Ted Williams
Pharmacy 728 Winter 2006
Ethics Paper
Introduction
The right of pharmacists to refuse to fill prescriptions is one of the hottest ethical topics in pharmacy today. Our pharmacy practice class has been conducting an online discussion of the moral dilemma. The positions presented there mirror the arguments in the popular culture. The other side asserts that the right to refuse is intrinsic to the pharmacist’s job is the ability to use their professional morals to determine if a prescription is appropriate. The arguments against the right to refuse cite the rights of the patient to receive a legally obtained prescription from any and all pharmacists. Both camps start from their conclusion and worked backwards to justify their position. To my mind these discussions miss the mark. There is very little discussion of the nature of the ethical violation. The discussions on both sides seem to concede that there was an obvious moral violation and that the pharmacist intentionally violated professional ethics for personal ethics. This approach precludes mutually beneficial agreements. Ethics discussions must explore how pharmacists canresolve moral dilemmas, either professional-personal or profession-professional conflicts. This seems the true kernel of the problem. How do we, as learned professionals, deal with moral conflicts?
Ethics Defined
Ethics are the rules defining right and wrong which guide behaviors (Wikipedia). Ethics and morals are, for the purpose of this paper, will be used synonymously. Everyone has personal ethics, which they follow or do not follow. Public policies are rules intended to govern behavior. Public policies generally come about to resolve contentious ethical issues. There are essentially four possible intersections of law and ethics, legal and ethical, legal and unethical, illegal and ethical, and illegal and unethical (Schnabel 2006).
Ethics of the Pharmacist
As members of the pharmacy profession, we have an additional set of ethics decided upon by members of our profession and the general public. It is impossible to discuss an ethical dilemma without clarification of the ethics involved. For this discussion we will use the APhA ethics.
Failure to follow professional ethics, may call into question an individual’s membership within a profession (Beauchamp and Childress 2001).
Ethical Dilemmas
What is an ethical dilemma
Ethical dilemmas are common in healthcare professions. There are several types of ethical dilemmas. Dilemmas can arise from disagreements about the facts (when does life begin), who’s rights are being infringed upon (pharmacists, patients, doctors) and which ethical rules are applicable (serving the community vs. patient autonomy) (Beauchamp and Childress 2001). In addition to the obvious ethical conflict between self interest and ethical behavior, ethical conflicts can arise from one course of action being more ethical than another ethical action. Ethical conflicts can also arise when all available options will break an ethical rule, i.e. a choice of the least of two evils (Beauchamp and Childress 2001). The union of these two sets of conflicts least to a host of complex ethical dilemmas.
Resolution of Ethical Dilemmas
This paper will use the following approach for resolving ethical dilemmas: 1) identify the nature of the ethical conflict, 2) weight the relative importance of the conflicting ethical rules, and 3) determine how best to weight conflicting ethics. This process will be applied to deconstructing the refusing to dispense Plan B contraception. Normally, representatives of all populations (physicians, patients, pharmacists) should be involved. In the absence of a roundtable discussion, I will use position papers and, when necessary, make and note assumptions.
What are the ethical dilemmas of refusing to fill
A chief assumption of this discussion is that the conflict does not involve a pharmacist which is knowingly acting in a way that violates APhA ethics for self interest. This type of behavior is categorically unethical and should be grounds to consider if the individual is fit to be a pharmacist. This was the case in which the Wisconsin Pharmacist refused to fill an oral contraception prescription and was reprimanded by the board (Alexander 2005). This type of behavior violates a patient’s right to autonomy and dignity without obviously serving any other pharmacist ethic. Likewise, if a pharmacist has no intention of filling a Plan B prescription and hides this from his employer, this would be a violation of tenant IV of the APhA code of ethics. This paper is interested in the discussion of pharmacists who have different interpretations of the APhA ethics or have conflicts between different ethical tenants.
