Personal conscience versus professional duties.

Abel at Terra Sigillata has a post about coscience clauses for pharmacists that's worth a read. In it, he takes issue with the stand of the American Society of Health-System Pharmacists (ASHP), a professional pharmacy organization, recognizing "a pharmacist's right to decline to participate in therapies that he or she finds morally, religiously, or ethically troubling" while supporting "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."

I'm going to have a go at the connection between a pharmacist's personal integrity and his or her professional integrity -- in my next post. First, I'm dipping into the vault to offer the way I was thinking about this issue on the ancestor of this blog back in April 2005. Here's what I wrote then:

There has been a fair bit of media coverage lately of conscience clauses for physicians and, more recently, pharmacists. The idea of such clauses is that one ought not to be forced, as part of one's professional duties, to participate in an act one objects to on moral grounds. In other words, under a conscience clause, a physician with a moral objection would not have to perform abortions. A pharmacist who had a moral objection to contraception would not have to fill prescriptions for contraceptives. A nurse who has a moral objection to choosing not to prolong life by any available medical means could ignore a Do-Not-Resuscitate order that a patient has entered herself.

The recent generation of conscience clauses go even further. They allow health care professionals to refuse to refer patients to professionals who might offer the services the patients are seeking.

Obviously, we've got a tug-of-war here between the moral convictions of the health care professionals and the moral convictions of the patients.

One claim that has been made in support of these conscience clauses is that patients can always find someone willing to provide a legal procedure or prescription. There is some question, though, of how easily they can find that someone, how far they will have to travel, how long the wait will be, and what it will cost. Is it ethically permissible that health care professionals withhold knowledge as well as service?

It may be that a more profound holding back of knowledge is happening at the level of education of new health care professionals. The word is that fewer and fewer medical students have access to training in controversial procedures (like abortions) -- whether or not the students themselves have any moral objections to these procedures.

A few big ethical issues are tangled together here. One is what the relationship between health care professional and patient/client ought to be. Does the doctor or pharmacist have a responsibility for the well-being of the patient/client? Is this responsibility for the medical well-being, or the moral well-being as well? What duties does the health care professional have to respect the moral values of the patient/client seeking care?

Is it unjustifiably paternalistic for the health care professional not only to withhold service but also to withhold information? (Wouldn't it be more ethical to provide information on how to locate other providers, even if these information was accompanied by an explanation of the first health care professional's objection?)

Is this a case where specialized knowledge and training really do bring with them a duty towards the people who depend on the services that can only be provided by those with such knowledge and training?

Are certain moral views fundamentally incompatible with becoming an ethical health care professional? (I'm not just thinking of extreme cases -- hedonistic cannibals ought not become surgeons. Should Christian Scientists become pharmacists? Should Jehovah's Witnesses become phlebotomists? Should people utterly opposed to abortion and contraception of any kind, under any circumstances, become OB/GYNs?)

It might be interesting to see what the professional codes of ethics for various health care professions say about these issues. (The exercise is left for the reader ...)

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Two very quick examples to suggest that the discussion need not be restricted to members of recognized professions.

1. Is there a difference between the pharmacist who refuses to fill a prescription for birth control and a clerk in the same drugstore who refuses to sell me condoms? Are the moral standards of one more worthy of respect than those of the other?

2. There have been a couple of cases in Canada of individuals authorized to perform civil marriages wanting an exception so that they would have to perform same-sex marriages. Is this acceptable?

By Scott Belyea (not verified) on 28 Feb 2007 #permalink

It's quite simple: If you are not comfortable fulfilling the duties required by your job, then you need to get a different job.

On my view of healthcare professionalism, any professional privileges and professional obligations must be related to efforts to promote health, which includes preventing and ameliorating pathological conditions. I take this restrictive view because it places principled limits on _appropriate_ medicalization.

Most of the real world cases where questions of conscientious objections have been raised involve reproductive choice. I think many aspects of human reproduction are inappropriately medicalized, especially as it affects females (surprise, surprise...).

By bob koepp (not verified) on 28 Feb 2007 #permalink

...any professional privileges and professional obligations must be related to efforts to promote health...

You can't really avoid the reproductive choice issue this way, though. Pregnancy certainly has profound effects on the health of the mother; an unintended pregnancy can have profound effects on her mental health.

Suppose I was a pharmacist morally opposed to certain groups of people breeding, such as the genetically handicapped, alumni from my rival university, other ethnic groups, or Republicans. Obviously, I am using these groups (except Republicans) as hypothetical examples. By the logic of these conciencious objectors, it would be OK for me to spike their antibiotic prescriptions with birth control drugs (or lethal poisons, just to make sure). Suppose I was a surgeon, and could sterilize them, free of charge during the course of a totally unrelated operation. Is this really what we want? Except for case of the Republicans, I think this most people would find this morally unacceptable.

This is a stimulating discussion, but I find the hypothetical questions at the conclusion off the mark. The more accurate question would begin with WOULD, not SHOULD. "WOULD Christian Scientists become pharmacists?" The simple answer is no. As someone who's studied Christian Science for years, I've found that the basis for my health and well-being, comes from understanding my unbreakable relationship to an all-good God. It's not achieved through drugs, pills, vitamins, or other pharmaceuticals. Assuming this is the experience of my fellow Christian Scientists, I can't conceive of anyone of us engaging in that profession. It's not a criticism of that industry, it's just why I feel your question is basically a disconnect.

Norm Bleichman

By Norm Bleichman (not verified) on 01 Mar 2007 #permalink

Muslim cabbies tell airport they won't bend in alcohol dispute

BLOOMINGTON, Minn. � For Abdi Mohamed, it's not a question of whether he'll carry passengers with alcohol in his cab. The question is whether he'll get punished for refusing to do so.
"I am Muslim. I'm not going to carry alcohol," Mohamed, a driver for Bloomington Cab, told a Metropolitan Airports Commission panel that gathered public opinion Tuesday regarding proposed penalties for cabbies who refuse service to passengers carrying alcohol.
Dozens of cab drivers showed up for the hearing at a hotel near the Minneapolis-St. Paul International Airport. Commissioners are charged with setting a new policy by May, when airport licenses for cab drivers are set to expire. Under the proposal, drivers who refuse service for any reason would have their license suspended for 30 days. A second refusal would mean a two-year revocation of the license.

By Mustafa Mond, FCD (not verified) on 01 Mar 2007 #permalink

If the license specifies carrying all persons and their goods, then refusal to carry some persons or some goods is a violation of the terms. The license becomes void.