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Pharmacists As Conscientious Objector - Is the refusal to fill a prescription a right or professional negligence?

Apr 1, 2007 Doctors are often called upon to treat violent criminals who have been wounded by the police. Public defenders are routinely assigned to represent people accused of horrendous crimes. Professionals who are committed to helping people must frequently perform their duties despite serious personal, moral, or religious conflicts. Most do so with the belief that any right to refuse care or services must take a back seat to the oaths they have taken as professionals. Some doctors, lawyers, and even religious observers, however, maintain that they have the right to conscientiously object to participating in certain situations, and their decisions are, for the most part, respected and permitted without penalties being imposed.

This concept has not been openly accepted, however, when it comes to pharmacists who unilaterally decide to refuse to fill prescriptions for a number of drugs on moral grounds. For example, three pharmacists in Texas were fired for refusing to fill a rape victim's prescription for emergency contraception because they claimed to do so would violate their morals. In Wisconsin, a pharmacist refused to fill, or even transfer out, a similar prescription claiming he did not want to commit a sin. As a result, he was put on trial for violating Wisconsin’s state regulation and licensing department's standards of care. After being disciplined for refusing to fill similar prescriptions, a group of Illinois pharmacists sued their employer for religious discrimination.

Although these and other examples of pharmacists refusing to fill prescriptions have been widely publicized and have received more public attention than in the past since they involve the issue of contraception, there has been an ongoing ethical controversy as to whether such conscientious objections are proper when they result in patients with valid (and needed) prescriptions being turned away.

Contraceptives, however, are hardly the end of the discussion in terms of the types of drugs that have spurred controversy among pharmacists, professional organizations, and state law makers. Among the classes of drugs that have met with increased resistance from some pharmacists on moral, religious, and ethical grounds are those used for assisted suicide, euthanasia, and capital punishment as well as erectile dysfunction drugs for convicted sex offenders and HIV-positive patients. There are claims that some pharmacists have even refused to fill prescriptions for psychotropic and pain medications because of moral objections, although there do not appear to be any documented cases of pharmacists refusing to fill legitimate prescriptions for these particular classes of drugs.

There are many pharmacists who support the “right” to refuse to dispense particular prescriptions on the basis of religious, moral, or ethical objections and claim that this is a personal choice that should not be questioned by fellow pharmacists, professional organizations, or state (or federal) lawmakers.
The underlying societal principles cited for the belief that this type of conscientious objections amount to a “right” are the pharmacists’ duty to do no harm (nonmaleficence) and professional autonomy. Nonmaleficence would encompass the belief that dispensing certain drugs has the ultimate result of causing harm to another human being including an unborn fetus, a death-row prisoner, a terminally ill patient, the potential sex partners HIV-positive patients, or a victim of a known sex offender. Professional autonomy is an even more important rallying cry, however, since the pharmacists in question insist that all they are seeking is the same right accorded doctors, lawyers, and clergymen who to decline services for ethical reasons.

Of course, those who oppose such refusals rely on the argument that a professional oath imposes a duty on the practitioner that makes conscientious objection, itself, wrong and immoral. Thus, when a pharmacist is not prepared to dispense unrestricted care that is legally permitted, efficient, and beneficial because of personal beliefs, many would have such an individual penalized, disciplined, or removed from the profession.

If the medical profession and lawmaking authorities (such as the FDA) have determined that a drug, or class of drugs, is approved for legitimate uses, it should not be for individual pharmacists to impose their personal beliefs in such a way as to deny patients access to those drugs when they are legitimately prescribed.

There is also the important factor that most pharmacists, who operate outside of a clinic or hospital setting, do not have access to a patient’s complete medical records. This makes the pharmacist far less able to make critical clinical decisions that impact a patient's health or medical situation.

In addition, once outside of a major urban area where there are numerous pharmacies with multiple pharmacists, the issue of conscientious objection becomes far more problematic. In areas where there are few (or only one) pharmacies or pharmacists, it may be impossible for a patient with a serious, immediate medical problem (such as a rape victim in need of emergency contraception) to find an alternative source for the drug that has been prescribed. Moreover, demographics being what they are make it inevitable that certain areas of the country will be far more likely to have a higher percentage of pharmacists with conscientious objections to dispensing certain drugs. In such areas it may be virtually impossible to find a willing pharmacist in a medical emergency.

