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Anto JM, Vermeire P, Vestbo J, Sunyer J. Epidemiology of chronic obstructive pulmonary disease. Eur Respir J 2001; 17: 98294. Humerfelt S, Gulsvik A, Skjaerven R, et al. Decline in FEV1 and airow limitation related to occupational exposures in men of an urban community. Eur Respir J 1993; 6: 1095103. Postma DS, Boezen HM. Rationale for the Dutch hypothesis: allergy and airway hyperresponsiveness as genetic factors and their interaction with environment in the development of asthma and COPD. Chest 2004; 126 (suppl 2): 96S104S. Somfay A, Porszasz J, Lee SM, Casaburi R. Dose-response eect of oxygen

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on hyperination and exercise endurance in nonhypoxaemic COPD patients. Eur Respir J 2001; 18: 7784. Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benets of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Am J Respir Crit Care Med 2003; 168: 103442. Larsson C. Natural history and life expectancy in severe alpha1-antitrypsin deciency, Pi Z. Acta Med Scand 1978; 204: 34551. Silverman EK. Genetics of chronic obstructive pulmonary disease. Novartis Found Symp 2001; 234: 4558.

When pharmacists refuse to dispense prescriptions

The dilemma of conscientious objection by US pharmacists has yet to be resolved. The issue was thrust into the mass-media spotlight when a pharmacist in Texas rejected a rape victims prescription for emergency contraception (the morning-after pill). The pharmacist argued that dispensing the drug was a violation of morals.1 Further cases have since been reported and include such acts as intimidation2 and conscation of the prescription by the pharmacist.3 Pharmacists argue that they are a health-care provider and, like doctors, should have the right to refuse to participate in services they morally object to.4 In fact, the policy of the American Pharmacists Association permits pharmacists to object to dispensing drugs but requires them to ensure another pharmacist is available to dispense or transfer the prescription to another pharmacy. Further, the Association argues that this approach is seamless and the patient is not aware that the pharmacist is stepping away from the situation.5,6 Seamless is probably not an accurate picture of what can happen. Many pharmacies do not sta their business with more than one pharmacist during late evening hours, so there might not be anyone else on the premises to dispense drugs. Additionally, many Americans have health-insurance policies that restrict coverage to pharmacies on a specic list of providers. If the objecting pharmacist refers a patient to a pharmacy that is not on the list, they will not have insurance cover for the drug. This situation could pose a nancial burden for some individuals. Transportation could be a diculty for some people, and they might not have access to another pharmacy that is farther away. Not thinking about the nancial eect of objections to dispensing is a direct failure of the pharmacist to assess a patients nancial capacity to adhere to their prescribed treatment plana requirement of the American Pharmacists Association.7
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Although standard contraceptives and emergency contraception are the drugs most frequently objected to by pharmacists, what others can lead to opposition? What if pharmacists refuse to dispense human growth hormone because they are against the idea of shortness as a disease? Might they refuse to give a patient testosterone because they believe that the drug should only be prescribed to married men? Suppose pharmacists refuse to dispense dronabinol because they view use of the drug to be no dierent from smoking marijuana? The question of what constitutes a moral objection is a valid one. In these situations, the pharmacist is preventing an eective doctor-patient relationship. While the obstruction might not cause a patients death, there could be other harms, such as unplanned pregnancy, mental distress, nancial burdens, and potentially, disease progression. In June, 2005, the American Medical Association adopted a policy entitled Preserving patients ability to have legally valid prescriptions lled.8 In this document, the Association says that individual pharmacists or

