Healthcare without Conscience - Unconscionable!
The Annals of Pharmacotherapy
2007 November, Volume 41
Reproduced with permission
Protecting right of
conscience for pharmacists means protecting this
right for everyone. . . .Once we breach this most
fundamental line, there will be another issue and
another class of citizens who will not be allowed to
follow their convictions. Either we defend this
liberty, or we will not have it.
The governor of Illinois has told pharmacists to
check their conscience at the door. They are not to
allow their personal convictions to alter their
professional activities. Specifically, pharmacies
are to fill all legal prescriptions, even if doing
so is contrary to deeply held moral or religious
beliefs of the pharmacists. More recently, the
Washington State Board of Pharmacy, under pressure
from its governor, crafted new rules increasing
pressure on pharmacists to fill prescriptions for
which there may be moral objection.1
Soon we may see help wanted signs saying,
"Pharmacists who wish to exercise conscience need
not apply."
While some are sympathetic to the pharmacists'
dilemma, the governor of Illinois and others seemed
more compelled by the story of a patient who was
embarrassed at the counter when the pharmacist
refused to fill her prescription. The story was also
presented in the context of the patient being denied
access to health care.
Pharmacists are currently on the front line in
the battle for right of conscience, but they are not
alone. Skirmishes have occurred with nurses and
physicians, most notably related to abortions. Court
cases have generally sided with the healthcare
professional, protecting his or her right to refuse
to participate in activities they deem morally
objectionable. However, recent legislative and legal
actions involving pharmacists challenge these
precedents. Perhaps pharmacists are seen as soft
targets for changing the paradigm.
Federal and state governments are scurrying to
respond. The 2005 Federal Weldon Amendment came to
the support of individuals and organizations that
refuse to perform abortions.2
It was subsequently upheld in courts. According to
amednews.com, at least 9 states were considering new
right of conscience legislation in 2006 (an
up-to-date, detailed list of state laws and
legislation can be found [here])
and 46 states have laws protecting some healthcare
professionals in certain situations.3
Medical journals are also addressing the issue.4,
5,6 The
controversy is far from resolved. A Supreme Court
case seems likely.
What Perspective Should Guide Our Law-Making?
Our founding fathers would not equivocate. They
established a precedent that has guided our culture
for 200 years by writing the First Amendment in the
Bill of Rights: "Congress shall make no law
respecting an establishment of religion, or
prohibiting the free exercise thereof…." While the
phrase "right of conscience" is not mentioned, it is
clearly what they had in mind. James Madison penned
the first draft: "The Civil rights of none shall be
abridged on account of religious belief or
worship.…"
Madison went on to say, "Religion, or the duty
which we owe our Creator, and the manner of
discharging it, can be directed only by reason and
conviction, not by force and violence; and therefore
all men are equally entitled to the free exercise of
religion, according to the dictates of conscience."7
Thomas Jefferson wrote, "[O]ur rules can have
authority over such natural rights only as we have
submitted to them. The rights of conscience we never
submitted, we could not submit. We are answerable
for them to our God."8
Preserving Right of Conscience Is Critical to
Our Social Order
Protecting right of conscience for pharmacists
means protecting this right for everyone. Said
differently, if this right can be taken away from
pharmacists, it can be taken away from anyone. Once
we breach this most fundamental line, there will be
another issue and another class of citizens who will
not be allowed to follow their convictions. Either
we defend this liberty, or we will not have it.
Since conscience is intimately wrapped in
character and integrity, what will health care
become if we undermine these ideals? Do we really
want our pharmacists and physicians to check their
consciences at the door-to simply be facilitators of
whatever the patient wants? This would have the
effect of turning healthcare professionals into
vending machines. Edmund Pellegrino and David
Thomasma remind us that all medical ethics finally
rest on the physician's or pharmacist's moral
character.9 In those
moments of clinical decision, when no one is
watching, the physician's or pharmacist's character
is the patient's last safeguard.
But What About Patient Rights?
Do not those in health care have an obligation to
meet the patient's expectations regardless of their
own moral convictions?
