The discussion we’ve had since Friday regarding the Bush administration’s latest foray into theocracy brought up some interesting points. We discussed implications of the draft regulations including likely limitations on access to safe and effective birth control. But there is another issue here that disturbs me greatly.
Last week we talked a little bit about medical ethics. I’m not an Ethicist (Mike! Are you reading?), but I am a “practical ethicist”, as are all health care providers. How do ethics inform the discussion of what care we can or cannot provide?
First, let’s take the gloves off for a moment. What is a “pharmacist”?
A pharmacist is a trained professional with an expert knowledge of medications. In the retail setting, their primary role is to dispense medications, but their actual role is far greater. Pharmacists check patients’ records for drug interactions, counsel patients on how to properly store and take medications, and communicate with doctors regarding potential problems with prescriptions. Pharmacists are not, in most settings, the patient’s clinician, and do not have the same type of (ethical) relationship to their customers as doctors do with their patients. They are, at the simplest level, technicians and scientists who help maintain the safety and integrity of patients’ medications. It is a great responsibility—one small mistake on the part of a pharmacist can kill, and one small mistake caught by a pharmacist can save a life.
When a pharmacist receives a prescription from a physician that they believe may pose a threat to a patient, they call the doctor. For example, if I were to write a prescription for levothyroxine 125mg daily, the pharmacist would call me up to see if I meant micrograms rather than milligrams (125 mg is a helluva lot of this drug). If I tell the pharmacist to shut up and dispense the damned drug as written, they might refuse to pending further research, discussion, etc. This often happens with opiates. I may prescribe a cancer patient a very large dose of morphine and the pharmacist will call me to confirm. I’ll explain that they have been on this dose and tolerated it well, and the pharmacist will likely be satisfied that I know what I’m doing.
A pharmacist that receives a properly written prescription for a medication that any reasonable doctor would consider safe may not ethically refuse to fill it. The doctor and patient are the ones who make the decision on what meds are proper. In this case the pharmacists only remaining job, after checking for allergies and drug interactions, is to fill the legal prescription. If they don’t wish to do that, they should be fired, just as the check-out clerk would be fired for refusing to ring up a candy bar (and no, it doesn’t matter how fat the customer is). It has come up frequently that pharmacists sometimes refuse to fill birth control pills. This is unconscionable. The doctor and patient have a clinical relationship; the pharmacist in this instance is an intermediary, and could theoretically be replace by a sophisticated vending machine. Hmmm….
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The relationship between physician and patient is a bit more complicated. There is an asymmetry in the power relationship—anything the doctor says and does is potentially coercive. The doctor and the patient both count on this asymmetry—a patient goes to the doctor for advice, a doctor hopes their position of authority will help persuade the patient to do what is necessary (more on this issue of autonomy vs. paternalism here).
If a doctor tells a patient that smoking is dangerous, the patient is likely to believe them and will treat the words differently than if they had come from someone else. The same goes for a doctor’s opinions. If I tell my patient that I love Obama and that voting for McCain would ruin the American health care system, I’m probably using my influence in a bit of a shady manner. If a young woman comes to me wishing to terminate a pregnancy, and I tell her it is tantamount to killing a child, it means something very different to her than if she sees it on a billboard. If I oppose abortion, and feel I wish to be a “conscientious objector”, to share that with the patient is no longer an act of conscience, but an act of coercion. It is a desertion of my duty as a physician. I have patients who are Jehovah’s Witnesses. I give them very detailed information about the medical (not moral) consequences of their beliefs, but I stop there.
Doctors are activists—activists for the rights and needs of our patients, to which we subsume our own values to a great extent. This is one of the great challenges of medicine, and if you’re not up to the task, it’s time to get out.
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