Conscientious objection by health professionals: day two

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?

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32 thoughts on “Conscientious objection by health professionals: day two

  1. I think that there are some pretty simple examples – when I have a prescription from a physician that is legal and medically appropriate, I just want the pharmacist to do his job and fill it. I don’t want him inconveniencing me by imposing his “moral standards” on the transaction, I don’t want him to tell me to come back tomorrow and speak to a different pharmacist or get back in my car and drive somewhere else. I just want him to do his job and fill the prescription.
    If he feels he’s not able to, I really don’t much care what the reason is, and whether it’s based on religious prohibitions, personal morality, or the phases of the moon. If he won’t do his job in a professional manner, he should look for another line of work.

  2. I don’t like people using their moral convictions and monopoly on prescribed drugs against people. I think that a pharmacy has an obligation to fill all valid prescriptions. An individual pharmacist can deny care, but they better have someone available who is willing to do their job. We wouldn’t have this argument about a Mormon cashier who is unwilling to sell alcohol.

  3. Abel – First, I’m not a doctor of any sort. Rather, I’m a perpetual student.
    Second, I’m an old-fashioned liberal who views freedom of conscience as a fundamental freedom, one that can’t be trumped by anything less than a showing of compelling societal interest. So if there’s a way to eliminate the conflict between pharmacists and their clients without compelling pharmacists to act contrary to their sincere ethical beliefs — which there manifestly is in this case — that’s the route to take.
    Third, there’s an assymetry in the moral situations of the pharmacists and their clients in the instant cases. The pharmacists are being asked to provide material assistance in the performance of actions that they think are morally prohibited. In contrast, those seeking to get prescriptions filled presumably do not think their actions are morally required, only morally permissible. So unlike the pharmacists in question, they are not being asked to do something which they believe is morally prohibited.
    Regarding the question you pose regarding the responsibilities of pharmacists, I take it that the fundamental/constitutive fact about the practice of pharmacy is preparing and dispensing drugs to treat or prevent medical pathologies. I don’t think a pharmacist has a professional obligation to dispense drugs for non-medical purposes, anymore than I think a surgeon has a professional obligation to perform cosmetic procedures. If they want to provide such services, and they do it competently and safely, that’s their business. But it’s not our business to require them to do so.

  4. This reminds me of the story out of St. Louis about how they had a problem with Muslim cab drivers refusing to transport people with alcohol from the airports because according to their religion transporting alcohol is immoral.
    Then you have the story of this doctor who wouldn’t treat an ear infection in a little girl because of her mothers tattoos offended his religious beliefs.
    This is even more idiotic than the cab driver stuff. When you are a professional it is your duty to serve the public in the capacity that your professional organization describes. The fact that the professional organization in this case is misguided into thinking they should allow their members to pick and choose who they will serve is very sad.
    If it’s not illegal to fill the prescription they should. If you have ethical problems with your job, you need to find a new job. It’s no excuse to conflate personal ethics with general moral behavior or inability to adhere to professional ethics. These people have a personal ethical code that is at odds with society at large and is hindering their ability to do their job. Either get over it, or get a new job. The other problem here is that some people’s sincere ethical beliefs are stupid and should be ignored. Like the idea treating someone who has tattoos is wrong, or transporting alcohol isn’t your job if you’re a cabby. Those may be your beliefs, but if you can’t get over that and join the modern world, why don’t you just go Amish and quit inconveniencing the rest of us. All ethical beliefs are not equal, and some deserve contempt and professional consequences if they end up being applied to those these people are trying to serve.

