R.Ph.s who refuse to dispense raise ethical concerns

Some pharmacists who believe they have a right to refuse to dispense medications are taking the offensive to secure a conscience clause. Such a clause will allow them to duck under the same legal umbrella shielding physicians and nurses. In the process, they are forcing the profession to take notice of moral dilemmas that are only going to grow more complex.

In Wisconsin, an anti-abortion group is backing a bill to protect pharmacists who refuse to dispense certain drugs against retaliation by employers or lawsuits filed by patients seeking damages. In Ohio, anti-abortion pharmacists are being urged to oppose passage of a new pharmacy practice act because it does not contain a conscience clause. In addition, a California R.Ph.-pharmacy manager made national headlines last May when he refused to dispense so-called morning-after pills to a patient who blew her cork and the whistle.

The original Wisconsin conscience clause singled out pharmacists for protection, but the bill has been redrafted to include other health professionals, said Michelle Grothe, Pro-Life Wisconsin spokeswoman. The first draft stated that a pharmacist could not be required to engage in "a practice of pharmacy" if he or she objects on moral or religious grounds and has stated such an objection in writing. That broad provision has been narrowed to the specific situations of abortion, abortifacient drugs, nutrition and hydration, euthanasia, and sterilization.

In Ohio, Pharmacists for Life International, an anti-abortion group based in Powell, has hit the e-mail trail, urging R.Ph.s to oppose the proposed revision of the state's practice act because it does not include a conscience clause. A sample letter intended to be sent to legislators states, in part, "It is also noteworthy that in Ohio, pharmacists do not enjoy the same legal professional status as physicians and nurses with respect to matters of individual conscience and ethics in their practice. Until the autonomy of the pharmacist as a therapeu-
tic decision-maker is given due legal respect ... it would be best not to expand the scope of the practice of pharmacy at this time."

Ohio pharmacists already have discretion when it comes to whether to dispense an Rx, said Franklin Wickham, executive director of the state pharmacy board. "Essentially there is no law in Ohio requiring that pharmacists have to fill a prescription," he said. "The board of pharmacy would address it in terms of public health and whether people who need medications can get them. I personally feel that this will become a bigger and bigger issue, especially in terms of assisted suicide."

A search of state pharmacy practice acts failed to turn up any reference to a conscience clause or conscientious objector provisions, said Carmen Catizone, executive director, National Association of Boards of Pharmacy. The NABP model practice act does not specifically address the issue either. However, he said that professional conduct provisions, which address the moral responsibilities of the pharmacist to the patient, are quite common in state practice acts.

"Unlike the [American Medical Association], pharmacists do have a duty through standards of practice and implications in the state practice acts to refer patients back to the doctor when problems arise or the pharmacist is not sure that the treatment is in the patient's best interest," said Catizone. "However, there are no requirements for pharmacists to make such referrals when it becomes an issue of the pharmacist's objecting morally to a course of therapy, unless, once again, the therapy is not in the best interest of the patient."

Legislative efforts to enact a pharmacist's conscience clause may present more problems than solutions, said Catizone. "It has been our experience that it is difficult, if not impossible, to legislate morality or moral issues that are not clear-cut," he said. "It is not illegal to hold certain philosophical or religious beliefs that may be contrary to the majority or minority. If I as a pharmacist object to something morally, my objections may be an aberration. There is little way to legislate an evaluation of my beliefs and whether or not those beliefs should be thrust upon patients. I don't know what the Wisconsin [bill] says, but I would be surprised if it can address this complex area."

Abortion may be the current flashpoint, but the issues pharmacists will have to confront are going to increase, said Michael Rupp, professor of pharmacy administration, Purdue Uni-
versity. Physician-assisted death, euthanasia, and capital punishment by lethal injection are certainly areas in which pharmacists could be involved.

Since the moral/ethical thicket will grow even thornier, Rupp favors the idea of individual pharmacists being able to determine what they will and will not participate in professionally. As a consequence, he said that there is also a need for a conscience clause to forestall retaliation by employers against R.Ph.s who refuse to participate in activities that run counter to their personal beliefs.

