Denialism

A very confused pharmacist

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by

MarkH
in , ,

I’ve written often about the ethics of doctors and pharmacists imposing their own morals on their patients and customers. Our Sb pharmacologist has as well. And even though all of our legitimate professional organizations recognize this line, Bush’s Department of Health and Human Services has jumped into the ring to join a fight that should never have started. And just to demonstrate how single-mindedly idiotic an evangelical (small “e”) mindset can be when applied to medicine, PZ Myers, uber-atheist, received an interesting solicitation (please, don’t quote-mine that).

To remind you of the issue at hand, there are a number of doctors and pharmacists out there who think that their own religious beliefs should trump the standards of good medical care and the needs of their patients. This is why I write of “evangelism”: professionals who are trying to teach the Good Word (any Good Word) to their patients have stepped very far over an ethical line.

Soliciting PZ Myers for a religious issue—wow. That’s bringing the stupid. Perhaps it was just an email list, but still…wow.

But I think that, with this issue, my righteous anger might even outshine PZ’s. This pharmacist makes all the usual mistakes of conflating contraception and abortion, but the biggest mistake is thinking that ANY OF HIS CUSTOMERS NEEDING THIS MEDICATION GIVES A SHIT WHAT HE THINKS. His job is to dispense safe, lawfully written prescriptions. If he can’t do that, he needs to find a new job. Also, he should consider shutting the fuck up on his evangelical tour of lies. I’m pretty sure lying isn’t a particularly Christian value. If he’s against birth control, he should grow a pair and admit it, rather than trying to pass it off as some mysterious type of abortion.

Which leads me to the “what can little ole me do?” part. You have a job, and that job is to help stop people like this from interfering with your health care.

Until September 20th, HHS Secretary Mike Leavitt is taking public comments on his proposal to allow this kind of bullshit. One nice comment is here. Hurry up and write.

Comments

  1. bob koepp

    I read the “nice comment” to which you directed readers, and I found it neither cogent nor persuasive.

    The writer of that nice comment claims, without providing any sort of supporting rationale, that abortion, sterilization, etc. are “medical procedures”. Well, of course they can be, when they are medically indicated. But what about the many cases when they’re not medically indicated?

    Similarly, when you assert that a pharmacist’s job is “to dispense safe, lawfully written prescriptions” you ignore the question of whether those prescriptions represent medical indications. I would counter that a pharmacist’s “job” (more properly, professional duty) is to dispense treatments prescribed for the prevention or treatment of medical pathologies.

    Anger, whether righteous or not, isn’t conducive to clear thinking.

    Reply
  2. G Barnett

    Well, of course they can be, when they are medically indicated. But what about the many cases when they’re not medically indicated?

    So, to use a “politically neutral” example (I hope), if a man goes to an outpatient clinic for a voluntary vasectomy then because it’s not due to any disease/preexisting condition then it’s not a medical procedure?

    Baloney. Any procedure which the skills and training of a doctor or nurse to be safely performed is by definition a medical procedure, voluntary or not.

    I would counter that a pharmacist’s “job” (more properly, professional duty) is to dispense treatments prescribed for the prevention or treatment of medical pathologies.

    Again, baloney. The prescribing doctor is the one who makes the judgement as to whether or not the patient has need for the medication and it is the duty of the pharmacist to fill it; no judgement call needed or desired on the part of the pharmacist.

    Reply
  3. bob koepp

    G Barnett – So, cosmetic amputations are “medical” procedures; and using the skills and training of a doctor to administer exquisite torture makes it a “medical” procedure. Baloney, indeed.

    Reply
  4. N.B.

    You think you’re pissed? You’re a medical professional, but think about how the pharmacists in the audience must feel.

    Every time I hear about this nonsense my blood pressure jumps another point or three. How much of a self-righteous dick do you have to be to deny other people desired medical services on the basis of your personal beliefs? I can’t believe that these people have managed to delude themselves into thinking that they’re somehow doing the public (and women in particular) a favor by protecting them from the evils of birth control.

    Reply
  5. Susan

    “I read the “nice comment” to which you directed readers, and I found it neither cogent nor persuasive.”

    This is an interesting comment form “Bob” who, if he isn’t using his real name, I presume is still male. I get miffed by men who jump into the pro-life fray. Bob will never be in any danger of getting pregnant so Bob should shut up.

    Reply
  6. G Barnett

    G Barnett – So, cosmetic amputations are “medical” procedures; and using the skills and training of a doctor to administer exquisite torture makes it a “medical” procedure. Baloney, indeed.

