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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

My, my. I seem to have ruffled a few feathers.
OK, I'll put the ball in the court of those who think it's irrelevant (or worse, a symptom of either intellectual or moral pathology) to consider whether a condition for which someone wants a drug dispensed by a pharmacist (but to be otherwise unavailable?) counts as a disease or medical pathology. I'll even leave aside the question of why it should be necessary to have a physician prescription to obtain a drug which, as my earlier discussion has assumed, can be safely self-administered.

Are we to assume, then, that any condition for which any MD might prescribe drugs is a bona fide medical pathology? How about short stature, when there is no hormone deficiency causing it? How about not being able to hit more than, say, seventy homeruns in a standard baseball season? Or how about that feeling of exhaustion at the end of long, busy day? Prescription amphetamines will make you feel so much more energentic, so much more alert. So of course, this sort of perfectly normal exhaustion must be a disease, too. Let's just forget about outdated notions like disciplinary integrity and say that anything you can find a physician willing to "treat" is, ipso facto, a medical pathology, and pharmacists should be compelled to dispense the treatment without bothering to use their critical faculties.

Nah... I persist in my view that biologically normal pregnancy usually is not a pathological condition, and that the prevention or termination of such a pregnancy, while perfectly ethical (at least by my lights) usually is not something that health care professionals are morally obligated, as health care professionals, to provide. They might be morally obligated as concerned, caring fellow humans -- but that's another matter entirely, one which should not determine the content of _professional_ obligations.

"I'll put the ball in the court of those who think it's irrelevant (or worse, a symptom of either intellectual or moral pathology) to consider whether a condition for which someone wants a drug dispensed by a pharmacist (but to be otherwise unavailable?) counts as a disease or medical pathology."

It's not irrelevant to consider whether condition x counts as a disease. It is, however, irrelevant to the job description of a pharmacist.

"Are we to assume, then, that any condition for which any MD might prescribe drugs is a bona fide medical pathology?"

If "we" are an individual, in charge of his own health care, of course not. You do so at your own risk.

If "we" are a pharmacist: vis-a-vis the body of medical knowledge, vetted by the population of properly-educated medical doctors, overseen by the AMA (etc.), prescribing medications which themselves are vetted by same and approved by the FDA (etc.)...uh, yes, "we" are to assume that "we" aren't qualified to second-guess the physician, except within the bounds of our plenipotent pharmacist acumen (e.g. he wrote this dose but must have meant this dose; let's call and find out).

The pharmacist's rights are the same as the cashier's in ringing up the sale. He can quit. He can refuse to make the sale and quit. Nobody is asking for his expertise in this matter because he doesn't have any.

It's clear that quisp thinks that whether prescription drugs are being used to prevent or treat diseases or medical pathologies, or whether they are being used for non-medically indicated purposes, should not enter into the minds of working pharmacists. For such thoughts to cross a pharmacist's mind would constitute a sort of pretense to expertise. Still, we're told that "It's not irrelevant to consider whether condition x counts as a disease." So -- who are the experts in determining what counts as a disease, and where can I find a good explanation of the criteria they use in making such determinations?

medical school

Actually Bob, it's not the job of the Pharmacist, nor is it appropriate (for a Pharmacist), to ask a patient to provide a diagnosis for which the prescription is written. As such, your comment as to whether a pharmacist considers or should be allowed to require a what they consider to be a bona fide pathology to be present is completely irrelevant. Medications can (and are) prescribed prophylactically. Physicians are also allowed to prescribe for off-label indications. It is not the place of the Pharmacist to insert his/her moral position in determining whether to honor a prescription provided to prevent a condition (pathological or not) or for off-label use.

Additionally, a patient should not have to be subjected to a physical exam and medical history by a pharmacist. As the pharmacist is neither trained for nor licensed to perform these procedures, make clinical diagnoses, or treat medical conditions.

If we allow these pharmacists to make moral decisions as to which prescriptions to fill, they could decide to present a barrier to other medications that have abortifacient potential (any medication that could increase peristalsis in smooth muscle) hence denying women access to medications for GI conditions (for example, misoprostol was approved and used for ulcers; it also attenuates late allergic reactions and, on it's own, has very weak abortifacient potential).

The point those who defend the CO clauses choose to ignore is the fact that there already is an avenue those who do not want to fill prescriptions for contraceptives can take that has no impact on patients who would present with prescriptions for them: work at a pharmacy based in a Catholic hospital; open their own pharmacy or work at another pharmacy that does not stock contraceptives. There can only be one reason why this would not be an acceptable alternative for these people and that's the fact that they're not objecting to the duty to prevent their personal emotional pain; they want the right to inflict pain on those who use these medications

Ol Cranky!

