Wednesday, January 16, 2008

Don't Allow a Pharmacist's Religious Views to Impede on the Doctor-Patient Relationship

Indiana is in the midst of a property tax crisis, we are experiencing more mortgage foreclosures than most other states, crime is (or at least appears to be) on the increase, the Colts lost in the playoffs, and many Hoosiers cannot afford quality health care or health insurance. Yet, rather than attempting to work on addressing these issues that are of grave concern to most Hoosiers, Indiana State Senators Patricia Miller and Jeff Drozda have once again introduced a series of mean-spirited bills aimed at limiting a woman's reproductive rights and inserting the State of Indiana into religious debates and religious doctrine that is thousands of years old.

What exactly have Sen. Miller and Sen. Drozda done? Let's take a look at the two bills: Senate Bill 3 and Senate Bill 146. I'll address Senate Bill 3 today and leave Senate Bill 146 for another day (as it raises even more fundamental and troubling problems that I want to take more time to address).

Senate Bill No. 3 (SB3)

This bill falls into a category of legislation that has been cropping up around the country, referred to alternately as a "pharmacist refusal" or "pharmacist conscience" bill/law. According to the official digest of SB3 (as updated January 9, 2008), the bill provides, in part, that:
a pharmacist may not be required to dispense a drug or medical device if the drug or medical device would be used to: (1) cause an abortion; (2) destroy an unborn child; or (3) cause the death of a person by means of assisted suicide, euthanasia, or mercy killing.

Think, for a moment, what this bill is really saying. Even if a doctor prescribes a particular medication, the pharmacist has the right not to fill the prescription because of the pharmacist's own beliefs. SB3 allows the pharmacist to insert his or her own religious views into the doctor-patient relationship. Just it case it isn't obvious, parts (1) and (2) of the bill are clearly aimed at the emergency contraceptives (like the so-called "morning after pill").

There are numerous problems with SB3. First, how does the pharmacist know that the doctor didn't prescribe one of the medications described in part (1) or (2) as a result of the doctor's concern for the health of the mother? What if the mother is physically frail or suffering from a serious illness and her life will be jeopardized by the pregnancy? Who should really be deciding if this woman can have an abortion. What if the medication were prescribed because the woman was raped or was the victim of incest? It may be difficult enough for her to go to a doctor, let alone go to the pharmacy to get the prescription filled. But now, she has to worry about whether the pharmacist will fill the prescription. Just imagine her anguish as she goes from pharmacy to pharmacy.

This may not really be a major issue in large cities. If the pharmacist at Wal-Mart won't fill the prescription, the woman can walk across the street to CVS or Walgreen's. But what about small towns that might only have a single pharmacy? If that town's pharmacist refuses to fill the prescription, the woman may be entirely out of luck or might have to travel to another city, just to get a legal medication that was legally prescribed for her by her doctor. And consider that, in the case of emergency contraception, time is of the essence. The drug must be administered within 72 hours. If a patient has to "shop" for a pharmacist that will honor the prescription legally given by the patient's doctor, there is a possibility (higher in rural areas) that time might run out.

Which raises another interesting point. Isn't there some likelihood that the woman who is unable to obtain the emergency contraceptive will, instead, seek an abortion? Query which is worse: Providing a prescription which will prevent a fertilized egg from implanting in the uterine wall or forcing a woman to begin an unwanted pregnancy only to terminate it shortly thereafter? In other words, a pharmacist can rely upon his religious beliefs to force a woman into confronting one of the most difficult decisions that any person should ever have to make. Available and effective birth control should lead to fewer abortions, so making birth control harder to obtain makes no real sense.