    Actually, cosmetic amputations — as viscerally repugnant as they may be to those who can’t fathom a psychological need to not have a certain body part — would definitely count as medical procedures. And no, I haven’t had anything like that done myself, but I can still appreciate that they would require competent medical skill and thus count.

    Torture is a complete nonsequitur and you know it — we’re talking about voluntary things done with the consent and prior knowledge of the patient.

    I stand by my statements.

    Reply
  7. Susan

    G Barnett – So, cosmetic amputations are “medical” procedures; and using the skills and training of a doctor to administer exquisite torture makes it a “medical” procedure. Baloney, indeed.

    What is a “cosmetic amputation?” Is this a fancy way of saying “abortion?” Are you refering to vasectomys? How is that cosmetic? What’s “exquisite torture”? Are people getting bits of their bodies lopped off for fun? Somehow I doubt any legimate doctor would do something like that. Sounds very Marques de Sade to me. What does any of this have to do with being denied the right to use birth control?

    Reply
  8. LanceR

    Actually, lying for Jeeeezus is a pretty common evangelical trait. They rationalize it thus: If a lie brings the person to christ, then it serves a good purpose. Therefore, lying for Jeeeezus is a good thing.

    Also, Bob, you’re a moron. See “Fractally Wrong” A pharmacists is *not* a physician. He (it’s always a he, isn’t it?) has no business injecting his personal beliefs into the doctor/patient relationship. Period. End of story. 30.

    Reply
  9. LanceR

    A pharmacists? Hmm… Obviously I need a nap!

    Reply
  10. The Ridger

    Ummm, Susan? Some people do indeed get parts of their bodies – legs, for instance – cut off because they want to. It does happen.

    Reply
  11. Ames

    #1, I’m the guy who wrote the “nice comment” (thanks for the shout out Doc 🙂 ) – what do you mean, abortion isn’t necessarily “medically indicated”? My expertise is law not medicine, so I’m curious what you mean.

    Reply
  12. Curious

    I’m neither a doctor nor a lawyer (haven’t played either one on TV even) but does this mean if I go to my pharmacist with a prescription for a drug for lactose intolerance and she’s a vegan, she could refuse to fill it?

    How about showing up at a small ER following a terrible auto accident and the only MD on duty is a Jehovah’s Witnesses? Does that mean no transfusions for my badly bleeding children?

    Just Curious.

    Reply
  13. wazza

    Pregnancy will always entail a certain amount of danger to the mother, and therefore should only be continued if the mother actually wants the child… which means that abortion and contraception are always medically indicated.

    Reply
  14. Tikaysha

    Basically, these pharmacists are saying “I won’t fill this prescription because I don’t like what this drug does.”

    The odd part to me is that they only seem to care about drugs that allow women to control when and how they become pregnant. You don’t hear about pharmacists refusing to fill prescriptions for penicillin or ever a psychiatric drug. Just the ones that give women agency over their own body. Which is bullshit. Men can get a prescription for a drug that lets them have sex- a drug that is never necessary for life, just comfort and self-esteem. But women get denied not just EC, but regular birth control too, which is used to help treat and control more than just ovulation.

    Reply
  15. bob koepp

    Ames – In medical practice there is a difference between procedures that are medically indicated and those that are not. Sometimes the latter are called ‘elective.’ The relevance of the distinction is due to it’s role in delimiting the scope of procedures that can be given a medical rationale in terms of preventing or treating pathological conditions. Individual physicians are generally not under a professional obligation to provide elective procedures, though they might have a duy to refer. I tend to view the professional obligations of pharmacists in an analogous manner.

    Reply
  16. PalMD

    Bob, you often make very good points around here, but you’re wrong about this one.

    What is considered “elective” vs. “medically indicated” is basically something you’ve made up. In medicine, the only time we use similar distinctions is for insurance purposes. We recommend any treatment or procedure we think is in the patient’s best interest, insurance companies decide whether or not to pay for it. It the patient thinks it’s important enough, they’ll pay out of pocket even if it the carrier deems it “elective”. Physicians certainly can’t be forced to provide procedures they don’t feel competent in (for instance, no matter how much my patient wants me to do an appendectomy, it ain’t gonna be me).

    The pharmacist never gets a role in that process. Never. They get to check to make sure a prescription is safe (within the standards of care) and lawful. Then they dispense it. Period. Anything else is malpractice.

    Reply
  17. I am so wise

    I agree with Bill Maher on this one. Pharmacists are too low on the medical totem pole to get uppity about this. They dispense pills and work at Wal-Mart.

