Professionals or automatons?
Should pharmacists have the right to act according to their consciences,
or are they prescription-filling robots?
MercatorNet, 16 April, 2009
Reproduced with permission
The right of acting
according to one's conscience is under threat in
many countries at the moment. In the US, the Federal
government is studying whether to rescind protection
of conscience regulations implemented in the dying
days of the Bush Administration. Healthcare workers
there are worried that they may have to participate
in unethical procedures - or lose their jobs. A
Canadian pharmacist and bioethicist, Cristina
Alarcon, explains what is at stake in her
pharmacists find legal developments in the US and
Canada disturbing. Why?
Alarcon: The big thing
in the news is the removal of the Bush
Administration's Conscience Protection Rule. Pending
a review, the Obama Administration intends to
rescind it. In a sense this rule shouldn't have been
necessary at all, as the rights of freedom of
conscience and religion of all citizens, those of
healthcare providers included, ought to have the
protection of the American constitution. If the rule
is rescinded, it may set a precedent for handling
conscientious objectors in other parts of the world.
If Americans want to see what is going to happen,
they can just look over the border. In Canada,
although the Charter of Rights and Freedoms is
supposed to protect freedom of conscience and
freedom of religion as well as freedom of
expression, healthcare professionals are
increasingly being pressured by licensing
authorities to provide all legal products and
services. Pharmacists with conscience issues are
having a particularly tough time.
MercatorNet: But what does
ethics have to do with pharmacy? Aren't you just
doing a job?
profession faces ethical challenges. Pharmacy is no
exception, and may have more than most. For
instance, a drug addict may ask for a refill of her
legally prescribed narcotic way too early. What
should I do? It can be very difficult to withstand
the pressure and abuse hurled at you by an angry
woman addicted to prescription drugs.
MercatorNet: But the big
issue here isn't drug addicts. It's basically women
who want something which is perfectly legal:
emergency contraception. They say that their lives
could be ruined if they can't get what they want.
Alarcon: You've tangled
up at least three issues here.
First of all, just because something is legal, it
may not be appropriate for the person who is asking
for it. For example, it is my ethical and
professional duty to ensure that a prescription is
appropriate and the dosage is correct. A perfectly
legal prescription may be contra-indicated for a
particular patient due to an incompatibility with
other drugs or with a medical condition. It would
therefore not be ethically sound for me to dispense
it. Furthermore, in pharmacy school we were always
taught to be particularly careful not to give a
harmful drug to a pregnant woman. Should we comply
now just because she does not want a baby? Why the
Second, because something is legal, it may not be
ethical. Should pharmacists or other medical
professionals be forced to assist in the provision
of euthanasia drugs or drugs for execution if these
become legal? Pharmacists in Belgium, the
Netherlands, and some American states are already
facing these issues.
Third, pharmacists should be allowed to follow
their own consciences. They are not automatons but
morally and ethically responsible agents.
MercatorNet: But you are a
professional. Shouldn't you hang up your conscience
at the door when you start work?
Alarcon: Being a
professional precisely means bringing conscience to
bear in my work. I am not there just to follow
orders, but to take full responsibility for my own
actions and omissions. If I am a consistent person,
then my ethical standards will necessarily influence
the decisions I take. No one can be forced to have
two systems of morality: one for work and another
for home would produce a fragmented personality
For instance, if someone asks for my opinion on a
certain herbal remedy, I tell them honestly whether
it is a good idea to give it a try. My patients
really appreciate this. They know they can trust me.
Some pharmacists will not take the time and will
just give patients whatever they ask them for.
MercatorNet: Do any
professional associations recognise a right of
Alarcon: In the United
States, the American Pharmacists Association
supports the idea of pharmacists being allowed to
step away from participating in an activity to which
they have a moral objection. This was because of
Oregon's law regarding physician-assisted suicide.
Some Pharmacy Boards (these are the licensing
authorities) also support conscience clauses.
In contrast, since the mid-1990s, most Canadian
boards have established new codes of ethics that
show little respect for the right to refuse to fill
a prescription for anything that can be perceived as
personal moral reasons. They really fail to see that
it is difficult to separate moral conscience from
professional conscience, and that while pharmacists
do not like to have to inconvenience patients, the
reality is that inconveniences happen every day for
a variety of reasons and not only due to moral
conflict; because a product may not be in stock, or
a particular pharmacy can't get it, or simply
because a pharmacist is against ordering it for
If Americans follow the Canadian model, they will
see the demise of their basic civil liberties.
I must say that the US has seen some pretty
crafty, not to say shady, characters recently. Take
for example the disgraced former governor of
Illinois, Rod Blagojevich, who issued an executive
order in 2005 (following his own ideology and in
violation of state laws), forcing all retail
pharmacies "without delay" to provide levonorgestrel
emergency contraception. While the ruling resulted
in immediate access for a comparatively small number
of women, it also resulted in court battles and in
dozens of pharmacists being fired or suspended for
refusing on ethical or religious grounds to dispense
the drugs. His executive order was disgraceful
pandering-to-the-public populism. It then turned out
that he was a colossal fraud, as he was caught in a
political corruption scandal. Perhaps no respect for
a pharmacist's conscience also means little respect
for one's own.
MercatorNet: Hang on, why
can't you just refer to a neighbouring pharmacist?
Doesn't that solve all the difficulties?
Alarcon: Answering this
is straightforward. To refer for a product or
service I myself would not provide would be like
providing it myself. It would be cooperation with
the wrongness of the act itself. Can't you see how
ridiculous it would be if I were to say "Sorry, Mrs
Jones, I cannot help you to kill yourself, but my
colleague here will."
MercatorNet: But Canada is a
vast country. There must be many isolated towns
where the local pharmacist is the only provider of
emergency contraception. What excuse is there for
Alarcon: Although we
hear a lot of talk about reproductive freedom, there
is no freedom in treating pregnancy as though it
were a disease and a woman's fertility cycle as
though it were an accident of nature. If women knew
just how well orchestrated their bodies are, they
would not want to put this type of garbage into
them. They would regain a healthy respect for the
beauty and wonder of human reproduction coupled with
However, the world being what it is, if women
insist on having this product made readily
available, then dispensing machines could easily be
installed in all the isolated towns. Already the
product is readily available off the shelves in most
Canadian provinces, so what is to stop a woman from
stocking up? But the consequences, both medical and
psychological, of repeated use of these powerful
steroids (an overdose of birth control pills) may
only be realized years down the road. Don't blame me
MercatorNet: I have the
impression that you think that the pharmacy boards
in the various provinces of Canada are spineless
wonders. Am I right?
wonders! I like that! It is true that while Canadian
pharmacy regulatory boards consider themselves to be
world leaders in promoting professionalism and
pharmaceutical care in pharmacy practice, most have
failed to properly discharge their duty of care to
pharmacists. They really take no note of Canadian
and international human rights laws and their codes
of ethics betray a one-size-fits-all pragmatic
approach to patient care. Some Boards go so far as
to warn pharmacists against preaching or imposing
their morality. Surely, sharing ideas or convictions
is not demeaning.
Fundamentally, the Colleges or boards fail to see
that some pharmacists really just want to live
coherently as unified persons, not fragmented
personalities living by different ethical standards
according to whether they are at work or at home.
Their professional realization, which forms part of
a truly happy and peaceful life, and their ability
to genuinely care for the welfare of their patients,
can be achieved only by living a truly integrated
life, wherein they say what they believe, do what
they say, and keep their word, all in accordance
with their individual conscience and with ethical
dignity and freedom.