The Hijacking of Moral Conscience from Pharmacy Practice: A Canadian
Perspective
Annals of Pharmacotherapy, Apr
2009; 43(4) 748-753.
Reproduced with permission
Cristina Alarcon*
The introduction of
discriminatory legislation into North American
pharmacy practice that began in the mid-1990s is a
sign of the times. . .Ensuing policies promote
patient choice above all else and take no account of
the democratically protected rights of freedom of
conscience, religion, and expression of all
individuals.
Canadian pharmacy has shifted from a
products-focused, pharmacist-focused profession
toward one that is primarily patient-centered and
outcomes focused.1
Thus, pharmacists today play an expanded role in
direct patient care, leading to a closer bond
between pharmacist and patient, but also to an
increased probability of ethical or moral conflict,
and to the need of ensuring that the rights of
everyone involved in such conflicts are properly
addressed. Concurrently, changes in pharmacy codes
of ethics and policy statements have led to the
prioritizing of patient autonomy at the expense of a
conscience- and virtues driven professionalism of
some practitioners that would encompass freedom of
ethical and moral belief and expression. In the
words of one member of the British Columbia College
of Pharmacists Ethics Advisory Committee, "the old
code of ethics had more to do with how pharmacists
should treat themselves than how they should treat
their patients," a so called "paternalistic
approach" that has now "yielded to the modern era of
patient autonomy."2
This axiomatic statement begs the following
questions: Do some pharmacists have to "give up" who
they are and what they believe to serve the public?
Is there any room for ethical diversity?3If,
as stated in the official bulletin of the British
Columbia College of Pharmacists,4"the
ethics of the individual pharmacist cannot take
precedence over the ethics of the profession as a
whole," upon whose principles should the ethics of
the profession as a whole be based, and is not
collective responsibility a false utopia? Finally,
do pharmacy college/board codes reflect the fact
that pharmacists are free, responsible moral agents,
or have they been "hijacked" by the ideology of
choice and convenience under he guise of patient
autonomy, thus limiting the richness that ethical
diversity and dialogue bring to pharmacy practice?
The Trumping of Conscience by Patient Autonomy
Both international and national human rights
treaties have consistently upheld the rights to
freedom of conscience of all peoples; however, the
recent upsurge of ambiguously worded pharmacy codes
of ethics mandating continuity of care against one's
conscience can lead us to believe that these basic
rights can be trumped by appeals to patient
self-determination. These codes do not take into
account the fact that freedom of conscience is not
whimsical license. Rather, it is a right that is
innate because it carries a corresponding duty: no
one can take responsibility for the actions of
another. A pharmacist is ethically and
professionally responsible for ensuring that a
prescription drug is appropriate and the dosage is
correct. Filling or transferring a prescription
knowing that these conditions are not met may not
make the pharmacist liable if the physician is
consulted, but it does not take away individual
moral responsibility. The fact that a prescription
can be legal but not ethical should not come as a
surprise, as legality does not always make something
right. Thus, a pharmacist may be held liable for
refusing to fill a legal prescription he/she deems
unethical. A pharmacist would certainly be held both
legally and ethically accountable for giving a
patient a poisonous substance, even if the patient
begged for it. While continuity of care and respect
for patient autonomy are important, it is not true
that they can always be respected. Think of the drug
addict who presents a legal prescription for yet
another narcotic to be filled far too early. Are
pharmacists obliged to mindlessly fill all legally
prescribed products? Should they be forced to
provide drugs for nontherapeutic purposes, such as
execution by injection or euthanasia? If a patient
insists on taking an overdose or a contraindicated
medication, is a pharmacist obliged to comply by
dispensing that medication?
Code of Ethics or "Yoke" of Ethics?