    On the other hand, I like the idea of discharging job related responsibilities while still getting paid the same.I work at museum, but I object to history. Pay me while I watch TV. It’s my right.

    Reply
  18. Reginald

    I’m a web designer and my client just asked me to build a registration portal with a ‘blue’ feel. I’m religiously opposed to the colour blue so I’m just going to not do my job. Perfect sense!

    Reply
  19. Dan S.

    Super-judgmental vegetarian working at McDonalds. ‘Would you like fries? Cause I’m not serving you dead cow. And here, let me lecture you about how you’re a horrible, horrible person for eating meat.’

    How long would that last?

    Reply
  20. Racter

    I see my physician’s role as that of an advisor. I make the substantive decisions, he makes the procedural decisions. In providing him with the information he needs in order to advise me, I may share with him details of my life I regard as private, with the understanding that he will keep them in confidence.

    The procedural decisions made by my doctor become substantive decisions when passed to the pharmacist, and he assumes the procedural role at that point (checking for possible drug interactions, etc). If my doctor attempted to make substantive decisions for me, say performing an operation without my consent, he would place his career (and his leviable assets) at great risk.

    If I ever encountered a pharmacist who attempted to co-opt the authority to make substantive decisions regarding my health (when I don’t even give my doctor that much authority), I think my reaction would be much the same as if my mail carrier informed me that he intended to open and read each piece of mail addressed to me so as to better decide whether my recieving it was consistent with his personal belief system.

    Reply
  21. Lightnin

    They dispense pills and work at Wal-Mart.

    Do you have pharmacies in supermarkets/department stores in the US?

    Reply
  22. Bee

    There’s a simple solution for these pharmacists. They can quit being pharmacists, or better still, never become pharmacists in the first place. I doubt you’d find a practicing Jehovah’s Witness who’s decided to become a doctor, because they know there will be multiple procedures that will be against their beliefs to perform. Few Muslims are likely to work in pig abbatoirs, or Hindus in cattle slaughterhouses. Those that do foolish things like this (like the Muslim cabbies who wouldn’t carry alcohol in their cabs) should be told to seek employment that won’t conflict with their religion, rather than inconveniencing complete strangers with different beliefs.

    Pharmacists who refuse to dispense birth control medications and devices are imposing their personal beliefs on people who don’t share them, and who may be seriously inconvenienced or even harmed by going to one of these guys, only to discover they can’t get their prescription filled without driving another hundred km – that would certainly be the case in my area. Interestingly enough, my local pharmacist is a Muslim, but I’ve seen no indication that he fills prescriptions based on his beliefs.

    Don’t want to dispense birth control? Find another profession.

    Reply
  23. bob koepp

    PalMD – Thank you for the compliment, but I’m afraid it’s you who’s wrong here. The way in which I’ve used the terms ‘medically indicated’ and ‘elective’ is quite common, especially with reference to abortion and to plastic surgery. And just to tweak your memory, and encourage consistency, here’s something you said in the course of an earlier discussion of precisely this point: “Doctors are not ethically obliged to perform elective/cosmetic procedures, in most cases.” You didn’t expand then on the “in most cases,” explaining what would constitute an exceptional case. Perhaps you could do so now.

    BTW, for the benefit of certain “commenters”, I’ll note that I’m solidly pro-choice — so you’re wasting your bile.

    Reply
  24. Fitz

    @Lightnin

    I would think they do. We have them in the UK.

    Reply
  25. Miss Grace

    In the UK doctors can refuse to sign abortion consent (I am sure there are very few who do) but they MUST refer you to a colleague who will…(sounds ridiculous to me – do they think God is pedantic about admin?). It seems to me that we are retreating into a dark age where the religous beliefs of individuals are accorded the same ‘equality’ under law as gender, sexuality or race. I don’t think this should be the case – if your faith prevents you doing certain aspects of your job, you are not fit to do that job.

    Reply
  26. Chuck

    There’s another simple solution for these pharmacists. They can work at or create pharmacies that do not stock the items they find objectionable.

    Reply
  27. DuWayne

    G Barnett – So, cosmetic amputations are “medical” procedures; and using the skills and training of a doctor to administer exquisite torture makes it a “medical” procedure. Baloney, indeed.

    Sure as hell they are. Regardless of the reason for the procedure, it is good to have a physician do it (if you can find one who will), because yes, it is a medical procedure. The fact that a procedure may not be medically necessary does not change what it ultimately is.

    At one point, I was interested in having sleeves installed under my pectoral muscles, that would allow me to be hung by them (I was very enthusiastic about hallucinogens, extreme pain qualifies). Absolutely unnecessary, yet still, it’s a medical procedure.