  5. “Regarding the question you pose regarding the responsibilities of pharmacists, I take it that the fundamental/constitutive fact about the practice of pharmacy is preparing and dispensing drugs to treat or prevent medical pathologies. I don’t think a pharmacist has a professional obligation to dispense drugs for non-medical purposes, anymore than I think a surgeon has a professional obligation to perform cosmetic procedures. If they want to provide such services, and they do it competently and safely, that’s their business. But it’s not our business to require them to do so.”
    Since when has it been established that being pregnant (or the possibility thereof) is not a medical condition, Mr. Koepp? If a woman is pregnant and does not want to be, feels distressed by being pregnant, and feels carrying the pregnancy to term would in some manner handicap the conduct of her life, is that not a pathology? If a person wants to avoid conceiving, is he/she not in effect attempting to avoid a pathology? And the ultimate sovereignty an individual has over his/her body trumps a medical professional’s conscience about dispensing their services to the patient. If a personal moral conviction prevents you from dispensing services (e.g. drugs or information about contraception), then you should indeed consider whether you want to be a medical professional in the first place.
    In the larger sense, if you don’t think you can function in a society where a people are allowed to determine the circumstances under which they reproduce, perhaps you should consider if you can live within the society.
    Get hip, man!
    “Tune in, turn on, and drop out.” (T. Leary, ca. 1966)
    GE

  6. I don’t quite agree with one line you stated, Mr. Koepp:
    “Regarding the question you pose regarding the responsibilities of pharmacists, I take it that the fundamental/constitutive fact about the practice of pharmacy is preparing and dispensing drugs to treat or prevent medical pathologies.”
    This is not completely true in practice. They are, in fact, the gatekeepers of medicine that is used to regulate various ‘conditions’ including, but not restricted to, pregnancy and fertility, neither of which are necessarily ‘medical pathologies’. The fact that you must go to a pharmacist in order to get these types of ‘medications’ alters the business of the pharmacist immediately. The job then, of the pharmacist, is to dispense medications as requested by the medical profession, and to prevent drug and allergic incompatibility when possible.
    Therefore, anything within the power of the pharmacist to dispense must be dispensed, unless it can be proven that there is a medical condition that will harm the patient from a medical point of view. There is room for argument there in this case, but not on a moral basis. There are many professions where morality plays a part, and equally ridiculous (I said it) to the right of a pharmacist to go against the will of the patient and doctor relationship is a police officer who refuses to arrest people who meet certain arbitrary requirements, or a soldier who refuses to carry a gun in a combat zone.

  7. Dr. Koepp has very effectively moved the goalposts: pharmacists only must treat or prevent medical pathologies. What incredibly narrow range of medications is that? No pain medication? There’s nothing pathological about pain; it’s perfectly natural. No acne medication? Absolutely no contraceptives. How about anti-depressants, as they don’t treat an actual medical pathology; would you force a pharmacist to dispense them? What about a rape victim who will suffer great harm if she get pregnant? Surely such cases exist. Should a pharmacist be forced to prescribe Plan B in that situation?
    Further, in such a scenario would one have to prove a certain amount of illness prior to getting treatment, such that antibiotics would only be prescribed if a patient was sufficiently sick, for example?
    This is nonsense–it requires at a minimum that the pharmacist be the one to determine “medical pathology.” I, naively, assumed that is what doctors are for. Dr. Koepp sets up a two-tier plan–first a doctor prescribes medication. Second, a pharmacist, who knows nothing about you or your medical condition except the bare minimum gets to second-guess the doctor.

  8. Re your piece on DCA and how it causes liver cancer in mice…. how many women take Tamoxifen and do not know it causes liver cancer in rats according to the published pharmaceutical contraindications. If that doesn’t stop the use of a high priced drug like Tamixofen why should it be so prohibitive in a cheap possibility like DCA????
    Yours for equality of access,
    j

  9. If a pharmacist questions the “medical need” for a specific, valid prescription, she can take it up with the prescriber not the patient.
    I work with a bunch of smart, experienced and well-trained pharmacists and they would be the first to tell you that they aren’t here to diagnose your illness, but rather once you come to them with a diagnosis to help you find the most appropriate drug. 95% of the time that means filling the prescription, the rest of the time they will call the doctor for clarification or to point out possible problems with the prescribed med.
    Personal religious beliefs (because overwhelmingly these cases revolve around religion not ethics) have no standing in a secular workplace.
    Brook

  10. Personal religious beliefs (because overwhelmingly these cases revolve around religion not ethics) have no standing in a secular workplace.
    Brook

    Amen!! No, wait … I meant to say “I agree completely.”
    I really don’t see the pharmacist/prescription example as any different than the clerk in the same drugstore that refuses to sell me the package of condoms that I take up to the desk.
    Or of the civic official that refuses to marry a couple … as has happened in a case or two of same-sex marriage in Canada.

