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March 30, 2005

Why pharmacist malpractice matters

Amy Sullivan writes:

The Washington Post says there is, devoting a frontpage article to the issue on Monday, declaring: "Pharmacists' Rights at Front of New Debate." But let's look closer. "Some pharmacists across the country are refusing to fill prescriptions for birth control..." "The trend has opend a new front in the nation's battle over reproductive rights..." Says Steven Aden of the Christian Legal Society, "More and more pharmacists are becoming aware of their right to conscientiously refuse..." [...]

Hmm. What kind of a sample are we talking about here? Is a trend thousands of pharmacists? Hundreds? Even a few dozen? Halfway through the piece, reporter Rob Stein admits that "no one knows exactly how often [this] is happening" but notes that cases have been reported in ten states.

Never you mind whether this is a real problem or a trumped-up political issue on both sides, though, because, as we are told in melodramatic fashion: "Pharmacists often risk dismissal or other disciplinary action to stand up for their beliefs, while shaken teenage girls and women desperately call their doctors, frequently late at night, after being turned away by sometimes-lecturing men and women in white coats." [Emphasis added.]

This is a political issue, but it's hardly trumped-up. The issue is not how many wingnut pharmacists are currently refusing to supply birth control but rather how many states permit them to do so and how many more jurisdictions may soon give their pharmacists the right to opt out of modern scientific medicine.

Friends of unwanted pregnancy want to give pharmacists a special dispensation to refuse legally prescribed contraception--a practice that directly or indirectly violates all eight articles of the American Pharmacists Association's Code of Ethics for Pharmacists.

The majority of pharmacists are employees of large drugstore chains. Not unreasonably, most drugstores demand that every pharmacist fill every prescription from every licensed prescriber for every paying customer. These chains reserve the right to fire any pharmacist whose "scruples" interfere with the fundamental condition of his employment. (Except, of course, where local laws prohibit them from doing so.)

So-called "pharmacists' rights" groups are demanding impunity for pharmacists who refuse to fill prescriptions. Ortho Tri-Cyclen alone is among the the top 25 most-commonly prescribed branded drugs in America. These rankings don't even reflect the combined popularity of smaller BCP brands and generic BCP. Given that contraception is bread and butter for most pharmacies, any pharmacist who won't fill a BCP prescription is a worthless employee who deserves to be fired. If I were a pharmacy manager it would be one of the first questions I'd ask any potential pharmacist, out of concern for my bottom line, if nothing else. (I don't know of if so-called conscience clauses prevent pharmacy owners from asking job candidates if they intend to do their jobs.)

Pharmacists who won't do their jobs don't deserve special protection. As healthcare professionals, they are responsible for doing what is medically best for each patient--and since staying non-pregnant is medically safer than being pregnant or getting an abortion, a pharmacist has no right to disregard a pregnancy-preventing prescription.

Pharmacists who refuse to honor legitimate prescriptions should be subject not only to job action by their employers but also to malpractice suits for any damages their primitive superstitions might cause their patients. This goes double for pharmacists who are so ignorant as to claim exemption on the groups that emergency contraception is abortion. Any pharmacist who is so unclear on the basic facts of human reproduction is a quack who deserves to lose his license regardless of his prescription-filling predilections.

Update, granted, Pharmacists For Life is a slick and well-funded lobby group who seems to be getting a free ride publicity-wise. [Media Matters]

[However,] a quick glance at the map shows how far this theocratic madness has already spread:


According to Pharmacists for Life, Illinois also has a so-called "conscience clause" for all healthcare professionals and Ohio is currently considering a similar measure.


As a pharmacist, I must say that I can't believe what is happening here. Oral contraceptives "prevent" ovulation. Plan B, the emergency contraceptive, also, "prevents" ovulation, IF it is taken at the correct time in which to do so. Emergency oral contraceptives, can also create an undesirable environment for implantation into the endometrial lining. Conception is hopefully, prevented. The alternative is pregnancy. Abortion does not occur. Pharmacists now require a doctor of pharmacy degree and they still do not understand the reproductive cycle. Also, if religion (e.g. Catholic belief that contraception is wrong) is the issue here, then it seems to me that the patient is the one who has to answer for that. Not the pharmacist. The decision to take these prescription drugs is the patient's. The pharmacist only has to answer for his/her own actions.

