Bioethics Discussion Blog: More on Plan B: Conscientious Objection by Pharmacists

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Friday, April 22, 2005

More on Plan B: Conscientious Objection by Pharmacists

On January 28th and March 30th of this year I posted the ethical issue of whether physicians or hospitals should deny patients the “morning-after” Plan B pill if the providers had moral objections to the use of the pill.
Now, in the news, is the hot ethical question whether pharmacists who have conscientious objections (CO) about the dispensing of the “morning-after” Plan B pill should be required to fill the prescription or may they refuse. Excerpted from the New York Times, April 19 2005:

“In at least 23 states, legislators and other elected officials have passed laws or are considering measures in a debate that has attracted many of the same advocates and prompted much of the same intensity as the fight over abortion.

In some states, legislators are pushing laws that would explicitly grant pharmacists the right to refuse to dispense drugs related to contraception or abortion on moral grounds. Others want to require pharmacies to fill any legal prescription for birth control, … which requires pharmacies that stock the morning-after pill to dispense it without delay. And in some states, there are proposals or newly enacted laws to make the morning-after pill more accessible, by requiring hospitals to offer it to rape victims or allowing certain pharmacists to sell it without a prescription.”


An ongoing discussion on this issue by ethicists is appearing on a bioethics listserv currently. Two different views are anonymously presented below regarding whether conscientious objection clauses should be within the codes of ethical behavior of a profession, such as the profession of pharmacy.

The View For CO Clauses

“Is there to be no room for conscience-clauses within a profession? Can those occupying
the minority position be granted no latitude? My own sense is that
conscience-clauses come along with pluralism and disagreements resolved by
a majority while giving minorities some room to hold to the view that the
profession itself does not embrace. Conscientious objector status is the
majority's concession to the minority opinion. As such, it comes along
with a recognition that we differ over what is ethical. When a people
realize that they differ over their view of the good, they can agree that
while the majority's view of the good will prevail, others will not be
coerced to follow it in those respects that they find it objectionable. To
the extent to which our times are marked by disagreement, I would think
that CO clauses would abound.”



The View Against CO Clauses

“I don't think there is room for CO clauses for pharmacists that would allow
them to abstain from implementing classes of prescription. In rega to
medicines, I think physicians have a duty not to prescribe poisons and the
like or to prescribe narcotics without a proper license, and a duty to do
the best job technical job they can with prescription choices, taking into
account side effects. For their part, pharmacists have a general duty to
implement the prescriptions presented to them accurately. Within that
general duty, pharmacists also have a duty to apply their particular
knowledge about drug dosages by age and weight and drug interactions (based
on knowledge of all the drugs being taken) and get back to physicians about
possible prescription changes needed for efficacy reasons, and to respond
to queries from patients to the best of their knowledge. I don't think it
rises to a duty but it is certainly a good characteristic of pharmacists if
they take the trouble to suggest generic drugs to the physicians when that
would result in lower consumer prices or copays. Allowing pharmacists to
make CO objections to types of legally prescribed medications opens a
Pandora's box and interferes with these desired roles: what if the
pharmacist's religious beliefs suggested that pain should be fully
experienced, for example, and therefore they should abstain from filling
certain pain prescriptions? What if their beliefs compelled or prohibited
uses of various types of psychoactive drugs? What if the pharmacist
believes in so-called "natural" classes of drugs to the exclusion of
others? Will we need a procedure for determining whether the pharmacist's
beliefs, as with those of military COs, come from a properly established
religion or just a strongly held belief, and will this matter? What kind
of disclosure of their own beliefs must the pharmacist give the patient,
and when? Must they be posted on the pharmacy wall, giving at least some
consumers a chance to take their business to pharmacies that leave their
subjective morality behind. And do we have time for all these processes to
play out? If pharmacists can introduce their own moral filter that
includes information about the patient's marital status and social behavior
(e.g. no contraceptives for unmarried individuals), it implies at best that
dispensing pharmacists have a relationship with patients and their complete
social history in ways that cannot be assured. … I think
pharmacists who cannot or will not fulfill legal drug prescriptions because
of their own particular moral objections to a class of meds or to use of
certain meds in certain social circumstances (as opposed to technical
grounds of objection to what seem to be prescribing errors of too little,
too much, or the wrong med) should get a new occupation. Further, it seems
to me that condoning pharmacists in their adding a subjective moral filter
to prohibit certain prescriptions will undercut all efforts to see the
pharmacist as a health team member whose technical expertise about
pharmaceuticals should be expressed to and heeded by physicians. I have
always been a staunch advocate that pharmacists should raise objections to
a prescription that seems wrong to them and have wanted to elevate the
status of pharmacist at the true medication expert.”



Any more comments on this issue? ..Maurice.

10 Comments:

At Tuesday, April 26, 2005 6:47:00 PM, Anonymous Anonymous said...

I don't take issue with a pharmacist who refuses to fill certain prescriptions as long as there is someone else available to fill the prescription. But even that presents a problem.

What if there is no other available pharmacist to fill the prescription or the pharmacist refuses to give the patient their prescription back so that they can have someone else fill it? Or if the patient can't come back when someone else is on duty? Or if the patient can't get to another pharmacy, for whatever reason? Or their insurance won't allow them to go to a different pharmacy?

