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While it is permitted by law in some states within the United States for a pharmacist to refuse to fill a prescription for emergency contraception drug or any contraceptive for reasons of conscience, is this really ethical?
Physicians, throughout the United States are permitted not to perform any procedure to which they have ethical, moral or religious objections to perform, though if they have established a doctor-patient relationship, they must attempt to provide the services of an alternative physician who will perform that procedure. This subject is discussed more fully here on Medpedia in the Question "Are physicians to serve as moral gatekeepers?"
http://www.medpedia.com/questions/1154-are-physicians-to-serve-as-moral-gatekeepers
But a question posed in recent years is how far down the chain of those who assist the physician in medical care of the patient should have similar permission and of particular importance is that of the pharmacist and the filling of prescriptions presented by patients for an emergency contraceptive drug or any contraceptive medication if this act would be against the ethical, moral or religious conscience of the pharmacist. In the United States such "conscience clauses" have been become state law,
http://www.ncsl.org/default.aspx?tabid=14380
giving the pharmacist the right to make such a refusal. But are such laws ethical? And this raises the question as to what is the relationship between a pharmacist and a customer that would permit the writing of such state laws? Is it the same or similar to a doctor-patient relationship? If not, in what ways is it different? Should a patient-customer walking into a drug store expect that a valid (written by a physician) and properly written (no pharmaceutical errors) be filled if the drug store has the drug available? If not, why not? Would it be appropriate for the pharmacist to have another pharmacist in the store to fill the prescription or would that be morally wrong for the first pharmacist to be aiding the completion of an action which was felt to lead to a moral wrong? Any answers? ..Maurice.
http://www.medpedia.com/questions/1154-are-physicians-to-serve-as-moral-gatekeepers
But a question posed in recent years is how far down the chain of those who assist the physician in medical care of the patient should have similar permission and of particular importance is that of the pharmacist and the filling of prescriptions presented by patients for an emergency contraceptive drug or any contraceptive medication if this act would be against the ethical, moral or religious conscience of the pharmacist. In the United States such "conscience clauses" have been become state law,
http://www.ncsl.org/default.aspx?tabid=14380
giving the pharmacist the right to make such a refusal. But are such laws ethical? And this raises the question as to what is the relationship between a pharmacist and a customer that would permit the writing of such state laws? Is it the same or similar to a doctor-patient relationship? If not, in what ways is it different? Should a patient-customer walking into a drug store expect that a valid (written by a physician) and properly written (no pharmaceutical errors) be filled if the drug store has the drug available? If not, why not? Would it be appropriate for the pharmacist to have another pharmacist in the store to fill the prescription or would that be morally wrong for the first pharmacist to be aiding the completion of an action which was felt to lead to a moral wrong? Any answers? ..Maurice.
asked Feb 19, 2011 at 08:47PM in Other
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0Votes
answered Feb 21, 2011 at 11:06AMMaurice,
This is one of those questions for which the exceptions will probably define the rule. Most thinking people would probably agree that morality is, in most cases, a relative concept. This is certainly true among various cultures and therefore, in a country like the US where we pride ourselves on our multi-cultural heritage (well, most of us do, anyway), we need to make allowances for these difference.
Let's begin with a simple premise; no one should be forced to do anything they find morally or ethically objectionable. The converse, however, is that no matter how morally objectionable you find something, you have no right to force your view on someone who doesn't share them; whether though legislation or coercion. I do not believe the issue is whether the rules that apply to physicians should be extended down some arbitrary "chain," but rather one of simply not requiring a pharmacist to do something they believe to be wrong.
The "flip" side of the coin, however, is that the patient should not have to be held to the beliefs of the pharmacist. If they have a valid prescription, it should be able to be filled. If one pharmacist feels they cannot fill it, then it should be given or sent to another who will. Does this mean that the pharmacist making the referral to another is acting immorally from their own standpoint? Perhaps, but with authority comes responsibility and with a personal right comes obligation to respect others' rights. There are many people and actions with which I do not agree and whose actions I believe to be morally bankrupt, yet while I have a right to try to convert them to my point of view, I also have an obligation to allow them theirs.
Ultimately, all morality is "opinion;" frequently based upon an unprovable belief. We are all entitled to our opinions. -
0Votes
answered Feb 21, 2011 at 11:16AMapolologies for some self-promotion, but in a word, no
see http://phsj.org/files/Women%27s%20Health/Emergency%20Contraception%20-%20Virtual%20Mentor.doc
martin
Martin Donohoe, MD, FACP
Adjunct Associate Professor, School of Community Health
Portland State University
Chief Science Advisor, Campaign for Safe Foods and
Member, Board of Advisors
Oregon Physicians for Social Responsibility
Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center
http://www.publichealthandsocialjustice.org
http://www.phsj.org
martindonohoe@phsj.org -
1Votesanswered Feb 21, 2011 at 08:04PMIf we agree that a pharmacy dispensing drugs to the public represents a governmental licensed public service and that except directly from a licensed physician there is no other resource from which a patient may obtain the needed drugs, therefore it appears that a pharmacy has a public responsibility and the pharmacist has a professional duty to provide the drug as physician prescribed regardless of any moral apprehensions on the part of any of the pharmacists. Can there be any ethical argument to the contrary? ..Maurice.