    Susan –

    “Cosmetic” amputations are exactly what the name implies, amputations. This could be anything from a finger, to the lower leg or other parts. Not very common.

    Reply
  28. Interrobang

    I had an “elective” cholecystectomy. The difference was explained to me that the reason it was considered to be “elective” was because a) I had asked to have it done, and b) it wasn’t life-threatening. However, since I also had (very bad) gallstones, it also fell under the rubric of “medically necessary,” at least as defined by the Canada Health Act. (So that’s why OHIP paid for my ostensibly “elective” operation.)

    Or, you know, “You keep using that word. I do not think it means what you think it means…”

    Reply
  29. JK Finn

    His job is to dispense safe, lawfully written prescriptions. If he can’t do that, he needs to find a new job.

    Exactly. Besides, the only reason he gets away from dispensing substances designed to alter the human biochemistry is that he is doing so based on those lawfully written prescriptions – his function is analogous to a “common carrier” in telecommunications. As soon as he starts to “filter” the prescriptions in any way, he becoms liable to each and every pill, tonic, salve and whatever he does dispense. After all, if there are some problems with anyone’s medication, he could have prevented it by witholding the medication in the first place.

    Doctors rejoice, the pharmacists now cover the malpractice suites…

    Reply
  30. N.B.

    I am so wise said:

    I agree with Bill Maher on this one. Pharmacists are too low on the medical totem pole to get uppity about this. They dispense pills and work at Wal-Mart.

    Yeah, you’re right. There’s absolutely no expertise required to make sure that patients aren’t inadvertently being prescribed (medically) inappropriate drugs. It takes no intelligence to evaluate and prevent potential drug interactions. Answering questions about drugs and drug therapy? You could clearly replace pharmacists with a walking PDA. Forget about the fact that pharmacists are the first point-of-care for many patients and that they are essentially the masters of outpatient triage–they can’t diagnose illnesses or write prescriptions, so how can they possibly have any medical authority?

    Not to jump down your throat, but you’ve invoked one of my pet peeves. Pharmacists do a lot more than “count pills and work at Wal-Mart.”

    It’s a real shame that whenever the whole “refusal to fill birth control” issue comes up there’s always somebody who jumps in and says that pharmacists shouldn’t be doing this not because it’s wrong to deny agency to patients but because pharmacists don’t have the “medical authority. A pharmacist who doesn’t fill your prescription because it might kill you is doing his job. A pharmacist who won’t fill your prescription because he thinks you’re immoral is being a dick. Don’t claim an entire profession is “too low on the totem pole to matter” when what you really mean is “people who are dicks shouldn’t be able to force their beliefs on others.”

    Reply
  31. PalMD

    I hopefully made that clear in my earlier posts, but just to second NB, I really do count on pharmacists to help prevent errors. Pharmacists are a crucial part of health care, which makes it even more disturbing when they abuse their power and privelidge to impose their morals on patients, when their time could be better spent making sure a doctor doesn’t give a patient on amiodarone a nice dose of avelox.

    Reply
  32. bob koepp

    PalMD and others – It’s good to know that at least a few people around here appreciate that pharmacists are healthcare professionals, and not mere functionaries in the medical-industrial complex.

    Now maybe we can work a bit on getting clear about the legal/ethical issues implicated in refusals to provide requested services. I’ll suggest that we start with the acknowledgment that a refusal to render assistance is usually not viewed in either law or ethics as equivalent to imposing one’s views on another, obstructing another’s actions or, generally, violating another’s autonomy. Gratned, some of the intellectually challenged healthcare providers who refuse to provide certain services may see their own actions as attempts to prevent women from exercising their right to choose whether or not to bear offspring. To that extent, they are attempting to violate the rights of others, and trying to cover their asses with appeals to conscience. They deserve to be slapped down. But in some cases, it appears that they really are trying to avoid making a personal contribution to an act they sincerely view as immoral. In such cases, the law of the land and several centuries worth of ethical thought about moral agency are actually on their side.

    Reply
  33. N.B.

    Health care professionals are in a unique position regarding their obligations to render services. If I refuse to sell you a pizza or let you into my taxi because I don’t like your face it’s unlikely to have lasting consequences (though it might).

    If I refuse to perform surgery on someone because they have tattoos (which some religions consider immoral), don’t treat alcoholics suffering from DTs (because they’re getting what they deserve), or won’t dispense birth control because I think it violates the will of God, I’m breaking the oaths I took when I put on my white coat.

    Consider the oaths of the pharmacist.

    The first line: At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy.