To refer or not to refer

The heart of the issue seems not to be whether an individual pharmacist has the right to refuse to dispense medications on moral-ethical grounds. The profession's real dilemma is whether that R.Ph. has a higher duty to refer the patient to another pharmacist or pharmacy willing to dispense the medication. Does the pharmacist's personal belief that dispensing some drugs may take the life of another human being outweigh the patient's right to that medication? If the patient is referred to someone else to get the Rx filled, has the pharmacist nevertheless participated in an activity that violates his or her beliefs?

Pharmacists who have moral or ethical reservations about certain medications should not be expected to refer patients to another R.Ph., said Jack Justice, Pharm.D., M.B.A., who is president of Adherence Inc., a Cincinnati-based CE provider and editor of the Pharmacy Ethics and Community Practice newsletter. Such referrals make the R.Ph. a passive, if unwilling, participant in what ensues. Noting that some in pharmacy have suggested that compromise is in order, he argues that something cannot be ethical or moral by degrees.

"People writing in this area tend to think that there is such a thing as allowable passive participation," said Justice. "Whether to be passively involved should be the individual's decision, and the right to do so should be protected if possible through professional organizations."

In practical terms, patient referral is a non-issue, observed Karen Brauer, a pro-life Indiana community R.Ph. who said she was fired last year by a discount chain after she refused to dispense Micronor (norethindrone, Ortho Pharmaceutical), which can be used as a morning-after pill, and transferred the Rx to a competitor. "A pharmacist of conscience should not have to tell a patient to do the obvious, namely, try another pharmacy," she said. "When he does that, he's telling the patient that he has certain ethics but he knows a particular pharmacist colleague who does not. When a pharmacist gives a [morning-after pill] referral, with or without an explanation, he's telling the woman to go somewhere else to do something he thinks is detrimental to her. That does not agree with the oath I took upon graduation from pharmacy school. When a pharmacist explains why he won't dispense a drug, he's risking a fight with the patient and the doctor. Many pharmacists don't have the stomach or the time for that."

Call to action

It would be a "prudent practice" for R.Ph.s who refuse to dispense an Rx for any reason to contact the prescriber to explain the rationale behind the refusal and fix the problem or ascertain whether alternative therapies are available, suggested NABP's Catizone. "In the conscience cases, if a pharmacist calls and says, 'I can't fill this prescription for an abortion-type product because I don't believe in abortion,' there will ensue a spirited debate between the prescriber and the pharmacist and probably a call to the state pharmacy board," he said. "At this time, most boards would probably respond that there is no legal mandate to require the pharmacist to dispense the prescription. The minority of boards, a very small minority at best, may contact the pharmacist and indicate he could face disciplinary actions if he does not dispense the prescription."

Pharmacy has not yet adequately addressed the issues posed by a refusal to dispense on moral-ethical grounds and needs to do more to open a profession-wide dialogue, said Catizone. He feels that if there is an issue the majority of R.Ph.s object to from a public health standpoint, perhaps national groups should take a stand and publish it. "For example, if physician-assisted suicide is an activity that most pharmacists feel is wrong, then our national pharmacy groups should issue public statements denouncing such activity and urging pharmacists not to participate ... and state boards to declare such participation as a violation of the pharmacy practice act."

Both Catizone and Justice agreed that more regulation is not the answer. Justice added that the courts use the standard of practice as a yardstick of professional expectations and conduct so that a pharmacy-wide consensus incorporated into state pharmacy practice acts would be a legal shield for pharmacists. Justice believes that it would be a foolish employer who would not comply with that practice standard.

After reaching a consensus, pharmacy should then work to make sure that pharmacists are protected in any physician-assisted death legislation introduced in the various states, said Justice. For example, the Oregon physician-assisted death law that is up before the voters again this election legally protects anyone who participates in the process. However, the right to refuse to participate is limited to health-care practitioners who are "licensed or permitted to administer medications," which leaves pharmacists out in the cold. "The language should be changed to protect administration and dispensing of medications," he said.

Pharmacy's powers that be should establish a standard of practice right now, but pro-life forces outside the profession are already ahead of the conscience clause curve, said Brauer, who now works part-time for a national chain. "The pro-life crowd is faster and will probably repeat the Wisconsin story several times over," she said. "Also more all-encompassing laws protecting medical employees will be passed. Pharmacy associations are going to be bypassed if they don't get the lead out on this issue."