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answered Feb 21, 2011 at 08:13PMI feel that the pharmacist has the right not to fill the prescription that he/she knows is being used to abort a living fetus if in fact he feels morally obliged not to do so.
Just like the physician or the nurse in hospitals have that right, so should the pharmacist. My God, there are so many pharmacies now-a-days no person living in the USA could possibly have a problem finding a pharmacy that will take care of their needs. -
1Votesanswered Feb 21, 2011 at 08:27PMec is a legal medication and its name denotes the fact that it is an "emergency" medication
...if an individual pharmacist decides that ec represents abortion, which many scientists and the FDA would disagree with, and there was another pharmacy close by at which the patient could get this medication, then some might argue that the pharmacist's refusal to dispense the medication might be ethical......but, this does not guarantee that the patient has the time and/or transportation and/or money to do this, and therefore she may not be able to fill the prescription, which could put her health at risk, and therefore i do not believe that such an argument is valid......furthermore, physicians and nurses do not have any right to refuse emergency treatment of any kind (this violates EMTALA laws, ethical statutes, etc., and could lead not only to loss of license but to criminal prosecution)... therefore pharmacists, if they want to be considered health professionals, with the rights and privileges that come with being a profession, have to respect their duty to their patients......if they cannot, they should find another field in which they can help others without violating their own sense of morality
martin
Martin Donohoe, MD, FACP
Adjunct Associate Professor, School of Community Health
Portland State University
Chief Science Advisor, Campaign for Safe Foods and
Member, Board of Advisors
Oregon Physicians for Social Responsibility
Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center
http://www.publichealthandsocialjustice.org
http://www.phsj.org
martindonohoe@phsj.org -
0Votesanswered Feb 22, 2011 at 07:05PMMartin
I can not believe you think that EC is a true "emergency" medication just because it's name has the word emergency in it.
There are lots of over the counter medications that have the word emergency in them. Emergency Cure is quack medication for hangovers -- are now hangovers an emergency life and death condition????
In a hospital situation where lets say the mothers life was in jeopardy then I will agree with you.
Also remember that Plan B or levonorgestrel (a synthetic progestogen) can be taken up to 72 hours (3 days) after unprotected intercourse.
There are hundreds of pharmacies just about anywhere you might live and for you to demand that the one pharmacist that might have a moral objection to dispensing the medication MUST dispense it is absurd.
Should a pharmacist with a moral objection to dispensing the drug just not stock the item in his pharmacy or should we make a law that dictates what every pharmacy must stock. -
1Votesanswered Feb 22, 2011 at 07:23PMEdmund, can you tell us in a scenario as to how a pharmacist within the environment of a pharmacy will communicate to the customer the pharmacists moral value and his or her decision not to fill a prescription which would be contrary to that value? I presume when the customer presents the prescription to the pharmacist there would be more said, such as an explanation, other than "I cannot fill this prescription". Should there be signs to warn the customer before interacting with the pharmacist? Do you think that most customers would be in agreement with such a conscience right on the part of the pharmacist? I wonder if there has been surveys about this? I am pleased that we have a pharmacist on this Medpedia Question to look at the issue from that point of view. ..Maurice.
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1Votesanswered Feb 22, 2011 at 08:57PMWith regard to my question about public surveys, here is a beginning which I found from the Free Library
http://www.thefreelibrary.com/Prescriptions+denied%3A+pharmacy+refusal+clauses+have+become+the+latest...-a0136262286
"Public opinion on the issue of pharmacy refusals is solidly on the side of full access to prescribed pharmaceuticals. When Americans were asked whether or not pharmacists who personally oppose birth control for religious reasons should be able to refuse to fill an order for birth control, a full 80 percent say no. Only 16 percent believed that pharmacists should be able to refuse service. Even 74 percent of "prolifers" opposed giving pharmacists this power. (Lake Snell Perry Mermin/Decision Research poll for NARAL Pro-Choice America, June 6, 2005) "
Well, it appears that unlike President G.W. Bush, President Obama is following the public opinion polls as described in the February 18 2011 issue of the Washington Post
http://www.washingtonpost.com/wp-dyn/content/article/2011/02/18/AR2011021807443.html
An extract follows:
"After two years of struggling to balance the rights of patients against the beliefs of health-care workers, the Obama administration on Friday finally rescinded most of a federal regulation designed to protect those who refuse to provide care they find objectionable on moral or religious grounds.
