Letter to the Editor, Globe and Mail

18 December, 2001

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Michael Valpy quotes Janet Cooper to the effect that 4,600 prescriptions for the 'morning-after-pill' in BC are believed to have prevented 300 pregnancies. (The Long Morning After, 15 December, 2001). This is consistent with a study Cooper cited last year in the Canadian Pharmaceutical Journal.¹ Doing the math, one finds that only about 6% of these women might have been pregnant. One might ask whose interests are best served when women are convinced that they absolutely must buy a product that 94% of them won't actually need.

This does not mean that the 'morning after pill' could not be made more widely available. But it does underline the reasonableness of pharmacists like Maria Bizecki, who ask only that they not be forced to assist in dispensing a drug that they know may cause the destruction of an early human embryo.

Mr. Valpy is, in fact, much more tolerant than most Canadian authorities and professional associations. Manitoba is the only province where a protective policy exists. In British Columbia, conscientious objectors have even been the target of completely unsubstantiated imputations of dishonesty aimed at them in a bulletin from their own College.

Nor do objectors ask too much, as Mr. Valpy asserts, when they refuse to make referrals. What is at work here, perhaps, is a notion that one can keep one's hands clean by having someone else do something thought to be morally objectionable. This was the reasoning of a Newsweek columnist who recently suggested that the U.S. could avoid a conflict of conscience about torture by handing unco-operative terrorist suspects over to "less squeamish allies." 2

Alternatively, Mr. Valpy might think that the 'morning-after-pill' is clearly a good thing, and that people who don't agree are wrong and should be forced to assist in its delivery by mandatory referral. In that case, he should explain why he is a better judge of morality than those whose conscientious judgement he would overrule.

Ultimately, he may find it much more productive to use his imagination to find ways to distribute the 'morning-after-pill' without suppressing freedom of conscience in pharmacy or other professions.

Sean Murphy, Administrator
Protection of Conscience Project

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Notes
(Provided to facilitate editorial verification)

1. "In 16 months of ECP services, pharmacists provided almost 12,000 ECP prescriptions, which is estimated to have prevented about 700 unintended pregnancies." Cooper, Janet, Brenda Osmond and Melanie Rantucci, "Emergency Contraceptive Pills- Questions and Answers". Canadian Pharmaceutical Journal, June 2000, Vol. 133, No. 5, at p. 28.

2. Alter, Jonathon, "Time to Think About Torture". Newsweek, 5 November, 2001, p. 45.

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Letter to the Editor, Pharmacy Practice

22 July, 2001

Reproduced with permission

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Re: Ethics and Patient Care, in the June issue of Pharmacy Practice

I fully agree with Frank Archer's premise that " a long time ago pharmacy established itself as a patient-centred profession".

Also a long time ago, medical professionals took a Hippocratic Oath in order to protect patients from those who would do them harm.

Is Mr. Archer insinuating that pharmacists who object to providing "contentious services" (such as euthanasia drugs, were these legal, and abortion pills), should leave the profession? His comparison of soldiers who will not perform their duty in battle to pharmacists who will not provide objectionable services is totally nonsensical.

Rather, just as a soldier would not kill innocent civilians, nor will some health-care providers participate in treatments that could result in the death of an innocent human being (ie. abortion). Furthermore, if pharmacists are going to act responsibly, they need to act conscientiously, and not like robots. Patient convenience cannot trump the pharmacist's freedom to act according to his/her own moral convictions.

Thank you!

Cristina Alarcon,
Vancouver pharmacist.

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Letter to the Editor, Pharmacy Practice

10 July, 2001

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Far from illuminating fundamental ethical issues, Frank Archer's preference for mantras like "recognized pharmacy services" casts a shadow over discussion. (Ethics and Patient Care. Have your say- Openers , June, 2001 Pharmacy Practice)

"Recognized pharmacy services" in some jurisdictions now includes preparation of drugs for assisted suicide or euthanasia. Last year, Mr. Archer's own College even speculated publicly about future pharmacy services like providing drugs for involuntary euthanasia. (The bulletin had "suicide", but that was an error.)

