Tuesday, July 26, 2005

Birth Control, Abortion and Fundamentalists, Oh My!

7/27 - Update: I came across this today, at Prochoice Action
On July 25, a U.S. House of Representatives committee held a hearing on whether pharmacies should be allowed to refuse to fill women’s prescriptions. Anti-choice Rep. Steve King (R-IA) told a witness, who had been denied birth control and emergency contraception by her pharmacist, that she had no “right” to her prescriptions - she only believed she did. Anti-choice Rep. Marilyn Musgrave (R-CO) told a witness whose prescription had also been rejected by a hostile pharmacist, that her “minor inconvenience” – that is, risking an unintended pregnancy – was nothing compared to the “conscience” of a pharmacist.

(This is the first in a series of entries about my impressions of the radical right and their positions on reproductive rights. I don't claim to offer any new and stunning insight on the issues at hand, but feel compelled to comment on them in my usual cranky fashion.)

On Birth Control:

When the radical right's opposition to Roe v Wade hinges on the presumption that life begins at conception, their efforts are unlikely to stop at simply overturning Roe. The ultimate goal, by logical extension, will be a ban of all hormonal birth control.

The argument is that hormonal birth control hinders the uterus lining from adequate development. In the event an egg is released and fertilized, it will be unable to implant properly. This "interruption" would qualify as a thwarting of conception, and fall, therefore, well within the parameters fundamentalists say envelops and justifies their opposition to Roe v Wade.

(Note: There is debate over whether or not the prevention of implantation is actually caused by hormonal birth control. Manufacturers claim is does, while scientists assert there's no evidence to support the claim, and that in reality, hormonal birth control suppresses ovulation. While it's a germane point to a discussion of drug efficacy, it isn't particularly relevant to those opposing its use, and therefore, is not terribly relevant to this, a principally political discussion).

While I wouldn't ordinarily ascribe a great deal of logical or philosophical consistency to the radical right, there are plenty in their numbers sharp enough to follow the path to which their position leads. After all, being as fond as they are of "moral absolutes", they can't reasonably argue that defeating conception in one instance is "an abomination", but is acceptable in another. Consequently, opposing abortion, while ratifying hormonal birth control, in the end, is the same kind of "moral relativism" the left is regularly derided for.

In support of this prediction, I invite you to look at the recent controversy regarding "conscious clauses" and the refusal of pharmacists to dispense birth control prescriptions. This is an issue that the radical right can easily rally behind, on the grounds that pharmacists shouldn't have to "surrender their beliefs" in the course of their employment. Yet the tactic is grotesquely short-sighted, and demonstrates how little the fire & brimstone crowd understands about hormonal birth control and why it's used.

"What's more, oral contraceptives aren't only used to prevent pregnancy. The Pill may cut the risk of ovarian cancer by up to 80 percent and is used by women at high genetic risk for this hard-to-detect and usually fatal cancer. "There are easily more than 20 noncontraceptive uses for the Pill in common practice," says Giovannina Anthony, MD, an attending physician of obstetrics and gynecology at Beth Israel Medical Center in New York City. "This drug saves women from surgery for gynecological conditions like endometriosis, fibroids, and severe bleeding and pain."

These noncontraceptive uses are nothing to scoff at. Anyone suggesting otherwise is, well, a moron.
"'The pill' does far more than prevent pregnancy. For years physicians have prescribed birth control pills to regulate heavy or irregular menstrual periods, to treat ovarian cysts, to decrease menstrual cramps or PMS, to increase appetite in underweight women and to reduce acne. We also know there are many other benefits to taking the pill. These include decreasing the risk of ovarian, endometrial, and colorectal cancer decreasing the risk of osteoporosis."

Evidently, these uses are trivial to the radical right and like-minded pharmacists, and I expect they'll claim that the percentage of women engaging in noncontraceptive use is below statistically significant levels. However, given that some 12 million women are reported to be on the pill, I would take any such claim with a grain of salt. Should any of you find hard data on this, please share in your comments.