  11. Is it relevant that the moral position of the pharmacists is completely ludicrous? I don’t know, but if so, it clears things up tremendously. Would we react the same way if, for example, the pharmacist in question was a Scientologist who was refusing to give patients anything prescribed by a psychiatrist? Because the appeal that’s being made here is really no more sensible.
    “In contrast, those seeking to get prescriptions filled presumably do not think their actions are morally required, only morally permissible. ”
    That’s stupid. The patient has the potential for REAL HARM, and unwanted baby. Consider: what if the ER doctor won’t treat the patient that’s dying from a gunshot wound because he’s morally opposed to gangs? After all, maybe he thinks he’s “morally obligated” not to, whereas the dude dying on his table only finds it “morally permissable” to be patched up. Do we REALLY believe these people, or is it obvious they just want attention? Where’s the line?

  12. The inimitable Kevin Beck at Dr. Joan Bushwell’s Chimpanzee Refuge cited our discussion here by cutting to the quick with this metaphor:

    Other arguments against pharmacists’ need to keep their convictions out of their work are weak to frivolous. Invoking “conscientious objector” rhetoric doesn’t even apply. Someone with an objection to war makes this clear previous to being enlisted. For someone already [employed] at a Rite-Aid or a CVS, it’s a little late for that. There’s a difference between refusing to join the army and, once in Tikrit, refusing to do what you’ve sworn to do.

  13. “There’s a difference between refusing to join the army and, once in Tikrit, refusing to do what you’ve sworn to do.”
    So, just what is it that pharmacists are sworn to do? It’s getting a bid tedious reading all these comments about the duties of pharmacists with no accompanying rationale relating those duties in a principled way to the actual expertise of pharmacists.

  14. So, just what is it that pharmacists are sworn to do? It’s getting a bid tedious reading all these comments about the duties of pharmacists with no accompanying rationale relating those duties in a principled way to the actual expertise of pharmacists.

    From my perspective as a consumer, it’s really pretty simple – take my prescription, consult with the doctor if they see something like an interaction with other prescriptions, and then fill it and sell it to me.
    And keep their personal religious or moral feelings out of it. This is a transaction involving directions from my doctor, me, and a member of a profession which has a monopoly on dispensing prescribed material. Their moral qualms are no affair of mine.
    I’m curious – are you planning to educate us on exactly what pharmacists are sworn to do or to suggest how you think a pharmacist should behave in the situations mentioned? Or simply sit back and condescend to people with wording such as “warped,” “knee-jerk reactions,” and “bloviate” (discourse at length in a pompous or boastful manner)?
    I do not mean to be insulting, but if there’s bloviating going on here, check the mirror …

  15. “It’s getting a bid tedious reading all these comments about the duties of pharmacists with no accompanying rationale relating those duties in a principled way to the actual expertise of pharmacists.”
    It probably seems tedious to you because you refuse to recognize that the expertise of pharmacists is, for present purposes, irrelevant. People don’t get to rewrite laws or their job descriptions on the spot on the basis of their educational background.
    What you’re arguing for, it appears, is people being be allowed to leverage their moral convictions with their degrees or professional qualifications. That’s crap.
    Doctors know a lot more about practicing medicine than hospital administrators, but this doesn’t give them latitude to not deliver interracial babies or treat PCP or tuberculosis because the believe that the HIV-positive patient who has it is moral scum. Civil engineers can’t refuse to work on a bridge (whose workings and construction they comprehend beautifully) because it’s going to increase traffic through nonwhite neighborhoods or whatever. Do you see physicists taking positions with the Department of Defense and then trying to decide on their own which counties would one day be okay to hit with tactical nukes and which are off the list?
    Rather than pick apart these analogies to the last detail, as you may be inclined to do, consider in broader terms what I’m saying.
    What the hell does “principled way” mean, anyway? Even as you demand some sort of concrete “rationale,” you deploy a completely subjective term. Is “principled way” code for “whatever someone feels is right”? That would be problematic. One might think you are encouraging or sanctioning, say, religious anti-choice people who import their beliefs into the pharmacy profession in order to subvert it on an ad hoc basis.
    If all of the employees of a pharmacy decide they want to part of a particular item, such as condoms, fine. They should post the list of non-dispensed items on the door so that people can patronize a more suitable place. But if you take a job with, say, one of the chain stores knowing full well what’s expected, and you rebel, then you deserve to be reprimanded or fired, in which case you will probabvly find work in one of these putative Bronze Age apothecaries I mentioned above.

