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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.


Mark, there is a point at which inconvenience becomes, de facto, restriction of access. It makes a huge difference whether the pharmacist is the only person within 40 miles who can dispense the drugs, or whether he or she is one of 20 staff members at a large chain pharmacy. The size of the town where a person lives is no basis for organizing access to birth control.

I'd also have more sympathy for your concern if it weren't that at least some of these pharmacists aren't just objecting to dispensing the drugs themselves, but are also attempting to prevent women from obtaining them from someone else.

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?

An individual pharmacist might pass BCP prescriptions to a collegue. But as this shifts work to that collegue, the burden is on the objecting pharmacist to find a way to make the situation equitable, or accept the resulting fallout.

Or, the objecting pharmacist might simply refuse to fill prescriptions. Again, she would have the burden of minimizing harm to others, and must accept any resulting negative job performance review or violation of the professional Code of Ethics. A rational person might question the wisdom of training for a career doomed to failure, but that is an individual decision.

But the political issue here is the creation of special law to protect this employee from legitimate grievance of overburdened coworkers or dissatisfied employers. It is shifting the burden of accomodation from the objector to the rest of the world.

Yes, you can have your conscience. You can try to find a way to get along. But you must take the consequences of these choices.

It isn't "go screw yourself." It's "choose a different line of work." A cashier at a McDonald's won't long have a job for refusing to sell someone fries due to transfats. A receptionist at a hair salon won't long have a job for refusing to sell hair gel made with hemp because hemp is bad. What they can do, though, is get a different job where they won't have to sell transfats or hemp.

I have no wish for anything bad to happen to pharmacists who don't do their job. I simply wish for them to actually stick by their "scruples" (I love the implication that any pharmacist who does their job doesn't have any scruples) and choose a different career.

Your ability to participate in the day to day life of the community while objecting stops when your objections create a burden upon others. When you choose such actions, there are consequences. So, if a pharmacist wishes to not fill a prescription, I don't want there to be laws that say that its ok, the people they harm don't matter. They should suffer the consequences of their actions...since the people they've harmed will surely suffer because of them.

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

Some of them if not most are doing it deliberately, as a grassroots effort to control access. It's not like "Hmmm, I seem to have some new morals today. I think I'll stop filling BCP scrips." More like, "I think people should be prevented from having this, so I am going to get into a profession where I can stop people from having it."

Doctors are doing this as well; there are actually "pro-life" OB-GYNs who won't prescribe BCPs. And if you know what-all BCPs can be used for, you might wonder just how good of an OB-GYN such a person can be.

This link has more. regards the CO analogy with war. As I noted above, the analogy is useful to illustrate the level at which the objection should take place. Not at the level of individual actions but at the larger level of objecting to the practice of war. So, it would be choosing not to be a pharmacist, not choosing to refuse to fill certain prescriptions.

For might think basic training could be helpful, think it would be nice to have the camaraderie with other soldiers, like army boots, look good in green...but not like the part where they have to shoot someone else. They don't get to do all of the first parts and object when it comes time to pull the trigger. You object from the outset.

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 Pharmaceutical Association's Code of Ethics for Pharmacists.

All eight? I'm not following you here, Lindsay.

I'd be interested in reading a point-by-point explanation of what you mean here. It would be a fine post on its own merits.

Mark, in some cases, that pharmacist may be the only possible source of drugs. For instance, he may be the only pharmacist on duty at a 24 hour pharmacy that is the only one open in a town when time is of the essence for getting the script filled, as it would be with emergency contraception. He or she may be operating the only pharmacy in a town where someone may not have access to a car to drive two hours to the nearest pharmacy -- and other conditions besides emergency contraceptive needs require timely dispensing, including, for instance, when OCPs are used to regulate cycles for fertility treatment.

But the most telling act comes when a pharmacist takes the script -- knowing that he will not fill it -- and then refuses to give it back. That is, simply, obscene, and in that case the pharmacist is not exercising his conscience -- he is coercing others to try to live their own lives according to his conscience rather than their own.

Since when has it become a policy goal to foster a nation of moralizing busy bodies? Should a woman really be expected to spill her guts to the pharmacist as to WHY she needs the OCPs in order to determine whether the pharmacist considers her particular use to be morally licit?

Here's another creative legal argument: it is a violation of HIPAA privacy to use patient information for purposes other than treatment, and related services. A pharmacist who demands to know why a woman needs OCPs is using her medical information (the script) for a reason other than what he is entitled to do under federal law, which is to provide care. These people should be drowning in the shame of their self-righteous bullshit.

she has managed to pretend to be occupying a non-existent higher ground

Nice, Aunt Deb; that's the most cogent summing-up of Sullivan's schtick I've seen so far.