Moral conscience urges a person to do good and
avoid evil. Conscience allows the person to evaluate
the morality of his actions. The separation of moral
conscience from professional conscience invariably
leads to many inconsistencies. In fact, codes of
ethics that undermine moral conscience are fraught
with these. While most highlight the importance of
professional integrity, they make practicing it
rather difficult. For example, the Code of Ethics of
the International Pharmaceutical Federation
recommends that "pharmacists ensure the continuity
of provision of pharmaceutical services in the event
of conflict with personal moral beliefs…."5
In contrast, the American Pharmacists Association6
supports the idea of pharmacists being allowed to
step away from participating in an activity to which
they have moral objections.7
This came about as a result of Oregon's law
regarding physician-assisted suicide.
In Canada, the National Association of Pharmacy
Regulatory Authorities developed the Model Statement
Regarding Pharmacists' Refusal to Provide Products
or Services for Moral or Religious Reasons.8
Its goal was to "strike a balance between the
individual rights of pharmacists and professional
responsibilities to their patients," citing as its
instigation the "arising issue" of the "use of
prescribed drugs for emergency contraception and
[although not yet legal in Canada] euthanasia." The
policy, however, shows little respect for the
pharmacist's professional sense and freedoms of
conscience and expression, be they religiously
informed or not. It mandates that objections be
conveyed to the pharmacy manager, not to the
patient, and that referrals be made while
"minimizing inconvenience or suffering to the
patient or patient's agent." The same policy does
not appear to apply to the provision of
non-contentious products or services. For example,
not all pharmacies carry all types of home
healthcare products or herbal remedies that a
patient may want or require, and neither is a
pharmacist obliged to make these available.
A deeper look at Canadian pharmacy reveals a
disturbing trend. In British Columbia the College of
Pharmacists recognizes the effort of the pharmacist
to establish trust and respect with the patient as
an indicator of good practice. This trust is
established not only by means of competence in the
science of therapeutics but also by the "covenantal"
relationship that is established between pharmacist
and patient over the years. And yet, in cases of
conflict with anything that could be considered
one's "personal" moral or ethical beliefs, the
British Columbia College of Pharmacists' code of
ethics Value VIII9
obligates pharmacists to refer patients to another
pharmacist, and then to dispense the medication if
no one else is available to do so. Not taken into
account is the reality that there are many reasons
why a pharmacist would not dispense a legally valid
prescription; for example, if the prescription is an
overdose, if the patient is allergic to that drug,
or other contraindications. In addition, policy
number 3510
requires that the pharmacist not communicate the
reasons for his objections to either the patient or
physician. While the intent is to minimize
confrontation, this cannot be done by "muzzling"
pharmacists, preventing them from explaining as they
see fit the reasons for their actions or omissions.
Saskatchewan's College of Pharmacists11
goes so far as to warn against "preaching," stating
that it would be "improper and unethical conduct if
the pharmacist used the opportunity to promote
his/her moral or religious convictions, or engage in
any actions, which demean the patient" and that
"objecting pharmacists cannot abandon their ethical
duty of care to the patient, and respect of the
patient's right of autonomy to make informed
decisions to receive pharmacy products and services
based on objective and accurate information." While
the above statements appear to hold some truth, they
wrongly assume that the sharing of information or
views that differ from those of the College is
inaccurate and demeaning. Surely, it is not the
sharing of convictions, but the imposition thereof,
that is most demeaning.
Additionally, 4 licensing authorities
(Saskatchewan,11New
Brunswick,12
Newfoundland,13,14
Prince Edward Island15)
state that, when the product is provided by an
alternative means, "suffering or inconvenience to
the patient must be minimized." While no pharmacist
intends to make anyone suffer, the democratically
protected right to freedom of conscience and
religion cannot be usurped by an inconvenience or
the emotional trauma of the receiving party. Should
the case be that of a patient requesting euthanasia
drugs, many valid arguments can be made against
alleviating suffering by helping the patient end his
life.16
It is also true that patients are inconvenienced
every day in many ways, not always due to moral
conflict, but simply because not all products or
services are always readily available. Yet when it
comes to moral conflict, the difference is that
while the professional is being asked to offer
material assistance in an action he thinks is
morally prohibited, thus making him feel he is doing
something wrong and harming his own conscience, the
receiving party is not suffering the same guilt
pangs.