  16. Third, there’s an assymetry in the moral situations of the pharmacists and their clients in the instant cases. The pharmacists are being asked to provide material assistance in the performance of actions that they think are morally prohibited. In contrast, those seeking to get prescriptions filled presumably do not think their actions are morally required, only morally permissible. So unlike the pharmacists in question, they are not being asked to do something which they believe is morally prohibited.

    So what?
    As a physician, I say: Really, I mean it. That’s a red herring.
    If a pharmacist’s moral belief system does not allow him to fill prescriptions that are not only legal but that the vast majority of his customers considers to be morally permissible and, worse, he or she won’t even refer to a pharmacy that will (or if he or she is the sole provider for a long distance), he or she has no business being a pharmacist. Period. End of story. Sorry if you think that’s dogmatic or if offends your championing of these “conscientious objector” pharmacists.
    There’s also a huge asymmetry of power that you seem to neglect to mention, particularly in small towns and rural areas, where the pharmacist may be the only one around. I agree with Kemibe. If a pharmacist has moral qualms about prescribing various classes of legal prescription drugs, then that pharmacist should be obligated to post a list of those drugs in a prominent place with a notice that his conscience does not allow him to prescribe them. Customers can then judge whether they wish to continue to patronize his pharmacy or not based on knowledge. Similarly, if a pharmacist takes a job with a pharmacy that stocks these legal medications, he’s either deluding himself or an idiot if he doesn’t think he should be required to dispense them and should not take a job with that pharmacy. His employer is paying him to dispense all the drugs that are stocked; once he takes the job, a pharmacist cannot pick and choose and still expect to keep the job. The employer would be well within his rights to fire the pharmacist if he refuses.

    Regarding the question you pose regarding the responsibilities of pharmacists, I take it that the fundamental/constitutive fact about the practice of pharmacy is preparing and dispensing drugs to treat or prevent medical pathologies. I don’t think a pharmacist has a professional obligation to dispense drugs for non-medical purposes, anymore than I think a surgeon has a professional obligation to perform cosmetic procedures.

    What, pray tell, would these prescription drugs being dispensed for “nonmedical purposes be,” hmm? Do give us some concrete examples if you can and describe in detail how a pharmacist could appropriately determine whether a drug is being prescribed for a “nonmedical purpose.” If a drug is prescribed by a physician, the presumption is usually that it was prescribed for a medical purpose, unless there is a damned good reason to believe otherwise. How would the pharmacist know whether a physician prescribed a drug for what is a “legitimate” medical purpose? What specific criteria can be used to decide? The pharmacist most likely will not have enough information to make a reasonable judgment of that, anyway, because the vast majority of the time the physician will know the patient’s medical history better than the pharmacist.
    Questioning the appropriateness of a specific drug for a specific purpose in a patient because of other medical history or because of the potential for interactions with other drugs is one thing and entirely appropriate, as is questioning a dose that may be incorrect. Refusing to break the law by, for example, prescribing too much pain medicine to a patient is another (although the Department of Justice and its draconian intimidation and prosecution of physicians giving appropriately high doses of narcotics to patients in pain is unjust and bad medicine) is also appropriate. Passing judgment on whether a drug is being prescribed for a “nonmedical purpose” goes way beyond that and is not within the purview of a pharmacist. I can tell you that if I ever found out that a pharmacist refused to fill a medically appropriate prescription that I wrote because he decided it was for “nonmedical reasons,” I’d raise holy hell with the pharmacist first, and then, if I didn’t succeed in showing him the error or his ways in making that judgment and he didn’t succeed in showing me that I was wrong, from the pharmacist’s employer.

