Terra Sigillata

So reads the title of an excellent essay Medscape has reprinted from a recent issue of the American Journal of Health-Systems Pharmacists by Emily Evans (free reg req’d). Evans is a Pharm.D. faculty member at the College of Pharmacy of the University of Louisiana at Monroe. She writes:

In Texas, three pharmacists are fired for refusing to fill a rape victim’s prescription for emergency contraception because it “violated [their] morals.” A Wisconsin pharmacist refuses to fill, or transfer out, a similar prescription and is put on trial for violating the state’s regulation and licensing department’s standards of care. He stated that he “did not want to commit a sin.” A group of Illinois pharmacists sue their employer for religious discrimination after they were each disciplined for refusing to fill prescriptions for emergency contraception.

I wrote back in June on my professional objections to any pharmacist having the right to refuse filling any prescription based on religious or moral grounds.

But what shocked me about Evans’ article was that the professional organization that publishes the journal has recognized the right of pharmacists to object to fill prescriptions:

In an effort to present a compromise acceptable to all parties, the American Society of Health- System Pharmacists (ASHP) and other professional pharmacy organizations have developed policies addressing the topic and have shared these policies with legislative bodies. ASHP recognizes a pharmacist’s right to decline to participate in therapies that he or she finds morally, religiously, or ethically troubling and supports the establishment of systems that protect the patient’s right to obtain legally prescribed and medically indicated treatments while reasonably accommodating in a nonpunitive manner the pharmacist’s right of conscience.

To me, this is abhorrent and runs counter to any standards of professional behavior. As I wrote in June:

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.

This isn’t just about emergency contraception, where some states have passed legislation “respecting” the right of a pharmacist to refuse to fill certain prescriptions on moral or religious grounds. A pharmacist now has the support of professional societies to pick and choose what part of their profession they choose to practice.

So, for example, if you’re a cancer patient who has become so tolerant of the opioid pain medication that gives you relief such that you require very high doses, a pharmacist has the right to deny your prescription if they think you are selling your extra drugs on the side.

You can come up with your own examples of how such allowances can be abused.

In considering both sides of the issue, Evans states,

Some would argue that if a pharmacist is not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with his or her values, then he or she has chosen the wrong profession.

Comments

#1 Scott Simmons
February 28, 2007

Onion headline: “Christian Scientist Pharmacist Refuses to Dispense Any Prescriptions Whatsoever”
#2 Scott Belyea
February 28, 2007

You can come up with your own examples of how such allowances can be abused.

Indeed. And it’s not hard to predict that if this “catches on” for pharmacists, it will be used as an arguing point in favour of similar policies for a bunch of other professions and occupations. I’d guess it would go beyond recognized “professions.”

But even to stay there for a moment, I’m curious whether you’re aware of comment (in the article or elsewhere) about whether this should go beyond prescriptions. What about a pharmacist who refused to put through a transaction for condoms? What about the non-pharmacist employee who did the same thing … aren’t their moral convictions just as sincere as those of pharmacists?

From what I’ve read on the issue, both in your blog and elsewhere in other contexts, I’m firmly in the camp that says they do indeed have a choice – find a different line of work.
#3 Rick @ shrimp and grits
February 28, 2007

You can come up with your own examples of how such allowances can be abused.

Here’s mine. Let’s say that I’m a chemistry teacher, and that I convert to a sect of Christianity that finds the currently accepted model of the atom to be offensive. Do I then have the choice to stop teaching accepted chemistry and teach instead that the structure of the atom is best described by the first chapter of Ezekiel? Or, if that isn’t acceptable, to demand that I not be required to teach about the atom while still keeping my job as a chemistry teacher?***

Most sane people will say “Of course not! If you’re not teaching the scientific consensus about atomic structure, you’re not doing your job. Why should you get paid for not doing your job?”

From what I’ve read on the issue, both in your blog and elsewhere in other contexts, I’m firmly in the camp that says they do indeed have a choice – find a different line of work.

Exactly right. If your religious convictions prevent you from doing your job, you shouldn’t be trying to do that job.

***I can’t take credit for the “atoms are an affront to Christianity” idea. It came from here: http://www.commonsensescience.org/atomism.html
#4 persimmon
February 28, 2007

Of course such allowances can be abused. It’s up to professionals not to, and if they do woe to them.
#5 Bill
February 28, 2007

Just to pile affront upon affront, clinicians didn’t fare much better than pharmacists in a recent examination of their professionalism:

42 percent objected to prescribing birth control for adolescents without parental approval, and 52 percent opposed abortion for failed contraception. While a majority of the physicians surveyed believed that it is their responsibility to refer patients to other physicians who would be willing to perform procedures or prescribe medications that they, because of moral or religious beliefs, would not be willing to do themselves, 18% maintained that they were under no professional or ethical obligation to do so.

