Pharmacists cite personal reasons for refusing to fill

Personal autonomy vs societal duty

Increasingly, pharmacists are becoming involved in controversies over their right to refuse to fill a prescription. Emily Evans, PharmD, an assistant professor of pharmacy practice in the University of Louisiana at Monroe College of Pharmacy, says that although the issue has recently gained public attention because of situations involving emergency contraception such as Barr Laboratories' Plan B, in fact it is not a new issue to the pharmacy profession.

Writing in the American Journal of Health-System Pharmacy, Evans says many pharmacists also have strong feelings about dispensing drugs used for assisted suicide, euthanasia, and capital punishment, and have ethical questions regarding dispensing erectile dysfunction drugs for convicted sex offenders and HIV-positive patients.

"Delegates at a meeting of the American Medical Association have even claimed that pharmacists refused to fill prescriptions for psychotropic and pain medications because of moral objections," she says, "although no documented cases of pharmacists refusing to fill a legitimate prescription for these agents have been reported in the literature or news sites."

Many pharmacists believe that no one should question their right to refuse to dispense a prescription for religious, moral, or ethical reasons. They say this is a right supported by two basic societal principles: nonmalfeasance and professional autonomy. The principle of nonmalfeasance is cited by many who practice the right to refuse, according to Evans, because they believe that dispensing the requested drug can cause harm to another human being, whether it is a fetus, a prisoner on death row, a terminally ill patient, or a potential sex partner of an HIV-positive patient. Professional autonomy is cited even more frequently, as members of all professions are given an opportunity to decline to offer services for ethical reasons and pharmacists are asking for the same treatment as afforded physicians, lawyers, and clergy.

But not everyone agrees. Evans refers to one author's statement that, "When duty is a true duty, conscientious objection is wrong and immoral." Some would argue, she says, that if a pharmacist is not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with his or her values, then he or she has chosen the wrong profession. Those who do not support a pharmacist's right to refuse to fill a prescription say that those who invoke this "right" are denying patients medications for purposes deemed legitimate by their physicians, and it is their duty to dispense the drug. Also, they say, most outpatient pharmacists don't have access to patients' complete medical records and thus are not fully equipped to make clinical decisions that affect a patient's health because they do not, and cannot, know the entire situation.

Professional organization policies

The American Society of Health-System Pharmacists (ASHP) and other professional pharmacy organizations have developed policies on the topic and have shared them with legislators. ASHP recognizes a pharmacist's right to decline to participate in therapies that he or she finds morally, religiously, or ethically troubling, and supports establishment of systems protecting patients' right to obtain legally prescribed and medically indicated treatments while reasonably accommodating in a non-punitive manner a pharmacist's right of conscience.

Evans says the goal of ensuring patient access to legally prescribed, clinically appropriate therapy while allowing the pharmacist to step away from a situation because of personal beliefs is consistent among the policies of the American Pharmacists Association, American College of Clinical Pharmacy, and Academy of Managed Care Pharmacy. She says there also are organizations within the medical community whose policies mirror this underlying intent. Thus, the American Academy of Family Physicians believes that a pharmacist's right of conscientious objection should be reasonably accommodated, but that governmental policies must be in place to protect patients' rights to legally prescribed, medically indicated treatments in a timely manner.

As of May 2006, Evans reports, 10 states had enacted laws addressing the subject, with four of the states (Arkansas, Georgia, Mississippi, and South Dakota) allowing a pharmacist to refuse to dispense emergency contraception, and four (Colorado, Florida, Maine, and Tennessee) providing broad refusal clauses for healthcare professionals that do not specifically mention pharmacists or specific drugs. Illinois passed an emergency rule in 2005 requiring a pharmacist to dispense contraception subsequent to a legitimate prescription, and California pharmacists have a duty to dispense prescriptions and can refuse to dispense them only when their employer approves the refusal and the patient can still access the medication elsewhere in a timely manner.

At the time Evans wrote her analysis, there were 48 bills in legislatures in 21 additional states. Some 37 of the 48 bills would expressly give pharmacists and other healthcare providers the right to refuse to participate in activities that they find morally or ethically objectionable. Many of these bills would exempt the healthcare providers from legal consequences or disciplinary action from their employer or state board of pharmacy.

Bills take different approaches

Of the 37 proposed bills supporting the right to refuse, eight specifically mention emergency contraception; two deal with family planning issues, and seven deal with procedures of products resulting in abortion or termination of pregnancy. Of the 11 proposed bills that expressly prohibit the pharmacist's right to refuse, or impose fines on those who do, none mention specific drugs or procedures. Evans tells Drug Formulary Review that while many states are moving forward with legislation, there may ultimately need to be a national solution. It is imperative, Evans says, that new pharmacists be familiar with several aspects of the issue:

His or her views on controversial drugs and topics. Knowing the situations that are likely to present an ethical or moral problem ahead of time can help avoid potential problems in practice. Employers and coworkers should be made aware of any objections that are held. Pharmacists should try to determine how situations will be handled before they arise.

His or her employer's policies. As long as it does not violate state or federal law, employers have a right to set any policy that they choose regarding this issue. Ensuring employment with an entity that shares the pharmacist's viewpoint can help avoid conflict in future situations.

The laws and board of pharmacy rules in the pharmacist's state. Legislation on this dynamic issue is quickly changing. Regardless of a pharmacist or employer's viewpoints, state law will take precedence. Violating pharmacy board rules, whether actual legislation or not, can result in injunctions against a practitioner's license, and violation of state law can result in fines or prison time.

How to voice his or her opinion. If a practitioner has especially strong views on the issue, it is his or her duty to make those views known to the legislative bodies addressing the issue. Evans says the single most effective means of doing so is joining local, state, and national professional organizations that have strong lobbying groups. Direct communication with legislators also is important, she says, as are education and encouragement of other professionals through continuing education and inservice training.

Reference

  1. Evans E. Conscientious Objection: A Pharmacist's Right or Professional Negligence? Am Jrl Health-System Phar 2007;64(2):139-141.