Submission to the Alberta College of Pharmacists
Re: Draft Code of Ethics
27 February, 2009
Full Text
I.1. According to the Alberta College of
Pharmacists, the Draft Code of Ethics is the
product of "extensive review and deliberation of
codes from other pharmacy organizations, health
professions, and other industries around the world."1
That being the case, it is remarkable that the Draft
does not address the issue of freedom of conscience
for pharmacists, since a review of readily available
English language documents from pharmacy
organizations demonstrates that this is of
considerable interest within the profession.
Moreover, recent and ongoing controversies in Canada
and elsewhere indicate that freedom of conscience in
health care is an issue of increasing importance.2
I.2. This submission addresses only those parts of
the Draft Code of Ethics that could be
applied to restrict or suppress the exercise of
freedom of conscience of pharmacists in Alberta. The
principal concerns arise in Part V and Part VIII of
the Code.
II.1 Fifteen years ago the Canadian Pharmacists'
Association (CPhA) told the Canadian Senate that
objecting pharmacists, physicians and nurses should
not have to"take part" or " participate" in
euthanasia or assisted suicide. However, the
Association added that their professional duty would
oblige them to refer patients for the procedures if
were legal.3
The Association saw no reason to revisit this claim
in a review of the issue in 2000.4
II.2 In speaking for other professions the
Association exceeded its mandate, but other Canadian
pharmacy regulators appear to support its assertion
concerning a purported ethical responsibility to
ensure delivery of lethal drugs for euthanasia or
assisted suicide. The National Association of
Pharmacy Regulatory Authorities (NAPRA) claims that
"objecting pharmacists have a responsibility to
participate" in systems designed to deliver
"pharmacy products and services" - like "prescribed
drugs for emergency contraception and euthanasia."5
II.3 The NAPRA statement, including its explicit
reference to euthanasia, has been adopted by the New
Brunswick Pharmaceutical Society6
and the Prince Edward Island Pharmacy Board.7
The Ethics Committee of the College of Pharmacists
of British Columbia has gone further, foreseeing the
need for pharmacist involvement in "voluntary or
involuntary suicide, cloning, genetic manipulation,
or even execution."8
Notably, alone among regulatory authorities, the
College of Pharmacists of British Columbia not only
demands that objecting pharmacists refer for drugs
needed for such controversial procedures, but
insists that they dispense them if others cannot be
found to do so.9
II.4 Since it appears that the Canadian pharmacy
establishment explicitly equates filling
prescriptions for the post-coital interception with
providing lethal drugs for legal euthanasia, the
present discussion will follow their approach. The
Draft Code will be considered within the
context of a demand that an objecting pharmacist
dispense or facilitate provision of drugs for
assisted suicide, euthanasia or post-coital
interception.
III.1 The Draft Code states:
V. Respect each patient's right to healthcare
1. Having accepted professional responsibility
for a patient, continue to provide services
until they are no longer required or wanted,
until another suitable pharmacist or other
regulated health professional has assumed
responsibility for the patient, or until the
patient has been given reasonable notice that I
intend to terminate the relationship.
2. Where a patient has an emergency, take
appropriate action to provide care and reduce
risks to the patient and the public, taking into
account my competence and other options for
assistance or care available.
3. When unable to provide service, assist the
patient to obtain appropriate services from
another authorized provider within a timeframe
fitting the patient's needs.
4. Recognize my limitations, and when indicated,
refer the patient to other health professionals
whose expertise can address the patient's need.
III.2 Part V does not address the situation of a
pharmacist who, for reasons of conscience, refuses
to fill a prescription for assisted suicide,
euthanasia or post-coital interception. Further, the
failure to define several key terms in Part V (Draft
Code) complicates its application in such a
case.
III.4 "Health care"The application of Part V
(Draft Code) hinges upon the definition of "health
care." Those who object to assisted
suicide/euthanasia do not consider it to be a form
of health care, and would argue that Part V (Draft
Code) cannot be interpreted to require involvement
with it. Others assert that it is simply a natural
extension of palliative care, so that a failure to
assist someone to obtain euthanasia or assisted
suicide would constitute professional misconduct.
Similar disputes may arise with respect to
post-coital interception.
III.5
"Patient's right." Whatever "health
care" might mean, the Draft Code presumes
that a patient has a "right" to it. However, those
who object to assisted suicide, euthanasia or
post-coital interception would deny that patients
could have a "right" to something that (in their
view) is objectively wrong. Beyond that, objectors
would deny that patients have a "right" to demand
the assistance of those who believe that assisted
suicide, euthanasia, post-coital interception, etc.
are morally unacceptable.
