The Legal/Moral Interface

[rmthunter]

It's really a hot issue right now, but often obscured by the particulars of individual stories and cases. I ran across this one this morning that seems to me to illustrate the appropriate role of government in such circumstances:

http://start.earthlink.net/article/n...04021556440209

Gov. Rod Blagojevich approved an emergency rule Friday requiring pharmacies to fill birth control prescriptions quickly after a Chicago pharmacist refused to fill an order because of moral opposition to the drug.
The emergency rule takes effect immediately for 150 days while the administration seeks a permanent rule. . . .

"Our regulation says that if a woman goes to a pharmacy with a prescription for birth control, the pharmacy or the pharmacist is not allowed to discriminate or to choose who he sells it to," Blagojevich said. "No delays. No hassles. No lectures."

Under the new rule, if a pharmacist does not fill the prescription because of a moral objection, another pharmacist must be available to fill it without delay.

And please notice the attempt to take everyone's needs into consideration, evident in the last paragraph above.

There's also a story in the NYT:

http://www.nytimes.com/2005/04/02/na...2pharmacy.html

I think this shows in stark contrast to the behavior of Congress and the Florida leigislature in the case of Terri Schiavo and really does demonstrate the possibilities when the government is genuinely interested in safeguarding everyone's rights.

This is an issue that has come up not only with pharmacies and birth control, but in doctors and dentists refusing to treat patients with HIV and in some hospitals refusing to provide state-mandated birth control as part of their insurance programs. It's a difficult issue, and I think that Illinois has made a very good step in clarifying the requirements under the law while remaining sensitive not only to the women trying to fill prescriptions, but to the pharmacists who may have personal objections to disseminating birth control.(There is also a provision that if the pharmacy cannot fill the prescription, it must forward it to another pharmacy that can.)

And note that the rule is temporary, pending a more permanent and more carefully considered measure.

[frazzledspice]

When I lived in NY I knew an OB/GYN who had moral objections to providing birth control services. He solved this problem by entering into a practice with two OB/GYN's who had no moral objections to birth control.

This would be the best recourse for this pharmacist, too.

As an aside, birth control pills are almost never an 'emergency' prescription, as antibiotics would be for a young child with a raging strep. Most people probably buy birth-control pills through mail order pharmacies where they are less expensive.

The morning after pill would probably be considered an 'emergency' prescription.

In no case do I think a pharmacist should be forced to violate his conscience.

Twenty years ago my friend's nephew was in medical school, studying to be an OB/GYN. Because he was required to perform an abortion as part of his training, he changed his specialty to anesthesiology. I think that doctors in training should not be required to perform surgeries they have moral objections to. With stem cell research, these incidents will be more frequent.

[jgibson2[$]]

There have been conscience clauses in place protecting nurses and physicians from being forced to participate in abortions for more than 20 years. Not all programs acknowledged that protection or informed their students, though. A co-worker had to stand up to a nursing instructor and inform her of the law when she was a student.

I was fortunate to be in a Nursing school where they were not only aware of the law, but quite proactive in making certain that students were aware of this protection.

As for the pharmacist and birth control pills, I think he needs to be sure that they're for birth control before he decides that his conscience won't let him dispense them. Many women are put on birth control pills in order to control excessive bleeding. Not all of those women are sexually active. Inconveniencing them because someone else might use the same medication for birth control seems problematic to me.

A better option for the pharmacist might be to seek employment at a Catholic hospital, if he's near a major city.

There is an Ob/Gyn near Washington DC who runs an entirely birth-control pill free practice. He manages excessive bleeding with a non-hormonal approach (I don't know what that might be) and the only form of birth control available to his clients is Natural Family Planning. I understand he has a booming practice. No, none of the partners there prescribes birth control of any kind. If you want that, you have to go elsewhere.

[mjfrombuffalo[$]]

I'd disagree with the "most" people using mail order. I can't use my insurance coverage if I buy my Rx that way, for example.

Anyhoo - birth control pills are prescribed for other reasons than birth control. Should a woman with polycystic ovary syndrome, once having discussed treatment options and the like with her doctor, then have to justify her getting the pill to her pharmacist because the pharmacist believes birth control is "bad"?

Does a cashier at a retail establishment now have the right to refuse to check out the guy with the bouquet of flowers, stuffed animal, chocolate candies and box of condoms?

If I work at a supermarket and I believe in prohibition, do I have the right to refuse to stock the beer shelves?

[wivabef]

frazzledspice said

As an aside, birth control pills are almost never an 'emergency' prescription, as antibiotics would be for a young child with a raging strep. Most people probably buy birth-control pills through mail order pharmacies where they are less expensive.

The morning after pill would probably be considered an 'emergency' prescription.

In no case do I think a pharmacist should be forced to violate his conscience.