Better hope you don’t get sick…
#6 Rick @ shrimp and grits
February 28, 2007

Of course such allowances can be abused.

I think the point being made above was that this “allowance” – support by the professional society for not filling prescriptions based on non-scientific or non-medical reasons – already is abuse of patients.
#7 bob koepp
February 28, 2007

There are serious questions about the content and scope of professional obligations. Those serious questions deserve serious thought, not knee-jerk reactions and posturing.

It’s a pretty warped understanding of professionalism that would require professionals to violate their own sincere ethical beliefs. After all, someone lacking personal integrity probably isn’t going to be much concerned with professional integrity. “You can trust me because I lack the strength of my convictions.” Yeah, right….
#8 Scott Belyea
February 28, 2007

Those serious questions deserve serious thought, not knee-jerk reactions and posturing.

Presumably your post demonstrated serious thought. Are you suggesting that those which take a different position demonstrate “knee-jerk reactions and posturing”?

It’s a pretty warped understanding of professionalism that would require professionals to violate their own sincere ethical beliefs.

I think this has got it just about backwards.

It’s a pretty warped understanding of professionalism that enables professionals to violate their professional obligations because of personal beliefs. Surely personal integrity would require resignation if one couldn’t fulfill one’s obligations.
#9 bob koepp
February 28, 2007

Scott – I think it’s pretty unserious to bloviate about professional obligations without addressing what they are or what they are grounded in. Just to get the ball rolling, I’ll suggest that healthcare professionals have no professional obligation to provide services that are not medically indicated. Ponder that.
#10 Lee
February 28, 2007

If I have a prescription, or otherwise have legal valid access to prescription medication, then ***I*** get to choose whether use of that medication is within my own moral bounds. Period. My pharmacist legitimately acts as a legal filter, to make sure I actually do have legal access to that drug, but s/he does NOT have the right to supercede my own moral decisions about my own body.

A pharmacist has a state-granted monopoly on my access to medications to which I am legally entitled. That monopoly comes with obligations. If s/he does not want to live up to those obligations, then find another damn job.

If the pharmacist refuses to allow me access to my legally permitted medication because s/he thinks they have a superior right to make ***MY*** moral decisions about what ***I*** should do with my own body, then they should lose their license and find another job.
#11 Madrocketscientist
February 28, 2007

Bob Koepp,

Ponder This, if a doctor has given my sister a prescription for an emergency contraceptive, then the treatment is medically indicated and the pharamacist is Professionally Obligated to provide that contraceptive.

If a drug is available OTC, then a pharamcist is Obligated to provide that drug to any customer who wants it if the pharmacy carries it.

As far as I am concerned, if a pharmacist wants to refuse to fill a perscription, then he has to post a sign saying so (if he/she can impose his/her morals on me, I should be able to impose mine on him/her by refusing to take my business there). If he works for a company that carries a drug he disagrees with, he has a choice, provide the drug, or get a new job/start his own pharmacy.
#12 Scott Belyea
February 28, 2007

Bob Koepp said:

…healthcare professionals have no professional obligation to provide services that are not medically indicated. Ponder that.

That’s for another day.

I’d say it’s completely irrelevant to the present discussion …
#13 Scott Belyea
February 28, 2007

A side comment:

BobKeopp said (in 2 different posts):

Those serious questions deserve serious thought, not knee-jerk reactions and posturing.

Scott – I think it’s pretty unserious to bloviate about professional obligations without addressing what they are or what they are grounded in. Just to get the ball rolling, I’ll suggest that healthcare professionals have no professional obligation to provide services that are not medically indicated. Ponder that.

Bob, I hope that you’re not intending to sound as condescending and superior as it seems …
#14 Dr. Free-Ride
February 28, 2007

Trackback
#15 Joseph j7uy5
February 28, 2007

All moral questions ultimately boil down to just one question: Who gets to be the one to make the decision? That is, who has the power? Answer that, and you’ve resolved the moral issue.

In the case of emergency contraception, the argument goes like this: We all know that murder is wrong, since it is true by definition. There is no point in arguing that. The question is, which specific actions can be mapped into the general class of actions that we consider to be murder? Who gets to decide?