One other interesting point to note. Sen. Drozda, the SB3's author, claimed during a committee hearing on SB3, that the bill was not intended to cover contraceptives. "Contraception is not covered," Drozda is reported to have said. Yet, according to that same report, after the committee hearing, Drozda is further reported to have acknowledged that a pharmacist could interpret the legislation as protection for refusing to fill a prescription for birth-control pills. Drozda apparently stated that he intends for SB3 to cover the morning-after contraceptive. (See "Senate panel OKs measure to protect pharmacists", The Courier-Journal, January 10, 2008.) So, was Sen. Drozda lying to the Senate committee or to the reporter? And if SB3 is not intended to cover contraceptives, then what, precisely, is it intended to cover? For that matter, what, precisely, is an "unborn child"? At what point does a egg, blastocyst, zygote, embryo, or fetus become an unborn child? And are we supposed to leave that decision up to a pharmacist?

And consider the implications of part (3) of SB3. Recall, first, that euthanasia is illegal in Indiana (an interesting subject for another day...). Just imagine a terminal patient in hospice who is in terrible pain. The patient's doctor decides to prescribe a very, very heavy dose of painkiller to relieve the patient's suffering. But the pharmacist, concerned that the dosage might be too high, can simply refuse to fill the prescription. I would hope that a concerned pharmacist would communicate the concern to the doctor, saying, perhaps, "Gee, I think that the dosage that you prescribed is too high and puts the patient at risk of dying." But SB3 doesn't mandate this kind of communication or even direct the pharmacist to dispense a lesser dosage of the drug; no, SB3 allows the pharmacist to simply refuse, thereby interfering in the doctor-patient relationship and, potentially, allowing the patient to suffer. And if the patient is in a hospice or hospital and the pharmacist is on the staff of the hospice or hospital, how exactly is the patient to get the medication? Are we to exepct the bed-ridden patient to walk down the street to find another pharmacist?

One might ask to whom the pharmacist's duty lies: the patient or the pharmacist himself?

I also note that the website for the Indiana Pharmacists Alliance makes no mention of SB3. All that I can conclude from this is that it is not an issue high on the list of priorities to Indiana's pharmacists. The American Pharmacists Association ("APhA") supports pharmacist refusal provisions, but:
APhA’s two-part policy supports the ability of the pharmacist to step away from participating in activity to which they have personal objections—but not step in the way. The Association supports the pharmacist’s right to choose not to fill a prescription based on moral or ethical values. But recognizing the pharmacist’s important role in the health care system, APhA supports the establishment of systems to ensure that the patient’s health care needs are served.

The American Medical Association's resolution on the subject recognizes that responsibility to the patient is paramount and advocates that, in situations where a pharmacist may refuse to dispense a prescription, that the pharmacist either direct the patient to a pharmacy that will dispense the prescription or allow the prescribing doctor to dispense the prescription. SB3 would allow the pharmacist to refuse without telling the patient where the drug could be legally obtained.

I'm also worried about the slippery slope that this bill starts our state down. What's next? Might a pharmacist be granted the right to refuse to dispense any contraceptive? What about ED drugs (some might say that would be a good thing...)? What about other medications that the pharmacist doesn't approve of? (Apparently, one pharmacist who testified in favor of SB3 stated that she even refuses to dispense hormones!) What about generics (after all, the pharmacist might make more money only dispensing name brands)? Perhaps a particular pharmacist owns stock in Eli Lilly; could that pharmacist refuse to dispense brands made by other companies? Where does it end?

It is also worth examining the Code of Ethics for Pharmacists (promulgated by the American Pharmacists Association). Below are the relevant canons (emphasis added):

I. A pharmacist respects the covenantal relationship between the patient and pharmacist. Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.

II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private andconfidential manner.

III. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients.

IV. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients.


VI. A pharmacist respects the values and abilities of colleagues and other health professionals. When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient.

VII. A pharmacist serves individual, community, and societal needs. The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, the pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly.

VIII. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society.

Compare these ethics to a pharmacist refusing to dispense a prescription because it conflicts with the pharmacist's religious beliefs.