I suspect that one of the reasons we hear very little outcry from the general public regarding pharmacist refusals is little more than political correctness gone astray. We’re so indoctrinated now to avoid calling someone out on nonsense when it’s shrouded in religious beliefs that we look the other way in cases like these.

However, some simple logical questions must be asked of those defending the “rights” of these refusing pharmacists.
  • If a person’s religious beliefs prevent them from fulfilling their responsibilities of their chosen profession, should they not, instead, reconsider their vocational choice? We don’t see too many Buddhist pest exterminators, Hindu butchers, or Quakers in the military, do we? In the rare event there are, wouldn’t we consider them a bit ridiculous for standing unyieldingly on religious principle and refusing to perform their basic duties? After all, they knew perfectly well what their vocations would demand, but chose to deprioritize religious principles in favor of professional obligation anyway.
  • If I were a pacifist, it would make little sense for me to work at a gun shop. Furthermore, I’d have a very difficult time justifying my refusal to sell guns to the shop owner, wouldn’t I? My insistence that I can still sell flak jackets and canteens would do little to prove how useful I could be with “anything but guns”. Undoubtedly, his first question would be “Why the hell did you apply for a job HERE?!?”, and the shop owner’s befuddlement would certainly be justified.
  • Should a pharmacist’s religious convictions be so strong, why wouldn’t they surface during the exhaustive training required for state certification? And if they do, what does he say to himself, “I’ll deal with that later”? At best, this is a childish evasion of inevitability and one that speaks to a fairly myopic view of his future career.
By the time he is in the employ of a pharmacy, it is simply too late. At least in principle, he has entered into a contract with his employer to serve the local community, and in so agreeing, surrenders his right to arbitarily discriminate against individuals and their medical needs for purely personal reasons. Not only is it beyond his capacity as an employee to pick and choose which clients he will service and which he will refuse, but it is completely outside his professional capacity to presume to diagnose appropriateness in a glance, and refuse to fill a woman’s prescription because he believes he knows better than her or her physician. Companies like Wal-Mart that allow “conscience clauses” in their hiring agreements, I believe, are doing little more than serving their best PR interests. To parlay such a stance into “support for their employees’ religious views” is, at best, overstating the significance.

The arrogance of pharmacists that refuse to honor birth control prescriptions is a breach of professional etiquette and ethics, and simply a repugnant thing to do as a human being supposedly in the business of caring for others.

It is, however, what the radical right would love to see increasing number of health providers do, and as such, they will continue to support “conscience clauses” with glee. I won't be the least bit surprised when they use the refusals of pharmacists as leverage to pressure doctors and nurses to refrain from prescribing altogether. When health care providers yield to this pressure (at the risk of losing business), the radical right will add the capitulation to their legislative arsenal and make their demands of Congress:
“See? Even health professionals recognize that hormonal birth control is WRONG. If the experts are joining the chorus of your constituents, then you must submit to the will of the people, and acknowledge that birth control is an affront to our morals and principles! We therefore, seek a ban of its dispensation in toto. The reversal of Roe v Wade has opened the door for legal protection of all pre-born life, and it therefore cannot be undermined by allowing further prescription of hormonal birth control.”

I’d really like to be wrong about this, and know that I’ll be met with accusations of “liberal hysterics”. So be it. But when Frist and DeLay can insist that the Terri Shiavo matter become a federal case, when Rick Santorum can claim that working mothers are greedy, and when the radical right can garner support for stopping just short of criminalizing homosexuality, can you really blame me for my skepticism?

(cross posted, for those interested in any resulting parallel discussion)


Lily said...