    Also consider points three and seven of the pharmacist’s code of ethics:

    III. A pharmacist respects the autonomy and dignity of each patient.
    VII. A pharmacist serves individual, community, and societal needs.

    Pharmacists who refuse to fill legal, medically-appropriate prescriptions are violating both. You could argue that they are serving “individual needs” mentioned in point seven by moral refusals to fill, but they simultaneously violate point three.

    You can refuse to do your job if you don’t like it, but you shouldn’t expect special protection for doing so, and your employer has every right to send you packing.

    Reply
  34. Chuck

    “You can refuse to do your job if you don’t like it, but you shouldn’t expect special protection for doing so, and your employer has every right to send you packing.”

    An employer also has every right to hire you and not stock items it does not want to. There is no need for the government to get involved one way or the other.

    Reply
  35. bob koepp

    N.B. – Your examples of refusing service to people with tattoos or alcoholics couldn’t be justified by any “conscience clause” of which I’m aware, because those clauses specifically restrict objections to _procedures_, not to certain classes of people.

    With respect to clause III of the pharmacist’s code you cite, I think you might be misinterpreting the notion of autonomy in precisely the way I described in my just previous comment. With respect to clause VII, does the pharmacist serve the whole spectrum of individual, community and societal needs, or is there a more restricted type of needs (perhaps what we might call health-related needs)? This also feeds into your reference to “legal, medically-appropriate prescriptions”. Just what is this thing called “medical appropriateness”, and what distinguishes it from various other sorts of appropriateness? How such distinctions get drawn is crucial if we’re concerned with the moral/legal obligtions of people “qua healthcare professionals.”

    Reply
  36. N.B.

    Chuck:

    Yes, your employer has the right to do whatever it wishes. If you work for NationwideBigDrug and they choose not to stock contraceptives, that’s great for you if you don’t want to dispense them. But NationwideBigDrug is probably going to stock contraceptives because it’s profitable. So if NationwideBigDrug opts to stock contraceptives, and you decide not to dispense them, you are not serving NationwideBigDrug’s customers and are therefore not doing your job. As a result, they have a right to sack you.

    You have a “right” to refuse to do your job. You just don’t have a right to complain if you get fired.

    bob:

    Regarding my specific examples, no, I’m not referring to procedures with the tattoo example. I’m not talking about tattoo removal, I’m talking about a physician who refused to treat a child because his mother had tattoos and he found them inappropriate.

    I don’t think I’m misinterpreting anything about autonomy.

    The patient has made an independent, autonomous decision (they want birth control). You, the pharmacist, have taken an oath that you will serve the public. In this case, serving the public means providing birth control.

    You the pharmacist may very strongly believe that dispensing birth control is aiding and abetting a contraceptive act and therefore it is immoral. You may, as a result, decide that it is better for society if you refuse to dispense contraceptives. In essence, you are saying “what my patient wants is wrong, so I don’t have to give it to her.”

    This ties into the issue of “medical appropriateness.” Compare the case of a drug-seeker who is constantly trying to refill prescriptions for opioids weeks in advance. It is not “medically appropriate” to provide drugs of abuse to a drug-seeker because doing so is ultimately destructive to the drug-seeker’s health; it violates the principle of non-malevolence (“first, do no harm”). There have been instances in which pharmacists have inappropriately identified “drug-seekers” who were in fact chronic pain patients and have refused to fill prescriptions as a result. However, the appropriate response when refusing to fill a script for a controlled substance is not to say “you can’t have this,” but to say “I need authorization from your doctor to fill this.” At that point the pharmacist contacts the physician to verify that the patient has a legitimate medical need for the prescription.

    It might sound odd to claim that a doctor is writing a prescription for something that a patient doesn’t “legitimately need,” but some doctors write prescriptions for controlled substances without knowing, for instance, that another doctor just wrote them a prescription for the same drug yesterday. Usually, once a doctor has been informed that his or her patient is “shopping,” the doctor will request that the pharmacist void the prescription. It is sometimes difficult for physicians to determine who “really” needs certain medications, especially in the case of pain; the maxim on the subject is that “any patient who says he is in pain is in pain.” You can’t tell someone that they aren’t in pain, so physicians will occasionally provide drug-seekers with opioids under the assumption that it is better to treat a faker than to inadvertently refuse a sufferer.