As a teenager, I took the pill years before I was sexually active to help regulate my cycle. My parents and I, being catholics, had the big discussion as to whether or not this was something we should do. They trusted me to not use the Pill as an excuse to have sex. Funny, my pharmacy didn't even figure into this private matter.

If some DUDE who is so presumptuous as to presume that HIS moral codes allow him to interfere with my reproductive cycle, he can take his moral work standards to McDonald's where he doesn't have to deal with tricky questions that are, quite frankly, NONE OF HIS BUSINESS.

Perhaps he should check on the marital status of the men requesting Viagra? Or maybe he should follow that oxycontin out of the store to make sure the patient isn't selling it on the street?

Perhaps if he advertised that his pharmacy has certain standards, those opposed to his moral code could avoid waiting in the usual lines only to be turned down by St. Pharmacist. He already violated his profession's code by upholding his misinformed personal standards.

[eris esoteric]

On the other hand, should a pharmacist be fired for refusing to give a woman birth control if he knows that she is taking another medicine precribed by another doctor that will interact badly with said birth control?

[wivabef]

jgibson2 said

There have been conscience clauses in place protecting nurses and physicians from being forced to participate in abortions for more than 20 years. Not all programs acknowledged that protection or informed their students, though. A co-worker had to stand up to a nursing instructor and inform her of the law when she was a student.

I was fortunate to be in a Nursing school where they were not only aware of the law, but quite proactive in making certain that students were aware of this protection.

As for the pharmacist and birth control pills, I think he needs to be sure that they're for birth control before he decides that his conscience won't let him dispense them. Many women are put on birth control pills in order to control excessive bleeding. Not all of those women are sexually active. Inconveniencing them because someone else might use the same medication for birth control seems problematic to me.

A better option for the pharmacist might be to seek employment at a Catholic hospital, if he's near a major city.

There is an Ob/Gyn near Washington DC who runs an entirely birth-control pill free practice. He manages excessive bleeding with a non-hormonal approach (I don't know what that might be) and the only form of birth control available to his clients is Natural Family Planning. I understand he has a booming practice. No, none of the partners there prescribes birth control of any kind. If you want that, you have to go elsewhere.

This is a far nicer way to say what I just said.



Thanks, Judy

[mjfrombuffalo[$]]

eris esoteric said

On the other hand, should a pharmacist be fired for refusing to give a woman birth control if he knows that she is taking another medicine precribed by another doctor that will interact badly with said birth control?

Generally I've found the interactions negatively affect the birth control (i.e., make it not work) instead of the other way around. But anyway - the Pharmacist is NOT the doctor. If he sees there's a drug interaction, his job is to tell the patient. The patient can then talk to the doctors to see what needs to be changed. It's not his job to make the decision which Rx to fill.

[wivabef]

eris esoteric said

On the other hand, should a pharmacist be fired for refusing to give a woman birth control if he knows that she is taking another medicine precribed by another doctor that will interact badly with said birth control?

Usually when this happens, the pharmacist informs the patient and will call the doctor's office (if it's a good pharmacy). Something tells me that if the patient is told "you shouldn't take this with your other meds, let's call your doctor to find an alternative" they have been properly informed. Alternatively, if a pharmacist said "you shouldn't take this because you'll burn in Hell", the patient has been properly informed and can make their own decision about whether or not to experience 7 straight days of excessive bleeding or, to burn in Hell.

[eris esoteric]

Oh, I'm with you all over that one, Wivabef. I'm simply looking at problems that a flat out "you must provide x patient with x drug" statements from the government could cause.

[mjfrombuffalo[$]]

wivabef said

Alternatively, if a pharmacist said "you shouldn't take this because you'll burn in Hell", the patient has been properly informed and can make their own decision about whether or not to experience 7 straight days of excessive bleeding or, to burn in Hell.

I like this solution, 'cause then the customer can inform the Pharmacist he can go there first.

[jgibson2[$]]

eris esoteric said

On the other hand, should a pharmacist be fired for refusing to give a woman birth control if he knows that she is taking another medicine precribed by another doctor that will interact badly with said birth control?

That would be his JOB. He's supposed to catch those interactions and let the doctor know, so the doctor can prescribe something else.

[jgibson2[$]]

wivabef said

This is a far nicer way to say what I just said.



Thanks, Judy

What do you think is MY #1 reason for working in a Catholic hospital? It eliminates most of the ethical problems I might run into by working in maternal-child health in a non-Catholic hospital. If they'd just get their act together about the latex stuff, I'd be really happy with them.

[jgibson2[$]]

mjfrombuffalo said

Generally I've found the interactions negatively affect the birth control (i.e., make it not work) instead of the other way around. But anyway - the Pharmacist is NOT the doctor. If he sees there's a drug interaction, his job is to tell the patient. The patient can then talk to the doctors to see what needs to be changed. It's not his job to make the decision which Rx to fill.