Well Cantbtch I think that you touched on the "life begins at conception" aspect that many anti-abortionists discuss and the implications on birth control-so- no more needs to be said there, however, there are certainly many instances where people have a moral vs. professional ethics dilemma. I am not sure I agree that we should take away a person's right to refuse to fill prescriptions. it is offensive to me, this idea that a pharmacist would do this, but still STILL I would say that he/she has the right on the basis of their moral/religious/whatever position.
Legally, "beliefs" have been upheld for conscientious objectors, faith healers, exceptions from immunization requirements, kosher food in hospitals...we can point to many cases where the law indicates that one code of conduct can be grounds for the superceding of another. I would be very careful about denying that pharmacist's right to that determination WHILE ALL THE WHILE I would never want to see this happen. But because it is wrapped up in the abortion debate, it is perhaps viewed differently. But the standards of law must be applied regardless of our emotional response to the "right" and their obvious agenda. I urge caution about rights here though- I would rather see women drive to the next pharmacy for their birth control (freedom to purchase) than deny a person (pharmacists) their right to act on their convictions. Civil liberties involve many unpleasant double edged swords, my friend. We have to accept that what protects us, protects them. Even when we do not like the result of this affirmation.
And guess what? I think a doctor has the right to refuse a non-emergency patient, a vet can refuse a nasty pet...and a pharmacist must obey the rules of their employer with whom they have a contractual understanding....there is no such covenant between CVS and Cantankerous Bitch.

Lily said...

And... Not everyone who opposes abortion does so on the basis of religion or life "beginning at conception". Remember some people oppose it on the basis of perceived cruelty, that it is largely unknown how a fetus responds to pain. We know that most abortions occur between 10-16 weeks. We know that some clinics will NOT perform them before twelve weeks. (too hard, more accurate with larger body) Now moms will recall that this is now after the first trimester. We are talking toes, eyelids, brain activity, nervous system.. Anyone who looks at the new sonograms of a sixteen week fetus knows exactly what I am saying here... The belief that regardless of when life begins or when a fetus can live outside the womb (another definition of "life" which is in my opinion ridiculous, even a baby born cannot live without intervention) it is unknown to what extent this fetus feels pain. Now at three weeks old- nah. Five weeks- probably not. But this is not when abortions are performed. They are performed often on a fetus sucking its thumb. Look up a sixteen week old fetus. it is not a blob of cells. THAT is the part that gets left out of the bible versus birkenstocks debate. WHY is it a debate about all or nothing, and not a discussion of perhaps a more humane method? An earlier method? Why can we not get these earlier abortion pills on the market??Why are we not clammoring for that instead of rehashing Roe v Wade over and over? Why so limited a view on this? we have the right or we do not...nothing about a standard that makes more sense given technology. Why not laser technology to do it even sooner? Where is a discussion on early detection and laser embryo detachment, non-invasively????
Now I have always taken the position that my opinions are my opinions. But yet I assert that my opinions on people we kill in Iraq matter (which incidentally Pro-lifers have no problem with. Does not occur to them that bombing civilians may result in bombed pregnant mothers whose unborn one would think have the same right to life) and I say they matter here too, and that we can insist on using technology that changes the process we are talking about. it is too hard to have three camps- pro-life, pro choice, and PRO USE A FUCKING LASER AND HAVE SOME HUMANITY IF YOU'RE GONNA DO IT camp. Where I am.

Cantankerous Bitch said...

...I am not sure I agree that we should take away a person's right to refuse to fill prescriptions. it is offensive to me, this idea that a pharmacist would do this, but still STILL I would say that he/she has the right on the basis of their moral/religious/whatever position.

See, but I think there is a valid distinction here, though. If the objection of pharmacists is based on a straw man characterization of what hormonal birth control actually does, then the legitimacy of their argument is a rather hollow. Refusing to prescribe RU486 (as much as I might dislike that as well) would at least be supported by the drug's intended use. Their refusal to dispense (in the absence of a company mandate to the contrary) is more easily justified. However, when they object to b/c based on an inaccurate claim of its function, then supporting their refusal isn't honoring their right to principle, it's deferring to political correctness. Further, do we dismiss, out of hand, noncontraceptive uses? What right does a pharmacist have to presume how this particular drug is being used? What right does he have to act on that assumption and when in error, deny a woman access to medication she requires? This denial is decidedly not in the purview of a pharmacy or its employees.