To date, only 4 (Saskatchewan,11
Alberta,17
Manitoba,18
Nova Scotia19)
of 9 Canadian Anglophone provinces do not enforce
mandatory dispensing or referral that goes contrary
to the pharmacist's moral conscience.
Whose Public/Professional Morality?
Popular today is the notion that public ethics
should remain "neutral," while private ethics (which
is equated to personal morality) should have no
social relevance.20,21
Also popular is the notion that there is an
imposition of values when a minority of healthcare
professionals refuse to provide services that are
perceived as rights by some (ie, right to die, right
to have a child, right to not have a child).
Although healthcare professionals who object to
providing such services are not stopping colleagues
from providing the wanted services, as a general
measure against fear of hindered access, codes of
ethics are set up so that each medical professional
must now give up being a single moral entity, but
live via a personal private conscience at home and
via a public, "neutral," "guidelines-driven,"
pragmatic conscience at work-a difficult feat
indeed!
Furthermore, claims to moral neutrality by the
state/professional associations are an obvious sham.
Experience shows that preconceived ideas and
ideologies do have an impact on law and policy
makers. A blatant illustration is that of Illinois
governor Rod Blagojevich, who, following his own
ideology and in violation of state laws, issued a
2005 executive order forcing all retail pharmacies
"without delay" to provide levonorgestrel emergency
contraception.22,23
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.
In 2006, the governor of Washington adamantly
opposed any kind of legal protection for the rights
of conscience of pharmacists and threatened to
replace members of the Pharmacy Board who supported
a conscience clause.24
The Freedom of Choice Act, reintroduced in April
2007, has only served to fuel fears of medical
professionals who do not wish to be forced to
provide services that go against their deeply held
belief that all human life is inviolable. On
December 18, 2008, the Department of Health and
Human Services responded to these fears by issuing a
regulation that would afford some protection of
rights of conscience for healthcare professionals
working in federally funded institutions. In January
of 2009, the US government was sued by 7 states
claiming that the federal rule would trump state
laws protecting women's access to birth control,
reproductive health services, and emergency
contraception.25
Finally, on March 10, 2009, under a new
Administration, the Department of Health and Human
Services proposed a rescission of the above
regulation pending reevaluation of its necessity.26
Concerned pharmacists and other healthcare
professionals can submit their comments by April 9,
2009.
The Canadian Pharmacy
Association presented a Government Brief to the
Senate Committee studying euthanasia and assisted
suicide, which stated, "From an ethical perspective,
should euthanasia be legalized, the pharmacists we
consulted feel that the right to choose must be
safeguarded at all levels of the decision making
process and that the right to choose must be
respected. The physician, the pharmacist, and the
nurse should have the right to take part or not take
part in assisting a person once he or she has
reached a decision to put an end to his or her life.
Should they elect not to participate, their duty to
their patient requires that they refer them to
health professionals who will assist them."27
Although the brief states that the Canadian
Pharmacists Association has not taken a position on
this issue, the fact is that it has taken a very
clear position on the duty to refer. I would also
argue that not taking a position is already taking a
position, as lack of firm opposition to euthanasia
leads to its support by default, a clear indication
that a "neutral" position is not possible. In this
case, the Association is clearly upholding one side
of a debate that is understood to have 2 valid
sides-unless, that is, the ideology of choice at all
costs has somehow trumped the conscience of some
practitioners and beliefs that our own Constitution
safeguards as a "fundamental right and freedom."
Most recently, Ontario's Human Rights Commission
instigated a strong debate about removal of
physicians' rights to freedom of conscience and
religion.28
The very commissions that are supposed to uphold and
protect the basic rights of citizens are instead
fostering discrimination.29
Protection of Conscience
Protection of conscience is crucial if we are to
foster a society in which individuals are free to
dissent from popular opinion or state/board laws
should these clash with their moral convictions.