Rights conflicts are inevitable. Reason and
experience have taught us to protect the more
fundamental right. It was no accident that the
writers of the Declaration of Independence listed
the inalienable rights in order of their priority:
"life, liberty and the pursuit of happiness." Life
rights should trump liberty rights, and liberty
rights should trump pursuit rights. Requiring
pharmacists to dispense every prescription results
in the patient's pursuit rights trumping the
pharmacist's liberty rights. While the patient has
the right to pursue her care, she cannot do it at
the cost of liberty to a fellow citizen. Patient
pursuit and preference should not trump the liberty
of others. Making exceptions of healthcare
professionals makes them second-class citizens.
Moreover, we should consider whether patients are
truly being denied access. Public reports have
indicated that only a few patients have been
inconvenienced or embarrassed. Accessing
prescriptions via in-town competition or Internet
pharmacies with overnight deliveries are preferable
alternatives to passing laws that coerce
professionals to participate there are moral
objections. Neither do we need coercive laws to
remedy the problem of patients' being offended.
While patients should not be treated rudely, we can
find better solutions for unbecoming professional
conduct than sabotaging the fundamental right of
conscience. Additionally, if concern over patient
access were truly the motivation of those who would
deny pharmacists their right of conscience, they are
better advised to deal with the economic
inaccessibility of pharmaceuticals affecting a large
number of our fellow citizens.
Surely our society is resourceful enough to
provide a means by which patients can acquire legal
prescriptions (or other healthcare services) without
forcing healthcare professionals to be complicit
against their will. Pharmacies can clearly post
their policies. Patients can seek alternatives.
There need be no awkward encounters.
Do the Pharmacists' Objections Have to Be
Popular to Be Defended?
Many of us may not embrace the particular
conviction that compels some pharmacists to refuse
to fill certain prescriptions. However, lack of
popular support for a conviction should not be the
criteria for denying the right to act on that
conviction. If so, public whim would soon place in
question all fundamental rights.
We stand at a crossroads. Some advocate
compromise- a balancing of these rights. The result,
however, would be an erosion of something precious
to all of us. Dr. Farr Curlin summarizes, "Acting
conscientiously is the heart of the ethical life,
and to the extent that physicians give it up, they
are no longer acting as moral agents. …
Conscientious practice in a pluralistic world is
messy even when peaceable. Yet the alternative is a
society in which physicians are required to forfeit
conscience in order to join the profession. Patients
will not be well served by moral automatons who
shape their practices, without struggle or
reflection, to the desires of patients and the
dictates of whatever regime is currently in power."10
Gene Rudd MD, Senior Vice President, Christian
Medical & Dental Associations,
2604 Highway 421, PO Box 7500, Bristol, TN 37621
Fax 423/844-1017, gene.rudd@cmda.org
Reprints: Dr. Rudd
References
1. Washington State Pharmacy
Association. Legislative items.
www.wsparx.org/file/legislativeaffairs/legislative.asp
(accessed 2007 Jul 24)
2. Div.
F, Title V, 508(d), Pub. L. 108-447.
3. American Medical
Association. Broader conscience clauses would expand
physicians' right of refusal.
www.ama-assn.org/amednews/2006/03/06/prl20306.htm
(accessed 2007 Jul 24).
4. Curlin FA, Lawrence RE, Chin
MH, Lantos JD. Religion, conscience, and
controversial clinical practices. N Engl J Med
2004;356:593-600.
5. Cantor J, Baum K. The limits
of conscientious objection-may pharmacists refuse to
fill prescriptions for emergency contraception? N
Engl J Med 2007;351:2008-12.
6. Genuis SJ. Dismembering the
ethical physician. Postgrad Med J 2006;82:233-8. DOI
10.1136/pgmj.2005.037754
7. Hutchinson WT, Rachal WME,
eds. The papers of James Madison. Vol. 1. Chicago
and Charlottesville: University Press of Virginia,
1962-1991:175.
8. Peden W, ed. Notes on the
State of Virginia, Query 17. Chapel Hill,
NC:University of North Carolina Press, 1954:159.
9. Pellegrino ED, Thomasma DC.
The virtues of medical practice. New York: Oxford
University Press, 1993.
10. Curlin F. Religion,
conscience, and controversial clinical practices
(letter). N Engl J Med 2007;356:1889-92.