11 March 2006

Pharmacists VS Patient Autonomy

This really pisses me off:

Druggists want right to say "no" to certain medications

This is not a new development, per se. It is, however, the first time this ugly little beast has reared its head in Washington State, and I am sorry to see it. It personally makes me angry. I do not see how pharmacists, who I generally respect as health care professionals, get off carving out a 'conscientous objector' exemption to providing care to certain persons of whom they disapprove.

Perhaps it is my own background that makes me so sensitive to this issue. I am compelled, both ethically and legally, to provide care to a great many persons whom I dislike or disapprove of. I have cared for Neo-nazis, drug users, spousal abusers, child abusers, felons great and petty; I have cared for individuals who have insulted me and assaulted and injured my staff; I have cared for individuals whose behavior I found deeply immoral and objectionable. I have no legal exemption to refuse to provide them with health care, nor would I claim such a right were it a legal option for me. Because it would be wrong.

When you sign up to become a physician, to a certain extent it means you have to check your personal prejudices at the door. When you are the provider of medical care, you are in a position of power, and the patient is at their most vulnerable. If you are providing a service which is urgent and/or not readily available elsewhere, your duty to the patient is at its highest, and any threat to withold that care is abusive. To be sure, in a non-urgent setting, or for services which are readily available elsewhere, I have no problem with a doctor saying that for personal reasons he or she cannot care for a given individual or provide a particular service. But it is an ethically dicey matter to do so, and must be done in a manner which is consistent primarily with the patient's best interests and only secondarily with the provider's personal values.

The pharmacists have little ground to claim any such exemption. Their involvement with the patient's care in these cases is minimal and their relationship with the patient is superficial at best. Their power, however, is disproportionately magnified, since they have the ability to refuse to allow the patient to fill a prescription written by a provider with whom the patient has a stronger relationship. In essence, the pharmacist has little involvement in the decision-making process, yet for some reason feels they should be able to exercise a veto. And one should not assume that, refused at one pharmacy, that patients will necessarily be able to fill their prescriptions at another nearby one.

Now I am not dissing pharmacists -- many an alert PharmD has prevented me from making errors or helped with a difficult case. But that some pharmacists are upset about abortion or feel that it is wrong: I am not particularly sympathetic. The principle of patient autonomy and self-determination should trump their (and my) delicate sensibilities about what we feel is right for the patient. We as health care providers can guide patients to make good decisions, we can provide information and counsel, but we cannot project our own values onto patients in their hour of need.

And it is even more irritating that I suspect that this is an issue not truly because there are a lot of pharmacists who truly feel that their consciences are being violated, but rather that the right wing has found themselves a new wedge issue to play politics with health care.


  1. As a person who is not a health care professional, I will tell you that I consider the pharmacist an agent of my doctor and me. That agent has in some cases been an invaluable source of knowledge to me in getting medicines, mostly in the case of my children.

    As far as that goes though, I would be pretty angry to find that my pharmacist would wield an opinion about my healthcare above a simple sanity check or proferred knowledge on the dry facts of a particular drug or treatment. In other words they are there (in my opinion) to carry out the wishes of my doctor and me, and should intervene only in the case that there is reason in their professional opinion that the treatment or medicine I am taking is counter to *my or my doctor's* intended course.

  2. I generally try to give pharmacists credit as being more than human pill dispensers. I do know that there have been many times that I have gotten a call from the pharmacy regarding an order/prescription I have written where the pharmacist said "I noticed that patient is on drug X and it interacts with your order, how about substituting it with Y?" Or where they have helped with dosing a drug I use infrequently. Or where I prescribed a drug the patient was allergic to. So, again, I value their input as members of the health care team.

    But you put it very succinctly -- they are agents of the patient&physician who determine the course of care, and should not interject themselves into the decision-making process unless there is a relevant technical reason. I couldn't agree more.

  3. Here in IL, some pharmacists were refusing to fill birth control prescriptions for the simple fact of they (and their religion) did not believe in it! Well, that's all fine and dandy for you, but I believe in it so gimme my damn pills!

    I have noticed that the prescriptions in jeopardy are birth control of some sort, be it the morning after pill or daily birth control pills. Religion and personal beliefs do not mix with medicine! As you said, you have to treat ANYONE that walks into the ER, and you'd lose your license if you didn't! So how can a pharmacist discriminate and get away with it?

  4. So, with regard to abortion in particular, would you, Shadowfax, as a doctor be required to perform one if a patient so demanded?

    I imagine the answer is "no", because you would refer the patient to a specialist. However, if that wern't the case, could you refuse to perform the procedure on some other grounds?

  5. Well, I can't answer this because I am not an OB. Having said that, there are many times a patient has requested a certain course of treatment and I said no on medical grounds. There's no obligation to provide care which is not medically necessary or which, in my medical judgement, is more likely to hurt than to help the patient. This is definitely the case with elective things like plastic surgery or, one would suppose, abortions. There are lots of OBs who do not perform abortions. Usually that is more because of the hassle involved than for any moral objection. But there's no mandate to provide the service, or even to provide a referral for the service.

    But that's not really the question, is it? Are there things that I could claim a moral exemption from? Hard to think of an example in the ER. I suppose if a patient came in with complications related to an abortion, some ER docs who are pro-life might not want to be involved because they would not want to be complicit in the crime. But ER docs are unique in that we have a federal law, EMTALA, which is controlling and requires the ER doc to at a minimum, "stabilize" the patient. Maybe if a family wanted to make an inappropriate end-of-life decision, I might refuse to go along. Again, it's usually pretty black and white in the ED. If the family says "no code," we let the patient die -- I've never had a family say that in a case where I felt the patient should be resuscitated. If that happened, it would probably be pretty easy to err on the side of life, remove the family from the room, and resuscitate the patient, then let the lawyers figure out later what should be done. OTOH, if the family says "do everything," in a patient who is obviously too far gone, I can tell them it's too late and on grounds of medical futility, override their request. That would be pretty risky, and in the rare case where there is disagreement I tend to err on the side of life, send the patient upstairs, and let the ICU ficure things out in a more deliberate manner.

  6. Very well written argument, "Shadowfax". I agree with you entirely.

  7. On a short vacation and perusing your blog. Powerful stuffs!

    Any way, on the subject of pharmacists refusing Rx, there have been many times after taking care of a sexual assault victim, I write a prescription for emergency contraception (usually 2 tabs of Ovral to take 12 hours after the dose given in the ED, or just Plan B) the patients return to the ED informing that they could not find any pharmacy in town that carries the meds. Horse pucky, I have personally called these pharmacies and confirming that many do carry them. The pharmacists are making personal decisions not to fill them. I call up their corporate headquarters and literally all of them leave the judgement up to the personal discretion of the pharmacists on duty to fill them or not. As for the rape victims going to the pharmacies to get their Rx fill, who would want to tell the pharmacists that they've been sexually assaulted. Furthermore, it's none of their business, frankly. In the state that I work at, it's illegal for the hospital/ED to dispense meds for patients discharged from the ED. So you can't write "Ovral 2 tabs PO now and dispense 2 tabs to be taken in 12 hrs." I called the Board of Medicine in my state regarding this and yup, that's the stupid law.


Note: Only a member of this blog may post a comment.