Between Amy & Andrew, I'm beginning to wonder what's up with people named "A. Sullivan" that makes them so insufferably self-righteous...

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.

Completely inapposite, Mark. Conscientious objectors are exempted from combat. They don't go into battle with their comrades and then just stand around passively; they do something else. As far as I can see, an equivalent status for pharmacists would have to involve giving them something to do other than filling prescriptions; i.e., they would no longer be "pharmacists."

Alan, that's an interesting idea for a post--maybe I'll do a full point-by-point version later. Here's the top line summary: I) The pharmacist's primary role is to help the patient derive maximum medical benefit from medication. The patient and society trust the pharmacist to fulfill that duty above all. A pharmacist who refuses to honor a legitimate scrip is violating that trust. II) Refusing a patient in need is neither caring nor compassionate. As Barbara mentioned, a refusal may also violate her privacy. III) Respecting the autonomy and dignity of each patient--the decision to use OCP or EC is between a woman and her doctor, the pharmacist has no right to interfere. IV) "A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients."--Do these pharmacists sell Viagra to single men? Those who do are discriminating against their female patients. Excessive religiosity impairs professional judgment and dedication to the best interest of patients if it precludes dispensing medicine. V) Professional competence (this one only applies to the pharmacists who incorrectly believes that EC is abortion) VI) "A pharmacist respects the values and abilities of colleagues and other health professionals."--A pharmacist who refuses to fill a legitimate prescription disrespects the MD or NP who wrote it by usurping their authority and overstepping the bounds of his profession. VII) The pharmacist serves individual, community, and societal needs--women need birth control, their communities and societies need pharmacists who will do their jobs. VIII) Justice in the distribution of health resources: Refusal to fill a prescription will be especially burdensome for the most vulnerable women--the very young, the poor, residents of small towns and remote areas. These are the people who will have the most trouble finding alternative sources of medication.

No one here can simply assume the role-requirements for 'pharmacist' and then argue that pharmacists who think it improper to fill BC pill prescriptions are violating that role and thus acting improperly. For one thing: roles themselves are fluid; we can meaningfully rethink what counts as being a 'good pharmacist.' For another thing: even if the role itself requires dispensing whatever drug is prescribed, we can ask the further moral question whether one ought to adhere to every demand of that role, or whether there might be some demands of the role that should be conscientiously rejected. Any such quick arguments are laziness.

I think it likely that most of the commenters here are so deeply unsympathetic to the notion that use of birth control is wrong that they cannot imagine even what it is like to think that it would be wrong to dispense such pills. Perhaps the following might bring things into focus. Suppose that there were a perfectly legal drug whose use was to reduce the severity of the common cold. The downside is that this drug is produced through a process that involves torturing chimpanzees to death. If I were a pharmacist, I hope that I would refuse to have anything to do with the dispensing of such drugs. If I were to aspire to that career, I would hope that I would not be required to dispense that drug. Now, if it turns out that such exemptions are in fact totally unworkable, then perhaps I would have to simply decide that I cannot occupy that role. But one would hope that that would be the end result of a process of looking to accommodate sincere dissent, not the first maneuver.

No, Mark, your role would be to petition your employer, the government, the FDA, the manufacturer through boycott or whatever means to stop production of the drug. It is wrong to penalize individual patients who may not care about chimpanzees at all by denying them the drug. If a pharmacist wants to exhort a woman not to use OCPs that's fine, if they want to sign petitions or try to get a legislature to outlaw OCPs, that's fine too. Penalizing individual women whose conscience does not prevent them from using OCPs oversteps the boundary between exercising one's own conscience and coercing others, as I said above. At any rate, I wouldn't necessarily make a pharmacist do anything any more than I would make a Catholic hospital do something -- but I would make them advertise, conspicuously, all the services that they would normally be expected to provide but refuse to provide. They don't like to do that for obvious reasons and therefore, as far as I'm concerned, can't even claim to be putting their money where their mouth is.

This is a response to Mark's post about the hypothetical drug that tortures chimps and his hope that he would not be required to dispense that drug.


A pharmacist is an ATM for drugs. His expertise -- and any intervention that might arise from his expertise -- relates solely to ensuring that mistakes related to dosage and the patient's safety are not made. Nobody on this earth wants his moral judgment any more than they want the bank's moral judgment about what they (the bank customers) are going to spend their money on.

Why limit it to pharmacists? WHy not the cashiers at the drug store? Sorry, I won't ring this up for you. I don't believe it would be morally right to encourage [whatever]. Then they could get rid of all those condoms, too. Or maybe they could just poke holes in them before they sell them, or put placebos in the birth-control-pill dispensers. Then they could sell them and rest easy.