Now, ethics committees and pharmacy colleges may believe that their 'decrees of recognition' should be accepted as binding and infallible moral judgements. But prudent pharmacists realize that Mr. Archer's logic will one day extend to them. To whom will they then turn for support if they now join him in driving heretics from the profession?

In view of his College's speculation about assisted suicide and execution by lethal injection, Mr. Archer's comparison of objecting pharmacists to soldiers failing in their duty to kill was most unfortunate. It was also misplaced. A more accurate analogy would have considered the situation of soldiers dutifully engaged in active service who have been ordered to bomb civilian targets or to "take no prisoners". Conscientious objection to such orders would hardly be impugned as neglect of duty.

Mr. Archer appears to believe that other pharmacists should have to practise according to the dictates of his conscience. He has yet to explain why they should prefer his conscientious judgement to their own.

Sincerely,

Sean Murphy, Administrator
Protection of Conscience Project

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Letter to the Editor, The Ottawa Citizen

4 July, 2001

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It is both remarkable and shameful that nurses like "Alice" must use pseudonyms when commenting on freedom of conscience, something that the Canadian Charter of Rights proclaims to be a "fundamental freedom" (The medical profession's conscientious objectors: Pro-life nurses want guarantees that they can't be forced to participate in abortions. The Ottawa Citizen, 1 July, 2001). This is inconsistent with the assertion that the College of Nurses of Ontario has supplied "a good ethical framework" for the management of conscientious objection.

It took five years, a civil suit and a human rights action for eight nurses in Markham-Stoufville to secure an agreement that they could not be forced to assist in abortions. The costs incurred- economic and emotional - were staggering. Legal expenses ran to the thousands of dollars, while their ability to pay was hamstrung by the loss of full-time employment. As the case dragged on, one nurse died of cancer and others suffered stress_related illnesses. What "good ethical framework" gave rise to this kind of conflict?

The College guidelines specify that when a client's wish conflicts with a nurse's moral convictions, the nurse must arrange for the wish to be fulfilled by someone else, or fulfil the wish herself. Note that what is spoken of is the wish of the client, not the needs of the patient. An expectation that a nurse will meet a patient's legitimate medical needs is one thing. It is quite another to "live in fear of being fired or demoted" for declining to fulfil a client's wishes. With respect, the language of wish fulfilment does not contribute to a sound ethical framework for addressing freedom of conscience in health care.

Sincerely,

Sean Murphy, Administrator
Protection of Conscience Project

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Letter to the Editor, MS. Magazine

25 June, 2001

Reproduced with permission

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I still don't get it. How can those who stand for the "right of women to make their own decisions" at the same time argue that a doctor, nurse, or pharmacist should be legally coerced into performing an act that violates her most deeply-held beliefs? ["Unconscionable Care", Emily Bass, June/July 2001]

The article minimizes this contradiction by contending that it's somehow wrong to talk of an "institutional" right of conscience for organizations like Catholic hospitals. But the law grants such "individual" rights to institutions all the time, whether it be the free speech rights of Ms. or the free exercise rights of the local synagogue. Instead of asking these hospitals to check their beliefs at the door, we should applaud them for often being willing to serve communities that other health care providers have abandoned. Needless to say, such hospitals are more likely to reduce the services they provide rather than contravene their faith by, for instance, performing abortions or aiding those who do. The result: underprivileged communities receiving even less health care than they do today.

Rather than deal with the hard questions, Ms. Bass presents a Good vs. Evil smackdown pitting the "right to health care" against "so-called" rights of conscience. But the right to receive a particular medical procedure does not include the right to force another to perform that procedure against her will. The logic of personal autonomy grounds the reproductive health care rights Ms. Bass supports so strongly, and it hasn't changed simply because HMO's have replaced house calls. Adherents of this logic should recognize that it cuts both ways, protecting those whose beliefs prevent them from providing certain medical services as much as those who seek such services out.

Kim Daniels
Associate Counsel
Thomas More Center for Law & Justice
7821 Stratford Road
Bethesda, MD 20814

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Letter to the Editor, Canadian Pharmaceutical Journal,

19 June, 2001

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Dear Mr. Reinboldt:

Further to our e-mail exchange of 24 May, 2001, I am writing to thank you for your editorial response to my criticism of Frank Archer's opinion piece in the Journal last year. With your permission, the editorial has been posted on the Project website.