Apparently, some pharmacists have argued that the bill is needed because requiring pharmacists to dispense drugs for purposes that violate the pharmacist's religious beliefs is a violation of the First Amendment. Yet this argument is a red herring because the pharmacist is not taking the medication; rather the pharmacist is simply dispensing a legally prescribed medication. Could a police officer refuse to arrest someone for polygamy on the grounds that the police officer's religion permits polygamy and forcing the officer to enforce the law that he disagreed with would violate his religious beliefs? Could a teacher ignore (or even teach contrary to) adopted state educational standards if those standards conflicted with the teacher's religious beliefs (don't get me started on the whole "intelligent design" debate)?

At the end of the day, we need to recognize that the role of the pharmacist is to dispense the medications that a doctor legally prescribes. If the pharmacist is concerned that the particular medication will be dangerous for the patient (e.g. a drug interaction or allergy), then it is the certainly the role of the pharmacist to raise this concern with the patient and/or doctor. But it is not the role of the pharmacist -- nor should it be -- to tell a patient which prescribed drugs they can or cannot have on the basis of that pharmacist's religious beliefs. Nor should it be the role of the pharmacist to insert his or her own belief systems (as opposed to medical, chemical, and biological knowledge) into the physician-patient relationship.

But the, I doubt that Senator Drozda cares about any of this; his only concern appears to be preventing abortions.

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At Sunday, April 06, 2008 8:23:00 PM , Anonymous Anonymous said...

Hi, I read your post and respect your opinions, but would like to add my own opinion and arguments.

Physicians and other health professionals can refuse to prescribe for any moral/ethical reason, but they receive little flak for it. However, when a pharmacist refuses to dispense, they can be fired and public opinion is usually against them. I don't see any difference between a physician who refuses to prescribe and a pharmacist who refuses to dispense. Pharmacists should be able to refuse as long as they don't rip up the Rx.

"At what point does a egg, blastocyst, zygote, embryo, or fetus become an unborn child? And are we supposed to leave that decision up to a pharmacist?"
Are you saying that physicians, nurses, physician assistants, etc are capable of making that decision and pharmacists are not? Pharmacists are totally capable of making that decision. They teach us Anatomy, Physiology, Microbiology and Biochemistry in pharmacy school which is enough to make a decision. We have to go to at least 2 years of undergraduate study and then 4 years of graduate study and graduate with the PharmD degree.
"At the end of the day, we need to recognize that the role of the pharmacist is to dispense the medications that a doctor legally prescribes.?
I'm assuming you don't know yet that pharmacy is changing. Many pharmacists today don't dispense. Instead they counsel patients and advise other health professionals on the best cost-effective drug for a certain disease state. I hope and think in the near future, pharmacists will be able to prescribe drugs just like doctors, nurses, and physician assistants.

At Friday, April 11, 2008 12:04:00 PM , Blogger MSWallack said...

Thanks for sharing your thoughts, anonymous. Let me briefly respond:

First, I think that some medical professionals do get "flak" for failing or refusing to treat or prescribe. But, and this is the critical point, if a doctor refuses to prescribe, the patient can seek out another doctor. The same does not necessarily hold true with a pharmacist. Moreover, as I mentioned, most often, the pharmacist does not have the full range of information available to the doctor (for example, take the situation of a woman who is the victim of incestuous rape; the pharmacist may know nothing other than that a physician has prescribed the "morning after" pill without knowing why).

As to the decision of when an egg, blastocyst, zygote, embryo, or fetus becomes an "unborn child", no I don't think we should leave that up to the doctor any more than we should leave it up to the pharmacist. Rather, issues surrounding the beginning of human life should be (mostly) left up to the patient and her conscience, informed by science and family, and if appropriate, religion.

You indicate that in pharmacy school, you are taught enough science to make that decision. Yet scientists and scholars (both religious and secular) have debated those points for thousands of years. Today, well meaning Christians and Jews disagree on when "human life" begins. While I respect the education that you receive and the job that you perform, I don't believe that your education is necessarily sufficient to let you make that decision, especially if your decision is informed, in part, by your own religious views.