  17. One other thing. These pharmacists who want to be able to be “conscientious objectors” seem to want to have their cake and eat it too. They want to be able to refuse to dispense legal medications based on their religious or moral beliefs but don’t have the strength of those beliefs to quit the specific job that requires them to do what they consider to be so immoral.

  18. Many things to respond to in this thread, and Wilkins’ question about herbal medicines will require another post.
    But as to the duties of a pharmacist, here is what the Board of Pharmacy in my progressive Southern state has to say about a ‘conscience clause’:

    Q: Does North Carolina have a “Conscience Clause” for dispensing emergency contraceptives?
    A: The Board has adopted a policy on pharmacists’ refusal to dispense prescriptions in certain circumstances:
    A pharmacist should function by serving the individual, community and societal needs while respecting the autonomy and dignity of each patient. The best practice by a pharmacist is to promote the good for every patient in a caring, compassionate and confidential manner. Pharmacists should discuss and resolve any questions about emergency contraception prior to employment. Compassionate care and conscientious objection are not mutually exclusive.
    A pharmacist has the right to avoid being complicit in behavior that is inconsistent with his or her morals or ethics. It is unacceptable, however, for pharmacists to impose their moral or ethical beliefs on the patients they serve. Pharmacists who object to providing a medication for a patient on this basis alone, therefore, should take proactive measures so as not to obstruct a patient’s right to obtain such medication.
    The Board notes that although pharmacists have a right to avoid moral or ethical conflict, they do not have a right to obstruct otherwise legitimate prescription dispensing or delivery solely on the basis of conscientious objection.
    Board of Pharmacy staff interprets this policy to mean that if a pharmacist refuses to fill a prescription for emergency contraception then that pharmacist has an obligation to get the patient and the prescription to a pharmacist who will dispense that prescription in a timely manner.
    Phrases and Concepts From:
    American Pharmacist Association Code of Ethics
    May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?, Cantor & Baum
    New England Journal of Medicine, November 4, 2004, @ Pge. 2008
    Rev 4/05

  19. Responding to several points:
    I haven’t suggested that pharmacists expert knowledge is relevant to rewriting laws or job descriptions. I have claimed that it’s relevant to claims about professional obligations.
    There’s a huge difference between objecting to participation in a particular procedure or action and objecting to provision of services to a particular class of people. The right to conscientious objection has never been interpreted to allow the latter.
    The assymetry I noted between the moral situations of the pharmacists and their clients was indeed relevant given claims about the former imposing their values on the latter. In both law and ethics, a refusal to provide assistance is not generally viewed as a violation of another’s freedom. This is entirely consistent with the quoted material Abel provides in his recent post.
    So long as the prescriptions Orac writes are medically appropriate, I would agree with his taking to task a pharmacist who refused to fill them. The key is getting clear about what constitutes medical approriateness. I’ve been suggesting that it has something to do with serving a medical purpose such as promoting health, preventing or ameliorating pathological conditions. I’m not sure how Orac is interpreting this notion.
    I’m certainly not suggesting that pharmacists in particular, or professionals generally, have any special recourse to conscientious objections. I’ve consistently framed the issue in terms of freedom of conscience, which I assume applies universally — even to those who have moral views with which I disagree.
    Finally, I wish half the energy expended condemning a few pharmacists was directed toward demedicalizing access to contraceptives and abortifacients. We could start by lobbying the FDA to stop restricting access to Plan B against the recommendation of its own scientific advisors.

  20. Perhaps another approach could be taken with respect to pharmacists who object to filling prescriptions they consider morally objectionable: they or their employers could be held liable for any damages, including pain and suffering, that resulted from their actions.
    It might be difficult to secure a judgment in the most conservative parts of the country, but even one high-profile case would motivate most drug store chains to adopt policies to avoid such consequences.