This is especially important in modern Western
democracies, where the concept of majority rule can
lead to the mistaken notion that "might" makes
"right"; thus, if professional colleges or boards
were genuinely concerned with the protection of
conscience of their members, surely they would take
on a more active role in providing lists of
pharmacies that provide certain types of services
and their Web site could provide such information,
readily accessible to all. This could help avoid
individual referral or dispensing problems that
would otherwise violate the conscience of the
professional.30
In Canada, various attempts have been made over
the years to implement more specific conscience
legislation.31
However, unlike our neighbors in the US, who have
traditionally enjoyed the most well-developed
legislations and jurisprudence worldwide on matters
of conscientious objection,32
the attempts in Canada have been largely
unsuccessful. In the US, it was the Supreme Court's
ruling in Roe v Wade on a woman's right to
privacy that sparked the creation of all sorts of
conscience laws. Yet in spite of these laws, some
medical professionals across the US have been
harassed over the years regarding matters of
conscience.
Why Should Pharmacists be Concerned?
While court cases regarding policies on
conscience clauses affecting healthcare workers are
rife in the US, the policies have yet to be
challenged in Canadian courts. In British Columbia,
some pharmacists have repeatedly petitioned the
College of Pharmacists to make amendments to Value
VIII of the code of ethics.33
This culminated in a presentation to the Ethics
Advisory Committee in May 2007.34
After reviewing information from other Canadian
jurisdictions and from the US, the Committee found
"no compelling reason to adjust the wording of the
existing Code of Ethics Value VIII."35
As the code does not reflect Canadian human rights
law, its retention shows a lack of deep reflection
of the issues at hand and its possible legal
consequences for both pharmacists and their
employers. In Alberta, it was not until after a
pharmacist was suspended from her job for refusing
to dispense drugs to which she had a moral objection
that the College backtracked and changed its
policies, rescinding its mandatory dispensing and
referral of morally objectionable products.36
(Pharmacist Maria Bizecki was reinstated in her
workplace after legal proceedings, having reached an
agreement with her employer and with the Alberta
College of Pharmacists that allows her to refuse to
dispense abortifacient drugs and contraceptives,
which would be in violation of her morals.)
In British Columbia, the code of ethics is
binding in law.37
Although practice policies such as policy number 3510
are less binding than regulations or bylaws, they
are more than just advisory. And so, presumably,
pharmacists can be reprimanded for acting coherently
with their conscience, following what they genuinely
believe to be for the good of the patient.
Summary
The introduction of discriminatory legislation
into North American pharmacy practice that began in
the mid-1990s is a sign of the times. I believe it
to be a deviation in the moral compass of the
pharmacy profession and of the medical professions
as a whole, sparked by an ideologically orchestrated
effort to medicalize lifestyle choices of a
non-lifesaving or non-life-preserving nature.
Ensuing policies promote patient choice above all
else and take no account of the democratically
protected rights of freedom of conscience, religion,
and expression of all individuals.
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 who seek to live a
holistic private and professional life that is, for
them, ethically coherent and unified. By their
prescriptive legislation, these boards take no note
of Canadian and international human rights laws and
impede individual pharmacists as they seek to
practice their profession with their personal
conscience-informed freedom. As moral agents who
practice a medical profession, pharmacists do not
seek to thwart access to needed health care, but to
discharge their duties with integrity and with a
full sense of responsibility.
Fundamentally, they want to live coherently as
unified persons, not fragmented personalities living
via different mores in different settings. 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 accord with
their individual conscience and with ethical dignity
and freedom.
Reprints: Ms. Alarcon,
cristinaalarcon365@hotmail.com
I thank Prof Dr. José López Guzmán, University of
Navarre, Pamplona, Spain; Iain T Benson BA MA LLB,
Centre for Cultural Renewal, Ottawa, Canada; and
John Wilks BPharm MPS MAACP for their input and
insight into this commentary.