While I disagree that Mr. Archer's statements about the position of conscientious objectors were purely speculative, I am grateful that the Journal has acknowledged concerns about the column. Readers may now realize that there is no evidence to support blanket allegations that conscientious objectors mislead patients or otherwise act dishonestly, and that it would be a mistake to draw that conclusion from Mr. Archer's article.

I appreciate your efforts to maintain a balanced editorial position in a contentious debate.

Sincerely,

Sean Murphy, Administrator
Protection of Conscience Project

Letter to the Editor, Post-Crescent

3 May, 2001

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An article about a bill in the Wisconsin legislature (Megan Mulholland, Conscience bill offers no easy answers, 30 April, 2001) concludes with the observation that it raises tough questions but "no easy answers."

Protection of conscience laws acknowledge the existence of serious moral disagreements. They ensure that dissenting minorities are not driven from their jobs, professions or homes in order to secure the hegemony of a dominant moral viewpoint. Disagreements must not be overcome by coercion, harassment and discrimination, but by rational argument and honest dialogue.

However, productive dialogue demands attention to language. Note, for example, how objectors' beliefs are said to "interfere" with their "duties". Since there can be no duty to do what is wrong, an assertion that a health care worker has a "duty" to provide something clearly derives from an a priori assumption about the very point in dispute. This is what leads to the accusation of 'interference' - a pejorative term..

Of equal moment is the description of objectors' beliefs as "personal" or "private", the connotation being that dissenters are moral eccentrics whose opinions can be set aside by majority rule. In fact, their beliefs are often held in common with hundreds of thousands or even millions of others, particularly in the case of the great religious traditions. From this perspective, the term "private" may more accurately describe a professional code of ethics than the beliefs of conscientious objectors.

Finally, laws that prohibit murder, rape, theft and perjury and laws that mandate alimony and child support demonstrate that morality often is imposed by legislation. Nonetheless, protection of conscience laws neither imply nor impose a moral judgement about medical procedures. They insist only that citizens should be free to serve their communities in accordance with their fundamental convictions.

Sean Murphy, Administrator
Protection of Conscience Project

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Canadian Pharmaceutical Journal
Editorial- April 2001

Reproduced with permission

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Back in August, in the thick of our series on emergency contraception, Sean Murphy, administrator of a group called the Protection of Conscience Project, sent us a letter criticizing a column we published by Frank Archer, a member of the BC College of Pharmacists ethics committee. Said Mr. Murphy: "In his May column (Mr. Archer said) that conscientious objectors believe they are entitled to lie to mislead patients, and that they wish to obtain patient consent by dishonest means." He asked us "to provide evidence to substantiate the accusations, or print a retraction and apology for having published them."

At the risk of revisiting an offending passage -- but in the interest of fairness here's what Mr. Archer wrote in May: "A third concern is that pharmacists should be able to deny certain legitimate pharmacy services exist, if requested to provide them, or at least to be able to attempt to dissuade such patients, under the guise of patient counselling, by stating religious or moral beliefs as if they were scientific facts. This establishes that lying is justified if pharmacists object to providing contentious services."

To me, Mr. Archer's comments are not the stuff of apologies and retractions.

Important in this example, the article -- an opinion piece -- appeared early in the EC debate and was meant to establish and comment on possible scenarios in the pharmacy. That's shown when Mr. Archer writes that "pharmacists should be able to" deny services, or "be able to attempt" to dissuade patients from trying EC. He does not claim that some pharmacists "do" deny that EC exists, or "do" counsel patients by stating religious or moral beliefs. Instead, he was covering the bases in what was a fairly exhaustive review.

Having said all that, proofreaders will argue that the CPJ confused matters by neglecting the sentence, "this establishes that lying is justified...'. And they would be right. It should have read "this would establish," to agree with the rest of the paragraph.

