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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:

Pharmacist_bcp

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.

Comments

To liken a person to a machine is dehumanizing.

"Pharmacist" is a job description. It's not a person. No-one is "dehumanizing" the people who perform this job. It is a question of describing the job, what it is and what it is not. You are simply trying to expand the job description to add duties which are not there. I, meanwhile, am trying to define those duties. Thus, ATM. Substitute "bank teller" if the machine thing confuses you.

To refuse to cooperative with another's evildoing cannot be dehumanizing to that other, because evildoing can only be done by rational beings.

"Danger! Will Robinson!"

Generally-speaking, modern medicine does not address the problem of "evil." I do hope, however, that the protesting pharmaicsts choose to use the phrase, "I rufuse to cooperate with your evildoing." This will, I think, put the entire debate into the proper light.

Or you could look at it this way.

I have the right to practice any religion I want. I have the right under the law not to be fired because of my religion. But that doesn't mean I retain that right or protection if I decide to become, say, a Catholic priest. If I get fired for being Jewish or Buddhist or athiest, I can't really claim wrongful termination, can I?

(probably somebody has tried this, I don't know. but it's still stupid.)

I hope that I would have enough moral conviction to sacrifice my livelihood...

I also hope the pharmacists that violated those patients' rights also have the moral conviction to sacrifice their livelihoods. Otherwise, their religious convictions are worthless.

Everyone wants it both ways - I get to demonstrate my religious "passion", but I get to demonstrate it at no risk. What worthless faith.

I never said anything about the pharmacist's views trumping anything. I said that it is a legitimate interest -- the very same legitimate interest that is being protected when folks conscientiously object to making war. Of course, there is always the option of refusing to fight and being jailed for it. But we think (thought) that we can serve the needs of the military through the draft even by allowing exceptions for those who conscientiously oppose it. We could not make this exception if it turned out that the right was so open to abuse, or too difficult to implement, to serve the military needs in question.

That would be the first step in thinking through this. Instead of bringing out a parade of horribles, ask the question that Amy Sullivan first asked, that everyone here seems to think is beside the point: how big a problem is it that some pharmacists want to refuse? and how big a problem would it be if the exemption were made law? Would the result be inconvenience for women seeking the pill? Or would it be massively burdensome? As far as I can tell, everyone here thinks that so long as anyone is inconvenienced, there is no legitimate interest served in allowing pharmacists with scruples to refuse to fill these scrips. But on that reasoning, conscientious objection to the military is out right away. People are inconvenienced in extremis.

peBird: You've offered no argument. You assume that patient's rights are violated. That is what is in dispute. On your view, one would be a hypocritical religious person for protesting against any law that imposed a sacrifice on him or her for acting in accordance with sincere religious convictions. Your palpable contempt for religion reflects far more poorly on your own views than on your opponent's.

"...the very same legitimate interest that is being protected when folks conscientiously object to making war. Of course, there is always the option of refusing to fight and being jailed for it..."

You would have an excellent point if it weren't so stupid. Until there is some risk to the public at large of being drafted against their will into pharmacy, your argument about contientious objector status for pharmacists is silly. And as far as your military anaology, this is already a Monty Python skit. I'm thinking of the Eric Idle character who has enlisted in the army but now wants out because "someone could get hurt." You forfeit your contientious objector status when you volunteer.

Mark, when a pharmacist refuses to fill a script, refuses to refer the patient to another vendor, and refuses to give the script back, that patient has been inconvenienced. This has actually happened, it is not theoretical, so I ask you: are you condoning this?

And even if "no one yet" has been inconvenienced, clearly, the potential for inconvenience exists. But what I object to most is the idea, for instance, that when I go fill an OCP script because I need it for a non-contraceptive purpose, which I have actually done and which thousands of women do every day, there is a possibility that I will be put in a position of compromising my privacy in order to justify my moral standing to a stranger whose life and values are of zero interest to me.

Does the pharmacist ask a man who is filling a Viagra prescription to show off his wedding ring to be sure he's not going to commit adultery or fornication? Should we refuse antibiotics to someone diagnosed with an STD? Should we stop filling HIV drugs because it only encourages immoral behavior to make the disease less catastrophic?