    A prescription for a contraceptive would be “medically inappropriate” if it would be likely to cause direct harm to the patient. Some medically valid reasons to refuse to fill a prescription for an oral contraceptive (OC) would be: Existing pregnancy, patient allergy to a component of the medication, or undiagnosed vaginal bleeding. If the patient has been to their OB/gyn and the doc saw fit to write a prescription for an OC I pretty much have to assume that the patient is not pregnant and is not bleeding from the vagina (they would definitely have had an opportunity to notice). If it turns out that the patient is allergic to some component in a particular OC (say a dye) it is easy enough to have the physician switch to a different OC without that component. There’s an issue with OCs and heavy cigarette smoking (especially in advanced age), but a pharmacist can’t refuse to fill an OC because he thinks the patient is a smoker–taking a patient history and using it to make prescribing decisions is the physican’s job, not the pharmacist’s. The physician has obviously decided that it is okay for the patient to have the medication. The pharmacist always has the right to withhold the prescription until he consults with the doctor, but once the doctor says “fill it, it’s fine” (and the pharmacist makes appropriate documentation of their conversation to cover his own ass) the prescription should be filled without further issue.

    To summarize, the only thing “wrong” with filling the prescription is “you don’t want to.” At that point you are letting your morals (which do not constitute sound medical judgment) influence your medical practice in a way that is a disservice to your patients. And from an ethical perspective, you can’t do that, because you have sworn to put the needs and desires of patients before your own, as long as their requests are medically appropriate. It doesn’t matter whether you think you’re “contributing to immorality.” If you do that, you’re putting your own needs (a desire not to contribute to immoral activity) ahead of your patient’s (a desire to control her own reproduction).

    Reply
  37. bob koepp

    N.B. – If you’re interpreting ‘autonomy’ correctly, then we agree that a refusal to provide a requested service is not equivalent to a violation of the requesting person’s autonomy. Right?

    Is dispensing birth control serving a “medical” need? As I’ve noted previously, sometimes it is, but not always. Are pharmacists professionally obligated to serve non-medical needs? I don’t think so.

    You’ve described several scenarios where actions might be medically inappropriate — cases where the actions might well result in harms of a medical nature. But that doesn’t answer the question of what it is that makes something medically appropriate, since medical appropriateness is not just the complement of medical inappropriateness. Some things are neither medically appropriate nor medically inappropriate — sometimes such things are described as “elective”, and individual healthcare professionals might choose to provide them or not at their own discretion.

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  38. PalMD

    As NB put it, medical appropirateness is really none of your damned business. Safe, legal prescription = fill it or quit. You can morally object, but you must suffer the consequences. Conscientious objection is meaningless without consequences.

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  39. Calli Arcale

    Is dispensing birth control serving a “medical” need? As I’ve noted previously, sometimes it is, but not always. Are pharmacists professionally obligated to serve non-medical needs? I don’t think so.

    It is always medical. If it’s not medical, what is it — entertainment? Food? They are regulated as medicine, not entertainment or food or anything else. Elective procedures are a *subset* of medical procedures, not distinct from them. I think that’s where you’re confusing people, bob koepp.

    Lots of medical procedures and drugs are provided for what amount to elective reasons. One really good example of an elective drug is Botox. Now, a pharmacist won’t be dispensing that directly to a patient, for obvious reasons, but it is a drug which is often taken for cosmetic purposes, with no particular indication that it will improve the patient’s health, except in the rather tenuous sense of improving their self-image. It’s still most certainly medical, and thus governed by various regulatory agencies governing medical practice (including, but not limited to, the FDA and the state medical board).

    The real problem, though, is not the pharmacist’s unwillingness to dispense a drug that he deems inappropriate or not medically necessary. It is, after all, his duty to raise a red flag and refuse to fill prescriptions which he believes will cause harm. The real problem is that the pharmacist who refuses to fill a prescription for birth control is interfering in a medical decision without the information to do so. He has no way of knowing if birth control is being given for an appropriate reason, or if it is being administered as an abortifacient (though it is dubious to call them an abortifacient, and hinges mostly on some rather shaky early promotional material for the Pill which claimed it might prevent implantation despite lacking a plausible mechanism for doing so). For all he knows, the patient suffers from dysmenorrhea (abnormal menstrual periods). Birth control pills can sometimes tame those abnormal periods and give a woman some control over her life. (The condition really can be disruptive to a person’s life, causing crippling pain, constant anemia, and the constant need to visit restrooms regularly to change out the feminine hygiene products.) On the flip side, a pharmacist refusing to dispense Viagra likely will not know when it is being dispensed for a heart condition and not to treat impotence. In essence, the pharmacist is making a value judgment in the absence of sufficient information.