For some, that explanation probably won't do. Emergency contraception is an emotional subject, and pharmacists on both sides have been rigorous in defending their arguments. Mr. Murphy will have to decide if our response is fair, and I suspect he will share his conclusions.

Which leads us to another article -a letter, actually - that might offer some perspective.

Consider this passage from our May, 2000, issue: "I am very sorry, but just because a treatment is legal, it does not therefore automatically make it moral. Hitler also legalized mercy killing."

By publishing that argument, is the CPJ equating some health professionals with amoral Nazi butchers? No, of course not.

But we won't apologize or retract that comment either.

Hold that conscience:

Some health laws would force churches to betray their beliefs

Outlook 26 March, 2001,
US News and World Report
Reproduced with permission

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John Leo
Here in New York, Cardinal Edward Egan had a little chat with Gov. George Pataki last week about whether Roman Catholic institutions should be forced to provide contraceptive services and the "morning after" pill for their female employees.

Assembly Speaker Sheldon Silver and Planned Parenthood think they should. The cardinal disagrees. He thinks it's not a legitimate use of state power to force churches and religious institutions to violate their own principles. This is a wildly controversial idea in Albany, where Silver and the Assembly Democrats have torn the usual "conscience clause" out of the
two health bills they passed for women.

The Republican-dominated Senate passed the bills with clauses allowing religious groups to opt out of some provisions on moral grounds. The bill requires employers to offer a broad array of reproductive services in their health plans, including mammograms, Pap smears, osteoporosis screening, contraception, and various fertility procedures, some of which the Catholic Church considers immoral. This whole progressive package is in jeopardy because it got tangled in Planned Parenthood's national campaign to bring the churches (and Orthodox synagogues) to heel. Planned Parenthood and its allies in the abortion wars are out to eliminate conscience clauses everywhere. They even have a brand-new phrase to make acting on conscience sound backward and shady: "refusal clauses."

With a little prodding, the Equal Employment Opportunity Commission bought the dubious argument that "conscience clauses" are violations of antidiscrimination law.

So far the public and the news media have paid little attention to the debate, because contraceptive funding seems like a ho-hum issue. Most people, including many Catholics, do not consider contraception immoral. But some religious leaders think this is a slippery slope. The slide could lead to mandatory funding of the abortion pill, euthanasia, and assisted suicide. So, many churches feel they have to make a stand here, before they are dragooned into funding new abortion medicines, cloning, and suicide pills.

Joe Loconte of the Heritage Foundation wrote: "It is no whimsy to worry when people are forced to bankroll whatever reproductive practices are in vogue­today chemical abortion, tomorrow cloning."

Forced doctrine? Last summer the Washington, D.C., City Council tried to force all District employers to provide coverage for contraceptives and some abortifacients, with no exemption for conscience. With a burst of Ted Turner-style Catholic baiting, a councilman angrily waved around a picture of the pope, railing about dogma and the folly of "surrendering decision on public- health matters to the church." The National Association of Evangelicals expressed sympathy for Catholic leaders, saying that "requring birth control coverage is a veritable assault on the integrity of their religious institutions."

The D.C. council passed the bill unanimously, but when Congress threatened to intervene, D.C. Mayor Anthony Williams pocket-vetoed the bill.

In New York, the state Catholic Conference has a lot of clout on the basis of its massive spending on the poor and the sick. The group says flatly it will not be implicated in delivering services it considers immoral. But it is open to the idea of having the employees of Catholic institutions get these services directly from the state. The health bills affect millions of women, but only 10,000 to 20,000 would be affected by the conscience clause. The Catholic Conference says it would cost the state $4 million or $5 million a year to pick up the cost of contraception for these women.

So far, the strangest outcome of a struggle over a conscience clause has been in California. The state passed a law allowing only narrow use of the clause. It can be claimed by religious organizations that hire only adherents of their faith and devote their efforts to religious training. This turns Catholic charities, colleges, and hospitals into "secular" institutions, which must therefore provide coverage the church considers immoral. It is a nonsolution that makes little sense. If Catholics wanted to bar non-Catholics from their institutions in order to qualify for the exemption, they would have to violate state and federal antidiscrimination laws. Besides, even core institutions like seminaries and individual churches and rectories commonly have non-Catholic employees. More broadly, the California law reflects the elite notion that religion should be driven from the public square. If religious attempts to serve and change the culture can be separated out as somehow secular, faith isn't much more than an offstage pastime.