As to the future of pharmacy, I don't know. I will say that the idea of a pharmacist prescribing medications gives me some concern unless I can be sure that the pharmacist has the full medical picture of the patient's condition. I do think that it is appropriate for a pharmacist to use independent judgment, but I think that judgment should be limited to science and not religious or moral grounds.

At Thursday, April 24, 2008 11:18:00 AM , Anonymous Anonymous said...

I find it very interesting that you expect pharmacists to make decisions based on your view of what "science" is and "not to base the decision on religious or moral beliefs." Pharmacists, I happen to be one, are not robots. Do you make decisions based on science only in your life? I doubt it. I will not do anything that I do not feel is in my patient's best interest. I have seen too many women's mental health ripped apart by the consequences of their uninformed decisions. You are ridiculous and frankly not being honest when you say that they would not have another pharmacy choice. There are almost 4 pharmacies within every 5 mile area around me. I am sure that they could find at least one without a conscionce there. Save the babies and the mothers!!!

At Friday, April 25, 2008 5:04:00 PM , Blogger MSWallack said...


I don't expect anyone to make decisions based on my "view of what 'science' is". I don't have a view of what science "is". Instead, science "is" (to use a bad phrase) what it is. That some people don't accept certain elements of science because they are just "theory" or because those scientific theories contradict their religious viewpoint has no bearing on whether those concepts remain scientifically valid.

As to the use of science instead of moral or religious beliefs, I would say that it depends upon the nature of the decision being made. So, for example, when a woman is deciding whether to become a nun, only her religious and ethical views should matter and science has no bearing. Similarly, when a man is deciding whether to ask a woman to marry him, science probably plays no part. Yet, when a scientist is deciding whether the trajectory of a meteor is such that it could endanger earth, morals and religion play no part. In the case of a pharmacist or doctor deciding the best course of medical treatment for a patient, I believe that the decision should be based almost solely (if not solely) on the best scientific knowledge and evidence then available. Morality and ethics may play a role in suggesting options for the patient, but should not trump science.

I will readily admit that I am not a doctor, physician, or scientist (and didn't do so well in science way back when), so perhaps there is a nuanced position that I'm missing. But, that said, I think that people engaged in scientific-based professions, such as yourself, have a duty to put your knowledge and education to the best benefit of your patient without allowing your religious or moral objections to cloud that judgment. If you want to tell someone that you disapprove of a particular prescription or course of treatment and explain why, then be my guest; just don't allow that viewpoint to get in the way of the patient's treatment and well-being.

You say that you won't do anything that isn't in your patient's best interest, but if you are allowing your morals to influence whether your will honor the course of treatment prescribed by the physician, then you are not acting in the patient's best interest; you are acting in your own self-motivated interest to protect your own ethical standards.

Again, let me ask this: When a patient comes to you with a prescription, do you have as much information about the patient as the doctor? You may know the other medications that the patient is taking, but do you know much about the patient's family life? Is the patient suffering from depression or anxiety? Do you know about other ailments that the patient may be suffering from? Does the patient have slightly high blood pressure or get migraines? If the issue is pregnancy, do you know if the woman is married to the father or whether the woman was raped, perhaps by a relative? Do you know if the woman's health would be endangered by the pregnancy? Do you know the patient's moral and religious viewpoints on the issues, and if you did, would you care?

I absolutely agree that a patient's decisions should be informed and that religion and morality can play a part in that process; however, I believe that it is essential that a caregiver discussing moral and religious issues with a patient limit that discussion to the patient's religious and moral thoughts without allowing the caregiver's own opinion to dominate or overly influence the decision-making process. Just as many patient's suffer from ill-informed decisions, many others suffer from decisions taken out of their hands by people acting on their own religious or moral ethos which may be in conflict with the those of the patient or constituent.

