is the consensus of “the World Health Organization, the Food and Drug Administration, the American College of Obstetricians and Gynecologists, the Association of Reproductive Health Physicians, the American Public Health Association, and the American Medical Association” that emergency contraception is just that, not abortion. (Am J Health Syst Pharm 2004;61:1773-4)
But regardless, should a pharmacist have any rights regarding objection to filling a prescription? Hepler does the most concise job in making the argument for pharmacist rights:
Reasonable and strong arguments support conscientious objection. First, a pharmacist is not an automaton or a physician’s valet but a necessary member of the health care team. Pharmacists complete at least 6 years of rigorous education and clinical training and prove their knowledge by passing a licensure examination…Second, conscientious objection is a necessary right — actually an obligation — of every citizen in a democratic society. It is supported by an honorable tradition regarding compulsory military service and civil rights, to name but two examples. Third, employed pharmacists should not be coerced by laws or an employer to carry out acts that violate their consciences. Allowing corporate ethics, especially, to trump individual professional ethics would lead to disaster. We would be naive to expect a pharmacist to forsake his or her ethics in one area (e.g., abortion) while applying them for the patient’s welfare in every other area.
However, Hepler also notes that pharmacy plays a unique role in health care and, therefore, has serious responsibilities to patients who have supported the education and training of pharmacists:
Professions are, however, privileged monopolies. Safe and legal access to the most effective medications — including emergency contraception — is only through a pharmacist or physician, or more commonly both…Also, health care professionals seldom have paid in full for their professional educations. For most, some education was free and some was financed by scholarships, low-interest loans, and state and federal subsidies at state and other institutions. The clinical education of every physician, nurse, and pharmacist required cooperation by patients in teaching hospitals and clinics, who donated time and energy and who took the risks and occasional indignities of being objects of education.
When many of us were new assistant professors, we were amazed that our students would make far more than us (after our work for a B.S., Ph.D., and 2 to 8 years of postdoctoral training) in their very first year after graduation. Starting US pharmacist salaries outside California and Hawaii are over $85,000 per year, rising to six figures as more the rule than the exception. Pharmacy is also a great career for single parents because even part-time positions still pay at a rate of $40-50/hour. But, with such privilege should come considerable responsibility.
In a section on duties inherent in professional ethics, Hepler proposes the following:
Nobody is drafted into a health profession or a specific practice. Entry involves free choices, and it includes at least a tacit promise to do one’s professional job according to recognized ethical standards. The Code of Ethics for Pharmacists adopted by the American Pharmacists Association states that each individual patient is the center of each pharmacist’s practice. It states that a pharmacist should (1) be committed primarily to the welfare of individual patients, (2) recognize differing beliefs and values, and (3) respect each patient’s right to self-determination. When values and beliefs collide, the pharmacist should consult with colleagues or refer the patient to a colleague.
Pharmacists control drug distribution and have ethical duties to provide patient care. Denial of care, therefore, should put a burden of accountability on the pharmacist. The pharmacist who conscientiously refuses to dispense a medication should be able to account for his or her understanding of the facts, science, and ethical reasoning. Society has no such mechanism for accountability. The result can be a chaos of different arbitrary actions that can injure and even kill patients. This is a slippery slope toward arbitrary refusals based on bigotry.
And this is where I feel the greatest degree of discomfort with any ruling that permits pharmacists to object to fulfilling their professional duties. If a pharmacist incorrectly believes that filling a prescription for an emergency contraceptive is collusion in objectionable abortion, what’s to stop this pharmacist from denying pain killers to someone he/she thinks is an addict – or denying any prescription to someone on Medicare because they don’t believe in public assistance?
Tara’s story of a relative whose husband was denied a strong opioid painkiller is an example of where this could lead. In this case, the pharmacist illegally substituted a less effective, codeine-containing drug, and then was so incompetent as to suggest the pill did not contain codeine when the husband came back telling of he wife’s intolerance to codeine. Instead, Tara’s relative spent the night after breast surgery living through the pain with just aspirin, all due to the arbitrary imposition of values and misinformation of a pharmacist.
With regard to the case of emergency contraception, Cantor and Baum suggest a middle ground:
Although we believe that the most ethical course is to treat patients compassionately — that is, to stock emergency contraception and fill prescriptions for it — the totality of the arguments makes us stop short of advocating a legal duty to do so as a first resort. We stop short for three reasons: because emergency contraception is not an absolute emergency, because other options exist, and because, when possible, the moral beliefs of those delivering care should be considered. However, in a profession that is bound by fiduciary obligations and strives to respect and care for patients, it is unacceptable to leave patients to fend for themselves. As a general rule, pharmacists who cannot or will not dispense a drug have an obligation to meet the needs of their customers by referring them elsewhere. This idea is uncontroversial when it is applied to common medications such as antibiotics and statins; it becomes contentious, but is equally valid, when it is applied to emergency contraception. Therefore, pharmacists who object should, as a matter of ethics and law, provide alternatives for patients.
(FYI to anyone in need of emergency contraception with access to standard oral contraceptives: Planned Parenthood offers extensive educational information, including details about off-label use of many birth-control pills for emergency contraception.)
In stopping short of suggesting an absolute requirement for pharmacists to fill all valid prescriptions, Cantor and Baum note that pharmacists and other health care professionals have choices about where they practice:
In a secular society, [health care professionals] must be prepared to limit the reach of their personal objection. Objecting pharmacists may choose to find employment opportunities that comport with their morals — in a religious community, for example — but when they pledge to serve the public, it is unreasonable to expect those in need of health care to acquiesce to their personal convictions. Similarly, physicians who refuse to write prescriptions for emergency contraception should follow the rules of notice and referral for the reason previously articulated: the beliefs of health care providers should not trump patient care. It is difficult enough to be faced with the consequences of rape or of an unplanned pregnancy; health care providers should not make the situation measurably worse.
In response to letters in the NEJM telling Cantor and Baum that seeking a middle ground was unacceptable to supporters of either extreme (NEJM 2005; 352:942-944), they responded:
Two stopgap solutions emerge. First, consider physicians’ distribution of emergency contraception. The current system may be nonsensically slow, especially if encounters at pharmacies are more frustrating than fruitful. Distribution by physicians would streamline the process. Alternatively, we may need to extricate both pharmacists and physicians from the process. These letters lend strong support to granting over-the-counter status to emergency contraception. This change would make pharmacists’ objections moot. It would also leave a very private decision with the individual — which is precisely where it belongs.
Pharmacists are sometimes viewed by the public as the folks behind the counter who just pour, count, lick, and stick. But the movement of pharmacy in the late 80s to a 6-year doctoral degree was motivated by the proposition that pharmacy be considered a profession like medicine or nursing, rather than a simple service. To be considered a health professional, however, requires putting the needs of patients ahead of your own. If a pharmacist chooses to object to filling any valid prescription, I object to their licensure by my state.
Making an exception for a scientifically invalid moral stance opens the door to all kinds of abuses that ultimately compromise the pact between a profession and the public.