  21. So long as the prescriptions Orac writes are medically appropriate, I would agree with his taking to task a pharmacist who refused to fill them. The key is getting clear about what constitutes medical approriateness. I’ve been suggesting that it has something to do with serving a medical purpose such as promoting health, preventing or ameliorating pathological conditions. I’m not sure how Orac is interpreting this notion.

    “Medically appropriate” to me means “within the standard of care.” It’s just that simple. If a doctor prescribes a medication according to the standard of care at a dose that is appropriate and the drug will not have harmful interactions with other drugs, then the pharmacistshould fill it. Period. If for some reason he cannot for moral reasons do so, then he should find another job.
    But that’s the very point. In the vast majority of cases, the physician is in a far better position to judge what is “medically appropriate” and within the standard of care than a pharmacist. Similarly, it is the physician who will be sued if what he or she does is not within the standard of care and there is an adverse outcome.
    The idea of suing pharmacist who, for instance, refuses to prescribe emergency contraception, is indeed appropriate. I’m betting that a lot of these “conscientious objectors” would be a lot less dedicated to their beliefs if they found out that they could be all or partially on the hook for the cost of raising an unwanted child to the age of 21, for example, plus punitive damages. It’s the same thing as my comment about such pharmacists taking jobs at pharmacies that stock such medications or not resigning if a pharmacy for which they work decides to start filling prescriptions for such drugs. They want to exercise their “conscience” and impose their morality on others without bearing any cost for that decision. In essence, they transfer the cost of their religious/moral decision to a patient who does not share their religious/moral beliefs.

    Finally, I wish half the energy expended condemning a few pharmacists was directed toward demedicalizing access to contraceptives and abortifacients. We could start by lobbying the FDA to stop restricting access to Plan B against the recommendation of its own scientific advisors.

    Red herring in the form of the “you aren’t concentrating on the issue that I want you to concentrate on” fallacy. So, in other words, we shouldn’t criticize these moralizing pharmacists because the “system” leaves them no choice? Nice try at shifting the focus, but, sorry, it won’t fly. This is the system that we have, and being annoyed at these pharmacists does not preclude lobbying for the changes that you desire.

  22. Oh, and I forgot to mention: You still haven’t told me what all these prescription drugs supposedly being prescribed for “nonmedical” purposes are and what specific criteria a pharmacist would use to judge whether the purpose is “nonmedical.”
    You criticize me for being vague, but you haven’t exactly been a beacon of specificity yourself.

  23. If a pharmacist has a moral problem with dispensing either contraceptives or emergency contraceptives, the least he/she can do is prominently provide notice to prospective patients of their policy so that said patients may decide for themselves whether to use that pharmacy. This would be the ethical thing to do.

  24. Orac –
    1. “Standard of care” itself needs some unpacking. Is the care in question related to the health status of patients, or is it much broader in scope?
    2. Again, those who refuse to provide asisstance are generally not viewed, in either law or ethics, as “imposing their morality.”
    3. Red herring? I’ve noted that it’s because access to emergency contraception is inappropriately restricted that conflicts have arisen between some pharmacists’ moral beliefs and the desires of their clients. If demedicalizing contraception would moot conscientious objections, it can hardly be irrelevant to the present discussion.
    4. Contraception is usually not medically indicated, since pregnancy is usually not pathological.
    5. I wonder if you think conscientious objections are inappropriate just for pharmacists, or whether you would also reject appeals to conscience by physicians.

  25. When I was a waiter way back when, I was also a vegetarian. Had I refused to serve steak or chicken while working at a restaurant that had these items on the menu, due to an arguably moral objection to doing so, I would have been fired on the spot. Had I really objected to their being served, I could have gotten a job at one of the many vegetarian restaurants in my city. Note that slangin’ grub isn’t exactly a necessary public service, either.
    Any pharmacist who refuses to dispense contraceptives or morning-after pills due to “moral” objections should be canned immediately and lose thier liscence. It’s that simple.
    This, I think, is one of the areas in which religious fundies are trying to force their backwards ideas on the rest of us. I don’t think they – or anyone else for that matter – have the right to do that. It’s thoroughly unacceptable.