The decision guts one of President George W. Bush's most controversial legacies: a rule that was widely interpreted as shielding workers who refuse to participate in a range of medical services, such as providing birth control pills, caring for gay men with AIDS and performing in-vitro fertilization for lesbians or single women.
Friday's move was seen as an important step in countering that trend, which in recent years had led pharmacists to refuse to fill prescriptions for the emergency contraceptive Plan B, doctors in California to reject a lesbian's request for infertility treatment, and an ambulance driver in Chicago to turn away a woman who needed transportation for an abortion."
Interesting potential turn of events. ..Maurice. -
1Votesanswered Feb 23, 2011 at 03:21PMMedical opinion is such that this is an emergency drug, and to compare it to a quack cold remedy is absurd.
Reams of data show that there are not "hundreds of pharmacies just about anywhere you might live," in fact many women have very limited access to more than one pharmacy, whether it be because they are in a rural area or trying to fill a prescription after hours, which they might be doing on day 3 due to lack of access to health care or lack of awareness of EC. And, there are health consequences to not receiving EC. I respect my patients' rights, and would not want their access to something I prescribed impeded by a pharmacist, and I would be hard pressed to find another doctor would not agree with this level of patient advocacy - this is the oath we take when we get our degrees.
The data backing up my claims are in the article I cited above.
martin -
1Votesanswered Feb 23, 2011 at 08:41PMKim, as the patient's physician and not the pharmacist's employer, I can't do anything with regard to the pharmacist but I would still be responsible for attempting to get the drug I prescribed for the patient. This might mean taking time to contact the employer to get the prescription filled or to help the patient find another pharmacy. As the writer of the prescription and the patient's physician my professional responsibility would be to assist the patient in whatever way I can. It might require obtaining the drug from the pharmaceutical company so as to dispense to the patient. ..Maurice.
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1Votesanswered Feb 24, 2011 at 02:55PMMartin
Personally I think that if the pharmacist has such a strong conviction and moral objection to the dispensing of "Plan B" then the pharmacist should be obligated to have some sort of notice/sign explaining to his/her customers his beliefs.
I would not like the pharmacist to just lie to the customer and tell them he doesn't have the drug in stock or some quick statement to the customer that "we will not fill this request".
In New York there is no prescription needed for Plan B, I am not sure what happens in other states.
My feeling is that if the pharmacist wants to take such a strong stand on this he should be ready to explain to his customer the reasons for his refuse to fill the request.
Interestingly enough I would bet that if you walk in any Catholic hospital, where I am sure they would never perform an abortion or write a prescription for Plan B, that you would be hard pressed to find any sign or notice explain this to their patients.
Lastly I work in a hospital where abortions are performed and there are policies in place for MD's, RN's, PA's and NP's that they can opt out of ever assisting in or performing an abortion.
Maybe we can have Medpedia start a poll on the site asking this question. The problem is that I don't think there are many other pharmacists here. -
1Votesanswered Feb 25, 2011 at 10:11PMI agree with Dr Bernstein's answer to Dr Robinson's question.
EC is available OTC for anyone age 17 and older in the US, and may be available for 16 and 17 yr olds soon.
EC is available OTC in most other countries.42 million/year
Re Catholic hospitals, there are many who take issue with them receiving federal funds while marginalizing women via prohibiting legal services such as contraception and abortion. In fact, Catholic hospitals deny approval of uterine evacuation while fetal heart tones are present, forcing physicians to delay care or transport miscarrying patients to non-Catholic-owned facilities. Some physicians have violated these rules to avoid compromising patient safety.
Worldwide, there are 20 million unsafe abortions annually (97% of these in developing countries). The cost of treating women for complications of botched abortions = $19 million/yr (vs. $4.8 million to provide contraception). The consequences are 70,000 annual deaths (7/hour, which is 13% of all maternal deaths (585,000/year, and 1/4 - 1/2 of maternal deaths in Latin America. Other consequences include 5 million hospitalizations annually and 30 infections/injuries for every one abortion death. Furthermore, 220,000 children are orphaned each year by poorly performed abortions.
Many hospitals allow opt-out for providers re abortion, however there are others on site to do it (although not at Catholic hospitals, as noted above), and abortion is almost always not an emergency procedure (what is an emergency is when a woman gets one done outside the usual medical system and dies as a result, something that was unfortunately very common in the pre-Roe v Wade era in the US).
Unfortunately I don't have the time to discuss this complicated issue further due to competing clinical responsibilities, but all data, articles, ppts, etc. re these issues are available on the public health and social justice website.
martin-
Thank you very much for your answer, Dr. Donohoe. I had a rant on the same topic in another discussion. Correction: I am not a Dr., only a pathetic layperson attempting to add my interest in ethical dilemmas to discussions. I do have social work, including ethics, training.Kim M Robinson commented Feb 26, 2011 at 08:37AM
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