blog.bioethics.net

The prohibition on dispensing meds from the office is more ridiculous than conscientious objection. Let the physicians prescribe and charge for the pills.

- by Beverly on May 16, 2006 at 10:25 AM | link

Accidents happen? What, if you wet the bed you need a pill in the morning?

- by Laura(southernxyl) on May 16, 2006 at 11:12 AM | link

The problem I wrestle with, with regards to pharmacists having any right to refuse filling prescriptions, is that until recently the refusal to fill a prescription has been limited to the handful of medications some people believe cause abortions. Whether they do are not is sort of irrelevent, since it's the theological belief coming into play, and not really a grounded scientific one.
I don't think someone should be coerced into participating in an act they find morally wrong, such as abortion, and in the case of these pharmacists, prescribing the pill is tantamount to being a doctor providing a D&C. Since we don't force all doc's to provide abortion services, I'm not convinced we should force pharmacists to.
That said, I don't think the right to refuse prescription extends beyond that - pharmacists shouldn't have the right to refuse prescribing pain killers or antibiotics or HIV cocktails.
There seems to be a differentiation in function between these sorts of medications that is important to highlight.
Of course, I also think that the right to refuse service should only be possible if there's someone else either on site or within 20 minutes or so who can fill the prescription. If not, I think the patient's need for the prescription trumps the pharmacists right to refuse. And I realize that's fuzzy enough that it would never be practical to implement.
I just am not convinced that this issue is so clear cut as "pharmacists should fill the prescriptions handed to them, period."
...please be gentle when pulling apart my thought(s) - they're new and shiny and haven't been taken out for a test drive yet. (Mostly - I did manage to offend a pharmacy student a few weeks ago, when the piece I wrote for my University paper ran. Seems they didn't like being told they weren't doctors, and if they wanted to practice medicine they should have become MDs...)

- by Kelly on May 16, 2006 at 12:35 PM | link

"... wouldn't it just be easier to make it clear that pharmacists ought not have the power to refuse to provide medications that are FDA approved and for which a physician has written a prescription?"
FDA approval and a physician's prescirption aren't authoritative sources of morality for thinking people.
Wouldn't it be easier, and more respectful of _all_ parties directly affected, to make Plan B available OTC, period? That way it could be sold in virtually any venue, with no need for involvment by either physicians or pharmacists.

- by Bob Koepp on May 16, 2006 at 1:33 PM | link

I wonder why more of the medical profession isn't as vocal as ACOG on the issue of "pharmacist choice".
What pharmacists are doing is interfering in a physician-patient relationship, and violating privacy of patients when the pharmacists second-guess medical decisions.
In Oklahoma this legislative session we had a bill that permitted pharmacists to refuse to fill prescriptions for medications that could be used to prevent pregnancies, as well as medications that might "facilitate" ending life. That would include prescriptions intended for palliative purposes.
I'm not one who generally supports "slippery slope" arguments, but this is an issue when the argument is valid.

- by Ereshkigal on May 16, 2006 at 2:06 PM | link

I'd like Erishkigal and/or any like-minded souls to explain why a so-called "medical" decision which is not based on medical indications isn't fair game for second guessing by any and all? Isn't it about time for defenders of choice to recognize that the medicalization of reproductive decision-making is _not_ the way to promote autonomy?

- by Bob Koepp on May 16, 2006 at 2:26 PM | link

you can't force a professional to do something against their conscience.

- by enoch choi on May 16, 2006 at 3:13 PM | link

The idea of the conscientious objector argument for pharmacists doesn't hold. Any pharmacist is free to not dispense medications; that is, they are free to stop being a pharmacist. Being a pharmacist means that the person should have, and use, an understanding of pharmacokinetics of drugs, of the dangers of potential interactions of drugs and of basic dosing guidelines, all to protect the safety of the patient. It does not mean that the pharmacist should engage in medical decision making about what drugs a person should or shouldn't be allowed to take. The objection in this case is beyond even that level. The pharmacists who wish to refuse to fill prescriptions are not doing so based on any medical data or purpose; rather, they are doing so based on their own personal belief. Quite simply, pharmacists are not physicians so argument by analogy to the duties and rights and responsiblities of physicians fall apart fairly quickly.
Further, this is, in my opinion, a new paradigmatic example for slippery slope. Is one belief more important or more valid than another belief? If one group is allowed to refuse to fill legal, legally prescribed medications because they have one particular objection why is another group not allowed to refuse based on some other objection? HIV/AIDS is something only people who engage in risky sex or take IV drugs get, so no anti-retrovirals. It just goes from there. The next best example is coming down the road...the HPV vaccines that will be available quite soon. Already you can hear the objections from some that such a vaccine will increase teen sex rather than any substantive discussion of the excellent safety profile and amazingly high effectiveness rates.

