Personal integrity and professsional integrity.

On Abel's post on conscience clauses, Bob Koepp left this comment:

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."

I think the connection between personal integrity and professional integrity is an important one, so here are some preliminary thoughts on it.

Joining a profession requires some buy-in to the shared values of that profession.
If your first priority, as a matter of individual conscience, is to do harm, joining a profession whose shared values are expressed with the slogan "First, do no harm" strikes me as a really bad idea. Minimally, you're putting personal ethics and professional ethics on a collision course, where staying true to one necessitates violating the other.

I mention this as a way of suggesting that there may be limits on how much respect a profession can afford for the personal convictions of its members.

Letting values guide your actions starts at home.
Can a person who has no personal integrity really feel herself bound by the values of a profession she has joined? It might be possible, but it does seem reasonable that some pre-existing relationship with rational reflection about what you ought to do (as a person) might be useful practice for the activity of rationally reflecting on what you ought to do as a member of profession X. And, it's hard to know for sure whether the people who are really good at lying (for example) in their personal lives might also be lying in their professional lives -- either to the other members of that profession, or to the folks with whom members of that profession interact as part of their profession.

Can I cultivate my personal integrity and still fulfill my professional duties?
In the specific case of pharmacists, I'm inclined to say that there may be a way to respect the conscience of the individual and still discharge the professional duty. But a crucial element here is that cultivating my personal integrity requires that I treat other persons -- and the deliverance of their conscience -- as worthy of my respect. In other words, looking out for what my conscience requires ought not to give me license to dismiss the values and interests of others, particularly those others with whom I interact professionally.

Practically, this means that we're not witnessing the cultivation of personal integrity if a pharmacist actively thwarts a client's efforts to fill a prescription for emergency contraception in order that she not be able to obtain it during the 72 hour window in which it is likely to be effective. Nor does it count as cultivation of personal integrity to tell a client she will go to Hell if she uses RU-486 to terminate a pregnancy. Neither of these respects the client as a moral agent whose values matter in the interaction. To a certain extent, both involve the exercise of paternalism.

Let me suggest that any personal integrity worth cultivating includes at least some minimal level of respect for other persons. The fact that my values may differ from someone else's should not automatically lead me to conclude that mine are right and that the other person, therefore, need not be considered part of my moral community. Respecting that other person might, in some cases, require me to engage him about our differences in values. But there's a world of difference between respectfully trying to change someone's mind and unilaterally imposing one's own moral judgments on someone else who does not share them. Even "engaging in dialogue" is hard to do respectfully if there are power disparities (e.g., I have the power not to fill your prescription unless you listen to what I think of your values).

Being a professional gives you a certain kind of power with respect to the folks your profession serves. This is a good reason to have professional codes that spell out your duties as a professional. To the extent that the individual within that profession cannot fulfill one of those duties without violating her personal integrity, she has a duty as a member of that profession to be able to find someone else in that community who can fulfill that duty.

And finding another member of the profession who can fulfill the duty in question shouldn't be hard, because if one is cultivating personal integrity and understands that professional membership is defined (at least in part) by a set of shared values, then that person should be engaged in conversations with others around the contested values.

If no one in the profession is behind a particular value, that profession ought to drop it from the set of shared values that direct the duties of that profession. And if someone is serious about being a member of a profession, one ought to be committed to enaging seriously and respectfully with the other members of that profession.

There's undoubtedly more to say about this, but I'm out the door. Please use the comments to flag glaring mistakes or omissions.

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Yesterday's discussion of a pharmacist's right to refuse filling prescriptions based on moral or legal grounds generated some great discussion. I appreciate the thoughtful discussion of the commenters as well as two posts on the topic by Prof Janet Stemwedel. The first draws from her older post…

"To a certain extent, both involve the exercise of paternalism."

In the pharmacy context of the current discussion, I'm not sure that "paternalism" is the correct word. Shouldn't it be "authoritarianism"? This is both because the person in authority isn't always male and because, although the persons invoking this authority may claim it violates their personal integrity, it is in reality and in most cases violating the authoritarian dictates of their religious faith.

