Wednesday, April 4, 2007

Christian Pharmacists and Plan B

I attended a lecture today hosted by the Christian Pharmacist Fellowship on campus about right of conscience and Plan B.

Two things were striking to me.

The lecturer spoke briefly about independent practitioners vs dependent practitioners. This is very interesting to me in light of the recent lecture in our Disciplines of Nursing course on negligence, beneficence (doing good for a patient - treating each patient with utmost of my skill and ability) and non-maleficence (not harming a patient - which can at times mean going up the chain of command until a prescribed treatment that I know to be harmful to this patient is removed from the orders).
RNs are dependent practitioners in that we are providing only the medication, and in some cases, the treatments (such as dressing changes, restraints, O2 administration, etc) that is ordered by a physician, nurse practitioner, or physician assistant. That dependence on orders does not in any case excuse us from liability or responsibility to the patient's health and care.
I think that the lecturer conflated this concept of responsibility and dependent practice. He gave two examples of when a prescription violates what the pharmacist knows of the patient (interactions with other medications or treatments, and I'm drawing a blank on the other example) as support for the exercise of a right of conscience. He kept saying - Wouldn't the pharmacist have the right of conscience to refuse to dispense a medication they know or suspect to be likely to cause blah blah side effect?
Maybe I don't understand what "right of conscience" means. That sounds like negligence, and it's covered in the nursing practice act from our state. It isn't based on my personal moral convictions. The refusal to fill a prescription that may cause a lethal interaction with existing meds is motivated by the pharmacist's professional knowledge and ethical imperative to act, not a moral objection to the patient's death. It seems that he was drawing a connection between two dissimilar situations - one of medical knowledge and professional standards, and one of moral imperative being used for professional conduct. The impetus for non-maleficence is not moral in basis - it is via professional standards of care. The impetus (within my limited understanding from listening to this brief discussion) for refusing to distribute Plan B is that there is a small risk that it could prevent the implantation of a fertilized egg, deemed a human life, and could therefore be promoting abortion (as opposed to preventing pregnancy). The argument is that pharmacists may not be required to give a patient access to a drug that could kill a baby when the pharmacist has a moral objection to that death.
This risk is small, and exists with all manner of other medications, this idea is the direct result of targeted campaigns to frame Plan B as an abortifacient instead of contraception, and in my opinion the objection to contraception is likely the more prevalent moral objection of pharmacists. Furthermore, objection to contraception is so often concurrent with denial of the circumstances that lead to unwanted sexual activity. Women's health IS unique in that we are both able to become pregnant after sex with a man, and not able to avoid sex with a man.

Here's what I wished he would have talked about: Pharmacists seem to be a special kind of dependent practitioners. They are not directly administering meds, as an RN does with an IV push; they are making it available to the patient, with counseling and education. I wonder how this changes the debate, if at all. Some of the students seemed to be leaning towards the decision to dispense, but with vigorous counseling. It made me a feel a little itchy to hear the kinds of questions they would ask - sexual activity, usual birth control methods, informal referral to a primary practitioner - because of the likelihood that personal judgments would creep into a conversation like that. Is that okay for a pharmacist to ask those kinds of things? Is it okay for that kind of conversation to be taking place at the counter in a typical pharmacy?

The second point that I waited afterward to discuss (but never got a chance to, because I felt uncomfortable pushing ahead of pharmacy students) was regarding this idea that pharmacists can either give out the meds or step out of the process, but facilitate the patient's ability to get Plan B somewhere else. Number one - who decided that? (I'm sure a quick google and I can answer myself) But my question at that point becomes, why not just give it yourself? If the moral drive is so strong that you would advocate for the patient not taking Plan B (and again, I wonder how pharmacists can manage to be in practice without a clear understanding of the mechanism of the drug), then how can it be satisfying to send them to another pharmacy? What if the woman does become pregnant after unprotected sex because of her inability to get Plan B and ends up having a surgical or medical abortion? Are the rules about this different in an area where there is only one pharmacy, like an isolated rural town or military base? What if there are functional limitations on access - such as the patient does not own a car, or is only allowed a short break from work, and sending her across town or asking her to wait an hour until Pharmacist McWillingtoDispense comes on?

There was a brief conversation about the possibility that a Christian pharmacist may feel uncomfortable giving a transgendered person their hormone therapy, because of a moral objection to their decision to pursue gender re-assignment. It seemed that most in the room were in agreement that this would be motivated by a personal bias, rather than Christian doctrine, and everyone nodded when the lecturer said that it would be wrong and illegal to refuse needed medication to a black person because of racist attitudes. again - the example isn't good enough. What I wanted to understand was - how are you teasing out moral or religious motivations from personal opinions or bias? How can you absolutely say that they are different? And why did you retreat to the "easy" example of racial discrimination to respond to the question of transgendered rights - were you making the point that blacks are legally protected from discrimination but people who are transitioning from one gender to another are not?

I hope that my best friend from high school will comment to this - she's recently gotten her PharmD and started her own pharmacy, which is such an incredible accomplishment that I don't think I've made a big enough deal about. I'm so proud!

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