- by Chris on May 16, 2006 at 6:29 PM | link

Chris -
First, the "conscientious objector argument" is not based on an anology between medicine and pharmacy. It's a staple of _professional_ ethics. The burden of proof rests squarely on those who deny that this applies to pharmacists who are, after all, professionals.
Second, you presume too much when you say that pharmacists declining to fill prescriptions for Plan B "are not doing so based on any medical data or purpose." I know of one well-publicized case where the pharmacist stated quite clearly that he would fill a prescription for the same drugs if they were medically indicated.
If our desire is to promote choice and to respect moral diversity, this can be done by making Plan B available OTC.

- by Bob Koepp on May 16, 2006 at 7:12 PM | link

Bob, your discussion about conscience and professions is excellent and I appreciate your distinction between morality and legality.
If the FDA approves this drug for OTC, doesn't that make each voter in the country complicit?
What disturbs me is that the opinion that Plan B causes loss of an embryo is still conventional wisdom -- even among pharmacists and docs.
Isn't it time that we re-examined the issue of the actual function of the progesterone only "morning after pill"?
More than likely, the Plan B (and, probably, Preven, too, although the evidence is not as clear) only works about 5 days before ovulation, if it works at all. This is the message that would serve us best: it's the truth, and it decreases the inclination that leads to some of the "failures" from intercourse at other times.
We sometimes give progesterone to *support* a pregnancy. It's fairly clear that the only measurable change in the post ovulatory uterine chemistry after a levonorgestrel dose similar to "Plan B" is thickened mucous and the increase of glycodelin-A. In the uterus, Glycodelin-A functions to decrease the ability of the sperm to penetrate the zona pellucida and to support implantation. Croxatto and Durand have done excellent studies in women and found no evidence of post-ovulatory effects.
Everyone is still quoting 30 year old material from the package insert. For some reason, the manufacturers of Plan B nor the FDA have publicized this information which was made available to the members of the FDA committee looking at OTC status a couple of years ago.

- by Beverly on May 16, 2006 at 7:35 PM | link

Bob,
I did a poor job separating a couple of thoughts in my first comment. I didn't draw the contientious objector idea from an analogy between physicians and pharmacists. Not that anyone could tell that from what I'd written.
As a point separate from a discussion of contientious objecting I do not think that the rights and responsiblities of physicians and pharmacists are largely the same (though there is certainly some overlap) and so the ethics that apply to one profession would not necessarily apply to the other.
Is it the case that one of the key elements of contientious objecting is that it needs to be done ahead of time? It seems that it also should be undertaken with full acceptance of the consequences of such objections (loss of position, for example.) How would we judge the validity of an objection on the part of a pharmacist?
Lastly, I concur entirely that Plan B should be an approved OTC drug.

- by Chris on May 16, 2006 at 8:14 PM | link

Beverly - Whether all voters are complicit in the actions of an elected government is a question for political theory. I think a simple yes or no answer won't suffice.
I'm all for providing everybody who wants it the best information we have about mechanisms of action, safety and efficacy -- and then letting them make their own choices.
Chris - One point of overlap between medicine and pharmacy that I take very seriously is an overarching commitment to promoting the health of patient-clients. And it is by reference to that traditional goal of the healthcare professions that I define the notion of 'medical indications.' When reproductive decisions are based on non-medical reasons, I don't think that either physicians or pharmacists have any professional obligation to provide assistance.
As for conscientious objections being voiced "ahead of time," I think that would be ideal. But we don't always anticipate either changes in circumstance or changes in what individuals believe and value. And as for "accepting the consequences," I think you might be confusing conscientious objection with civil disobedience, though of course one might lead to the other (and frankly, I've never been persuaded that those who engage in civil disobedience are morally obligated to accept the consequences -- I think that's more an issue of tactics than ethics).

- by Bob Koepp on May 16, 2006 at 9:43 PM | link

Chris, you fear that some pharmacists' refusal to help women kill their unborn will enable other pharmacists to refuse to alleviate suffering because they suspect that patients brought it on themselves by their behavior. I think that's quite a stretch. And I don't believe any educated person in this day and time thinks HIV infection only occurs through risky sex and IV drugs.

- by Laura(southernxyl) on May 17, 2006 at 11:56 AM | link

And I don't believe any educated person in this day and time thinks HIV infection only occurs through risky sex and IV drugs.
*****************
Doesn't matter what you think, it matters what the person behind the counter thinks.
And if perceived lifestyle factors become a reason to deny treatment thatn that is a slippery slope I would rather not go on.
Plan B does not even end a pregnancy- it stops the egg from dropping down and makes it unable to be fertilized. This is wrong in what world? Anyone who practices the rhythm method is preventing a baby from being born.
RU 486 is the drug that aborts a fetus. Maybe the pharmacists have them mixed up, as it seems many other people do as well.
A pharmacist should not be allowed to say I DON"T BELIEVE IN THAT---- and then keep their job. If you cannot handle the job, then find a different one.
Where I work I do not get a choice as to what people I work with. I don't get to be pissed off if their issue is a result of bad choices, etc. I just do my job or quit.

- by impatientpatient on May 27, 2006 at 1:19 AM | link