As far as refusing to fill prescriptions......there are instances in which a pharmacist might and should refuse. These are times in which it is in the best interest of the patient, such as someone seeking narcotics through illegitimate means or as a result of misuse. This occurs daily in every pharmacy. Also, pharmacists sometimes must refuse to fill prescriptions which require clarification in order to be correct. The Controlled Substance Act states that a pharmacist MUST NOT fill a prescription for a controlled substance for a patient if they have knowledge that the patient is obtaining controlled substances elsewhere. A pharmacist can refuse to fill a prescription for someone with justifiable reasons, such as a patient who is verbally abusive toward them. Physicians refuse patient care under these circumstances too. One can only take so much. However, these situations are different. The pharmacist is directly involved in these situations or is somehow threatened by them. Oral contraceptives do not fall into the same boat. Pharmacists should take heed and be very careful about refusing to fill legitimate prescriptions that a patient needs in a timely manner. Lawsuits will be popping up everywhere.

So glad you posted on Sullivan's piece, Lindsay. I read it earlier this evening and thought that once again she has managed to pretend to be occupying a non-existent higher ground.

This is a very interesting post. It is remarkable, though, that it displays not even the slightest concern for the interest of a pharmacist to refuse to cooperate with what he or she takes to be an intrinsically evil act. So there is not a moment at which you pause to ask whether there might be a way to accommodate these conscientious objections in a way that is consistent with people's legal rights to receive these drugs.

As for Mary MacMorris's view that the problem is the patient's, not the pharmacist's: well, again, this may well involve illicit cooperation with evil. A comparison: no Catholic pharmacist could in good conscience dispense an abortifacent, or a 'suicide pill', regardless of whether or not these could be legally dispensed, any more than a Catholic gunsmith could provide a weapon to a violent criminal who wanted it precisely to commit murder. It is true that not all cases of acting in ways that enable others to commit wrongful acts counts as illicit cooperation. But providing the means to do so, means that were designed for the very aim of performing that wrongful act, surely must count.

And let's not forget the fact that the same pills used as oral contraceptives are also used to treat various medical conditions. I took them when my estrogen levels dropped due to sudden, rapid weight-loss (long story) and I'd stopped getting my periods.

I don't mean to say that this is any more important than using OCPs for contraceptive purposes, but it just adds one more example of potential malpractice.

Mark, I'm sensitive to an individual's right to act on conscience. For example, I know there's a remote but not absurd chance that I will someday be drafted to fight in Iraq. (At this point, I'm hardly losing sleep, but I'm not discounting the theoretical possibility, either.)

If and when my time comes, I don't expect the government to give me a free pass. As a human being, I reserve right to refuse to do something I know to be intrinsically evil. However, as a citizen, equal under the law, I must also accept the consequences of my defiance. If my CO status were refused, I would accept my right to choose jail over basic training. Pharmacists who refuse to fill legal prescriptions don't deserve a free pass any more than I do. If they refuse to do what their profession requires, their employers, their professional associations, and the courts may have something to say about it.

A comparison: no Catholic pharmacist could in good conscience dispense an abortifacent, or a 'suicide pill', regardless of whether or not these could be legally dispensed, any more than a Catholic gunsmith could provide a weapon to a violent criminal who wanted it precisely to commit murder.

I see you're trying to avoid the most germane question here, Mark.

If a person's conscience does not allow them to perform a legal act in the course of their job duties, they need to find another job. Particularly if their "objection" is part of a conjecture on their part: they assume that the 14-year-old girl has been prescribed the Pill for contraception when the doctor actually prescribed it for her painful ovarian cysts.

Some brain cancer patients are prescribed RU-486, the abortion pill, because it shrinks their tumors without surgery. Should your hypothetical pharmacist be allowed to refuse that prescription even though the drug is not being used for the "immoral" purpose that s/he deplores?

Pharmacists do not have the patient's full medical records and cannot -- should not -- judge whether a particular medication is being prescribed for a "moral" reason.

I don't understand why pharmacists are not held to the same standard as doctors and nurses, who may opt out of performing procedures they find distasteful or immoral (such as abortions) but are required to find someone to act in their place. So, a nurse who is a Jehovah's Witness is allowed to refuse to do a blood transfusion, but she cannot block the patient from receiving one at all because of her personal religious beliefs.

Can you at least agree, Mark, that pharmacists should not be allowed to confiscate prescriptions they do not agree with?

Clearly, any privately owned pharmacy is free not to stock any paticular medication or group of medications. I may not agree with an individuals choices, but any business has that lattitude.

