Sunday, March 06, 2005

Response to my previous post in re "Pharmacist Denies Patient..."

I will now try to address each of the four points, expressed in my post of 03/03/2005. Given the medium, I will attempt to do it with some brevity:

1) I feel that perhaps the whistleblowing comparison was somewhat off-the-mark or unnecessary. Either way, the following do relate and provide a better picture of my argument.

Moral obligations of the pharmacist should be bifurcated as such: a) the professional obligations of the pharmacist, which in turn become the moral prescriptions of the role; and, b) the moral obligations of the person who happens to fill the role. So the moral obligations of the pharmacist was to provide medicine for the welfare of the patient in a safe manner. The moral issue for the individual was the conflict between the morals of the profession and their own personal moral beliefs. How are we to evaluate this dilemma?

Applbaum, in his discussion of Personal, Professional, and Political Morality offers an analysis that should help to further frame the issue in hopes of providing a worthy response:

You may not impose on the public your personal, nonpublic, promissory obligations (for impartial reasons); your personal, nonpublic morality (for liberal reasons [understood to mean "justice"], or your personal view of public morality (for skeptical reasons). --p.68.

The pharmacist failed the impartial obligation above as imposing his beliefs went beyond the duties of his role; he failed the liberal obligation by imposing his personal moral beliefs on the public and at the cost of the public (i.e. the patient); and ,I don't believe that it is relative or that he failed the skeptical obligation above as he did not directly impose his beliefs on the patient (rather, she experienced the consequences of the first and second point as described by Applbaum). Breaking down role-obligations to the tripartite structure provided above helps to elucidate the elements which are relevant in any role because they break down the obligations of the role and the person to it's immediate level (i.e., the person), an intermediate level (i.e., the role), and the supra-level (i.e., society).

2) The role responsibilities of pharmacists is to provide medicine to patients in a safe manner. More specificity may be found as described in the
Code of Ethics for Pharmacists. A reading will show that the pharmacist in question failed to uphold numerous edicts outlined in that code.

3) Based upon the above, I would posit that the pharmacist was in deriliction of the duties prescribed by his role, and hence, it was wrong for him to deny the prescription. Additionally, there may have been other ways for him to protest or actualize his personal moral beliefs w/o acting contrary to his responsibilities. For example, by transferring the prescription to the other pharmacy --I can see that he would still have had to have "dealt" with the contraceptive and its moral consequence for him, but that would certainly be removed enough of a circumstance as to be radically abstract.


4) With regards to the health care repercussion of this point (i.e., the Kantian categorical imperative), I feel somewhat out of my element, but I'll give it a shot anyway: a) If each pharmacist did this, there would easily come to exist such an overwhelming number of types of pharmaceutical care that any semblance of a normative standard of care would be hugely difficult to establish; and b) patients may be harmed if they encountered a pharmacist who did not prominently advertise his beliefs and the resultant specifications of those beliefs on his role (i.e., not dispensing certain drugs) --to name a few that readily come to mind. The two points above are important for their relation to the philosophy of science and patient care.

The trouble is that the morals of the pharmacist don't exist as grounds for accepting them to be more established beliefs that could be the basis for proper law and public policy (e.g., utility, justice, liberty) because there is such variance in belief among reasonable persons holding religious beliefs.

--Referenced:
Ethics for Adversaries by Applbaum.

75 Comments:

Blogger The Clerk said...

I couldn't disagree with you more on this topic.
Where does this moral obligation to provide medication come from? Just because someone went to pharmacy school, he has a moral obligation to get drugs to everyone who brings him a perscription? No. I believe the moral obligations of the pharmacist begin after he agrees to dispense the medication (i.e. he has the obligation to do it correctly, safely, confidentially, etc). But, up until that point, he has no contract and no relationship with the patient. His refusal to dispense medication is analagous to a physician's refusal to provide certain treatments. (i.e. it is ethically acceptable for doctors to refuse to do abortions, provide euthanasia or provide cosmetic surgery to patients with somatoform disorders). Healthcare professionals have many ethical obligations. The so-called "duty to treat" is not among them. Healthcare workers have always had the right to refuse to provide treatment they view as unethical.

March 15, 2005 5:08 PM  
Blogger The Clerk said...

This comment has been removed by a blog administrator.

March 15, 2005 5:08 PM  
Blogger Bioethics Dude said...

Dear Clerk,
Thank you for your thoughtful comments. In response…1) the moral obligation to provide medicine comes from the morals of the role the pharmacist (or any other individuals in any other role –policewomen, etc.) serves. I would agree with you that up to the point of dispensing medication the pharmacist has no relationship with the patient, but that relationship or lack thereof does not comprise a moral obligation toward a patient…but that’s needless hairsplitting; 2) His obligations are described in the license issued to him by the state as well as the oath he took. So here’s a question for you: given the Hippocratic Oath that doctors swear allegiance to, what if they refuse to assist a patient because it would conflict with their own individual ethics and as a result do harm the patient? Among the reasons that these oaths, creeds, and licensing terms exist is to establish uniform ethical and moral standards that each role is to abide by IN ORDER to ensure uniformity of care –as much as possible anyway. 2a) Being a philosopher I cannot help but generalize from that particular: what if all pharmacists based dispensing/caring for folks upon their own individualized ethical beliefs? We may end up w/ tiers of folks w/ different well-being levels based upon the pharmaceutical community they live in…3) I would ask that you can see the CDC’s Public Health Law Program #4 Reading www.phppo.cdc.gov/od/phlp/PHlawreadings.asp, p. 7, wherein family planning is the third biggest contribution that public health has achieved toward ensuring public good (i.e., health of the populace). So withholding that form a patient harms them, and society; 4) I don’t believe that decisions of such nature should be made by one individual, the reason we have ethics committee’s is because there is an ethical equipoise about these things and a group of representative members should make such decisions, not one person; and 5) as usual, I’d welcome any citations you have that corroborate your point.