...Legally, "beliefs" have been upheld for conscientious objectors, faith healers, exceptions from immunization requirements, kosher food in hospitals...we can point to many cases where the law indicates that one code of conduct can be grounds for the superceding of another.

This is a difficult area to research, and if you've any specific direction in which to point me, I'd be grateful for the information. And while I appreciate the spirit of your arguments, however, on the face of them, I find the analogies to be imperfect.
In the case of conscientious objection, that is effectively a product of conscription. Pharmacists are not compelled by government edict to enter their profession. And as I understand it (please correct me if I'm wrong), if a person volunteers for military service, then finds him/herself needing to "conscientiously object", the military can discharge him/her if they so choose.
As for faith healers and immunization requirements -- I recall hearing of parents being prosecuted for failing to medically treat their children as a result of their religious views when the worst case happens -- the child dies. Haven't some of these parents been convicted? If immunization issues have not yet been prosecuted, I'd be surprised if it never comes to pass. Again, if you can point me to case history, I'd like to learn more.
As for kosher food, this doesn't strike me as equivalent. Do we know of cases in which a person's need to follow a kosher diet directly impeded their ability to perform a vocation?
The pharmacist issue, to me, is unique, in that a pharmacist is supposed to be a neutral third party with no role in diagnostics or treatment beyond dispensation. At best, they can and do speak to contraindication and drug interactions alone. Their philosophical intrusion into this matter violates the spirit of a doctor-patient confidentiality, even if it does not violate the letter of the law.

...Civil liberties involve many unpleasant double edged swords, my friend. We have to accept that what protects us, protects them. Even when we do not like the result of this affirmation.

And in general, I agree. For example, the KKK enrages me, but I know that the same amendment that protects my right to free speech also protects theirs. However, should I try to interfere in their right of free expression (as a pharmacist attempts to interfere in the dispensation of b/c), then I have crossed a line. My revulsion does not entitle me to present them with obstacles, no matter how insignificant or severe.

Further, the argument that one can simply choose another pharmacy, I worry, reflects an upper/middle-class suburban bias. What of the women in rural areas, for whom an alternate pharmacy is a prohibitive distance away? What of women for whom this travel would represent an undue burden in terms of access? Are we saying that a pharmacist's principles should trump a woman's right to equal access in the absence of legal restrictions of dispensation? I have a hard time endorsing this.

...And guess what? I think a doctor has the right to refuse a non-emergency patient, a vet can refuse a nasty pet...and a pharmacist must obey the rules of their employer with whom they have a contractual understanding....there is no such covenant between CVS and Cantankerous Bitch.

No, there is no covenant indeed. However, as a consumer, I get to exercise my "vote" anyway. In the example at hand, CVS, in response to recent media coverage, has issued a press release stating that they will honor all prescriptions, at all times. As a result, they will continue to get my business. However, the women for whom Walmart is their only practical pharmacy choice are not so lucky. I'm simply not ready to tell them "Sorry, but someone else's morals are more important than your medical care."

Cantankerous Bitch said...

And... Not everyone who opposes abortion does so on the basis of religion or life "beginning at conception". etcetera....

As to this, you'll forgive me if I fail to respond in detail here, as this strays from the original topic. Rest assured, however, I do intend to discuss abortion in this "series". Having said that, I think your points about methodology and technology are well made and I agree, they're sorely missing from the current debate. With your permission, I'll be sure to include them in the next installment (with credit given where it's due, of course).

Lily said...