The concept of religious accommodation exists under the law (Title VII), but it assumes that the employer must make reasonable accommodations. It does not protect employees who foist their religious beliefs on their employer's patrons, and at all times it maintains a standard of reasonableness. For accommodation to be reasonable here, basically, a pharmacy could never have a pharmacist exerting his right to refuse to serve patients working a shift alone, or probably even in a mangement position (God knows what he would do then -- direct everyone else to refuse to fill OCP scripts). Your theoretical dodges are comical. Provide practical suggestions.

Quisp, what is relevant in the analogy to conscientious objection to military service is very limited, and is simply this: that public policy has recognized the value of not requiring people to act against conscience, and in cases where the burdens of protecting that value are not too great, has seen fit to provide legal protections. That is the only point of the analogy.

If there is an analogy to the Monty Python type case, it would be that of a soldier who enlists and then is asked to fight a war to which he or she has very strong moral objections. Could there be a case made for allowing selective conscientious objection in these situations? The answer is not obvious. Of course it would be subject to abuse, and perhaps the abuse potential is so great that it would generate undue burdens, or such massive inefficiency, that it is not worth implementing. But it seems to me that it is an open question, to be decided by reference both to considerations of justice and efficiency, whether this would be a wise policy.

The extent to which folks think that the requirements of the role 'pharmacist' or 'soldier' are etched in stone, unable to be revised or rethought (the social role of pharmacist: love it or leave it!), is a little disappointing. In fact, the inability to envision alternatives is pretty much the central case of stupidity.

Mark, the first oral contraceptive went on the market in http://inventors.about.com/gi/dynamic/offsite.htm?site=http://www.invent.org/hall%5Fof%5Ffame/1%5F1%5F6%5Fdetail.asp%3FvInventorID=31>1960. I hope this aspect of the job doesn't catch any contemporary pharmacy graduate unawares.

Barbara, I think I condone the pharmacist's refusal to fill and refusal to refer, but not the refusal to return the prescription. That's a question about what I think about what the pharmacist did. But I take it that the main concern here is not with the rightness of this pharmacist's actions but whether there ought to be some legal protection for pharmacists to conscientiously refuse to dispense certain prescriptions.

I'm sorry that you take my posts to involve theoretical dodges. I'd rather, if you will, that you take them as humility: I am not a crafter of public policy. My objection is to taking the conscientious rejection of the pharmacist to be of no, or of trifling, account. That's what my first comment in this thread concerned, and what all of my comments on this thread have been concerned to defend.

One more thing. A heavy-handed rejection of such legal protection, or even further, a legal mandate that pharmacists be willing to fill all valid prescriptions, will not magically generate compliance and full access while leaving everything else unchanged. As more and more pharmaceuticals become available that are viewed by Catholics, evangelical Protestants, orthodox Jews (etc.) as anti-life, there would be more and more people who would have to reject becoming a pharmacist instead of participating in what they take to be evil acts. It is worth thinking about what consequences would result from the lowering in size of the pool of persons from whom our pharmacists are drawn.

Mark, a hallmark of receiving accommodations is asking for them. So a pharmacist, like a conscientious objector, has a duty to inform relevant parties (employers, the army) that they have these objections so that those parties can decide to what extent and in what manner they can make such accommodations. In the case of a pharmacist, for instance, it may be a transfer to a much busier store where there are always two pharmacists on duty. Neither the pharmacist nor the conscientious objector has the right to put his employer or his country, his fellow workers or soldiers, or his patients in jeopardy as a result of his conscience.

Pharmacies exist to serve patients, not pharmacists. That's not a complicated concept.

And in case it wasn't obvious, arguably, pharmacists already have some protection from discrimination on the grounds of religious conviction (like people who refuse to work on Sundays), but as I said above, they may not do that in a way that jeopardizes the employer's or their customer's interests. So if the idea is that such a "right" would in fact be exercised even to the detriment of the employer or the customer, then I think it would be unreasonable.

and i can't imagine that (m)any consumers, doctors or drug makers would tolerate such nonsense.