...If I were a pharmacist, I hope that I would refuse...I would hope that I would not be required...(I) would hope....

Mark, your hypothetical guy has alot of hopes.

Me too. I hope that a young woman would have a car to drive from pharmacy to pharmacy. I hope that a mother-of-five would not be tied to her house by childcare requirements. I hope that no woman is ever raped.

But my hopes are obviously silly. So I cannot make policy that depends on their fullfillment.

Your hypothetical guy is asking others to accommodate him. You say you want to discuss the matter. So what is your proposal? What system will work, given that my dreams will not come true.

The hopes are mine, not the hypothetical person's. I hope that I would have enough moral conviction to sacrifice my livelihood if I had to do so in order not to participate in the distribution of a drug produced in such a morally repugnant way. And I would hope that this choice would not be forced upon me, just as we generally do not want people to have to make choices between doing what they take to be evil and accepting large personal sacrifices. I trust that hopes like these are widely shared.

The claim that the hypothetical pharmacist is asking others to accommodate him begs the question. It assumes that those seeking the drugs have the right to be served by the pharmacist, and the pharmacist has no right to refuse to participate in what he or she judges to be evil. But the relevant rights, or better, legitimate interests, and their respective weights, are precisely what is at issue.

To treat a pharmacist as an ATM for drugs is, to note the obvious, dehumanizing. That you care about him or her only insofar as he or she serves your needs does not entail that his or her interests in not doing wrong are not legitimate interests.

Good grief is this ever circular.

Pharmacists don't have to participate in evil-doing. Easy choice. One many have touched upon but that you seem unwilling to accept as reasonable. Change professions or don't go into it in the first place. You haven't offered a way for pharmacists to both do their jobs without discriminating and be able to satisfy their desire to avoid evil.

Asking a pharmacist to do their jobs (dispensing drugs) doesn't seem to be to be dehumanizing. Professional judgement should enter in, they need to understand how drugs work together, to be able to talk with a patient about how to take drugs and other precautions that are necessary...about, for example, the dangers of grapefruit juice and antibiotics. But, refusing to dispense BCP isn't exercising professional judgement...its exercising moral judgement which isn't part of the job of a pharmacist. I don't wish to dehumanize or de-professionalize the job of pharmacist...but moralizing isn't a part of it.

i>To treat a pharmacist as an ATM for drugs is, to note the obvious, dehumanizing.

To treat women who want BCPs as immoral baby-killing whores who need to be saved from themselves is dehumanizing.

If I am being prevented from getting my legal pills by a total stranger, I am not especially inclined to care what their opinions are on what I should be doing.

*sigh* Damned HTML tags.

Good "fight" Mark, and I see that many folks are providing constructive comments, as yours. I would add that in reposte to your "role" argument that: 1) no one is assuming the requirements of the role -they're spelled out in the Pharmacists' Code and acceptable historical conduct of pharmacists; 2) agreed, considering the requirements of a role, more accurately -weighing them- against one's personal moral commitments is a fine and rational thing to do. After all, no professional filling a role is an automaton...however, whatever parts of the role may consider rejection have to be weighed in a utilitarian manner in order to maintain the good all around (i.e., harm to pharmacist and harm to patient). The pharmacist in question acted in such an absolute manner as to provide no benefit to the patient whatesover, and that weighs sufficiently more than their own right. A balance could simply have been found by informing the pharmacy of his beliefs, or the patient, and then transferring the prescription somewhere else. That's the part that gets to me: I don't believe he attempted a fair assessment of the requirements of his role and personal beliefs. -BD.

Mark, I think you don't understand what a pharmacist does and, more importantly, is not supposed to do.

A pharmacist at my boyfriend's work was fired and reprimanded by the state board for changing doctor's orders without permission. The situation was considered so serious that his supervisor was also fired, for not adequately disciplining him when the problem first presented himself.

A pharmacist who takes the role of a doctor and decides what medications a patient should and should not be given is a bad pharmacist.

My boyfriend checked the internet several years later and discovered that the guy's license was eventually taken away entirely because he persisted in changing doctors' orders.

A pharmacist who refuses to fill a valid prescription for anything other than pharmacy reasons (i.e. bad drug interaction discovered, etc.) is not adequately doing his or her job.

As I pointed out above, doctors or nurses whose consciences do not allow them to participate in abortions are required to find someone to take their place so the procedure may be performed. They are forbidden from blocking the procedure on the basis of their conscience.

At an absolute minimum, pharmacies should be required to have a back-up pharmacist available during pharmacy hours if the on-duty pharmacist has stated their opposition to dispensing birth control. If the pharmacist does not reveal his/her opposition before being hired so the employer can make adequate provision, the company should be able to fire them.

