blog.bioethics.net

It would be simpler to move a doctor who will do - whatever - around.

The alternative is to find a way to trust a doctor who will act against his conscience - to do what he considers the wrong thing for your pet issue - to do the right thing every other time.

- by Beverly Nuckols on Nov 29, 2007 at 11:20 PM | link

Greg asks, "Is there a way to resolve this issue?"

Yes. Demedicalize the control of reproduction when it is not medically indicated.

The payoff is twofold: improved access to the means of control for those who wish to exercise it, and mooting conscientious objections from healthcare providers.

Actually, I think there's a third payoff. Liberals, who generally favor unencumbered access to birth control, could unhypocriticlly defend freedom of conscience.

- by bob koepp on Nov 30, 2007 at 8:40 AM | link

Let's say I walk up to a clothing store and a sign over the door says sorry we don't sell stockings. I will be inconvienced, but okay.

If I go into a store with no such sign, hand over my money, ask for stockings and the wait staff says 'we don't sell stocking as only promiscuous and damned fallen women wear them' -- how is that in anyway reasonable service *or* ethical behaviour?

The wait staff in a store may know more about cloth and cut than me, but I decide my wardrobe, thank you. I am the expert on my own moral behaviour including whether I wish to submit to a moralistic lecture. And I don't.

The only reason not to have clear terms of limited service is the desire to give lectures to unsuspecting women.

- by emily on Nov 30, 2007 at 1:13 PM | link

Should a Jehovah’s Witness physician be able to say to a hemorrhaging patient, “I’m sorry, but I don’t believe in transfusing because it goes against my religious beliefs”? Should we not deliver medical care on the Sabbath? Physicians need to deliver medical care within the accepted standards of medical care and leave moral judgment to judges, Pat Robertson, Rush Limbaugh, etc.

- by Bob on Dec 1, 2007 at 8:23 PM | link

Up-front disclosure of denied services is the bare minimum that ought to be required in this situation if we even hope to achieve justice. This disclosure needs to be covered in every place the provider describes their services - including printed and televised advertisements and when answering the phone. I mention similar concerns in a recent blog post. An added check should include a provider publicly displaying their religious affiliation if such a belief system weighs heavily enough on their professional conduct that they will preach that religion's tenets to a patient.

Additionally, a large amount of the conflict stems from differing expectations of what a person who is certified by the medical community as a physician (or as a pharmacist) can be reasonably expected to do. Because there is a growing sharp division between providers who wish to lecture and promote their own personal beliefs in the form of action that runs contrary to common societal expectations of the profession, a tiered or differentiated certification process would be useful to allow both the professional community and the public to make informed and expedient decisions while preserving the integrity of professional certifications. An added bonus would be that "wanton physician importation programs", as harped on by one of our regulars, would be facilitated since it will be easier for a community to assess the current preachy-physician/real physician ratio.

- by SabrinaW on Dec 4, 2007 at 2:49 PM | link

It seems to me that a necessary prerequisiste to"preserving the integrity of professional certifications" in the healthcare arena is to get clear about just what falls under the rubric of 'healthcare.' As many people have noted, preventing or terminating a pregnancy usually isn't medically indicated. And I know of at least one pharmacist whose stated reason for refusing to fill a prescription for Plan B was that it wasn't medically indicated. He went on to say that he had no qualms about dispensing Plan B when pregnancy was contraindicated. So far as professional integrity is concerned, that pharmacist is probably on pretty solid ground.

- by bob koepp on Dec 4, 2007 at 4:46 PM | link

Bob, if that is the case, then I agree that a viable solution could be to remove contraception from the purview of healthcare providers. Some sort of change needs to happen to preserve a necessary level of transparency in this.

- by SabrinaW on Dec 4, 2007 at 8:20 PM | link

In regards to Bob Koepp's response: What expertise does the pharmacist have as to rendering a decision as to whether a prescription is medically indicated or not? Has this pharmacist taken a detailed medical history and performed a physical exam on the patient? Is the pharmacist licensed to perform a history and physical exam? Was such performed in the pharmacy in front of others waiting to get their prescription filled? Is the pharmacist legally licensed by the state to decide when a pregnancy is contraindicated?
I would say the pharmacist is standing on quicksand, not solid ground.

- by Bob on Dec 4, 2007 at 10:26 PM | link

Quicksand? If it's true that _usually_ preventing or terminating a pregnancy isn't medically indicated, then in a system where birth control has been medicalized it will be the case that usually prescriptions for birth control are not medically indicated. The problem is with the system, not the pharmacist's assumption. As far as Plan B is concerned, the problem is with the FDA which, against the recommendations of its own scientific advisors, still limits access to pharmacies.

- by bob koepp on Dec 5, 2007 at 8:13 AM | link

I argue that the problem as far as filling a legal prescription written by a licensed physician is entirely the pharmacist's problem. The pharmacist may have ethical, statistical, religious, psychosocial, whatever, problems with the medicalization of contraception but he in fact, has no knowledge about the patient in question. Does this patient have a medical condition that would place her life at risk with a pregnancy? Has this patient recently had a nuclear medicine exam that has exposed her uterus and embryo to unreasonable radiation levels? The list goes on. The pharmacist is not privy to this information and is not the physician with a physician/patient relationship and is making a judgment based solely on a hunch based on essentially zero clinical information.