All the analogies in the world can be made, and the intellectual paragraphs and phrasing can go on and on, but the bottom line is A) this is an attempt to "get a foot in the door" towards legalizing discrimination in terms of allowing people to impose their extremist Christian views on others, and B) an attempt to prevent women from getting legal pills which are usually used to prevent pregnancy.

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?'

Mark: I'm gonna tell you the same exact think I told the "prolifers" on the NARAL blog:
There's a very easy way for people to not be required to perform/be involved in activity they find morally reprehensible, it's legal, allows freedom of religion and does not require legislation: choose your profession wisely. If you don't want to be involved in an abortion procedure, do not work in the field of gynecology. Contrary to "prolife" groups claims, all med students/interns/residents are *not* required to perform abortions as part of their training. Proctologists don't have to perform abortions, Pulmonologists are not involved in an abortion procedure, Cardiologists and Opthamologists - nope, not required to do abortions.

Under these laws, an intensivist who decides they object to removal of life support on religious grounds would be permitted to disregard my advanced directive to do so or could even claim that since "every life is sacred regardless" they will ignore a DNI or DNR order (this BTW is battery). If you never want to be in a position in which you may be involved in removal of life support (including invasive nutritional support), do not go into any facet of internal medicine (as internists spend a lot of time in ICUs during their training and will be involved in those activities) or neurology (you rotate through the NICU during training). You probably want to avoid certain surgical specialties as well do to rotation through trauma/surgical ICUs.

This is not a case of discrimination, it's common sense:

A Vegan does not take a job at restaurant serving animal products because they find utilization of any animal product by humans to be morally repugnant. Someone against the death penalty shouldn't get a job as an executioner on death row and someone who has a very broad label of what they consider morally offensive pornography, shouldn't get a job as a stripper.

If someone chooses a profession or hobby in which that thing the find offensive is performed and is then required to perform that thing, they are not being discriminated against as they are the ones who made the choice to get involved. They can just as easily choose to withdraw from that required involvement. So an OB/GYN that finds abortion morally unnacceptable can go into private practive and make it clear that their practice does not provide or refer for abortion services for an reason other than ectopic pregnancy (they will have a booming "prolife" practice too). A pharmacist who find contraception morally offensive can open his/her own pharmacy that neither stocks nor sells any contraceptive agent (mind you, they can not refuse to return the prescription if someone tries to fill it at their pharmacy to intentionally thwart the patient from getting it filled elsewhere). These people could also get jobs at a Catholic hospital where abortion and contraceptives are verboten and they would not have to deal with the issues.

The only reason "prolife" people want this legislation is to be able to impose their views on unwitting patients, not to protect their own souls.

Lindsey: Michigan HB 5006 actually prevents "discrimination" against the "CO"s in hiring practices (interestingly, I think the bill excludes refusal to fill prescriptions for contraceptives).

I'm getting a headache from this one...anyone know where I could get some good narcotics no questions asked?

Anyone?

Would the result be inconvenience for women seeking the pill? Or would it be massively burdensome?

Personally, I would consider an unwanted pregnancy that could have been prevented by the morning-after Pill to be "massively burdensome." Particularly if said pregnancy was the result of a rape, as happened to a woman in Texas whose pharmacist "conscientiously" decided that a woman who had been raped needed to be as inconvenienced as possible and refused to fill the prescription.

But I guess you're one of those guys who thinks that pregnancy is no big deal, a walk in the park, only a minor inconvenience.

(Since you seem not to know this medical fact, the morning-after Pill must be taken within 72 hours -- the sooner the better -- or it does no good. There is a time limit, in other words.)

I think I condone the pharmacist's refusal to fill and refusal to refer, but not the refusal to return the prescription.

Please justify the refusal to refer, as it is a clear violation of the Pharmacist's Code of Ethics and an exception to all other medical "conscientious objector" statutes.

Why do you want pharmacists to have special privileges that doctors and nurses do not have?