    Of course, there’s another point to make. By making this decision, the pharmacist is also going against the accepted standard of care, which is often the rule of thumb used in malpractice cases. Are some ethical decisions difficult calls? Absolutely. But the standard of care is pretty clearcut when it comes to birth control and impotence treatment. If we allow pharmacists to violate the standard of care merely because they have moral quibbles with it, then we are threatening the entire regulatory system that protects us from malpractice. “I didn’t like doing it that way” is a dangerous defense to allow. I don’t think we’re in danger of having some PETA nut infiltrate the system and refuse to dispense drugs because they’re all tested on animals, but a more realistic possibility is a medical professional defending their use of quackery on the basis of religious conscience. Since there are genuinely malicious (or at least extremely self-serving) individuals out there, I think it’s dangerous indeed to allow someone to defend their refusal to meet the standard of care on the basis of what they state to be their personal convictions.

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  40. bob koepp

    PalMD – Since when is “medical appropriateness” none of the damn business of any citizen? Are we supposed to “just take the word” of people in white coats that what they do has a sound medical rationale? Is it possible that you are unaware of historical abuses of medical authority, or the coopting of medicine for the pursuit of non-medical goals?

    Please, stop arguing like a “denialist”.

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  41. LanceR

    Bob, as I’m sure you know since you’ve been around here for a while, the “No, *you’re* the denialist” is one of the signs of a losing argument. You are deliberately confusing what PalMD said. He is referring to a generic “you”, as in the pharmacist. “Medical appropriateness” is none of the pharmacists business. Going on to bring up “historical abuses of medical authority” is irrelevant, irrational, and an appeal to emotion.

    “Medical appropriateness” is what the doctor says it is. If you (speaking specifically, also “you” as a generic consumer) disagree, you are welcome and even encouraged to seek a second opinion. Your pharmacist should *not* be involved in any part of that other than to watch for drug interactions of which the doctor may not be aware.

    Read the actual argument rather than making up strawmen.

    Do we need another episode of Trollympics?

    Reply
  42. N.B.

    Patient autonomy is defined as the rights of patients to make decisions about their medical care. This autonomy allows the provider to advise the patient, but not to make decisions for the patient.

    Medical professionals are obligated to provide care to patients who want it–not necessarily legally, but according to their own code of ethics.

    A pharmacist who refuses to provide birth control on moral grounds is doing more than “not rendering a service.” He is making a decision for the patient (he is deciding, on the patient’s behalf, that she does not need birth control). He is also violating his ethical obligation to provide care.

    Refusing to provide medical care is not the same as refusing to provide other services because medicine is not the same as other services.

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  43. bob koepp

    N.B. – What you say about patient autonomy is true, but it doesn’t describe the constraints within which that autonomy operates. Physicians can provide a range of options to which patients might consent. Patients are even free to suggest options that a physician might have neglected and, if the physician concurs, expand the range of options. But patients don’t have the authority to dictate in such matters. They do, however, have the authority to refuse treatments physicians might seek to impose on them.

    As for the claim that “medicine is not the same as other services,” I couldn’t agree more. I think that whatever differentiates medicine from other human activities is probably quite important for understanding the scope and limits of physicians’ professional obligations. And I think it’s the focus on treating and preventing medical pathologies that is most distinctive about medicine. What I’ve been arguing is that whether or not a procedure or service can be given a rationale in terms of treating or preventing pathologies is relevant to the question of whether there is a professionally-grounded duty to provide it.

    There’s an alternative account of what is distinctive about the practice of medicine that doesn’t focus on the goal of treating and preventing pathology, but emphasizes instead the specialized tools and skills of medical practice. This approach seems to be implicit in a number of the comments here, but I don’t think it’s very plausible.

    Reply
  44. PalMD

    im not sure that even means anything

    Reply
  45. bob koepp

    Which part of it don’t you understand?

    Reply
  46. PalMD

    the part that didn’t explain why a pharmacist is allowed to decline to fill a lawful prescription at their own discretion, clearly violating the trust placed in them by society.

    Reply
  47. bob koepp

    “At their own discretion” is a caricature that does not even begin to capture the actual content of so-called “conscience clauses.” And the trust society places in professionals assumes they will cultivate personal integrity, which I assume includes moral integrity.

    Reply
  48. N.B.

    Yes, but whose moral integrity? And whose morals?

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  49. PalMD

    I have not been entrusted to cultivate or in any other way promote “moral integrity”, whatever that may be. I’ve been entrusted to serve patients using my knowledge of good medical practice. Contraception is accepted, good medical practice. Period. Anyone who isn’t in the room with me and my patient doesn’t get a say. Period. No one appointed a pharmacist as morality police. Pharmacists get years of training in pharmacology, kinetics, dynamics, etc in order to safely compound, dispense, etc. They do not go to seminary. They do not have the right to interfere with patient care. In fact, I would go so far to say that if a pharmacist refuses to fill Plan B, they should be liable for the costs of future care of mom and baby.

