Wednesday, July 27, 2005

A Pharmacist's Proposal

This comment, left by UndercoverRxer, was too good to be missed by those not inclined to read through the thread.

This commentary is from a legend in the field, a leader of the movement to move pharmacy from counting and pouring to helping patients achieve good treatment outcomes.

Solving ProblemsThrough Reasonable Processes

A middle ground exists between the positions of pharmaceutical ethics and religious morality. Conscientious objectors are not absolved of all professional responsibility by their moral beliefs. Suppose, by analogy, that a pharmacist is asked to refill a prescription for a Schedule II narcotic analgesic, which he cannot legally do. Although he may refuse to provide the medicine, he should do whatever he can to learn the patient's circumstances and to minimize the patient's suffering that results from his refusal. The situation should be no different for an ethical pharmacist when the law he is obeying is religious rather than legislated. Specifically, these options are open to pharmacists who object to the dispensing of emergency contraceptives:

1. Pharmacists absolutely opposed to contraception or abortion, or those who know exactly in what circumstances they would object, should accept two additional ethical obligations: avoid surprising a patient with a refusal to provide medication and ameliorate the consequences if it happens. Arrangements should include discussions with management and planning for referral (inside or outside the pharmacy). If an entire practice is opposed to dispensing certain medications, a notice to that effect should be posted in their place of practice. The intention to refuse should be communicated to local physicians. To wait silently and then pounce on an unsuspecting and often vulnerable patient appears to be avoidable and therefore unconscionable.

2. Pharmacists whose objection may be subject to fact, science, and ethical reason should accept responsibility for making sure of the facts,science, and ethics in each case, and consult with colleagues before acting. Again, they should accept responsibility for minimizing the insult, inconvenience, or injury caused by their refusal and should offer alternative means for the patient to obtain the medication. The immediate solution for a woman whose request for emergency contraception is refused should be to call Planned Parenthood at 1-800-230-PLAN. For a list of other providers, a patient should call the Emergency Contraception Hotline at 1-888-NOT-2-LATE or visit its Web site at

3. Pharmacy regulators should create procedures for review of conscientious refusals, and these should be similar to other kinds of professional regulation. Reviews can be initiated by the same kind of event as are other professional conduct reviews, such as a complaint from a patient or colleague. Conscientious objectors should assume that they may be asked to account for their actions and to describe how they balanced their consciences against the possibility that a patient might be injured by their conscientious refusal to provide medicine. Regulations should permit conscientious refusals but require that they be reasonable. Patients or family members should have a legal right to request a hearing (usually after the fact) that reviews the needs of the patient, professional responsibility, and professional accountability. Capricious and unreasonable refusals (in the fact or the manner of the refusal) should be treated as violations of professional ethics.

Some people may object that this proposal represents unreasonable or heavy-handed intrusion of state power into a pharmacists' private conscience. Pharmacists have chosen, however, to accept fiduciary duties and responsibilities that require a more exacting standard of conduct and review than would be appropriate for a private citizen. Framing the issue as opposing rights tends to subordinate or ignore the element of professional duty. That theory also seems to minimize the other duties owed by a conscientious refuser. This is unsafe for patients and could result in avoidable patient injury and coercive laws forbidding pharmacists such discretion.

The profession of pharmacy should ameliorate the unfair power struggle between a pharmacist who controls the drug product and a patient who needs it, usually within a short time, and who may be physically and psychologically vulnerable. In the political arena, by the way, the power balance could be the opposite. Then, as a recent New York Times editorial suggested, most people may favor access to prescriptions even at the expense of a pharmacist's right of conscientious objection.

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