Sorry for the brevity and delay, I have been having a bitch of a time posting since 03/11…I hear the folks at Blogger are working on it. Thanks for posting and I liked your blog. –BD.

March 17, 2005 8:46 AM  
Anonymous Anonymous said...

dude -
I don't think there's any ethically acceptable resolution of this conflict between the moral beliefs of the pharmacist and the rights of his customers to have access to contraceptives which confines itself to the zero sum scenario where if one "wins" the other must "lose." But if contraception was "de-medicalized" (biologically normal pregnancy, after all, is not a disease/pathology), an alternative would be available that could respect the rights of both -- namely, over the counter status for contraceptives.
If you can appreciate that contraception has been inappropriately medicalized, you might also rethink your interpretation of the role obligations of pharmacists.
Oh, and as someone with training in philosophy, you should know that the pharmacist in question is not "imposing his beliefs" on those he refuses to assist. He's simply refusing to act as if he shared their beliefs.
Bob Koepp

March 22, 2005 11:21 AM  
Blogger Bioethics Dude said...

Dear Bob,
First, thanks for the comment! I find it somewhat interesting how much attention this issue has drawn versus the others posts…perhaps I should focus more on the philosophical aspects of issues. I’ll respond in corresponding order: 1) in re having no ethically acceptable solution; I think that your going between the horns response vis-à-vis removing contraceptives from the prescription list is a great suggestion (hopefully though it would still have some way of educating the user). I didn’t think of this…also, the role of obligation of the pharmacist would then be a moot point. 2) By “imposing his beliefs” I meant such an imposition through an omissive act, rather than one of commission; and hope that this isn’t philosophical hair splitting. Perhaps I should have been more clear in my post about this nuance…Generalizing from your comment, I believe you would still disagree with this…and I’m not sure how to bridge that conceptual gap. Finally, 3) (and this may sound pissy, but it really isn’t) the training in philosophy is one element that I think allowed me to see this in its many facets and for the role conflict and imposition. Applbaum, from whom I took heavily, is a philosopher who addresses role ethics. If you’re interested –and it may make for constructive disagreement- this link has a pretty good abstract of the book with some detail of the contents: www.pupress.princeton.edu/chapters/s6629.html. Thanks for posting Bob!

March 22, 2005 2:07 PM  
Anonymous Anonymous said...

dude -
responding to your point #2: The distinction between acts of commission and acts of omission is standard fare in action theory, so don't worry -- it's not mere hairsplitting but absolutely essential. That said, we do still disagree, since it's also pretty standard to recognize that imposition involves acts of commission, not omission. I believe this is also recognized in the law (e.g., failure to rescue a drowning victim will (ceteris paribus) not get you charged with murder, or even manslaughter -- even if you're a lifeguard, the charge will be dereliction of duty contributing to a death; but not homicide).
Regarding your point #3: My earlier remarks about how considerations of inappropriate medicalization might affect one's interpretation of role obligations still stand. To illustrate: In another case in which a pharmacist refused to dispense contraceptives, he explicitly stated that he would willingly provide them if there was a "legitimate medical reason" for doing so -- but he thought that preventing a biologically normal pregnancy didn't meet that standard. In other words, he interpreted his role obligation as the provision of medications for the treatment or prevention of medical pathologies, and so excluded non-medically indicated contraception from his purview.
Bob Koepp

March 22, 2005 3:12 PM  
Blogger Bioethics Dude said...

In re #1: I’m unable to cite anything definite and philosophical to corroborate my point at this time (not sure if Applbaum covers this and I would have dig back further…what would Kant or Aristotle say…), but would continue to persist that omissive acts should be included, based also on the following point you made above: the legal system recognizes the failure to act by noting any penalty as a dereliction of duty (i.e., failure to act per the charge of the role). In re #3: Hmmm…I think I agree with you on this one actually, because the pharmacist specified their claim. That specificity is important to me as in the case we’re discussing the pharmacist’s action was overly broad to generalize from in such a way that it would not lead to inconsistency in the health care system, and general ethics. In particular, the distinction of basing such a decision on treatment – prevention is significant. Glad you commented! The Dude feels wiser, and it was a good exchange. What do you do? If you don't mind me asking...can contact off line...

March 22, 2005 4:26 PM  
Anonymous Cyberdog said...

Re #3: It is unethical for the pharmacist to make this decision. He's a pharmacist, not a physician, and he's certainly not the patient's physician. How would that "not lead to inconsistency in the health care system"? Pharmacists aren't licensed to practice medicine.

April 06, 2005 11:19 PM  
Blogger Bioethics Dude said...

Thanks Cyberdog...however, I think that we agree. I could not find anything to the contrary of the quoted text and your intent in my post. Thanks --BD

April 07, 2005 9:48 AM  
Anonymous Cyberdog said...

Sorry, BD. I was tired and reading too fast. I like Bob's suggestion about "de-medicalizing" contraception. Another approach might be to have doctors dispense the drugs themselves, and bypass the pharmacists that way. Thanks, Cyberdog

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September 25, 2006 4:53 AM  
Blogger Jaffe said...

Hi, Nice stuff. I found a cool news widget for our blogs at www.widgetmate.com. Now I can show the latest news on my blog. Worked like a breeze.

June 11, 2007 5:51 PM  

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