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
Onion headline: "Christian Scientist Pharmacist Refuses to Dispense Any Prescriptions Whatsoever"
Posted by: Scott Simmons | February 28, 2007 8:30 AM
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.
Posted by: Scott Belyea | February 28, 2007 8:39 AM
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?"
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
Posted by: Rick @ shrimp and grits | February 28, 2007 10:52 AM
Of course such allowances can be abused. It's up to professionals not to, and if they do woe to them.
Posted by: persimmon | February 28, 2007 10:56 AM
Just to pile affront upon affront, clinicians didn't fare much better than pharmacists in a recent examination of their professionalism:
Better hope you don't get sick...Posted by: Bill | February 28, 2007 11:09 AM
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.
Posted by: Rick @ shrimp and grits | February 28, 2007 11:24 AM
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....
Posted by: bob koepp | February 28, 2007 11:28 AM
Presumably your post demonstrated serious thought. Are you suggesting that those which take a different position demonstrate "knee-jerk reactions and posturing"?
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.
Posted by: Scott Belyea | February 28, 2007 1:14 PM
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.
Posted by: bob koepp | February 28, 2007 1:42 PM
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.
Posted by: Lee | February 28, 2007 1:42 PM
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.
Posted by: Madrocketscientist | February 28, 2007 3:39 PM
Bob Koepp said:
That's for another day.
I'd say it's completely irrelevant to the present discussion ...
Posted by: Scott Belyea | February 28, 2007 4:10 PM
A side comment:
BobKeopp said (in 2 different posts):
Bob, I hope that you're not intending to sound as condescending and superior as it seems ...
Posted by: Scott Belyea | February 28, 2007 4:16 PM
Trackback
Posted by: Dr. Free-Ride | February 28, 2007 4:22 PM
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?
Posted by: Joseph j7uy5 | February 28, 2007 5:16 PM
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.
Posted by: Dr. Free-Ride | February 28, 2007 6:06 PM
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.
Posted by: bob koepp | February 28, 2007 8:02 PM
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.)
Posted by: Abel Pharmboy | February 28, 2007 10:50 PM
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?
Posted by: bob koepp | March 1, 2007 8:07 AM
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?
Posted by: Hyperion | March 1, 2007 10:48 AM
Can a Jehovas Witness doctor refuse to perform a blood transfusion?
Posted by: andy | March 1, 2007 3:12 PM
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.
Posted by: Greg | March 2, 2007 1:48 AM