On Analogies and Role of the Pharmacist...First-No- they were not perfect analogies. Not intended to be. OF COURSE you can show differences. I'd be hard pressed to develop the perfect analogy that shows every subtlety of law- I assumed some indulgence because it seemed quite obvious to me that they were not intended to replicate the question. They were simply illustrative examples, I hoped, to show where I was going with the issue. The directional aspect, which was to say that often individual rights are indeed protected to our detriment- socially and in opposition to policy- as with immunizations. It was an example that had DIFFERENT subtleties... public health vs. freedom of religion, infection control vs. self determination and privacy, you follow. While we affirm the right to choose, we also commit to the clear need for rational public health policy. Yet in the face of that, personal rights have still won out. Yes, a parent can refuse to immunize if they meet certain bases for exception, often religious. Public good (via health policy) can and has been trumped by individual 'rights". This was the point really. That small distinction was the part I hoped to transfer to pharmacists and the right to refuse to dispense contraceptives or indeed, any drug that specifically and strongly violates a religious belief. No, my analogies are not all nearly nor exactly the same thing, but really- this is a comment box! When whole courses have been devoted to this thinking and I've taken them as a policy student. What you seek is scholarly research of a different sort than a housewife blogging, and I will assume you can research far better than I can. I won't insult you by telling you to google "ethics" to get the cases you seek. There are thousands of law sites, much is at your disposal and indeed we all must arrive at our own conclusions, trying of course to stick to facts and having an understanding of what we look for in law. (for example, you can view many cases where courts have upheld a parent's right to refuse to immunize, but it does not say "In case you are wondering if you can refuse immunization, you can." It is an APPLICATION of the right to religious freedom and has been upheld repeatedly, forming the basis for precedental acknowledgement)
Lets not spend precious time defending the integrity of this activity- I apologize profusely for my shitty, substandard analogies. I am an unversed regular ol' gal..and thankfully do not exude nor indicate ..what was it you said? Upper class suburban bias? I am decidedly low class, considerably pressed for time and cannot respond to each of your questions, and certainly to direct you to points of law would take even more time and I am not a lawyer. I read what I can and suggest we all strive to do the same. We should as citizens. Often I suggest going beyond the "big" oft cited cases and look to administrative laws that over time have shaped a running commentary on just what Americans DO think supposedly on a number of issues. The rules that govern an eligibility for example, tell you FAR MORE about your rights than a blanketing doctrine.It is the practice of what is largely conceptual until it is applied to society. This is where we find our rights.
Now I simply extended this to the discussion of pharmacist rights to refuse to dispense vs. rights of a customer. And yes- I DID say customer. You see, and correct me if I am wrong, but I do not know that everyone views their pharmacist in the manner you describe. Talking about why a particular medicine was prescribed, the consequences of an inability to get my narcotic, I view my doctor as the one who knows my circumstances and history. I would be offended if someone who knew so little about me presumed to discuss my medical profile. Sans chart! It is also irrelevant what the medication is used for although admittedly it bolsters ambiguity. "Use" was not my determinant in affirming a right to refuse. Business autonomy was the gist of that "right".
Now if an employer insists and the employee is an "at will" employee behaving in ways that constitute a violation of company policy that is another matter entirely and not one that lends itself to the public arena. That gets into employment and labor/management stuff. Another time perhaps!!!
I view my pharmacist as a person deputized by my doctor to give me whatever he/she writes on that pad to the extent that they can by law, by supply, by business practice, and by skill. Simple.
I take exception to the mention of poor customers who may not have choice, that this reveals a bias. It is not MY bias, lets be clear!!! It is inherent. I did not write the law nor do I practice it, influence it, or knowingly and actively enforce it. This bias you speak of is systemic and present in business regardless of the crux of your defense. Of course ANY limits on supply for any reason, not just a moral conviction to avoid contraceptives for example- hurts ANYONE who lacks consumer choice. I can think of thirty other examples where a decision to withold a product on ANYONE'S part constitutes a bias against the poor or those with limited mobility. That goes without saying. But we are talking rights and law, and we do not legislate fairness no matter how much you and I want to say that every person in America should have their pick of pharmacies.
So- Yes- it does hurt the poor disproportionately to assert the right to religious objection on the part of a local pharmacist. We can make that argument about everything from vegetables to doctor availability. But legislating opportunity and fair resource distribution has not been a matter of law AS IT APPLIES to business. A public health clinic, perhaps. A public hospital. perhaps. An exempt non-profit, perhaps. Not a private enterprise conducting private business!!!
From a consumer perspective, I still maintain that a pharmacy is a business, with trained professionals to function in conjunction with a medical team that have their own respective roles. Pharmacist not reliant on public subsidization, do not seem any more accountable to liberal virtues of access than Wal Mart or Chuck E Cheeses. They have the right to deny selling a bottle of pills just as a deli owner has the right to deny selling cheese. I am not talking about my personal warm and fuzzy sense that all people should have whatever they want from the closest pharmacist- I already stated that I would not WANT to see a pharmacist do this. I am thinking pharmacists put pills, developed by a for-profit company, into a bottle and charge me for them. Commerce, my dear, not social service. And the law seems to lean that way. I am saying that a business has the right to deny supply, and the pharmacist works in conjunction with and as agent of- that business. Rules and regualtions in turn govern the bahviors of what gets filled and what does not. A pharmacist, to my knowledge, cannot say "I decided to up your prozac, you seem sadder this week" That would be absurd. They take directives from a prescriber within their guidelines. Am I wrong on that??? There may be an elelment of cusotmer service or value added stuff that makes me choose Rote Aid over CVS... like little printouts on side effects...but the aspects you describe?? So much ambiguity? Do the regs not spell out pretty clearly what is permissable and what is not, and isn't it a line between regs and doctor's script? Do you even have the authority to "go there"? Take liberties, talk about needs, and options? Is the scope that freely defined? Damn, I couldn't even get my pharmacist to give me five extras for a vacation.
Throwing in poverty and access raises valid questions, but America is based on an exploitive system of business-friendly rules. I would love a law that says all businesses must act in good faith for the common good. Where they must give a shit about how Mrs. Jones needs her birth control. But they do not and they will not. And we do not legislate or litigate it to be so.
And that only speaks to ONE nuance of your commentary.... like I said, books have been created on all this, and have gone way beyond these questions into even more facets which are incidentally even more interesting... of note, public health, taxes, and representing the will of the people in coverage decisions for the uninsured.... make no mistake, I am of the liberal persuasion... but it does not make me tell the truth as I want it, but as I see it.