The reason that I would refuse to refer is I were the pharmacist in question is that referring involves telling someone how to get what he or she needs in order to do wrong. (Of course, it does not follow that a well-crafted law concerning conscientious objection to filling these scrips would not include a requirement to refer. As I have said probably a half-dozen times by now in this thread -- thus giving Chris a headache -- it is not clear what the best legislative response to these cases is. Anyone who assumes to know my view on this is more than a mind-reader, he or she is a fortune-teller.)

Of course pregnancy in such cases is massively burdensome. But the question is to what extent is access to the morning-after pill in fact denied, or to what extent would it be denied, by having statutory protection for pharmacists who don't think it right to dispense BCPs.

Barbara's remarks seem to be real progress. There she notes ways of accommodating conscientious objection, at least where there are alternative sources of the medication.

Consider two scenarios:

(1)a Jehovah's witness is hired by a car dealership whose busiest day of the week is Saturday. He discloses this when he is hired and the parties agree that he can normally expect not to work Saturdays, barring emergency needs, so long as he is willing to work every Sunday (the day off of choice of other employees).

(2) Jehovah's witness is hired, goes through training and the first time he is scheduled to work on a Saturday, calls 10 minutes before the dealer opens to explain that he can't work on Saturdays because of his faith.

Any right to refuse to serve patients that allows a pharmacist to essentially re-enact scenario 2 is simply wrong. Not only does it affect the performance of services that are more important and usually more time sensitive than buying a car, it also actually impedes the employer's reason for being in business -- the sale of drugs (rather than simply making it a bit more challenging).

This would include refusing to transfer a script. For those unfamiliar with the world of pharmacy, in many cases a "script" is not transmitted by a piece of paper, but by a phone call. The script is written down, but by law the pharmacist is not permitted to hand his transcription to the patient. The same is true for refills that have already been filled once by the pharmacy. The only method of transfer in either of these cases is for the first pharmacist to call a second pharmacist. Let me tell you, this can be inconvenient in and of itself, as you or the pharmacist must make phone calls to ensure that the second pharmacy has the drug, is open, etc. I once needed to refill pain medication that the first pharmacy ran out of, over a weekend, and the logistics of the situation were such that I ended up not getting the drug for three days, and I live in a very well-served community. So this "no transfer" policy is really the same as refusing to return the script and serve the patient.

I am usually willing to accommodate employees even when I disagree with the reason, but once it intrudes into patient care or the employer's ability to run its business, forget it. It's not reasonable. These are totally foreseeable circumstances to a pharmacist, and many of these refusals were clearly intended to have the effect of maximally inconveniencing the patients involved and to actively interfere with patient care. That is beyond conscience. It is unconscionable.

I need to preface my remarks by saying that I believe all women should be able to control their own bodies. I also believe, however, that it is morally repugnant, and unworthy of liberal minded people, to compel pharmacists (or anybody) to act contrary to their sincere ethical convicitons.

Lots of the chatter here about the "role responsibilities" of pharmacists ignores questions of medical justifications, medical indications, and the possibility that birth control is inappropriately medicalized.

Suppose a pharmacist interpreted her role as the provision of drugs for the treatment or prevention of diseases or medical pathologies. Although she might have no moral objections whatever to abortion or contraception, she might well say that unless they are medically indicated she has no professional obligation to dispense agents for these purposes. And let's face it -- a biologically normal pregnancy usually does not qualify as a pathological condition. Appeals to role responsibilities won't work here to underwrite any general obligation to dispense birth control drugs.

The rights of women to control their own bodies are brought into direct conflict with the ethical convictions of some pharmacists because access to contraceptives and abortifacients is "by prescription only." Yet while there once were good reasons for requiring a physician's prescription before dispensing such agents, those reasons are no longer compelling. The medicalization of birth control is no longer justified.

If the FDA would just follow the recommendations of its own experts and grant "over the counter" status to contraceptives and abortifacients, the problem would largely disappear. These drugs would very quickly become available in a variety of venues besides pharmacies -- just like happened when control of access to condoms was removed from health care professionals. Women would have greater access than they now do to the drugs they need to control their reproduction AND pharmacists would be able to honor the dictates of their consciences. Good all the way around.