How many of these people taking authority into their own hands are actually considering the ethics of the situation, and how many are merely acting on the dictates of their pastor or some other religious authority figure without thinking of the ethics involved?

In any case, I agree with your overall assessment.

Janet, I really appreciate you weighing in so thoughtfully on this topic today.

To the extent that the individual within that profession cannot fulfill one of those duties without violating her personal integrity, she has a duty as a member of that profession to be able to find someone else in that community who can fulfill that duty.

This is possible in S.F. or Philly, but there are many rural pharmacies in communities where choice is limited. I hold that the responsibilities of pharmacists in these less populated areas are more critical than in population-dense areas.

My concerns extend well beyond EC (although that is a primary concern). What about a Christian Scientist pharmacist who refuses to fill a Rx for an anti-depressant? This exercise of personal ethics could run the risk of allowing a patient at risk of suicide to follow through on their plans.

"How many of these people taking authority into their own hands are actually considering the ethics of the situation, and how many are merely acting on the dictates of their pastor or some other religious authority figure without thinking of the ethics involved?"

It seems likely that many of those people would not draw that distinction. That is, as far as they are concerned, the dictates of their religious leaders define what's ethical. I'm not sure to what extent that is true, but I suspect that it is a factor in a significant number of these cases.

I also agree with you. As an aspiring professional, I know that being part of my profession implies that I share the values of that profession, and that my duties are to my employer, client, and the public even above myself. If a pharmacist, or any other professional, is willing to put their own values ahead of their duty to their profession and their client, then they are not truly a professional and don't belong in that profession.

Quite specifically, if your interests (such as your morals) are at odds with the interests of your client (such as following their own morals), then you have a conflict of interest. In a conflict of interest, it's the professional's responsibility to remain objective, even if that means passing off the work to somebody else. However, withholding information or services from the client in such a manner that it detrimentally affects them would quickly get your fined, kicked out of your profession, and even charged for negligence.

I personally think this falls along similar reasoning as free speech. "I disagree with your views, but I support your right to have them." Likewise as a professional, "I disagree with your choice, but I will do what I can to help you follow it through," especially when this choice is generally accepted within the profession.

James has nailed it. As a professional, it's not about you, it's about providing what your patient needs. Using the power of your authority to manipulate others into the 'proper action' is paternalistic, is a misuse of authority, and is, frankly, wrong. This is a hard lesson to learn, and medicine was a whole lot more paternalistic in the past. It took WWII and Nuremberg to shift the medical profession.

By William the Coroner (not verified) on 01 Mar 2007 #permalink

Imagine a member of the Church of Christ, Scientist as head of the Red Cross. Their religion forbids blood transfusion, so they would be justified in shutting down the whole organization, right? And if you oppose them, that makes you a religious bigot, right?

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

It seems clear to me that if one's personal ethics prohibit the faithful execution of the duties of one's profession, then one is honor-bound to resign that profession and seek one in which personal and professional ethics coincide.

Not to hijack this thread, but these ethical concerns go much, much further. You will remember the case of the British Columbia JW couple who had sextuplets, refused them blood transfusions, two died, whereupon the Province took custody of their remaining children. Any comments? Perhaps if this is inappropriate for this Thread one of you SciBloggers would care to comment on a post of your own.

I second Mark's comment. I worked (briefly!) in a shop which among other things meant I had to sell cigarettes. I have a real problem with people smoking for personal reasons and felt really bad even touching the packs, but I realised that part of my job meant selling cigarettes and if I wasn't prepared to do that then I should quit. Luckily, I was in a position where I could, so I quit. If pharmacists (or any other professional) have a problem doing something that is a required part of their job, then they either need to get over it or find another job. Their job isn't to moralise over other people's decisions. It's to do the job.

Their job isn't to moralise over other people's decisions.

But it is their job to moralize over their own decisions.

If they refuse to act based on their own personal convictions, it may not be because of "paternalism" but because their own internal code doesn't allow them to act as enablers or to passively distribute drugs that are more marketing than therapeutic.