Lily said...

Now on the abortion issue- and the comment that it is not part of the thread- of course it is not part of the editorial thread because that is my point right there! The third category of people who view abortion differently, as a choice but also a choice that should be better handled- are always absent from the table on this! Its always about the religious right, or the "choice no matter whats". The same thing, Why redo it here? (Because its my blog, get your own damn blog, I hear her say...) Why not throw something new into the pot though? Bend your mind around something else. See, I see no need to rehash what 578,978,435,434 websites say far better than I can. Whats gained? Sport? But- rarely do I see a frank discussion that speaks to the techniques and the practice without Choice people getting red faced, because it becomes about limits and limits are seen as threatening. We lose the forest for the trees. I suggest simply that much is lost when the extremes forget to look at the people in the middle, that think there needs to be an aspect of personal choice but also finds current practices to be barbaric and would like to suggest some limits without being demonized as anti-choice. Think of the extremes- is life a blastula, can we use saline to induce birth of a seven month old fetus...I mean, we get bogged down by extreme "arguments" but say little about the practical implications which are that technology could make these procedures more....palatable? (totally for lack of a better word) But we DO love to rail against the right.. it flows so easily.

Cantankerous Bitch said...

I'll address your posts in reverse order:

To your second comment -
Let me try and explain myself a bit more clearly, as it's apparent I've missed the mark. The reason I didn't discuss your points above in Part One, or respond in much detail in this comment section, is because I intend to cover abortion in the next posts(s) in this series (hence the introductory disclaimer that this was the first in a series of entries, the title of which was intended to identify that the topic is forthcoming).

Point in fact, I was sincere in saying that "techniques" are something I do intend to cover, as many of the questions you raise have occurred to me as well. At present, however, my current treatise on abortion is nearly 3000 words, is by no means complete, and is still being edited.

I started where I did (the pharmacist thing) because there is recent political movement in this area (as observed here for example) and as such, made Part One more expedient to produce. Feel free to spank me for laziness, but I ask that you not condemn me in full for having yet to publish parts 2 and 3.