Although I'm usually very skeptical of conspiracy theories, in the present case I can't help but wonder whether the foot dragging of the FDA isn't a delaying tactic to allow various politicians to wring a bit more political advantage from this issue. Are the legitimate interests of both women and pharmacists being sacrificed to the interests of political opportunists?

No, Bob, not political opportunists, more likely, doctors and pharmaceutical manufacturers. These are the usual parties who oppose making a drug OTC. If a pharmacists "decides" that something has been inappropriately medicalized, that pharmacist is practicing medicine, which he most surely is not entitled to do.

As I discussed above, the law does grant certain rights of conscience to all workers, in the sense that employers may not discriminate against such workers and must make reasonable, albeit generally interpreted to mean "limited" accommodations. Sometimes those accommodations can't be made, and in that case, I think it is not too much to expect a medical professional to carry out the expected duties of his job.

One of the first cases I ever worked on involved the review of an individual employee who began to suffer from vertigo who had asked for and been denied accommodations in the performance of his job. Believe it or not, his job was maintaining radio towers -- you know, climbing up to the top in order to fix and maintain radio signals. There's a point at which your disability (or your conscience) just makes it unreasonable to expect an employer to hire you for a specific job. When the only possible accommodation requires someon else to do the job, that's a good sign that point has been reached. When that someone else is actually the employer's competitor -- well, it just seems inherently unreasonable for an employer to have to accommodate that level of non-performance.

Barbara -
1) I've been following the FDA's lack of action for some time now, and I see no evidence that the usual suspects (physicians and pharmaceutical companies) are responsible for holding up approval of OTC status in this case. The most recent so-called explanation for not granting OTC status had something to do with the possibility that minors (i.e., young women) might be able to access these drugs. Hmmm.

2) Medicalization is a social process that includes actors and interests well beyond the medical profession. I, who am not a physician, have decided that birth control (and lots of other things) are inappropriately medicalized. Do you think I'm "practicing medicine?" In the scenario I sketched, I imagined a pharmacist who appealed to the notions of medical justification and/or medical indications. One needn't be a physician to understand these ideas, or their relevance to the question of professional responsibilites.

3) In trying to sort out the ethical issues here, I'm unimpressed by appeals to what the law allows or not, since from my perspective it's precisely the current form of the law regarding availability of these drugs that's causing problems.

4) Pharmacists who are self-employed have as much, if not more, at stake in this debate as those who are employees. Tell them that they must hire additional pharmacists to be sure that the full spectrum of moral viewpoints is represented behind the counter to accomodate the full spectrum of consumer preferences -- or else give up working in their chosen field. That seems unnecessarily harsh given the alternative of simply making the drugs in question more widely available.

1. You are referring specifically to Plan B. I was referring to all contraceptives. The pharmacists involved are not simply refusing to dispense Plan B, but other OCPs as well. What's holding up Plan B are political interests. There's no doubt.

2. A pharmacist can generally decide, as you can, that some things have been inappropriately medicalized. Many people think mental illness has been inappropriately medicalized. But when he turns that thought into action -- as in, when he decides that drugs are contra-indicated for that particular condition he is exercising medical judgment, at least that's how it would be conventionally understood -- he's refusing to dispense a particular product because in his judgment it doesn't deserve medical intervention(how exactly he knows what the particular condition is, don't ask me -- I've only ever taken OCPs for fertility purposes). I don't propose to prevent anyone from having an opinion on anything.

3. You can be unimpressed by the current state of the law all want, and I happen to agree that many more products should be OTC -- but they're not. Just as the patient has to adhere to the law in order to get birth control, the pharmacist and the pharmacy have to adhere to a certain framework in giving it out and providing access.

4. Actually, I have assumed that a self-employed pharmacist is in the clear. All he has to do is display his business practice so that customers know up front what to expect. He doesn't have to hire anyone. Now, state regulations do require pharmacies to adhere to minimum guidelines, and may require pharmacies to have certain types of drugs. This became and issue when pharmacies tried to stop stocking Oxycontin because of its robbery target potential, threats to pharmacists, etc. Several states wouldn't permit pharmacies to refuse to dispense it. It's a highly regulated industry. Saying the laws don't matter would be news to those who work in the profession.