You are not allowed to impose your religious beliefs on me, just as I may not impose mine on your. Your decision to deny me birth control that my conscience permits me to take is privileging your moral decisions above mine.

Why do you think the law should be allowed to decide that one individual's religious beliefs outweigh those of another individual?

To liken a person to a machine is dehumanizing. To refuse to cooperative with another's evildoing cannot be dehumanizing to that other, because evildoing can only be done by rational beings. What you mean by 'dehumanizing,' Anne M., is rather more like 'someone who is choosing to do wrong.' And I suppose that this cannot be denied: pharmacists who refuse to dispense BCP's are treating these patients as people who plan to do wrong. Well, we can't get around this. That's what moral disagreement is. By that standard, you're dehumanizing the pharmacists in question.

Chris, look: if a role happens, through its contingent history, to take up into itself requirements that one judges to be wrong, it is not obvious that the thing to do is just to refuse to enter that role. The thing to do might be to argue for a reconception of it, or ask for leave to depart in some limited way from its requirements. That is what is being asked for here.

Another example: suppose it were the case that in the not-too-distant past part of the role of 'teacher' was to inflict corporal punishment on wayward students. Suppose I thought that was wrong, and asked to be exempted from that role requirement. Would the chorus at that point say "Mark, look, if you want to be a teacher, you have to be willing to whip ass?" Surely my response should be: "I want to be a teacher, I think that it is an important job, though I think that there is one thing about it that is just unacceptable. Is it possible for me to be accommodated? Can we think about this, before throwing me and everyone who thinks like me out on my ear?"

Mark, a pharmacist's role is usually like an ATM. Since both my parents are pharmacists I say this without deriding the many conscientious pharmacists who are out there. They are often asked to explain matters such as how a drug should be taken, what side effects to expect, and so forth. They are sometimes asked to explain the differences between OTC drugs (as in, an expectorant versus a cough suppressant). But a pharmacist is almost never permitted to "select" a drug, as in, prescribe medications, and unless questioned by a patient, does not typically interpose his personal or professional "judgment" in patient care matters. In some states, pharmacists are permitted to engage in limited prescribing, but this is very narrowly circumscribed and not the norm.

There is no doubt in my mind that pharmacists could serve a greater role than they currently do, but a pharmacist who won't dispense a drug based on conscience is of no use to his or her patients, and is putting his own well-being above theirs.

The thing to do might be to argue for a reconception of it, or ask for leave to depart in some limited way from its requirements. That is what is being asked for here.

Please, Mark,'ve gone round and round on this. How would you do it? How do you accommodate the conflicting demands in a way you think is fair? I think it's clear that if your way involves simply telling the customer to go get her pills someplace else, that's not going to sit well with most of the people here (myself included). So what are you proposing, beyond "thinking about it"?


But I DO only care about my pharmacist only insofar as he serves my needs. ADDITIONALLY, his or her interests in making moral judgments about which prescriptions to fill and which not to on MORAL grounds is not a legitimate interest.

I didn't treat a pharmacist as an ATM for drugs. I characterized a pharmacist as an ATM for drugs. I did not walk up to my pharmacist and start pushing buttons and opening drawers. I do not treat my own personal pharmacists with anything but courtesy and friendliness. This is because they are people and deserve to be treated with dignity and because -- in the context of my interaction with them -- they do their jobs. A pharmacist who refuses to give me my prescribed medication is in my opinion a broken pharmacist. I absolutely do not acknowledge my pharmacists' right to an actionable opinion on the morality of the medications I have been prescribed. I inserted the word "actionable" in the previous sentence because I do believe he has a right to his opinion, provided that his opinion in no way interferes with his ability to do his job. That is to say, as long as he keeps his opinion completely to himself and does his job exactly as if he had no such opinion, I'm fine with it. However, if he expresses his moral judgment of my (or anyone's) prescription -- to say nothing of actually denying the medicine -- I am done with that pharmacist. If I am a stock-holder in a company that owns pharmacies, and I find they allow their pharmacists to fill prescriptions selectively (or discuss morality with their customers), I am selling that stock.

i.e. the pharmacist's opinion is not welcome and is not his right to express, much less act on, any more than it's my toaster's right to choose not to make toast.

I would add, Mark, that you haven't addressed the fact that birth control pills are prescribed for reasons other than birth control. How does your hypothetical pharmacist figure out whether the pills are for a use he doesn't approve of, without a gross invasion of his customer's privacy?

Mark, I'm still waiting for you to explain why the pharmacist's morality should be allowed to trump the patient's morality.

Why are you promoting one individual's moral or religious beliefs above those of another individual? Isn't that exactly the kind of thing that the free exercise clause of the First Amendment is trying to prevent?

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