Don't Allow a Pharmacist's Religious Views to Impede on the Doctor-Patient Relationship

Indiana is in the midst of a property tax crisis, we are experiencing more mortgage foreclosures than most other states, crime is (or at least appears to be) on the increase, the Colts lost in the playoffs, and many Hoosiers cannot afford quality health care or health insurance. Yet, rather than attempting to work on addressing these issues that are of grave concern to most Hoosiers, Indiana State Senators Patricia Miller and Jeff Drozda have once again introduced a series of mean-spirited bills aimed at limiting a woman's reproductive rights and inserting the State of Indiana into religious debates and religious doctrine that is thousands of years old.

What exactly have Sen. Miller and Sen. Drozda done? Let's take a look at the two bills: Senate Bill 3 and Senate Bill 146. I'll address Senate Bill 3 today and leave Senate Bill 146 for another day (as it raises even more fundamental and troubling problems that I want to take more time to address).

Senate Bill No. 3 (SB3)

This bill falls into a category of legislation that has been cropping up around the country, referred to alternately as a "pharmacist refusal" or "pharmacist conscience" bill/law. According to the official digest of SB3 (as updated January 9, 2008), the bill provides, in part, that:

a pharmacist may not be required to dispense a drug or medical device if the drug or medical device would be used to: (1) cause an abortion; (2) destroy an unborn child; or (3) cause the death of a person by means of assisted suicide, euthanasia, or mercy killing.

Think, for a moment, what this bill is really saying. Even if a doctor prescribes a particular medication, the pharmacist has the right not to fill the prescription because of the pharmacist's own beliefs. SB3 allows the pharmacist to insert his or her own religious views into the doctor-patient relationship. Just it case it isn't obvious, parts (1) and (2) of the bill are clearly aimed at the emergency contraceptives (like the so-called "morning after pill").

There are numerous problems with SB3. First, how does the pharmacist know that the doctor didn't prescribe one of the medications described in part (1) or (2) as a result of the doctor's concern for the health of the mother? What if the mother is physically frail or suffering from a serious illness and her life will be jeopardized by the pregnancy? Who should really be deciding if this woman can have an abortion. What if the medication were prescribed because the woman was raped or was the victim of incest? It may be difficult enough for her to go to a doctor, let alone go to the pharmacy to get the prescription filled. But now, she has to worry about whether the pharmacist will fill the prescription. Just imagine her anguish as she goes from pharmacy to pharmacy.

This may not really be a major issue in large cities. If the pharmacist at Wal-Mart won't fill the prescription, the woman can walk across the street to CVS or Walgreen's. But what about small towns that might only have a single pharmacy? If that town's pharmacist refuses to fill the prescription, the woman may be entirely out of luck or might have to travel to another city, just to get a legal medication that was legally prescribed for her by her doctor. And consider that, in the case of emergency contraception, time is of the essence. The drug must be administered within 72 hours. If a patient has to "shop" for a pharmacist that will honor the prescription legally given by the patient's doctor, there is a possibility (higher in rural areas) that time might run out.

Which raises another interesting point. Isn't there some likelihood that the woman who is unable to obtain the emergency contraceptive will, instead, seek an abortion? Query which is worse: Providing a prescription which will prevent a fertilized egg from implanting in the uterine wall or forcing a woman to begin an unwanted pregnancy only to terminate it shortly thereafter? In other words, a pharmacist can rely upon his religious beliefs to force a woman into confronting one of the most difficult decisions that any person should ever have to make. Available and effective birth control should lead to fewer abortions, so making birth control harder to obtain makes no real sense.

One other interesting point to note. Sen. Drozda, the SB3's author, claimed during a committee hearing on SB3, that the bill was not intended to cover contraceptives. "Contraception is not covered," Drozda is reported to have said. Yet, according to that same report, after the committee hearing, Drozda is further reported to have acknowledged that a pharmacist could interpret the legislation as protection for refusing to fill a prescription for birth-control pills. Drozda apparently stated that he intends for SB3 to cover the morning-after contraceptive. (See "Senate panel OKs measure to protect pharmacists", The Courier-Journal, January 10, 2008.) So, was Sen. Drozda lying to the Senate committee or to the reporter? And if SB3 is not intended to cover contraceptives, then what, precisely, is it intended to cover? For that matter, what, precisely, is an "unborn child"? At what point does a egg, blastocyst, zygote, embryo, or fetus become an unborn child? And are we supposed to leave that decision up to a pharmacist?

