Protection of Conscience Project
Protection of Conscience Project
Service, not Servitude

Service, not Servitude

Submission to the Alberta College of Pharmacists

Re: Draft Code of Ethics

27 February, 2009

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I. Introduction

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. The context

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. Part V (Draft Code)

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. Part VIII (Draft Code)

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. Purpose and effect of the Draft Code

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. The issues

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. Responding to the issues

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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