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 on the topic nearly two years ago, illustrating that we haven’t come very far in this debate. As Janet noted then
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.
I’m also going to quote Janet heavily here since she spends her professional life working through scientific and medical philosophy and ethics:
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?)
Orac, a practicing academic physician-scientist, also reminded me of his own post on a related topic back in July.
From my perspective, once you take on the role of a physician, patients must come first…Weighing freedom of conscience against one’s obligations can be difficult, and, yes, there are gray areas. However, if your religious beliefs are such that not only can you not carry out the obligations of your specialty but you can’t even at the very least inform a patient of certain medically appropriate options or refer that patient to another health care practitioner, then you shouldn’t be in that specialty–even more so if your “conscience” will result in the harm of a patient.
The primary dissenting view has come from Dr Bob Koepp, an experienced bioethicist (first comment here and further down the thread.).
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.”
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.
Since I am a pharmacy educator and not a practicing pharmacist, I asked whether ther priviliged monopoly status of the physician-prescriber/pharmacy-restricted drug distribution chain and state licensure of pharmacists as agents of this public service trumps one’s personal belief system. Dr Koepp responded,
The basic tenets of professionalism, including expertise and fiduciary duties 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?
So, let me ask this question in return: what are the responsibilities of a pharmacist in return for state licensure to be one of the 175,000 professionals entrusted with (among many other activities) the dispensing of prescription drugs ordered by the physician to a nation of 300 million people?