There are too many variables to consider in these cases.

I sympathize with people who feel that their rights are being trampled on, but I don't think that that means that mine should be equally trampled on.

-Michelle

 
At Tuesday, April 26, 2005 10:11:00 PM, Blogger Maurice Bernstein, M.D. said...

This particular dilemma could be solved if the FDA would get the wheels moving and decide as their advisory panel had suggested that Plan B should be "over-the-counter" for those age 16 or older. Then the pharmacist wouldn't be involved in the decision unless it was whether to even include Plan B in the pharmacy stock. And then what is the next decision-- get rid of condoms in the drug store since one of the main actions of Plan B is to PREVENT fertilization of the ovum which of course is the goal of action of the condom. ..Maurice.

 
At Wednesday, April 27, 2005 7:29:00 AM, Anonymous Bob Koepp said...

What does it matter if "drug stores" (i.e., pharmacies) continue to stock condoms? They're already widely available in a lot of different venues -- and I'll bet my next paycheck that when Plan B is made available without prescription, it too will soon be on grocery store shelves.

 
At Thursday, July 14, 2005 4:06:00 PM, Anonymous Anonymous said...

Well, first of all, if the FDA would allow the sale of Plan B "over-the-counter", it would be sold from BEHIND THE COUNTER, just without a prescription! Which will involve a pharmacist big time!

A live embryo is a human life, just in the very beginning of it... So, it is not only a question whether a female patient should be helped or not. It is a question about what value a human life is going to have if the society starts to terminate embryonic forms of human life.
Same goes for euthanasia. If the society is going to approve abortions and euthanasia, THIS is going to open a Pandora box!

Passing a prescription for Plan B to another fellow pharmacist is NOT the way out. Although the pharmacist with no CO is not knowingly terminating a human life, how is it going to make the pharmacist with CO feel when he is simply passing this "duty" to another human being?
Terminating human life is evil. No one joined this profession to do that. We all thought we would be helping to preserve it...
What's goin on? Feeling upside down yet?

 
At Thursday, July 14, 2005 10:46:00 PM, Blogger Maurice Bernstein, M.D. said...

The primary effect of Plan B is to interfere with the sperm's fertilization of the ovum. Therefore there is no embryo to provide a moral dilemma. ..Maurice.

 
At Friday, July 22, 2005 4:45:00 PM, Anonymous Anonymous said...

I am a US pharmacist that works for a catholic hospital. I have chosen to work for an organization that supports my beliefs so that I am not faced with a situation that is in contrast with my ethics.

 
At Friday, July 22, 2005 5:47:00 PM, Blogger Maurice Bernstein, M.D. said...

It is true that associating with an institution which supports the employees' religion and beliefs can reduce dilemma issues with the institution.

Ethicist Dr. Robert Veatch has advocated that patients select physicians of the same religion as the patient along with similar other values as a better way to facilitate medical care. Unfortunately, as for the doctor-patient relationships this selection is not easily accomplished these days. ..Maurice.

 
At Friday, August 05, 2005 7:58:00 PM, Anonymous Anonymous said...

The primary effect of Plan B has not been established yet. The FDA approved this drug without the manufacturer conducted the usual in such cases randomized double-blind controlled trials... There was an interesting review article "Postfertilization Effect of Hormonal Emergency Contraception" published in the Annals of Pharmacotherapy in 2002 by Kahlenbom, Sanford, and Larimore. Accroding to the authors, the mechanism of action of even common BCPs is not very well established yet, with some studies pointing at their effects during the post-ovulatory stage which may inhibit the implantation of a live embryo. Let alone the effects of Plan B!
More information is needed to confirm that BCPs and Plan B do not act as abortifacients. Until then, the society should treat them as abortifacients. This means, patients should be informed of the possibility of a chemically-induced abortions before they are prescribed hormonal contracpetives and/or Plan B. Pharmacists and doctors should be given a good opportunity to avoid using/dispensing these drugs if they have CO. The best way of doing it is taking these drugs off the formularies of usual hospitals, and off the inventories of pharmacies. Just like in case of abortions and mifepristone, patients would have to go to specialized clinics.
To some it may seem like a very radical measure. If it does, it may be just because it is a very inconvenient one. Should we sacrifice the value of a human life to convenience?

 
At Friday, June 16, 2006 4:21:00 PM, Anonymous Mark said...

"I don't take issue with a pharmacist who refuses to fill certain prescriptions as long as there is someone else available to fill the prescription."

I understand what you're saying, but "Separate but Equal" comes in mind to me.

I'm willing to bet that in some states, they'd define "someone else available" as within 10,000 miles.

 
At Friday, October 13, 2006 5:55:00 PM, Anonymous reminder said...

Politics is always ugly when first introduced, right? It takes time for a group of humans to come to some common understandings.

Anyway, from my work at OnCellrx.com I have learned just how much of patient safety is *not* being guarded except by the patients themselves. Good to debate the ethics, but keep advancing patient advocacy and delivering more control to the consumer (patient or consumer of pharmaceuticals in my case) along the way. That makes it more of a win-win.

 

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