Should the decision be made by someone who is not going to be substantively affected by the outcome, or by persons who are directly affected? Who has power over whom?
#16 Dr. Free-Ride
February 28, 2007

If the morality of dispensing emergency contraception is framed in terms of murder, so too should the sale of condoms be frames, since both act to prevent conception.
#17 bob koepp
February 28, 2007

The question here isn’t about the morality of contraception or abortion or their relation to murder. of Conscientious objections arise precisely because there’s no consensus on those issues. The question posed by our Abel host is about the professionally-grounded duties of pharmacists. The idea seems to be abroad that professionalism requires setting one’s ethical beliefs aside when they conflict with those of patients. I think that’s absurd, and evidence of shallow thinking.
#18 Abel Pharmboy
February 28, 2007

Dr Koepp, I now recall that you had a similar, thoughtful objection to my line of reasoning back in July.

Where I feel that we differ is in our interpretation of professionalism vs. professional duties. I prefer that professionals possess personal ethics, but that one’s professional duties (to society as a whole) trump one’s ethical beliefs. I regret that you find the stance absurd and object that you find it evidence of shallow thinking.

To the contrary, I have thought long and hard about the balance between personal ethics and the responsibilities of a profession to society, regardless of the practices set forth by corporations such as chain drugstores. In my previous post, I noted Hepler’s notion (and Lee’s point above) that professions are privileged monopolies. Hence, their license to practice is granted by the state. When a medicine is approved, I hold that pharmacists have a professional duty to filling prescriptions for said medicines. While ethics should permit a degree of autonomy on the part of pharmacists, I hold that one’s personal autonomy becomes secondary when one applies to their respective state board of pharmacy and agrees to become an agent of the state (not to mention at a considerably comfortable salary within a controlled monopoly.)
#19 bob koepp
March 1, 2007

The basic tenets of professionalism, including expertise and fiduciary duites predate any licensing authority or monopolistic privileges. The entry of the state into the equation complicates matters, and in the present instance actually creates the environment where some pharmacists are brought into direct conflict with patients. There’s no good reason to require women to go through physicians and pharmacists to access contraceptives (and abortifacients) that can be safely and effectively self-administered. And the idea that pharmacists (or other licensed professionals) are agents of the state runs directly counter to the traditional understanding that professionals are agents for their clients.

And there’s still the huge question of just what are the professional obligations of pharmacists. It’s next to vacuuous to say that professionals are supposed to promote the “interests” of their clients. Surely not all the client’s interests, some of which have nothing to do with the professional’s area of expertise. As one species of professional inhabiting the world of medicine, pharmacists’ professional obligations ought to reflect such nuances as whether or not particular prescriptions are medically indicated. If they aren’t, then what could be the ground of a _professional_ obligation?
#20 Hyperion
March 1, 2007

There are several different issues here:

1. May a pharmacist refuse to fill a prescription based upon a medical issue (ie opioid painkillers when substance abuse is suspected)?

I think most everyone cn agree that this is not only the right of a pharmacist, but a basic duty and one major reason for having a pharmacist dispense certain medications rather than selling them OTC.

2. Do pharmacists have a right to refuse to dispense prescriptions for religious reasons:

Generally, one can receive religious accomodations in employment when such accomodations do not involve the essential duties of their position. So one could wear a hijab (muslim head-scarf) when working in an office job, because it does not effect the essential duties of typing, answering phones, etc. Now, this means that the essential question here, which really sums up the entire conflict, is:

3. Is the dispensing of prescription medications an essential task for the position of a (retail) pharmacist?

While I imagine that there are many positions in the pharmaceutical profession that do not necessarily involve dispensing prescription medications (such as that of the author of this blog), it seems that this particular position is one for which dispensing prescription medications is an essential task. Unless an employee can demonstrate that this is not an essential task, it seems quite clear that an employer has the right to fire an employee for their inability to perform an task that is essential to their position.

Also, I know that every time this question comes up, it is usually in reference to pharmacists of Christian denominations who refuse to dispense contraception, emergency or otherwise. Would this right also allow a Scientologist to refuse to dispense psychiatric medication, given that this would be counter to their religious beliefs?
#21 andy
March 1, 2007

Can a Jehovas Witness doctor refuse to perform a blood transfusion?
#22 Greg
March 2, 2007

When you sign up for this profession,
do just show your diploma, pay your fee, and demand a sales permit,
or do you also swear / promise some sort of professional oath?