I checked at a number of medical schools -- found no claims to any special expertise at defining "disease" (or "health" for that matter), though I did encounter an interesting variety of approaches. I've got my own views on the subject, but they're hardly relevant here.

Speaking as one crank to another, I didn't say it was the pharmacist's job to grill patients about their diagnoses. What I suggested is that it's not part of a pharmacist's professional obligations to dispense drugs for non-medically indicated uses. I have no doubt that among the pharmacists who have "appealed to conscience" we could find a few with less than pure motives. I don't, however, see the relevance of that to sorting out the professional duties of pharmacists.

But all this simply diverts attention from the way unnecessary restrictions on access to the drugs in question create the context in which this clash of moral world views arises. Adjusting the context in a way beneficial to the women seeking these drugs simultaneously moots the objections of the pharmacists. Oh yeah, it also deprives them of martyrdom. Give it some thought.

Bob,

I'm pretty sure I agree with your last paragraph.

What I suggested is that it's not part of a pharmacist's professional obligations to dispense drugs for non-medically indicated uses

If a prescription for an approved medication or device is written by a healthcare practitioner who is licensed to write prescriptions (eg., physician, PA, RNP, DDS/DMD) then the pharmacist must assume a medically indicated use. Pathology is not required for a medication/device to have a medically indicated use.

Bob, you might be interested to know (or maybe you already do) that in the 1950s, when the FDA was gaining in stature there was general consternation that it was making every product in sight prescription only. So Hubert Humphrey and someone else got a bill passed that set specific standards for when a drug should be prescription only, or OTC. It didn't slow down the FDA one whit. Many drugs are prescription only on the merest of pretexts. Why should Rogaine (hair loss) or Renova (souped up vitamin A for wrinkles) ever be prescription only? Because of the manufacturer pricing/physician control juggernaut. The need for prescriptions generates physician visits, and insurance coverage, both of which usually insulate the drug from quality and price competition. When Wellpoint HMO petitioned the FDA to make Claritin OTC, its petition noted that there wasn't a single western country (Canada or Europe) that had required a prescription for at least 5 years. It had been available OTC in Denmark for more than 10 years. It was marketed by its own manufacturer as being safer than OTC alternatives. Opposition came from -- allergists (Hmm) patients who wanted their insurer to pay (how about the uninsured?) and, at least at first, from the manufacturer. Yes, I emphatically agree with your last paragraph -- for many drugs, obviously not all.

Ol Cranky -
1) I've been talking about the content of pharmacists' professional duties. You seem to think these involve the assumption of some sort of "veil of ignorance" about the condition for which a prescription has been issued. As they march into valley of unprofessionalism, pharmacists can sing, "Ours is not to question why, ..." And by the way, pharmacists have been known to notify authorities when they suspect drugs are being prescribed for non-medical uses -- without being stripped of their licenses or otherwise professionally reprimanded.

2) Pathology is not required for medically indicated use?? I'm sorry, but I think that's bonkers. On what other basis would indications be characterized as "medical?"

Bob, I'll give you an example: At one point I had infections that usually occurred under specific circumstances. So I was given antibiotics prophylactically. I took them for 18 months. Any pharmacist (or certainly any doctor) would have known from looking at my record that those antibiotics were not being given to treat an active infection. There was no "disease state" (aka pathology) that they were treating. They were prophylactic.

But as to your first paragraph, it is extremely rare for a pharmacist to challenge the medical basis of a prescription -- it has to be really obvious, as in when, for instance, it appears that there is some sort of scheme to defraud insurers by doctors and patients. And yes, to a certain extent, pharmacists are expected "not to question why." In this respect, the medical profession is very hierarchical. Nurses and others are in the same position. When the doctor decides, the others stop chiming in. It may be wrong, but it's definitely the way things are. (As I said above, my parents are pharmacists -- it can be a very professionally frustrating experience.)

Barbara -
I'm no fan of the FDA, generally speaking. I do have more respect for the scientists of the FDA, however, than for the "administrators." The latter consistently behave like bureaucrats the world over, seeking to expand their turf, consolidate their power, and cover their asses. It ain't pretty.

Barbara -
I did explicitly include prevention along with treatment of disease/pathology in characterizing "medical" indications. I don't have my Dorlands handy, but my workaday dictionary defines prophylaxis as the prevention of or protective treatmnet *for disease*. You make my point very well.

Bob, many people would consider pregnancy to be a medical condition -- however "natural," it certainly elicits a great deal of medical observation and intervention and it carries not inconsiderable medical risks. Avoiding pregnancy therefore fits within your relatively broad definition of prophylaxis, prevention, or pathology. And I'll say it again, a pharmacist has some nerve assuming that his personal opinion on the same subject is more meritorious than his patients, just because he "can" deny access to medications.