III.6 "Emergency; risk." The
Draft Code
does not clarify what constitutes an "emergency" or
counts as a "risk," nor does it acknowledge that
"risk" is a highly subjective term. Post-coital
interceptives are described even in professional
literature as "emergency" drugs. However, statistics
produced by the drug's supporters can be cited to
reach a different conclusion. According to one
estimate, 12,000 prescriptions were thought to have
prevented about 700 births.10
Doing the math, one finds that only about 6% of
these women might have been pregnant: other
favourable estimates range from 6.2% to 8%. If up to
94% of patients do not actually need a drug, it is
difficult to understand how a request for it can be
characterized as an "emergency." But, if it is
considered an emergency, surely a prescription for
lethal drugs to end suffering would also be
considered an emergency, since the suffering is
immediate and real, and the need for the drug not
merely speculative. On the other hand, while
acknowledging that a patient's distress or suffering
demands a compassionate and ethical response,
objectors would not characterize assisted suicide,
euthanasia, post-coital interception, etc. as
compassionate or ethical.
III.7 "Unable to provide service."The
Draft Code does not distinguish between the case
of a pharmacist who is professionally incompetent to
provide service and one who is "unable" to do so
because it would compromise his personal integrity.
III.8 "Assist the patient; refer the patient."
Whether an inability results from
professional limitations or conscientious objection,
the obligation imposed here presumes that offering
assistance or providing a referral does not involve
the pharmacist in unethical or immoral conduct.
IV.1 The Draft Code states:
VIII. Serve as an essential health resource
1. Enhance access to pharmacist services and
care.
2. During public emergencies, be accessible and
make resources available to care for patients
and to mitigate further risk.
3. Serve patients who seek my care unless
limited by my competence or the lack of
information or resources necessary to do so.
IV.2 In this case, the failure to define or limit
key terms strongly suggests that pharmacists will be
expected to enhance access to assisted suicide or
euthanasia, even if they object to the procedures
for reasons of conscience. At the least, a limitless
obligation to "enhance access" provides limitless
opportunities to prosecute objectors for
professional misconduct.
IV.3 Like Part V, Part VIII of the Draft Code
does not address the exercise of freedom of
conscience by a pharmacist.
V.1 The present Code of Ethics discusses the
accommodation of conscientious objection, and the
present Code does not demand referral or
impose duties on an objector to assist a patient in
obtaining euthanasia, assisted suicide, post-coital
interception, etc. Hence, it is not unreasonable to
believe that deletion of reference to accommodation
of freedom of conscience and the construction of the
Draft Code Parts V and VIII are intended to force
objecting pharmacists to enhance access to
euthanasia, assisted suicide, post-coital
interception, etc. (Part VIII, Draft Code),
and to compel them to assist the patient to obtain
such services in a timeframe acceptable to the
patient (Part V, Draft Code).
V.2 To impose this requirement would effectively
close the profession of pharmacy to anyone who finds
such conduct morally unacceptable. It would present
current members who would refuse to facilitate
assisted suicide, euthanasia or post-coital
interception with the choice of compromising their
personal integrity or leaving the profession.
V.3 However, neither the ambiguous provisions of
the Draft Code nor its silence on freedom of
conscience can be construed to restrict the exercise
of fundamental freedoms acknowledged and guaranteed
by the Canadian Charter of Rights and Freedoms.
While even fundamental rights and freedoms are not
unlimited, the Charter requires that their
limitation by state authorities (like the College of
Pharmacists of Alberta) be "demonstrably justified"
and be "prescribed by law." The Draft Code attempts nothing by way of demonstration, and it
would strain credulity to argue that mere silence
and ambiguity constitute a valid legal prescription
for the suppression of freedom of conscience.
VI.1 Issue No. 1: Should the College of Pharmacists
of Alberta, through its revised Code of Ethics or
ancillary guidelines, demand that a pharmacist
actively facilitate a service or procedure he
believes to be wrong, such as euthanasia, assisted
suicide or post-coital interception? Put another
way, should a pharmacist's conscientious refusal to
refer patients or assist them in obtaining
euthanasia, assisted suicide, post-coital
interception, etc. constitute professional
misconduct?
VI.2 Issue No. 2: Should the College
of Pharmacists of Alberta include in its Code of
Ethics provisions that honour and fully accommodate
the exercise of freedom of conscience by
pharmacists? If so, how can this be done?
VII.1 A number of claims are commonly made to
support the view that pharmacists should be forced
to provide or facilitate services even if they are
contrary to their conscientious convictions.
Responses to these claims are provided in Parts
VIII to
XVII.
VII.2 A pharmacist who refuses to
facilitate what he believes to be wrong is motivated
by a desire to avoid complicity in wrongdoing. Part
XVIII addresses this problem and demonstrates
that pharmacists who refuse to refer or otherwise
actively facilitate assisted suicide or post-coital
interception are, in this respect, acting no
differently than colleagues and professional medical
organizations.
VII.3 Parts
XIX points out that beliefs about the nature of
the human person lie at the root of any attempt to
set limits to freedom of conscience. It is necessary
to engage at this level in order to develop an
adequate response to the issue. With this in mind,
Part and
XX offers a description of the human person that
is relevant to the present discussion.
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