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pharmacy chains should dispense legally valid prescriptions or provide immediate referral to an appropriate alternative pharmacy without interference. They also pose that doctors themselves should be allowed to dispense drugs when there is no pharmacist able and willing to do so within a 30-mile radius. Such a plan would be workable if doctors could accurately predict what drugs might be objected to; however, this situation also creates an entirely new practice for doctors oces (including labelling, inventory control and stock adjustment, pricing, billing). Many overburdened practices might not be able to assume such new tasks safely and eectively. One way the USA has attempted to address this dilemma is through legislative action. In Illinois, for example, pharmacies must dispense prescription contraceptives when they are in their inventory and a valid prescription is presented by the patient.9 This law also forbids unlled written prescriptions for contraceptives from being conscated by pharmacists. If the contraceptive (or a suitable alternative) is not in stock, it must be ordered or the prescription transferred to another pharmacy of the patients choice. This law is an example of the solution posed by Greenberger and Vogelstein3 in that the duty to dispense is shifted from the individual pharmacist to the pharmacy. In this way, the pharmacy (as a business, rather than an individual) bears the responsibility for ensuring that dispensing is done in a timely and professional manner. As worded, the Illinois law would also prevent pharmacies from categorically refusing to stock contraceptives, in that the provision that allows prescriptions to be transferred is an option available for the convenience of the patient, not the pharmacy. In tandem with placing the duty to dispense on pharmacies, the use of automated (robotic) dispensing might be helpful.10 Robots would not have moral objections to certain drugs and would complete the orders written by doctors. This idea is not science ction. In fact, many pharmacies and health systems use robotic dispensing. The systems can ll, label, and provide computer-assisted quality-assurance functions (including verication of the label). While the role of the pharmacist is not completely eliminated, it can be reduced enough to satisfy his or her comfort level in the setting of ethically controversial drugs. Another option is for certain drugs to be dispensed
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without any involvement of a pharmacist (over the counter); however, this strategy is not possible for drugs that have the potential for clinically signicant side-eects or risk of abuse (eg, human growth hormone, dronabinol). Even for drugs that are low risk, attempts to switch from prescription to over-thecounter status are sometimes dicult to accomplish because of non-medical factors (eg, politics).11 Because of the potential for abandonment of and harm to patients, laws about prescription refusals seem to be appropriate. Such laws should never leave any patient in the position of fending for himself or herself when they hold a valid prescription.12 Even without these laws, pharmacies should require that their pharmacists, as a condition of employment, agree to never abandon their patients no matter what their personal values and beliefs are about a particular drug. Katrina A Bramstedt
Department of Bioethics, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA txbioethics@yahoo.com
I am an ethics consultant to the US Food and Drug Administration and an Editorial Consultant for The Lancet. 1 Reuters. Texas pharmacist refuses pill for rape victim: woman with doctors prescription for drug turned away. Feb 3, 2004: http://www. msnbc.msn.com/id/4155229/ (accessed Oct 11, 2005). Johnson A. State probes drug refusal: pharmacist wouldnt ll order for contraceptive. May 10, 2005: http://www.jsonline.com/news/state/ may05/325131.asp (accessed Oct 11, 2005). Greenberger MA, Vogelstein R. Pharmacist refusals: a threat to womens health. Science 2005; 308: 155758. American Medical Association. Code of ethics: section 3d, professional independence. Chicago: American Medical Association, 2004. Winckler SC. Pharmacists policy on pills. Prevention 2005; 57: 170. Winckler SC. Letter to the Editor submitted by APhA to Prevention magazine. July 1, 2004: http://www.aphanet.org/AM/Template. cfm?Section=Public_Relations&Template=/CM/HTMLDisplay. cfm&ContentID=2689 (accessed Oct 11, 2005). American Pharmacists Association. Pharmacist practice activity classication (section A.2.1.1.5). Washington: American Pharmacist Association. 2005: http://www.aphanet.org/AM/Template.cfm?Section= Search&template=/CM/HTMLDisplay.cfm&ContentID=2908 (accessed Oct 11, 2005). American Medical Association. Policy D-120.975: preserving patients ability to have legally valid prescriptions lled. 2006: http://www. ama-assn.org/apps/pf_new/pf_online?f_n=resultLink&doc=policyles/ DIR/D-120.975.HTM&s_t=d-120.975&catg=AMA/HnE&catg=AMA/ BnGnC&catg=AMA/DIR&&nth=1&&st_p=0&nth=1& (accessed March 28, 2006). Illinois Pharmacy Practice Act 1330.91(j)(1), 2005. Guerrero RM, Nickman NA, Jorgenson JA. Work activities before and after implementation of an automated dispensing system. Am J Health Syst Pharm 1996; 53: 54854. Drazen JM, Greene MF, Wood AJ. The FDA, politics, and plan B. N Engl J Med 2004; 350: 156162. Cantor J, Baum K. The limits of conscientious objection: may pharmacists refuse to ll prescriptions for emergency contraception? N Engl J Med 2004; 351: 200812.

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