Do you promise to be governed by all published ethics,
or do you promise to uphold only the ones you feel like?

The issue of narcotics is a red-herring :
The ethics (and the law) require the pharmacist
to exercise special care,
including delaying dispensing until the prescription is verified.
#23 intransigentia
January 12, 2009

When we as a society have this discussion about lawyers, the concensus is that even the most reprehensible felon is innocent until proven guilty and has the right to be represented by legal council.

Isn’t it interesting that some (allegedly) professional pharmacists express the belief that a patient presenting with a prescription has less rights than an alleged multiple rapist.

If you want to be a professional, you accept that you serve the profession, and your personal feelings, whether they are about rapists or rape victims, come second to the standards of practice of your profession, regardless what profession it is.
#24 Cannonball Jones
January 13, 2009

This whole situation is disgusting, if you refuse to do your job properly then you shouldn’t be allowed to do that job at all. If a doctor has prescribed something for a patient – i.e. decided that said treatment is in said patient’s best interests – then you are morally obliged to fill out the prescription.

Here’s a little example which might explain to these idiots why they are in the wrong. Imagine I was a cop (an abhorrent idea to me but play along) and held the belief that religion was poisonous, harmful thing and should be discouraged at all costs. Now imagine I’m patrolling the streets of a Sunday morning when a visitor to my city approaches me inquiring as to the whereabouts of the nearest branch of his particular church so he can go and worship. Would I be right to refuse to give directions based on my deep-seated and sincerely held belief? No, I’d be a complete asshole. The tourist would make a complaint to my superiors and I’d be rightly disciplined.

No-one has the right to push their morals on other people but everyone has an obligation to carry out their job to the absolute best of their abilities. If your job involves the health of the general public then that obligation is absolutely inviolable, regardless of what religious beliefs you hold.
#25 S. Red Deer ; esq.
March 10, 2009

What an interesting discussion. I came across this website researching a law review article I am writing about the hysteria of oipoids from the medical community due to my disciplines “war on drugs”. My interest is both professional and personal. A phramacist at Walgreens (where I have been customer for several years) refused, on Sunday, to fill a perscription for MS Contin (obviously from my doctor) because he “that I should find some alternative pain relief”. Of course, he doens’t know that I am terminal or anything else about me. I have had a perscription for MS Contin since I was diagnosed 2 years ago; every month I have it filled there. This was pharmacist I have not seen before. When I asked what I should do, he shrugged. How do these people sleep at night? In my discipline and all PROFESSIONAL disciplines that I am familiar with; your own personal views cannot be allowed to interfere with your obligation to you client (or patient). In fact, if you are a court appointed attorney, you are obligated to represent that person to the very best of your skill and due diligence unless the person is so repugnant to you as to impede your defense of him / her. No mention of how we may feel about it. Only if the client would be affected. All personal moral and ethical issues are negated. Only the best interest of the client is relevant. It isn’t about the lawyer; it is ALL about the client. I thought that was the standard for all true professionals.
#26 Rich
May 29, 2009

I feel a lot of resentment and anguish is in this post towards pharmacists. I agree that pharmacists should not push their moral beliefs on others and do what is necessary for their patients good health, but to not allow them to exercise any kind of decision making is asinine.

Look it from the flip side, lets take Ms Contin for example (from the previous post)and lets say that a doctor wrote the prescription for 600 tablets and to take 20 tablets a day. Many of you are arguing that a pharmacist should and MUST fill this prescription since the doctor wrote it and it is legal, I must ask you if this really is in the best interest of the patient? It seems to me that its an overdose and lawsuit waiting to happen.

Lets look at another situation, lets say a doctor wrote 30 tabs of Ms Contin for 1 every day which was filled say 5/27, then the patient comes back with another prescription from the same doctor for the same directions with the same quantity at 5/30, then again at 6/15. Is the pharmacist required to fill all these scripts when the patient obviously is taking more than said directions and the doctor apparently does not care?

I agree pharmacists are there to serve the public, but so are many other professions. If I were a doctor and I believe that it would not be in your best interest to use said medication for said diagnosis, yet you disagree and demand it anyways, am I obligated to serve you by writing the medication I advise against using?

I’m not here to say what this pharmacist did was right, but you are not obliged to go back to that pharmacy and are free to go to a more open minded pharmacy if you so wish. The choice is out there for you to make, why not use that ability and go elsewhere? Instead, it sounds like we want to strip the pharmacists ability to their choices, regulate their decisions, and from what it sounds like impose your own belief to another that is resisting it.