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  50. LanceR

    I would go further than PalMD and say that refusal to fill a prescription should entail the loss of license, possible malpractice, and bar any future employment in any medical field.

    Seriously, if you don’t want to do the job, don’t take the job!

    Reply
  51. bob koepp

    It’s clear enough that you think pharmacists should not be permitted to refuse to fill prescriptions for uses they believe are unethical. What about physicians? Should they also be required to provide services that they believe are unethical or leave the profession?

    Reply
  52. PalMD

    Physicians have an ethical duty to perform procedures in which they are competent. If an OB doesn’t do abortions, she has the responsibility to refer her patient to someone who does in a timely manner.

    A pharmacist who has ethical objections to a medication has neither the responsibility nor the right to refuse to dispense. Pharmacists are a very different branch of the health care system. The analogy is the clerk who’s a vegan and won’t ring up the steaks.

    Reply
  53. bob koepp

    PalMD – You say “Physicians have an ethical duty to perform procedures in which they are competent. If an OB doesn’t do abortions, she has the responsibility to refer her patient to someone who does in a timely manner.”

    Just to be clear here, are you saying that even if the OB refers a patient to someone who does do abortions, because she will not herself perform a procedure in which she is competent (i.e., she does have the requisite skills) she has failed to fulfill an ethical duty? That goes well beyond any ethical guidelines I’ve seen for OBs.

    Reply
  54. PalMD

    Read this, then come back….

    Reply
  55. bob koepp

    PalMD – I re-read the ACOG Committee Opinion, and didn’t find anything relevant to the question I addressed to you. If I simply missed the relevance, perhaps you could point to the parts of the opinion in question.

    Reply
  56. PalMD

    yeah, that’s cuz i misread your comment…sorry bout that.

    A physician has to be able to easily refer someone, but the situations are very iffy…if someone comes to the ER for emergency contraception, the er doc and the pharmacy must both move quickly. Any delay would cause unacceptable detriment to the patient.

    Each ethical situation is different, but with certain commonalities. However, it’s very hard to imagine a situation where it would be ethical for a pharmacist to decline to fill a safe and lawfully written prescription.

    Reply
  57. bob koepp

    I think it’s clear that we’re never going to agree about healthcare professionals’ conscientious objections to the provision of services. So be it.

    But I’d like to at least mention that, on my view, there is no good reason why access to emergency contraception in the form of Plan B is restricted to pharmacies. And, from what I can tell from looking at the safety profiles of most contraceptives, they too should be available OTC. This wouldn’t settle any disputes about the ethical status of contraception, but it would make them largely irrelevant.

    Reply
  58. Owen

    That’s an interesting idea, Bob. For the record, I’m right behind LanceR on the supposed right of pharmacists to second-guess decisions that the patient and her doctor have already made. But if they are safe enough to be sold OTC (thinks… if they are, why are the drug companies not pushing that?) then that would sideline this entire discussion.
    Back when there was serious discussion of pharmacies not stocking Plan B, I was seriously considering dropping by the pharmacy counter and trying to buy some, just to see the pharmacist’s face when a guy asked for it.

    Reply
  59. bob koepp

    … if they are, why are the drug companies not pushing that?

    We live in a world askew. There are financial benefits to be had if one can control access to standard conctraception, which is used on a long-term basis. In the case of Plan B, the pattern of use is very different, and the most profit is likely to be had by making it widely available — so there actually was an application to get OTC status for it. Political machinations resulted in the FDA acting against the recommendations of their own scientific advisors who had concluded from the evidence that Plan B can be safely and effectively self-administered. So women still need to go to a pharmacist, instead of the convenience store around the corner, to get emergency contraception. A world askew.

    Reply
  60. Moldau

    First thing is, I’ll become a Christian Scientist. Next, I’ll become a pharmacist. Then I’ll deny everybody ALL their prescriptions because it’s against my religion. I can just sit there 8 hours a day and get paid for it. Genius!

    Reply
  61. earl

    Pharmacists should not be allowed to refuse prescriptions. Has anyone noticed a double standard? Many refuse to prescribe the pill, even to married, middle class women but I don’t recall even one incident where one would refuse to prescribe Viagra. Some insurance companies even cover Viagra for prisoners and sex offenders! Makes me sick.

    Reply

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