Finally, while I enjoy and appreciate a lively and vigorous debate, I draw the line at allegations of dishonesty. Yes, where I live, there are numerous pharmacies from which a patient may choose. However, in the most rural parts of our state (let alone more rural states), pharmacies are far less common. Moreover, it is those least able to travel (not owning a car, for example) that are most adversely affected by the dearth of rural pharmacies. So, just because there is a plethora of pharmacies near you and me does not mean that my argument against pharmacist "conscience" is dishonest.

Finally, your penultimate statement is simply offensive. To suggest that a pharmacist who would prescribe a medication that could induce an abortion, let alone a pharmacist that supports a woman's right to choose is "without a conscionce" [sic] is patently offensive. I support abortion rights (though that does not mean that I'm an advocate for abortion), yet I certainly have a conscience. Perhaps it is you, who would allow your own moral outrage to jeopardize your patient, who really needs to look at your own conscience.

At Saturday, September 20, 2008 11:23:00 AM , Anonymous Anonymous said...

I just happened upon this blog and again I find that the 'case of incest and/or rape' and 'life of the mother' defense for abortion are still being used. These are, by far, the two most succumbed to yet completely empty arguments that somehow have still managed to survive in the abortion debate arena.

First, lets look at 'just a fetus' or 'baby' if you will, the central component of the abortion debate. It is clear that it is one or the other. Science cannot prove that it is NOT human, and religion is almost always dismissed as merely human fancy. So the absolute conclusion is always uncertainty. Since the best science can offer us is 'We're not sure if its human or not' why is it that we allow each other to err on the side of the negative? This was exactly one of the many illegitimate defenses that was given by those who did not rise up against slavery (Well, we're not sure if those blacks are fully human so we won't fight for their rights). As appalling as that is, we can clearly wonder today why they wouldn't just say, I'm not sure, but to be on the safe side, let me at least believe they are.

So, we have established that we can't be sure that the 'fetus' is not human and that those with a basic sense of skepticism will at least take the safe side just in case it is human. Since we have to assume that at the very least, the fetus 'might' be human lets look at the first argument. Say your sister is raped and becomes pregnant. The baby is born and looks exactly like his father. She is completely overwhelmed by this and asks the doctor to have him euthanised. Appalling? Why? Moments before, it was her 'choice', but now what? Certainly, it is because it is now OBVIOUS that it IS a baby, whereas in the womb, well, we just can't be sure. Mom, its your choice, do you want to kill it? This applies to incest as well. Any one who defends abortion in these cases is at best excusably ignorant, or at least I hope so. Furthermore, why should the 'maybe-a-baby' suffer punishment because of the father's actions, regardless who the father is? That would be akin to saying that you could go to jail for a crime your father committed. Pretty senseless.

But what about the life of the mother? Surely only an insensitive jerk would expect a mother to birth her child if her life was in jeopardy. Again, lets look at how society (not religion or science) expects us to act. A mother who makes the decision to have an abortion to save her own life, takes time to decide: it is a difficult, emotional decision. If a mother were walking in the street with her young son, and a car came at them at such a rate of speed that there was only time to save one or the other, and the mother ran off leaving the child in the road, that might cause us some outrage, huh? And in that case, the mother didn't have time to think about it. What if a hurricane was bearing down on an island and the last boat to evacuate only had room for mother OR child, not both? What would we say to the mother who leaves the child? You can argue as much as you want that these examples are not the same as with pregnancy, and you would be right. At the least the children in my examples have a remote chance of saving themselves. Children in utero do not.

Now lets reexamine the scientific uncertainty of personhood for fetuses. Science proves over and over again that human life begins at conception when they use DNA for legal issues. DNA has become the determining factor of human uniqueness in criminal cases, paternal suits, and many other legal issues that are resolved when the DNA of the person can be ascertained. Except if you are a baby. At the very moment of conception that zygote, fetus, mass of cells, has unique DNA. But in the eyes of someone who defends or supports abortion this is simply not enough.

I hope that this sheds some light as to why even atheists are convinced that abortion should NEVER happen and NEVER be defended. As I said before, at best these are acts of sheer ignorance. Otherwise, they are willful murder or accessory to such.

Good day.


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