And consider the implications of part (3) of SB3. Recall, first, that euthanasia is illegal in Indiana (an interesting subject for another day...). Just imagine a terminal patient in hospice who is in terrible pain. The patient's doctor decides to prescribe a very, very heavy dose of painkiller to relieve the patient's suffering. But the pharmacist, concerned that the dosage might be too high, can simply refuse to fill the prescription. I would hope that a concerned pharmacist would communicate the concern to the doctor, saying, perhaps, "Gee, I think that the dosage that you prescribed is too high and puts the patient at risk of dying." But SB3 doesn't mandate this kind of communication or even direct the pharmacist to dispense a lesser dosage of the drug; no, SB3 allows the pharmacist to simply refuse, thereby interfering in the doctor-patient relationship and, potentially, allowing the patient to suffer. And if the patient is in a hospice or hospital and the pharmacist is on the staff of the hospice or hospital, how exactly is the patient to get the medication? Are we to exepct the bed-ridden patient to walk down the street to find another pharmacist?

One might ask to whom the pharmacist's duty lies: the patient or the pharmacist himself?

I also note that the website for the Indiana Pharmacists Alliance makes no mention of SB3. All that I can conclude from this is that it is not an issue high on the list of priorities to Indiana's pharmacists. The American Pharmacists Association ("APhA") supports pharmacist refusal provisions, but:

APhA’s two-part policy supports the ability of the pharmacist to step away from participating in activity to which they have personal objections—but not step in the way. The Association supports the pharmacist’s right to choose not to fill a prescription based on moral or ethical values. But recognizing the pharmacist’s important role in the health care system, APhA supports the establishment of systems to ensure that the patient’s health care needs are served.

The American Medical Association's resolution on the subject recognizes that responsibility to the patient is paramount and advocates that, in situations where a pharmacist may refuse to dispense a prescription, that the pharmacist either direct the patient to a pharmacy that will dispense the prescription or allow the prescribing doctor to dispense the prescription. SB3 would allow the pharmacist to refuse without telling the patient where the drug could be legally obtained.

I'm also worried about the slippery slope that this bill starts our state down. What's next? Might a pharmacist be granted the right to refuse to dispense any contraceptive? What about ED drugs (some might say that would be a good thing...)? What about other medications that the pharmacist doesn't approve of? (Apparently, one pharmacist who testified in favor of SB3 stated that she even refuses to dispense hormones!) What about generics (after all, the pharmacist might make more money only dispensing name brands)? Perhaps a particular pharmacist owns stock in Eli Lilly; could that pharmacist refuse to dispense brands made by other companies? Where does it end?

It is also worth examining the Code of Ethics for Pharmacists (promulgated by the American Pharmacists Association). Below are the relevant canons (emphasis added):

I. A pharmacist respects the covenantal relationship between the patient and pharmacist. Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.

II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private andconfidential manner.

III. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients.

IV. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients.

...

VI. A pharmacist respects the values and abilities of colleagues and other health professionals. When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient.

VII. A pharmacist serves individual, community, and societal needs. The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, the pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly.

VIII. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society.

Compare these ethics to a pharmacist refusing to dispense a prescription because it conflicts with the pharmacist's religious beliefs.

Apparently, some pharmacists have argued that the bill is needed because requiring pharmacists to dispense drugs for purposes that violate the pharmacist's religious beliefs is a violation of the First Amendment. Yet this argument is a red herring because the pharmacist is not taking the medication; rather the pharmacist is simply dispensing a legally prescribed medication. Could a police officer refuse to arrest someone for polygamy on the grounds that the police officer's religion permits polygamy and forcing the officer to enforce the law that he disagreed with would violate his religious beliefs? Could a teacher ignore (or even teach contrary to) adopted state educational standards if those standards conflicted with the teacher's religious beliefs (don't get me started on the whole "intelligent design" debate)?

At the end of the day, we need to recognize that the role of the pharmacist is to dispense the medications that a doctor legally prescribes. If the pharmacist is concerned that the particular medication will be dangerous for the patient (e.g. a drug interaction or allergy), then it is the certainly the role of the pharmacist to raise this concern with the patient and/or doctor. But it is not the role of the pharmacist -- nor should it be -- to tell a patient which prescribed drugs they can or cannot have on the basis of that pharmacist's religious beliefs. Nor should it be the role of the pharmacist to insert his or her own belief systems (as opposed to medical, chemical, and biological knowledge) into the physician-patient relationship.

But the, I doubt that Senator Drozda cares about any of this; his only concern appears to be preventing abortions.