Their view may not be that the patient isn't allowed access, just they don't want to provide it in this case. Thanks to the pharmaceutical industry pharmacies are as ubiquitous as banks so access to the POS is not an issue.

Does refusal mean that the client cannot get support either from an alternate pharmacist or from another pharmacy?

"But it is their job to moralize over their own decisions."

Incorrect. It is their job to dispense drugs. As I said earlier, if their views prevent them from doing their job, they should find another job.

If I were a pharmacist, as a professional I would take offense at the glib remarks here about "my job" being nothing more than dispensing drugs per some physician's prescription, regardless of whether those drugs are prescribed for a medical purpose.

To consider a parallel example, suppose a surgeon is approached by someone deeply desirous of a cosmetic amputation. Further, suppose (as is the case at least in some jurisdictions) there is no law against such surgeries. Does the surgeon have a professional obligation to cut off a healthy limb, or failing that, to refer the wannabe amputee to someone who will do the job?

By bob koepp (not verified) on 01 Mar 2007 #permalink


Are you grading a paper? Please give me partial credit or it will affect my GPA. My dad will be upset.

In your first post, where you said,

...It seems clear to me that if...

it seemed clear to me that you were posting a subjective opinion.

To be sure though, I am all for taking people out of the drug dispensing business altogether.

This discussion, I'm sorry, is very pointless.

There is no right to be a member of a professional organization. Everybody, who believes anything, is not guaranteed protection of their crackpot ideas to the detriment of those the professional organizations dictate. You don't have a right to be a doctor, or a lawyer, or a pharmacist or an EMT, just because you want to be.

What if the professional didn't feel they need to treat STDs because they feel that's god's punishment on sluts? Think that's outrageous? A logical leap? Can anyone honestly tell me that's not what's happening when they deny women, and not men, access to birth control? Isn't this just rank and disgusting misogyny?

People like to think women are treated equally but they still aren't, otherwise OCP would be covered the same as pills for ED. Women and reproductive issues are still given the short shrift by our society and they are seen as secondary or worse, punishment on women who have behaved badly.

All this talk of professional ethics is bullshit. And I can't help but see Bob Koepp's attitude in particular as worth anything but contempt. What this really is is cowardice. The fear of standing up to fundamentalism. The fear of telling Christians in particular, they have to stop inflicting their morality on everybody else.

Every example that's offered to counter the appropriateness of this behavior is an out-of-mainstream ethical position but no less valid. Whether it is Christian Scientist, scientologist, Jehovah's witness, Eugenicist, whatever. And what are the replies? There are none, because none of these "deeply held ethical beliefs" are any more legitimate than any others, because they're all based on the same type of overvalued ideas. But these other "deeply held ethical beliefs" can't possibly be compared, because when it comes to forcible imposition of morality on others, there's only one group's morality for which this is ok.

So, I'm sorry if I come across as a bit harsh on this but it's just so typical. Anything to avoid offending the Christians, anything at all. Professional responsibility? Screw it. How dare we expect a Christian to do anything other than what (their interpretation of) their religion dictates. But anyone else? Anyone out of the mainstream? Muslim? Atheist? Scientologist? Not a chance. We know who we're appeasing here.

Finally, Bob your latest horrible analogy about a surgeon has nothing to do with the discussion here. Such a surgery would be a violation of professional ethics first, not just personal ethics. That's not the discussion at hand, get them straight.

There are two key points which seem to be invisible.

Most professions are controlled. We regard them to require certain special skills and commitments to special duties / ethics. When a person shows competence in the skills, and promises to perform the duties and ethics, we permit them to practice the profession. We forbid all others. We retract permission should the person subsequently show incompetence or contempt.

Most professions require some sort of formal claiming of competence and promising to uphold (all) the ethics. Assuming pharmacists have formal ethics, and assuming pharmacists do promise to uphold those ethics, any pharmacist who refuses to fulfil (all) his promises has automatically forfeited his integrity. We will retract his license.

Of course, in the unlikely event that pharmacists have no formal ethics, or their ethics are not to the benefit of us who license them, or should they declare certain chemicals not to require their care and keeping, then we will give the job or part of it to whoever others will serve us properly.

