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

Cristina Alarcon*

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 profession.

MercatorNet: Many 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 If the rule is rescinded, it may set a precedent for handling conscientious objectors in other parts of the world.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?

Alarcon: Every 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 double standard?

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 indeed!

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 refusal?

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 financial reasons.

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 not supplying?

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 human love.

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 then!

MercatorNet: I have the impression that you think that the pharmacy boards in the various provinces of Canada are spineless wonders. Am I right?

Alarcon: Spineless 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.