The central issue here is an attempt to use state power to force churches to violate their own principles. Jean Bethke Elshtain of the University of Chicago Divinity School calls this an example of "liberal monism," an enforced monoculture created by people who talk expansively about freedom and pluralism but who, in fact, work to erase pluralism and bring private groups into line with state orthodoxy. The "conscience clause" issue has obvious implications for a government alliance with faith-based social action groups. If we want a partnership, forcing churches to compromise their moral beliefs is not a great start.

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Letter to the Editor, Pharmacy Practice (on-line)

1 February, 2001

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Freedom of conscience and religion enjoy privileged status in Canada and are "fundamental" goods guaranteed by the Charter of Rights, but the Charter does not similarly guarantee professional or economic self-interest. Frank Archer's claim that this observation implies an unrestricted "right to act on all matters of conscience and religion" is at least extravagant ("Whose Rights Are They, Anyway?" Pharmacy Practice, 8 January, 2001).

No one pretends that freedom of conscience is absolute, but there is a duty to accommodate conscientious objectors in the exercise of that freedom. The extent of accommodation required depends upon the facts of the case and the law, not upon Mr. Archer's code of ethics. This does not mean that his code of ethics is irrelevant, but it does not trump the Charter in evaluating conflicting claims in the workplace. The power of self-governance is not granted to the professions so that they can declare a "Charter-free zone" and deprive their members of fundamental freedoms.

Mr. Archer also accuses a conscientious objector of "imposing her own moral views" because she declines to help someone do something she considers immoral. Change the scenario: a worker with friends who mock an old man wearing a turban. He may be afraid to protest because, as Mr. Archer notes, he may have to "pay a price" for acting "contrary to the consensus view" of his peers. But if he disassociates himself from racism by walking away, would Mr. Archer complain that he is 'imposing his moral views'?

What is at stake in such situations is personal integrity, that 'wholeness' of the person that is violated when one is forced to live in contradiction to the core of one's being. That is the concern of the worker who refuses to be associated with racism, and a pharmacist who, for reasons of conscience, refuses to be associated with certain services or products.

Granted: Mr. Archer does not accept the moral outlook of the conscientious objector, and would deprive the objector of freedom of conscience simply because her viewpoint differs from his own. He is supported in this by the College of Pharmacists of British Columbia. But neither he nor any college of pharmacy in Canada has yet demonstrated that his ethics are superior to that of his dissenting colleagues. Perhaps he will make a start in this direction by explaining why his College deems it ethical to refuse to dispense Preven because the price isn't right, but unethical to refuse because it may cause the death of the early embryo.

Sean Murphy, Administrator
Protection of Conscience Project

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Letter to the Editor, Canadian Pharmaceutical Journal

29 January, 2001

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The January editorial ("Compromise") in the Canadian Pharmaceutical Journal is a welcome invitation to reflect more deeply on the serious obligation to accommodate freedom of conscience within the profession.

Is there, in fact, anywhere in Canada, a community in which a single pharmacist is the only health-care professional able to supply the 'morning after pill'? The editorial describes such a situation as "hypothetical"; "mythical" seems more appropriate. The main point, in any case, is that adequate access to the drug can be arranged without forcing dissenting pharmacists to assist in providing it.

The issue of referral ('pre-arranged access') is correctly identified as a key point in the disagreement between conscientious objectors and their opponents. The problem is that dissenting pharmacists have a visceral sense of wrongness that their opponents do not share, and the absence of that sense of wrongness makes it genuinely difficult for their opponents to appreciate their concerns.

A satisfactory resolution to this problem can be achieved with patience, perseverance, good will and, as the editorial suggests, some creativity and flexibility. Surely these virtues are not lacking in the profession.