You'll find in my future entries, that I'm not necessarily a "choice no matter what" advocate. My opinions on the issue might be strong at at times, stubborn, but I'm willing to concede a number of things in the interest of pragmatism, knowing that our political reality requires as much if any progress is to be achieved. The issues absent from this "table" are missing only *at this point* in this particular discussion. You're absolutely right that there are a number of facets lost in the battle between extremists on both sides of the debate. However, your argument that there is lack of interest in a reasonable middle ground, you'll discover, is not with me. I hope (and assume) that you'll find many points of interest in the pending discussion.

To your first comment -
Yeah, I do find the appeal of railing against the radical right fairly undeniable. However, at a time in which they are, increasingly, the power brokers of the controlling party, I feel the discussion is as merited now as it ever was. Why? Well, the majority of Republicans in my circle of family and friends are "Habitual Republicans", that is, people who vote with that party because they always have, but beyond that pattern of repetition, pay little mind to the ways in which the GOP dynamic has changed in the last decade(s). As a result, my conversations with them yield reactions of legitimate surprise over the movement, tactics and traction of The Dobson gang. This leads me to wonder how many more folks are like them, and as such, I am compelled to comment. If this relegates me to cliché, then that's why I started this blog -- to be introduced to ideas beyond my own (via challenging commentary such as yours) so that I might learn and become a better defender of what I believe.

(By the way - my inquiry as to suggestions you might have for avenues of research was sincere. Perhaps I'm getting lost in argumentative tone, but it seems as if you believe I meant to blow you off somehow. Let me assure you this is not the case. Your public policy experience is something I lack entirely, and part of why I value your contribution to these discussions.)

As to issues of access -- of course you're right. Pharmacies are private companies and are not beholden to our concepts of equal access as typically defined by public health policy. My objections are philosophical. Having spent my career in for-profit business, I understand the prerogatives of private ownership and policy making privileges. However, private ownership doesn't create an immunity to criticism, which is all I attempt to offer here -- particularly when I hear threats from the conservative right to federally legislate the right of pharmacists to refuse prescriptions at will, and in the absence of any supplemental or reinforcing corporate edicts. If these attempts should be successful, doesn't a formerly private company issue become a federal policy issue worthy of scrutiny?

You asked: "Do the regs not spell out pretty clearly what is permissable and what is not, and isn't it a line between regs and doctor's script?"

Recent press coverage, triggering my concern, suggests that the existing regulations have been ignored by some "activist pharmacists", and while some are reported to have been censured, other companies have come to their defense. I hope to learn more in the coming months about these regulations, as they would appear to be at the heart of the controversy.

Rules and regualtions in turn govern the bahviors of what gets filled and what does not. A pharmacist, to my knowledge, cannot say "I decided to up your prozac, you seem sadder this week" That would be absurd. They take directives from a prescriber within their guidelines. Am I wrong on that???

Absurd, exactly. But this is evidently what's happening. There are cases in which pharmacists have literally thrown prescriptions back at customers, saying that they find BC morally objectionable. This was not an exercise of private company policy, but of an individual refusing service for purely personal reasons. Again, let me be clear -- despite my distaste for a company refusing to dispense these medicines altogether, I'm fully aware that it's well within their right to do so. However, in the absence of a formal corporate position, I find it absurd for an individual pharmacist to make a refusal. He is obligated to follow company policy, and if his personal morals conflict with them, then the place to wage the battle is not over an individual patient's prescription, but with management. Or, alternatively, he might find a company to work for that will support his views.

That political elements within the radical right have come to the defense of these individuals is, to me, a chronic, knee-jerk defense of anyone holding up the veil of "religious liberty" to insulate arguably questionable actions from scrutiny. I think this pharmacist thing has potential to be added to the Wedge Issue Toolbox employed by those wishing to effectively theocratize our government. And in the end, that is what I cannot abide, at least not silently.

Lily said...