1) Yes, the current fuss is about Plan B. But all the good reasons for making Plan B OTC apply with equal force for contraceptives and abortifacients generally. My view is that if they can be safely self-administered, they should be available without prescription.

2) You're willingness to allow people to form their own opinions would be commendable if you were also willing to allow them to act on their opinions, given the usual qualifications about not infringing on other's liberties. And just to avoid confusion -- refusing to assist someone in the exercise of their liberties is not, except in special circumstances, an infringement of their liberty.

I didn't suggest that my hypothetical pharmacist had decided that a drug was contra-indicated for some particular condition. Nor did I say anything about conditions "deserving" of medical intervention. What I suggested was that the pharmacist had decided that the condition in question was not a bona fide medical pathology. And again, one needn't be a physician to do the thinking necessary to arrive at such a judgment. To undermine that judgment you'd need to address the reasons, the criteria, etc. that went into its formulation. I suggested (quite reasonably, I think) that these might involve notions of medical justification and medical indications.

3 & 4) Well, if the discussion is normative, about what *should* be done or what *should* be the case, the law is not determinative. That's all I meant by saying I wasn't impressed by appeals to the law.

If a pharmacist decides "that the condition in question was not a bona fide medical pathology" then he is exercising what is customarily considered to be medical judgment. But even if it is not a medical judgment, then it is a personal judgement, and he is always entitled to his opinion, as I said. However, he does not have a personal relationship with a person who asks him to fill a script. His relationship is professional, and, at least in most states, fiduciary in nature. Which is all to say that (1) if he is making a medical judgment (which I believe he is) he is way over the line of the limits of his scope of practice or (2) if he is making a personal judgment he has no right to bring it to bear on his professional relationship with patients.

Be that as it may, I would be very surprised if any of the pharmacists involved in refusing to fill an OCP Rx would agree with you that it would be appropriate for them to determine which pathologies should be considered medical in nature. Finally, as I said above, they have no way of knowing what a particular prescription is being used for. Many women use OCPs for manifestly medical reasons -- such as the treatment of endometriosis.

"What I suggested was that the pharmacist had decided that the condition in question was not a bona fide medical pathology. And again, one needn't be a physician to do the thinking necessary to arrive at such a judgment."

Nobody asked him. It's none of his business. His opinion is unwelcome and irrelevant. Just because he has the power to offer it and cause you trouble if you don't listen to it -- like the plumber who wants to lecture you on whatever and you tolerate it because you need your toilet to work -- doesn't mean he has the right to offer it, or to act on it.

Preumably, if a pharmacist has the "right" to deny medication that are prescribed by qualified professionals and p.s. approved for their purpose by the FDA, then does he not also have the right to dispense medication that has NOT been prescribed by doctors? If he's deciding who needs what medication and who doesn't, whether on medical or moral grounds, isn't he diagnosing patients? Why, yes he is! And is he qualified to do this? Why...no, he is not. And do his customers or employers expect him to be treating patients as though he were a doctor? Hmm, let me think.

No. This is just so much bullshit. He has no such descretion. We trust that pharmacists we go to act as PHARMACISTS. Their MEDICAL opinion is NOT EARNED.

[when my wife was pregnant, we often had to call the OB for advice on whatever was happening that day, and of course we would want to talk to a nurse if not the doctor. At the OB's practice, in order to talk to anyone, you had to go through the receptionist, who insisted not only on conducting an extensive interview with you, but then you had to listen to her medical opinion, which she felt entitled to because she answered the phones at a doctor's office. And you had to listen, because if you didn't you wouldn't get to the nurse or the doctor.]

It strikes me that the people who argue for this bullshit idea of "pharmacists' rights" are just like teenagers making an argument to their parents which nobody -- teen included -- believes. They're trying to pull a fast one. Period. Not for one second do these people really want their pharmacist to have the ability to tell THEM what drugs they can or cannot or should or should not take. They only take this position because they want to use it to bend OTHERS to their will, and they don't expect this ever to bite them in the ass because after all they will never be in a position to be taking medication that is immoral. Or at least, this is in the oath they have to swear at their little meetings.

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