There are limits on emergency treatment as well. A hospital is not required to have an ER, and some don't. Particular treatments are not always available at all locations.

To suggest that an individual pharmacist has an inherent right to gain employment, and then place extraneous requirements on the drugs that pharmacist will dispense is nonsense.

Of more concern are the stories of pharmacists who not only refusing to dispense meds, but reportedly holding on to a scrip. This should be grounds for not only civil suits, but entail a criminal liability. I do not know who actually owns the presription slip, but it certainly seems that would be a theft.

Amy has a pathological need to believe that things are not as bad as they are. She thinks that things will get better if we just pretend.

A pharmacist who won't honor a prescription should be legally liable for any harm that may come of his refusal. It's morally wrong for anyone take up one of his state's limited pharmacy licenses knowing that he doesn't intend to do his job. If colleges of pharmacy have any respect for their profession they will eject zealots who refuse to cooperate with twenty-first century medicine. If these self-regulating professional organizations won't show some spine, the legislatures will be forced to step in. Their choice.

I've been doing a little research and a lot of thinking about this, and have come up with a few areas that can be used to push back:

1. Refusal to fill prescriptions, particularly the cases where the pharmacist confiscates the Rx, amounts to illegal, unauthorized practice of medicine.

2. Instances where the pharmacist has made a point of harrassing the patient - saying, loudly, exactly why they won't fill the Rx - violates the Code of Ethics prohibition on disclosure.

3. The 'generalization' test: If "any" pharmacist can invoke religion as a reason to refuse to fill "any" prescription for "any" patient, the logical consequences are mind-boggling. As I said at ObiWi, we could have wiccans refusing to fill non-organic Rxs, Hindus refusing to fill Rxs that use bovine ingredients, Jainists refusing to fill Rxs that were made of or tested on any living thing; and so on and so on. Clearly, allowing a religious refusal exception fails of its own chaotic consequences. Equally clearly, limiting refusal exceptions to Christians is unlawfully discriminatory.

Amy needs to understand that we can't wait until this becomes a "widespread enough" problem. This is a movement trying to gain momentum, and waiting will make us too late.

Amy needs to understand a lot of things.

When we come down to it; the Religious Right has a very serious problem with sex. Abstinence and gay bashing are symtems of this problem. Why would Christians want to deny birth control to married women? The only logical reason is that people have a problem dealing with sexuality in an adult manner. If they wanted to prevent abortions then they would be happy that the pill was available.

What's next? Protests to save the sperm?

Michael's right.

Here's part of what I wrote to Amy: The fact that most Americans support birth control does not matter when the radical "Pharmacist's Rights" people make enough headway to be allowed to discriminate and control access to birth control. It will be used as precedent to legalize other forms of discrimination. Therefore, the problem needs to be exposed so that Americans understand what is being attempted, even if it looks like exaggeration.

Thanks for a great post.

I'd like to suggest a slightly different take on the political risks here. Anne M. rightly points out that these laws will be used a precedents for other laws. So, even if pharmacists aren't, in the aggregate, a very big problem right now, that doesn't mean (i) that they won't become one (think of how anti-evolution types have infiltrated school boards) and (ii) that their example won't be cited by, say, doctors who don't want to treat gays. And let me add this: the Right's goal is to pass many, many such laws. And even if they don't come to control all of the pharmacies, they might come to contol 5% of them, along with 10% of the school boards and 5% of the hospitals and 10% of the movie theatres and . . . I don't know what else. At the end of the day I'll feel like I'm living in a society permeated with hateful, prudish scolds. I'll never know when some asshole will refuse me service for whatever "sinful" activity I'm trying to pursue. It won't be a theocracy in every detail, but it will feel like one.

So, let's fight 'em tooth and nail, starting now. Amy S. is foolish to suggest we not worry about this one because it's not, right now, a big problem.

Re "..If these self-regulating professional organizations won't show some spine, the legislatures will be forced to step in. Their choice..." (from LB)
Well, sure- except that, if it's a DeLay-friendly legislature, they'll try something like putting BCPs on the "Controlled Substance" list of fine pharmaceuticals, perhaps... ^..^

Hey, Lindsay, you have a definite talent for attracting a coterie of intelligent commentors to your blog! Makes for quite an enlightening and entertaining exchange of ideas.