That is why I started with my imperfect analogy of the Immunization requirement because I believe it does illustrate an issue set- that there are children now exposed to diseases that were thought to be eradicated, that the eradication was due in large part to immunization regs, (public good) and yet people ahve the right to refuse (personal religious freedom) We again get to a Typhoid Mary type of scenario. (I love that example because it truly describes the dilemma of public health and welfare)

Simply, how do we weigh right to refusal for your pharmacist vs. need for medication given the issues described? You are really talking about weighing public good vs. individual rights. And throwing in religious grandstanding.. (thumping?) Sometimes individual rights must trump society for the conceptual good, the premise of it.. On what basis we deny those rights is the million dollar question. In cases of terror, in cases of shortage, in cases of greatest good? Who says? Certainly some cases are more egregious than others- when I say that there is too much too cover, this is what I mean. It is largely a many vs. few stance. And a rights issue, as so many are. And that is how they make their way to court. Were my rights violated as a result of the denial of x,y,z? What harm was done to me by that denial, and how can we quantify that?
I WAS a bit touchy about the bias remark because I wanted it to be clear that the bias is, as stated, systemic. I was trying to explore the basis of right to refuse, not insert my wishes which are of course that they shut up and give me meds. Working for years as a case worker and advocate, I certainly know a little about the issues of access, choice, and as I stated the disproportionate burdens placed on the most vulnerable populations. But in my mind the really vulnerable are the children- a great book is Ruth Sidell's "Women and Children Last". She uses the analogy of the Titanic, the massive ship with every appointment, every detail, with such a level of luxury...that was beyond comprehension- and yet, so many perished in steerage, so concerned they were about crowding the decks with lifeboats. (we all know the story now) That is the simplest way to describe America and its attitudes toward children. Wealth, yet a shitty infant mortality rate. A shitty standard of living. Long hours, low wages, and the polarity between haves and have nots could make you crazy. Who asks about the children, who speaks against the toxic sludge, lead, hormones, frankenfoods, mercury, not to mention that we are destroying the earth...and when we do it will not matter if we have birth control pills. Cancer will take care of those good ol' ovaries.

Cantankerous Bitch said...

Just this evening, I've been reading about the increasing number of children entering the foster care system, the increasing number waiting to be adopted, the shrinking pool of available foster parents and the shrinking pool of parents suitable for adopting. I find it to the height of irony that the very group that champions cuts in federal family planning programs is the same group that opposes comprehensive sex education, Roe v Wade, same-sex adoptive couples, and it looks increasingly like, unfettered access of birth control. This is what makes me so nuts. I don't care what position a person takes on an issue, but I do demand a certain degree of philosophical consistency in their world view. Like the folks that oppose abortion, but support the death penalty. Well, is "all life sacred" or isn't it? Assigning conditional value in that example is the same kind of moral relativism the left is attacked for all the time. Or, (to desperately try and wind my tangent back to the original idea), why should these pharmacists take a staunch position on BC and, evidently, nothing else? Do they have equally debilitating qualms prescribing Oxycontin, for instance? Do they fill Methodone scripts without a blink? To say nothing of Viagra prescriptions in the absence of the patient showing proof of marriage and fidelity...
Anyway, I hear what you're saying re: public good vs. individual rights, and I take your larger point about balance. I don't presume to have any tidy answers in my back pocket. Hell, if I did, I wouldn't be blathering here on a blog, I'd be in a swanky office on K Street. I get very twitchy, though, when the public good, however, is defined by religious dogma, however carefully veiled, and I have grave concerns that far too many folks in Washington are perfectly content to define "public good" based on religious precepts. The lion's share of my own patriotism springs from our first Amendment guarantees and when revisionist historians start threatening to reshape policy based on their narrow views of "acceptability", it's hard for me to stay rational.

Lily said...

Yes, we are in agreement there- but that is also why I hate it when people frame an issue around religious terms (or terminology) from the outset.
And yes- you are correct, where are all these good Christians when it comes time to open their homes to a child, particularly a minority or disabled child? Someone had a bumper sticker with something like "prolife, but not after birth" or something to that effect. Children get the shaft... I hear ya.