  26. In both law and ethics, a refusal to provide assistance is not generally viewed as a violation of another’s freedom.

    Maybe, but in the law (and probably there’s some ethical underpinning to this as well) if someone dies as a result of another’s neglect – or “refusal to provide assistance” – that’s manslaughter, and five to ten. One of the Freedoms put forth in the UN Human Rights Convention (Article 3) is the “right to life, liberty…” etc. So one could argue that refusal to provide assistance to one in need is a violation of that person’s freedom. This ought to be especially pertinent if it’s one’s job to provide assistance to others.

  27. There are 2 fundamental values at work here:
    1) the value of the pharmacist’s ethics/morals and
    2) the value of the patient getting their prescribed medication.
    The only question is: where does the line lay between the two? As a scientist, I would object to doing cruel and unusual human research and I would be offended if I were required to do so by my job. However, I would make these objections known at the outset of being informed of the research and, if it proceeded forward anyway, would seek employment elsewhere.
    There is a huge difference between personal morals and professional morals. Professional morals are set by the regulations upon the given industry, its consensus, and the societal attitudes thereof. Personal morals are one’s own, and if they come into untenable conflict with the professional morals, then it is one’s professional obligation to seek employment elsewhere.

  28. Bob Koepp: “Third, there’s an assymetry in the moral situations of the pharmacists and their clients in the instant cases. The pharmacists are being asked to provide material assistance in the performance of actions that they think are morally prohibited. In contrast, those seeking to get prescriptions filled presumably do not think their actions are morally required, only morally permissible. So unlike the pharmacists in question, they are not being asked to do something which they believe is morally prohibited.”
    Oh, Jesus H F*cking Christ – if person A morally opposes something which person B considers morally acceptable but not required, then person A’s beliefs trump person B’s freedom to do that thing?
    Your bioethics comes down to ‘what is not required is forbidden’, apparently.
    Mark Kleiman summed this up best with: “I’ve suggested before that bioethics ought to be a felony, except as practiced by Hilary Bok and whoever she chooses to license. It seems to me that this case nails down the case for that proposal.” (http://www.samefacts.com/archives/health_care_/2007/02/girls_boys_bioethics_chastity_and_the_hpv_vaccine.php).

  29. Note – I’m quoting Mark about something else entirely; I was pulling the quote as a witty way to express my belief that ‘bioethics’ is another example (so frequent in the past six years) of academic ‘disicplines’ in really bad need of thorough purge.

  30. By the way, Bob, are you related to Steve Fuller (alleged sociologist of science, who supports the teaching of Intelligent Design)?
    There’s that same verbiosity combined with vacuous BS.
    Forgive me if I’m wrong, but the resemblance is extraordinary.

  31. Since when is pregnancy a “non-medical” condition? If a woman requesting emergency contraception is pregnant, then she has a medical reason for obtaining medication. If she isn’t pregnant, then any denial on “moral” grounds is moot.
    All this is just wordplay until you look at the larger context of what these people really want: the subjugation of women.
    Early in the Bush II administration, Searle was pressured to write a warning letter regarding misoprostil to OBGYNs. It warned against possible adverse effects associated with using the drug to facilitate childbirth. This warning came in spite of the fact that the drug’s use for this purpose was already widespread, well studied, and considered safe and effective by the American College of Obstetrics and Gynecology, which in turn objected to the letter.
    Now, misoprostil is a prostaglandin initially developed to protect the stomach lining against things like NSAIDs, but it turned out it could be used as an abortafacient as well. Apparently, this made it unfit for ANY use in gynecology in the minds of the religious right, even if it safely eased and shortened the time of delivering a child, AND was approved by the medically trained individuals who used it. The drug company, who would normally love their product to be used for a common off-label purpose, must’ve bowed only to considerable pressure. We’ve seen the magnitude of this pressure being applied to the FDA for Plan B as well.
    This isn’t an isolated case of some women that couldn’t get their ‘scripts filled. It’s much more dangerous and pervasive.

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