If there is a dangerous interaction, the pharmacist has a legal and ethical obligation NOT to fill the prescription -- and to immediately contact the physician for an alternative. They don't just leave it up to the patient. Pharmacists get to spend way too much time on the phone in the course of a day.

[mjfrombuffalo[$]]

jgibson2 said

If there is a dangerous interaction, the pharmacist has a legal and ethical obligation NOT to fill the prescription -- and to immediately contact the physician for an alternative. They don't just leave it up to the patient. Pharmacists get to spend way too much time on the phone in the course of a day.

The way Eris wrote it, I thought she meant the Pharmacist would just be saying "I'm not going to fill this" to the patient. You and I agree on what the outcome should be, it's a manner of how involved the patient is in the ultimate decision that I was concerned with.

[realtraveller]

Can't you just see it coming a mile away.

Two people apply for pharmacist position. Pharmacy already has a pharmacist who objects to dispensing the morning after pill due to religious beliefs.

Candidate A has no such religious beliefs.

Candidate B does.

Pharmacy has to inquire about religious beliefs (a legal no-no) and since Illinois law requires them to have a pharmacist who will dispense the morning after pill must refuse to hire Candidate B due to his religious beliefs.

Pharmacy is sued for employment discrimination. Will the Illinois law be a complete defense? Should this situation be an exception to non-discrimination laws based on religious beliefs?

[wivabef]

realtraveller said

Can't you just see it coming a mile away.

Two people apply for pharmacist position. Pharmacy already has a pharmacist who objects to dispensing the morning after pill due to religious beliefs.

Candidate A has no such religious beliefs.

Candidate B does.

Pharmacy has to inquire about religious beliefs (a legal no-no) and since Illinois law requires them to have a pharmacist who will dispense the morning after pill must refuse to hire Candidate B due to his religious beliefs.

Pharmacy is sued for employment discrimination. Will the Illinois law be a complete defense? Should this situation be an exception to non-discrimination laws based on religious beliefs?

No, the pharmacy would NOT have to inquire about religious beliefs because the law is on their side. Regardless of religious beliefs, the pharmacist would have to dispense the prescription, or the pharmacist would be breaking the law. It is not up to the pharmacy to uphold the pharmacists moral code. It is up to the pharmacist to find a job that doesn't compromise his moral code, as Judy did.

If you are a dancer who doesn't believe in stripping, do you go work at a strip club because it's the only job in town?

And as Rob pointed out, this is a temporary measure to protect patients until a more carefully phrased measure can be put in place.

[frazzledspice]

If a pharmacist asked me whether I was filling a prescription because I was sexually active (particularly if I was a teenager or unmarried) or experiencing menstrual problems, I would be very offended.

If my daughter were taking BC pills for menstrual problems (and she's not) and a pharmacist asked her whether she was taking them for BC purposes, she would just about fall through the floor.

It's none of their business why you're taking a medication. If they are concerned that they will be violating their conscience by filling a prescription for birth control pills for their primary medical purpose, they should partner with someone who doesn't have the same ethical problems.

But they shouldn't be snoops, particularly if their purpose is to look down at the patient disdainfully and say, "My moral code won't permit me to give you that medicine."

[realtraveller]

wivabef said

No, the pharmacy would NOT have to inquire about religious beliefs because the law is on their side. Regardless of religious beliefs, the pharmacist would have to dispense the prescription, or the pharmacist would be breaking the law. It is not up to the pharmacy to uphold the pharmacists moral code. It is up to the pharmacist to find a job that doesn't compromise his moral code, as Judy did.

If you are a dancer who doesn't believe in stripping, do you go work at a strip club because it's the only job in town?

And as Rob pointed out, this is a temporary measure to protect patients until a more carefully phrased measure can be put in place.

Here's an interesting article on this constitutional quandry from the National Law Journal.

http://www.aclj.org/News/Read.aspx?ID=1185

There is a federal statute that prohibits religious discrimination by private companies.

Illinois law has a very broad 'conscience clause' that already allows any health care professional to opt out of any procedure to which they have religious objections.

Apparently, many religious discrimination have already been filed, all of which have been settled, so that the constitutional battle between access to health treatment and freedom of religion has not been directly addressed.

One pending case involves an EMT who refused to drive a woman to an abortion clinic.

[jgibson2[$]]

realtraveller said

One pending case involves an EMT who refused to drive a woman to an abortion clinic.

Here in MD they eliminate that problem by declining to transport non-emergent cases. If it's a freestanding clinic and not an ER, you get to call a cab. Seems fair to me. The EMS folks have to transport enough people to ERs who could get there in cabs without also providing cab service to other sorts of clinics, regardless of the services provided.