We basically do not care what pharmacists believe. We offer a quasi-monopoly to whoever can.. and will.. administer the supply of certain important substances to our satisfaction. To _our_ satisfaction.

They make promises, we reward them with privileges.
They repudiate the promises, we withdraw the privileges.

No one said anything about "whether those drugs are prescribed for a medical purpose." Where did you get that? If you check state laws, I think you will find that pharmacists are not allowed to prescribe drugs; I think that's reserved for physicians. But if you disagree that a pharmacist's job is to dispense drugs, then what do you think it is?

Ted, you also seem to think that a pharmacist's job is not to dispense drugs. I am having a hard time figuring out what you think it is, and why they should be called phamacists if it's not their job. Maybe they should be called preachers instead.

I don't know quitter; the general tone of this seems similar to, "America, love it or leave it" as if one should walk away if the general trend turns against you.

These questions are mainly political in nature. A pharmacist (or really any professional), may have spent a sizable investment of time in the technical aspects of the field. One day the government passes a law, and their career should be willingly jettisoned because of it? I expect them to fight to change the condition of their field. A professional does not remain passive; he/she strives to have an impact in their profession.

1. Can you point out the relevant section in the professional ethics code that supports your statements?

2. Is the code of professional ethics voluntary or is it mandatory? If it's mandatory, do changes to the code need to be ratified by all members of the profession (even ones that have been practicing for decades)? If they don't accept the changes, are they decertified then? Is there a retirement and retraining fund that professionals contribute to, so that they can care for those they evict?

Under rules like that, I don't think you're going to get many takers to take up a professional career field that requires nontrivial depth of knowledge.

There doesn't have to be a professional code of ethics to expect that one actually do one's job. If a pharmacist owns his own business, I doubt that anyone is going to tell him he must dispense any particular drug. All he has to do is not carry that drug, and he can send his customers elsewhere. If, on the other hand, the pharmacist is an employee of the business, the owner is perfectly within his rights to expect the pharmacist to do it or look elsewhere for employment.

If the drug in question is legal and prescribed for its intended purpose, I think it at the very least exceeds the pharmacists scope of work to decide that it should not be dispensed. That in itself seems to me to be a violation of an ethical standard of behavior since the pharmacist is replacing the judgement of the responsible parties (physician and patient) with his own judgement. There is a clear separation of duties in this process. By law, as I understand it, only physicians can prescribe drugs. Pharmacists can, of course, offer advice on side effects and drug interactions, but they cannot substitute their judgement for the physician's. It is simply not their job to decide what drug is appropriate for a customer.

I'm with quitter. I am witnessing first hand similar foolishness with the taxi drivers at the Minneapolis airport refusing to transport people who have been drinking, who possess alcohol, or who are blind and use a service dog. They keep harping on their "freedom of religion." I think they and the pharmacists under discussion are missing the point of "freedom of religion." The following letter appears in today's Minneapolis Star Tribune newspaper. I believe it sums the argument nicely.

There is a growing movement from religious fundamentalists to trivialize our freedom of religion by using it as an excuse not to do their jobs. Requiring cab drivers to do their job without exception does not infringe on freedom of religion, nor does requiring pharmacists to dispense medication.

Fundamentalists do not understand the true meaning of freedom of religion. Our freedom means that, whatever our religion, we can be confident that the rule of law still applies to us, that we will be treated the same as others. It does not mean that our religion trumps the Constitution or this nation's secular laws.

There is no constitutional right to decide which parts of your job you like and dislike. When people refuse to do their job, there is no rule of law. What would you say to a policeman who only enforces laws he believes in, or a teacher who leaves out parts of the curriculum she disagrees with?

Thanks for letting me participate.

LM Wanderer

By LM Wanderer (not verified) on 02 Mar 2007 #permalink

Love it or leave it is right. It's a profession, not a country. It's a privelege, not a right. If you don't want to perform the duties of your profession, and instead use your petty position of power to inflict your religion (I won't confuse this issue with morality or ethics like others seem to) on others, than you don't deserve this job.