Well, if this weren't such an overall depressing developmnet, it would be entertaining to contemplate various and sundry Republicans trying to run interference between the interests of Ralph Reed on the one hand, and Johnson & Johnson on the other, the number one maker of OCPs, and, naturally, one of the most influential lobbying organizations in Washington.

My parents are both pharmacists and I agree with everything Mary MacMorris said. The only time my dad refused to dispense related to what was suspected or known illicit narcotic prescriptions.

I like the idea of blasting such pharmacists for the unauthorized practice of medicine -- and at a minimum I think every pharmacy -- the license holder -- has the duty to post publicly and conspicuously that due to the conscience of its employees it cannot guarantee that it will be able to fill OCP scripts. That way I can boycott such pharmacies, and other women can be put on notice that they should be going elsewhere.

I'm sure a compromise will be found. Soon, it will be discovered that only generic birth control is immoral, but name brand drugs, still under patent, have a special moral additive.

This is a very interesting post. It is remarkable, though, that it displays not even the slightest concern for the interest of a pharmacist to refuse to cooperate with what he or she takes to be an intrinsically evil act. So there is not a moment at which you pause to ask whether there might be a way to accommodate these conscientious objections in a way that is consistent with people's legal rights to receive these drugs.

Not every opinion that is held is worthy of concern simply because it is held. The remedy for such people is really quite simple...get a different job. Conscientious objections need to happen on a more global level.

For don't want to kill someone in a war and are don't go to the war, you go to jail. You don't go and comply with your draft notice, get into a platoon and then decide after all of the training and once you're there with a rifle that now you're going to object. Much more serious offense in that case. And this presumes you were forced to make the choice.

Pharmacists weren't forced into their profession. They chose it. Making this even more clear cut than someone who was drafted. If a pharmacist wishes to object to a particular kind of medication, then he/she needs to object to the profession as a whole, not simply make their own decisions about which medications are ok and which aren't.

Because, ultimately, these are people who want to both moralize as they choose and still draw a paycheck.

There is a long tradition in this country of trying to allow people to participate as fully as possible in the day-to-day communal life while nevertheless honoring the demands of their conscience. The thread of argument in these comments that basically says "If you don't want to dispense birth control, don't be a pharmacist" simply spits in the face of that tradition. "Are you a serious Catholic who thinks that he or she is called to be a pharmacist, but cannot in good conscience dispense birth control? Then go screw yourself." Surely we can do better than that.

There is an alternative. The alternative is to at least try to see whether the demands of conscience can be met. Is it really impossible for women to get the birth control pills that they are legally entitled to receive while allowing pharmacists who have scruples about it to refuse to fill these prescriptions? What are the actual effects of allowing such an exception? Is the inconvenience it might cause in some cases really an unjust infringement on access to birth control?

Lindsey brings up a proper analogy in the case of conscientious objection to war. The draft has traditionally been tempered by allowances for conscientious objection. The rationale for this is that respecting conscience is a valuable thing, and the (assume for the sake of argument) valuable social goals that require a draft can be realized even while allowing exceptions for conscientious objection. Where Lindsey errs is in thinking that this analogy works in her favor, given that the discussion here is not 'should pharmacists comply with the law, if the law requires them to dispense BC pills?' but rather 'should the law encode a right of pharmacists to conscientiously reject dispensing BC pills?'

I still want to know; if I'm a pharmacist in, say, Georgia and I convert to Christian Science (which prohibits any frorm of medication) is my job legally protected even though my beliefs prohibit me from doing a lick of work at my job?

One does have to wonder why someone would choose a career in which they will be constantly faced with a moral dilemma?

What are we to do about a Jehovah Witness (I beleive that they take no medications at all and just rely on prayer to heal -- if that is not the religion, sorry but there is a religion that beleives this and that the one I mean) who becomes a pharmacist simply to refuse to fill any prescription and thus force their beliefs on others?

What about the cashiers? Shouldn't they also be given the right not to participate in the sale of something they consider evil or immoral? Why should a cashier be forced to choose between their conscience and their job?
How would Wal-Mart feel about a law forbidding them from firing a cashier that refused to ring up meat sales? or condoms? or guns?

What's the difference? Is it that if you don't have a college degree you aren't allowed the luxury of a conscience?

I could not agree w/ Lindsay more, especially her comment of 03/30 emphasizing the issue of role responsibility generally trumping personal beliefs. Not to shamelessly self-promote, but I also posted a brief philosophical examination of this issue with an analysis of role ethics:


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