Both the APhA and the Christian Pharmacist Fellowship International (CPFI) agree that pharmacists should be able to refuse to fill prescriptions if they feel that harm will be done to the patient (APhA Code of Ethics and CPFI). This agreement allows the pharmacist to preserve their own ethics and do what they feel serve the greater societal need. This position strikes a balance between the autonomy of the patient, respecting the opinions of other healthcare providers, and allowing for the pharmacist to practice within their interpretation of non-malfeasance. Neither organization supports the right of a pharmacist to interfere with a patient filing a legally obtained prescription. Withholding a prescription violates several ethical tenants (patient autonomy, respecting other professionals) while not acting to serve any ethical tenants of the pharmacy profession. This is another situation of promoting self interest and personal morals at the expense of professional morals. But baring the last situation, an individual pharmacist can ethically refuse to fill a prescription while still allowing a single patient to receive the appropriate medical care.
But should a patient be forced to shops their prescription around town to find a pharmacist willing to fill it? This situation seems like a clear violation of the patient’s dignity. But should a pharmacy be required to fill a prescription they think is morally wrong? A careless analysis would suggest that pharmacist’s refusal to fill inevitably will seriously harm the patient’s dignity and possibly their health. I would assert this is not the case. Resolving this problem requires a bit of thought, creativity, and focus on the morals.
One proposed solution is to require pharmacists to refer patients to a pharmacy which will fill the prescription. Although this solution solves the problem of retaining the patient’s dignity, it does not address the pharmacist right to non-malfeasance. Passive malfeasance can be argued to be morally equivalent to active malfeasance. This solution does not seem to achieve a balance between patient rights and pharmacist’s right.
The problem remains as to how to allow the patient to obtain a prescription from a pharmacy willing to dispense the drug without forcing the patient to shop around. If only two players, pharmacist and patient, are considered, this is a very difficult problem. But if the physician is considered, a mutually acceptable solution becomes obvious. If the physician takes on some responsibility for referring the patient to an appropriately equipped pharmacy, then individual pharmacists are allow to follow their morals, patients are able to preserve their dignity, and medically appropriate prescriptions can be delivered to the public. This situation does not seem dissimilar to Naturopathic physicians who prescribe custom estrogen combinations. To expect a patient to go to Fred Meyer and pick up a custom cream of bio-identical E1, E2, E3, Testosterone and Chrysin-50 is ridiculous. The physician has some professional obligation to inform the patient of where they can obtain such a specialized medication. Likewise, with such a controversial medication like Plan B, it doesn’t seem unreasonable for a physician who prescribes Plan B to provide a list of pharmacies which dispense Plan B. It seems appropriate for the Board of Pharmacy (BOP) to maintain such a list for physicians to use, but the physician could easily provide the list to their patients.
The above arrangement would be feasible in urban areas where dozens, if not hundreds of pharmacies are available to provide Plan B. A new problem arises in more rural areas, where there may only be a few pharmacies within a hundred miles. Patient’s rights could be compromised if all of the area pharmacists refuse to fill the prescription. This situation could be addressed by the Board of Pharmacy acting to protect the public without treading too heavily on pharmacists right. One of the responsibilities of the BOP is to license pharmacies. It would seem reasonable for the BOP to require that if a pharmacy is the only pharmacy within some distance (e.g. 10,15, 25 miles), then they would be required to stock Plan B and have a pharmacist on site or on call that would fill the prescription. If a pharmacy fails to fill such a prescription, then its license could be revoked. This proposal allows for individual pharmacists to refuse filling a prescription, and preserves the patients right, while only restricting commerce somewhat. This solution illustrate how focusing on the ethics of a problem can prevent heavy handed legislation while preserving the rights of pharmacist and patients alike.
Conclusions
A physiological illness can be identified by symptoms. But symptom relief does not necessarily relieve the disorder. Likewise, addressing the manifestations of ethical dilemmas and disagreements does not lead to mutually acceptable outcomes. As a profession, pharmacists must accept that ethics are always subject to conflicting interpretation. The goal of identical interpretations of ethics is an unreasonable and unproductive goal. A better goal is to teach pharmacists how to proactively identify and resolve ethical conflicts by working collaboratively with all stakeholders. This goal leads to ethical pharmacy practices and superior patient care.
References
APhA Code of Ethics Downloaded from on 2/28/2006
Christian Pharmacist Fellowship Ethics Statement. Downloaded from on 2/28/2006
Ethics Defined. Wikipedia Downloaded from on 2/28/2006
Joe Schnabel, Winter 2006, Pharmacy Law Lectures
Principles of Biomedical Ethics, 5th ed. Beauchamp, T. L., Childress, J.F. OxfordUniversity Press, 2001 New York