Oh, and one google search later (I hate when people demand sourcing for obvious stuff that's at their fingertips)

One version of APA code, I think II, III, VII and VIII are relevant.

The IACP code is pretty similar, but more directed towards marketing and financial ethical problems.

ASCP's code, again asserts primacy of the patient first, and a dedication to evidenced based medication interestingly.

I'm sure the religious apologists in the audience will read all these ethical codes asserting the primacy of the patient as meaning "Pharmacists should make paternalistic decisions about their patients' medical care contrary to physician orders".

Love it or leave it is right. It's a profession, not a country. It's a privelege, not a right. If you don't want to perform the duties of your profession, and instead use your petty position of power to inflict your religion (I won't confuse this issue with morality or ethics like others seem to) on others, than you don't deserve this job.

This paragraph is rife with a lot of questionable posturing. Petty position of power? WTF? :-)

It's not up to you to judge what people deserve (such as a job -- which is between them and their employers). You have an opinion, but like I said before, this is a political action, and although you dismiss morality and ethics, they are deeply rooted here. The fact that you appear dismissive toward Christians and their values doesn't do your argument any favors.

These things have existed for a while. (Please) Look here:

Health provider "refusal clauses" (also known as "conscience clauses") were first enacted in response to the United States Supreme Court's decision in the Roe v. Wade case, 410 U.S. 113 (1973). Roe v. Wade was the landmark decision establishing that most laws against abortion violate a constitutional righy to privacy, overturning all state laws outlawing or restricting abortion. Some states have subsequently proposed legislation and passed laws designed to allow doctors and other direct providers of health care to refuse to perform or assist in an abortion, and hospitals to refuse to allow abortion on their premises. Now, the issue is expanding as pharmacists are refusing to fill emergency contraception and contraception prescriptions. This movement resulted in the term "conscience clause," which gives pharmacists the right to refuse to perform certain services based on a violation of personal beliefs or values. Most of the debate revolves around a pharmacist dispensing emergency contraception. Emergency contraception is used to prevent a pregnancy, not terminate a pregnancy, and is a general term used to describe several different types of birth control pills that are used in increased doses within 72 hours of unprotected intercourse. Emergency contraception is not the same thing as Mifeprex, which is the brand name of mifepristone in the United States and is sometimes referred to as non-surgical abortion, medical abortion, or RU-486. Pharmacists do not play a role in administering these medications.

In some states, legislators are introducing bills that would explicitly grant pharmacists the right to refuse to dispense drugs related to contraception on moral grounds. Other state legislators are introducing legislation that would require pharmacies to fill any legal prescription for birth control, much like Governor Blagojevich's emergency rule in Illinois, which requires pharmacies to provide the morning after pill.

Four States (Arkansas, Georgia, Mississippi, and South Dakota) have passed laws allowing a pharmacist to refuse to dispense emergency contraception drugs. Illinois passed an emergency rule that requires a pharmacist to dispense FDA approved contraception. Colorado, Florida, Maine and Tennesee have broad refusal clauses that do not specifically mention pharmacists.

This issue is political, although you're trying to make it something else. Were you this vociferous when it was hospitals and doctors?

BTW, I read the ethics links you provided. If this is the best that professionals can come up with, they should probably stop calling themselves professionals, or hire some bright HS kid to help them out.

I still do not believe this is an argument about ethics. This is about the imposition of a religious belief on other people. Largely because the medication in question is no different than other contraception in terms of mechanism. They're basically making a judgement about their female patients' sex lives and masking as an "ethics" issue. What is the ethical concern? These drugs prevent conception! This should be an ethical non-issue for Christians, it prevents that whole silly ensoulment thing they believe in.

This would never happen with male contraception or ED medications, it's just a typical attempt to try to make an "ethics" argument for sexism and misogyny based on religious beliefs. This is an inappropriate behavior for any professional, and in any workplace.

Trying to mix this up with abortion, which presents a real ethical dilemma for many people is silly. It's contraception, not abortion.

Quitter might be right about the motives the particular pharmacists who have made the news. I don't know, since I can't read minds.