In summary then, the following arguments are advanced by each side in this debate:
Pro-Conscientious Objection Arguments include: (1) pharmacists can and should exercise independent professional judgment; (2) professionals should not abandon their morals as a condition of employment; and (3) conscientious objection is fundamental to democracy.

Anti-Conscientious Objection Arguments include: (1) pharmacists have chosen to enter a profession governed by well-defined fiduciary duties; (2) emergency contraception is not an abortifacient; (3) pharmacists' refusals to dispense medications significantly affect patients' health; and (4) refusal has significant potential for abuse and discrimination.

In 2006, bills were introduced in 21 state legislatures to permit pharmacists to refuse to fill certain prescriptions. Although none of the proposals made it out of committee, supporters have not given up and vow to be back with new bills to be filed in upcoming legislative sessions. Currently, only four states (Arkansas, Georgia, Mississippi, and South Dakota) have laws that allow pharmacists to refuse to fill emergency contraception prescriptions. Four other states (Colorado, Florida, Maine, and Tennessee) have refusal laws that could encompass pharmacists’ refusal to fill prescriptions for contraceptives. Illinois passed an emergency rule in 2005 requiring a pharmacist to dispense contraception under a legitimate prescription. California pharmacists have a duty to dispense prescriptions and can refuse to dispense them only when their employer approves the refusal and the patient can still access the medication elsewhere in a timely manner.

Since it must be assumed that even the most committed conscientious objector would not want to harm a patient with a serious medical condition who is in need of a drug that has been legally prescribed by a licensed physician, there must be room to compromise on the issue in order to avoid serious consequences to innocent patients. To that end, pharmacists’ organizations, educators, medical ethicists, legislators, and medical professionals continue to seek acceptable standards that respect a pharmacist’s professional autonomy and individual beliefs while ensuring the rights of all patients to receive proper and timely medical care requiring the dispensing of prescription drugs.

The American Society of Health-System Pharmacists (ASHP) and other professional organizations have developed policies addressing the issue. ASHP recognizes a pharmacist's right to decline to participate in therapies on moral, religious, or ethical grounds and supports the establishment of systems that accommodates these considerations while still protecting a patient's right to obtain legally prescribed and medically indicated treatments.

Some options that have been proposed to avoid harm and inconvenience to patients while respecting the pharmacist’s conscientious objections include:

  • Pharmacists totally opposed to dispensing certain drugs such as oral contraception or abortion, or those who know precisely in what circumstances they would object, should accept the additional ethical obligations of avoiding surprise to a patient with a refusal to provide medication and ameliorate the consequences if it happens by revealing the problem ahead of time 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 and the intention to refuse should be communicated to local physicians. It would be unconscionable to simply wait silently and then surprise an unsuspecting and often vulnerable patient when the problem could have been avoided by appropriate procedures set up in advance.

  • If a pharmacist’s objection is based on fact, science, and ethical reason, the pharmacist should act responsibly by confirming the facts, science, and ethics in each case and consulting with colleagues before acting. Again, care should be taken to minimize the insult, inconvenience, or injury caused by the refusal and alternative means for the patient to obtain the medication should be provided or made available.

  • Government regulators should adopt procedures to review conscientious refusals that are similar to other kinds of professional regulation. Objectors should be prepared to account for their actions and to describe how they balanced their consciences against the possibility that a patient might be injured by their refusal to dispense medicine.

It must be remembered, however, that when the dispensing of prescription drugs is involved, time is almost always of the essence. Thus, remedial or compromise measures that look to administrative proceedings (initiated by complaints, for example) as the means by which to address the issue, may not offer a satisfactory solution to what may be an immediate medical crisis. For this reason, any pharmacist or pharmacy that has conscientious objections to filling prescriptions for any particular drug (or class of drugs) or for multiple classes of drugs used to treat different medical problems, should make every effort to put in place a notification system that provides advance warning and a workable referral system that leaves patients with an alternative means by which to obtain the needed medications.  

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