Barbara -
Medicine is a very conceptually nuanced discipline. To discourse intelligently about it's practice, one needs to use concepts very carefully, respecting very basic distinctions.

On reflection, it should be obvious that a condition which is itself non-pathological can carry considerable medical risks (i.e., risk of disease/pathology). Biologically normal, non-pathological pregnancy is an excellent example. And because it is risky, pregnancy often warrants a great deal of medical observation and intervention -- generally intended as preventive measures.

Sometimes the risk of pathology associated with a pregnancy is so great that preventing the pregnancy is the best way to prevent the pathology in question. But that doesn't turn the pregnancy itself into a pathological condition -- rather it is recognized as a "risk factor." Contraceptives used to prevent an such an unduly risky pregnancy should be (and generally are, in medical circles) recognized as medically indicated.

Termination (in contrast to prevention) of a very risky pregnancy is explicitly recognized in medical practice as a medically indicated intervention. It's called a therapeutic abortion, and it's viewed as distinct from non-medically indicated, so-called "elective" abortion.

But this discussion should not be about the propriety or not of contraception or abortion. It should be about protecting (I'd say enhancing) the ability of women to control their bodies without compelling pharmacists to violate their ethical beliefs. Our willingness to attempt this even if we disagree vehemently with those ethical beliefs is a mark of liberal mindedness. I am saddened by the generally illiberal attitudes I've encountered here, even if I've enjoyed the exchanges.

Bob, perhaps our thoughts would be liberal enough for you if it weren't so obvious that this is a concerted attempt to change women's behavior to meet the standards of others by denying them access to prescriptions. We don't have to apply that famous liberal tolerance to just anything, you know.

I particularly like what quisp said, and it's something that I haven't seen mentioned very much -- "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."

And Ol Cranky -- "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." Exactly. It is clear that those who object to filling or prescribing BC pills are doing so deliberately, and have chosen these professions as part of a bigger picture control pattern. Trying to pose this as a "pharmacists'/doctors' ethics are being violated" strikes me as disingenuous.

Controlling fertility is arguably the keystone in women's rights, and this is known by the other side as well.

But here's some news from Illinois -- http://www.nytimes.com/2005/04/02/national/02pharmacy.html?ei=5088&en=f575c3ca0f09d1a0&ex=1270098000&partner=rssnyt&pagewanted=print&position=

Anne -
Tolerance is of value only when it is being tested.
-Anonymous

Oh I like that -- we have to use medical terminology with precision and accuracy -- sure -- your point only underscores another point -- there is no way to know where to draw the line between a medical and natural condition, except by resort to consensus view at the time. Acne is a natural condition associated with puberty. Urinary tract infections are also quite natural, and most other biological processes are natural too. Many of these "natural conditions" are quite amenable to natural remedies or no remedies (as in, they go away with time) Whether one sees them as "medical conditions" has to do with whether or not one agrees with the medical intervention being proposed, not vice versa.

It is the pharmacist's tolerance that is being tested here. The woman in question isn't asking of him anything that he hasn't held himself out the public as being willing and able to provide (most of these pharmacists do not advertise their proclivities beforehand -- a sure sign that their intention is to inconvenience others, not to keep their hands clean). I don't have to tolerate anybody's attempt to coerce me to live according to their conscience.

Barbara -
You are venturing into the territory of philosophy of medicine. There is a huge body of literature that is directly relevant to your assertions. I recommend it.

Your use of 'natural' can easily be shown to play on a simple ambiguity. Oh, and I didn't use the term 'natural' -- though I would have if the discussion had gone in the direction of explicating the concepts of 'health' and 'disease' as they are used in medicine -- without ambiguity, I might add.

As I said, tolerance is valuable only when it is being tested.

Well, that's too bad, Bob. I don't tolerate someone deciding whether I can get legal drugs I have been prescribed.

I've tried to keep my end of the discussion civil, even when I was being quite critical of other's comments. And I've tried to stay on point.

It's becoming increasingly clear, however, that my fellow discussants are less interested in finding ways to resolve or eliminate the problem posed by pharmacists who object to dispensing drugs for birth control than in venting and posturing. That's a waste of everybody's time, so I'm outa here.

I'm reminded of the writings of a friend about tolerance: http://www.livejournal.com/users/mcsnee/336455.html

And by the way, pharmacists have been known to notify authorities when they suspect drugs are being prescribed for non-medical uses -- without being stripped of their licenses or otherwise professionally reprimanded.

They can notify authorities when they suspect drugs are being prescribed for illegal use as they should (and are, in many cases, required to do). Contraception is legal and, regardless of your personal philosphy, prescription for a pathology or prophylactic birth control is still a medical use.

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