It's simply wrong, however, to think that whereas abortion can present a _real_ ethical dilemma, contraception could not. There are actual living breathing specimens of humanity who embrace what's called a natural law ethics; people for whom acting to prevent normal functional processes (e.g., conception) would be morally impermissible. Even if I don't agree with their understanding of ethics, I have good reason to think they are sincere in their beliefs. And that's all it takes to get a dilemma up and running.

By bob koepp (not verified) on 05 Mar 2007 #permalink

If people in this day and age are so flummoxed by birth control that they can't do their jobs, they're pathetic and need to go join some insular community where nothing ever changes or offends them.

Not being able to tolerate birth control prescriptions, in this day and age, is unacceptable in a health care professional. Especially given the inherent sexism of denying women birth control, with no similar debate about condoms. This is just cover for the need of religious bigots to punish promiscuity in women.

I still do not believe this is an argument about ethics.

And all I'm saying is that the terminology of choice is "conscience clause" and I take that at it's face because to try to read a subtext is to presume too much into the ethics of another. The laws (attempted and passed) spell out the details sufficiently.

Unless you have something specific in mind to stop it, I don't see how you can curtail these people without impinging on their freedom of speech or freedom of political expression. You may think they are misguided, and yet, they do have a right to a political voice unless we ship them into the ovens. And I'm not willing to go there either as a shipper or shipped.

The alternative is to educate them. The Simpsons this week covered the dilemma of the home schooled (represented by Cletus and his clan). Obviously, not all home schooled people fall into that category, but if a shared common education standard cannot be mandated, I see no chance of these people coming to your understanding. There is a conflict of arrogance vs. implacability.

Trying to mix this up with abortion, which presents a real ethical dilemma for many people is silly. It's contraception, not abortion.

I didn't mean to compare contraception to abortion, but I did intend to point out that conscience clauses did exist politically both for doctors and pharmacists. So to demand that people be expelled from their profession when they are politically protected is untenable and screechy.

Also, I do not pretend to be able to discern what constitutes real ethical dilemmas in the mind of others. If they say they have an ethical dilemma, I take them at their face value. Would you want someone to doubt your own ethical motivations? I wouldn't.

It seems clear that looking at the legislative link I posted, that availability is not really being curtailed because most of the clauses are failing. I'm assuming that they're failing because they're badly written, not because they have no merit. I expect that at some point they will pass when they are written with the proper guidelines and context.

If people in this day and age are so flummoxed by birth control that they can't do their jobs, they're pathetic and need to go join some insular community where nothing ever changes or offends them.

Hello? We're talking about American citizens here. Poster children for insularity; they're already in the community.

There seems to be some confusion here about the relationship between the pharmacist and the customer. The pharmacist provides a service, and should execute some level of judgement when performing that service. For example, a certain prescription might not get filled right away because the pharmacist is aware of a possible bad interaction with another drug the customer is currently taking.

Take a different example: A pharmacist has a customer currently getting an anti-depressant prescribed by a doctor. The customer comes in with a prescription for sleeping pills that came from a different doctor. Does the pharmacist simply act like an automaton and dispense the drugs, or does the pharmacist, suspecting a possible suicide attempt, make an effort to gather more information? The second would constitute "interference" in the choices of the customer, but it might be the right thing to do.

The market, freedom of religion, and freedom of association come into play as far as the dispensing of "emergency contraception". A pharmacy should have the right not to carry a drug if its owners have strong moral convictions against its use. Nor should they be required to help a patient do something that they morally object to. The patient, for her part, is free to choose the source of her drugs (granted, this freedom is limited in some cases). If you don't like a pharmacist's business practices, you don't have to shop there.

My wife's OB/GYN is a natural-family-planning-only OB, meaning that he will not perform abortions, will not prescribe contraceptives, and will not refer patients to other doctors who will. It is up to the patient, if she so chooses, to find another provider that suits her. Since he made this decision, he has lost some patients, but he has gained some others, and in all of this he knows he is doing the right thing. If he could not continue to make a living as an OB/GYN with this conviction, he would have to find another line of work. In his case, however, it is working.