- by Bob on Dec 6, 2007 at 6:46 PM | link

Bob - I don't know, and I suppose that you don't either, whether the pharmacist I mentioned asked the woman presenting a prescription for Plan B why it had been prescribed. How does that affect the general point about the inappropriate medicalization of contraception? Remember, it's because contraceptives are only available through the medical system that the moral scruples of some healthcare professionals are brought into direct conflict with the desires of clients. This is a systems problem.

Or has the question been shifted from, "Is it morally permissible to refuse to fill prescriptions for non-medical purposes?" to "Is it morally permissible to make assumptions about whether a prescription is medically indicated?" Different questions, different issues.

- by bob koepp on Dec 7, 2007 at 7:51 AM | link

I in fact do not know. That places me in the realm of the rest of the entire world (excluding her physician), especially including the pharmacist, who has no understanding of this particular patient’s medical condition and need.
Does contraception deserve medicalization? Well, birth control pills can cause hypertension as well as deep vein thrombosis which may result in pulmonary embolism, stroke and brain death resulting from thrombosis of intracranial veins, especially the superior sagital sinus. One could probably make a reasonable argument that these conditions point to a need for medicalization of contraception.
But since there are considerable medical risks which should be monitored by a physician with common birth control methods, perhaps you are arguing that contraception, beyond condoms or abstinence, should not be allowed lest they become medicalized?
Contraceptives are in fact, not just available through the medical system. One needs only to wash ones hands in a truck stop to know better than that.
I do not think the question has shifted at all from "Is it morally permissible to refuse to fill prescriptions for non-medical purposes?" to "Is it morally permissible to make assumptions about whether a prescription is medically indicated?"
The pharmacist has no knowledge as to whether the prescription is for medical or non-medical purposes. So how could he possibly make this medical/moral decision? To assume otherwise is a gross step beyond professional licensing and certification and warrants a review and possible revocation of that license. In fact, the pharmacist is assuming that he is somehow now morally certified to decide what is morally acceptable beyond the medical laws of the state.

- by Bob on Dec 8, 2007 at 11:46 PM | link

Bob - When you begin with "I in fact do not know." and conclude the next sentence by asserting (i.e., stating as fact...) that the pharmacist in question "has no understanding of this particular patient’s medical condition and need," you've abandoned intelligibility.

As for contraception being available outside the medical system -- yes, that's true for condoms, but not for Plan B, even though the FDA's scientific advisors concluded that Plan B can be safely and effectively self-administered. My point is that if Plan B were available on the shelves of grocery stores, right next to the condoms, then pharmacist's conscientious objections would be mooted; i.e., rendered irrelevant.

Your assertions about professional licensing and certifications are in need of textual support. Have you even looked at licensing and certification provisions as they exist?

- by bob koepp on Dec 10, 2007 at 9:32 AM | link

To claim that I do not have the level of understanding of the physician involved in a particular patient’s care and further claim that neither does the pharmacist who is simply holding a piece of paper issued by that physician, does not seem to me to abandon intelligibility. For anyone to claim they have the understanding of all the intricacies and implications of the doctor/patient relationship would seem to imply supernatural powers. I don’t have them and I suspect the pharmacist in question doesn’t have them either.
If Plan B and birth control pills and Viagra and Ritalin and other medications with significant side effects and contraindications were in fact placed next to bread and acne medication in the food store then yes, the pharmacist’s conscientious objection and even presence in the building would be irrelevant.
To answer your last question: Since I have been a licensed and board-certified physician for a couple of decades I am in fact familiar with provisions as they exist.

- by Bob on Dec 13, 2007 at 10:14 PM | link

Bob - Again, neither you nor I is in a position to state as fact that the pharmacist in question is "simply holding a piece of paper" issued by the prescribing physician. A simple question, such as, "Is there a medical reason why you should not become pregnant?" might be all the pharmacist would need to ask to find out whether the prescription was "medically indicated."

Since you are familiar with existing licensing and certification provisions, could you inform as to which of these such a pharmacist would have violated?

- by bob koepp on Dec 14, 2007 at 9:26 AM | link

"Is there a medical reason why you should not become pregnant?" That is a question that a physician should explore in depth with the patient. For a pharmacist to assume that he/she will be able to acquire a sufficient understanding of the intricacies of a patient’s medical needs with a single question such as this in a non-clinical setting, without access to a detailed history and physical exam, at best goes against current medical understanding, and at worst is ludicrous. In fact, over one third of adult Americans have limited health literacy. Even if the question was legitimate for a pharmacist to ask, (and I do not believe this is the case) is there any reason for the pharmacist to assume that the person being asked this question is one of the two thirds of Americans who might actually understand the intricacies of the question? What information and evidence does the pharmacist have available to make this decision?
Without the knowledge of a detailed history and physical exam, which will hopefully have taken into account the patient’s ability to understand medical information, the pharmacist is in fact just holding a piece of paper with the assessment of the physician who has performed this task.
While I am not intimately familiar with the parameters encompassed with a pharmacist’s license, I’m going to go out on a limb here and speculate that performing a detailed history and physical exam on a patient and then deciding what is appropriate therapy is not within the scope of their license. I apologize in advance if I am wrong on this assumption.

- by bob on Dec 15, 2007 at 11:14 PM | link

Bob - Perhaps you would not prescribe Plan B unless you had done a detailed history and physical exam, _and_ satisfied yourself that pregnancy was medically contraindicated for the patient in question. Somehow, I think that's not how it usually works. And even if you are the sort of physician who would go through this routine before prescribing Plan B, the FDA scientific advisors think it's not necessary.

- by bob koepp on Dec 17, 2007 at 4:42 PM | link