Sean Murphy, Administrator
Protection of Conscience Project

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Letter to the Editor, The London Free Press

17 January, 2001

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Sharon Osvald's op/ed piece (Can Workplace, Conscience, Co-exist? 16 January, 2001) refers to a difference in belief about conception. The controversy about the 'morning after pill' actually begins to swirl around the definition of conception. Traditionally, science has defined conception as the union of sperm and egg (fertilization). Standard texts on human embryology continue to use this definition, and describe this as the point at which a new human individual begins to exist. The existence of the individual is not a matter of belief, but can actually be observed in the case of in vitro fertilization.

Only with the fact of this existence does belief enter the picture, and then, indeed, the controversy begins to blow a full gale. Some believe that this human individual deserves the same protection and respect due to individuals who have been born, and others do not. The disagreement is not about the existence of a human individual, but about what moral obligations are called forth by that existence.

Dissenting health care workers have every reason to challenge the competence of their employers or professional associations to adjudicate this disagreement, which is not about science, but about morality.

Sean Murphy, Administrator
Protection of Conscience Project

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Can Workplace, Conscience Co-exist?

The London Free Press,
16 January, 2001 (Editorial/Opinion)
Reproduced with permission

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Sharon Osvald

It's something most people will have to face at least once in their lives. Whether it is being asked to work in a dangerous environment or operate a vehicle that is not safe, it can be difficult to balance your convictions and responsibilities at work without affecting your job.

The first time it happened to me, I was pressured into working a shift under-staffed in a group home and therefore had to diffuse a violent situation alone. It was then I realized an employee's rights on paper and rights in practise are two different things.

Perhaps it was struggling with the morality of removing a feeding tube that would end a patient's life or being asked to assist in abortions, but up until now it was mainly doctors and nurses that had to walk this tightrope when it came to matters of ethics and conscience in the workplace.

Recently, more and more pharmacists are finding themselves involved in the battle of professional expectations versus conscience.

A current controversy surrounds two emergency contraceptives, Preven and Plan B, nicknamed the morning-after pill. Both have been approved in Canada and recently have become available without a doctor's prescription in British Columbia.

In actual fact, it is not new. Celeste McGovern of Pharmacists for Life says, "Doctors have given women fearing unwanted pregnancy concentrated birth control hormones within 72 hours of sex ever since Albert Yuzpe observed their effect on the endometrium (lining of the womb) in the 1970s: the hormones make the womb a hostile environment for a newly fertilized egg."

Some medical professionals believe conception does not occur until the egg is implanted in the uterine wall, thus making this another form of birth control, while others believe conception occurs when the egg is fertilized. For them being forced to prescribe these drugs is a violation of their conscience.

Other pharmacists are concerned promoters and marketers of Preven and Plan B have misled the public about the effects of the drugs, (one columnist compared it to taking an aspirin), especially if taken repeatedly at a time when manufacturers are trying to reduce the hormone content of oral contraceptives due to side-effects and health risks.

Those pharmacists are reluctant to hand a customer (soon, without a doctor's prescription) a drug that is four times the dose of a birth control pill and, in the case of Plan B, a chemical composed of Progesterone, 20 times the dose in some birth control pills.

It's not only the morning-after pill that will challenge convictions.

With current and imminent advances in medical and pharmaceutical knowledge, things that once were medical procedures are being replaced by a pill.

Post-coital interception, abortive drugs, controversial reproductive medications and euthanasia drugs are some examples.

Concerned Pharmacists for Conscience, a Canadian organization, says physicians and pharmacists in Oregon are already offering assisted suicide with drugs.

The Ontario College of Pharmacists code of ethics allows a pharmacist to refer the patient to another pharmacist when ethics are at stake, but many Canadian pharmacist groups feel the conscience clause is not strong enough.

They are asking that no one be denied employment or be discriminated against in the workplace due to acting on his or her conscience.

A Canadian group, the Protection of Conscience Project, claims many professionals have been denied employment, dismissed or penalized for acting on their ethics.

Unlike pharmacists who have some protection, the London pharmacy technician I spoke to recently did not and is still feeling uneasy after being pressured into dispensing the morning-after pill, despite voicing concerns of conscience.

Those in the medical field deserve the right to serve the public without doing a disservice to themselves.