Wacholz 1 Anthony Wacholz Professor Nicole Biever English 201 May 4th, 2012 Pharmacy Ethics: Professional Obligation

vs. What is Right Imagine yourself a pharmacist who has been asked to fill a prescription for birth control pills for a sixteen year-old girl. Would you refuse to fill the prescription? Conflicts like this arise fairly often in the medical field, where a single action or decision can create many issues. The debate of whether a pharmacist deserves the right to refuse filling a prescription based on their moral beliefs exists as one of the most debatable topics in pharmacy. After doing thorough research on this topic, I conclude that pharmacists by nature should retain the right to refuse prescriptions they believe morally unjust. Many debatable topics exist pertaining to pharmacy ethics that could be discussed, but this essay will mainly focus on the most controversial: birth control pills (contraceptives) and assisted suicides pills. According to the American Pharmacists Association (APhA), all candidates entering this professional field agree to follow and uphold the Code of Ethics for Pharmacists. The organizations web site claims, "This Code, prepared and supported by pharmacists, is intended to state publicly the principles that form the fundamental basis of the roles and responsibilities of pharmacists" (Code of Ethics). The Code of Ethics for Pharmacists states: A pharmacist respects the covenantal relationship between the patient and pharmacist. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist respects the autonomy and dignity of each patient. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist

Wacholz 2 maintains professional competence. A pharmacist respects the values and abilities of colleagues and other health professionals. A pharmacist serves individual, community, and societal needs. A pharmacist seeks justice in the distribution of health resources. (Code of Ethics) The Oath of a Pharmacist exists as another important aspect to consider when discussing pharmacy ethics. It plays a crucial part in the initiation process a pharmacy student undergoes when becoming a licensed pharmacist. The medical community considers the oath very important to pharmaceutical decisions. The Oath of a Pharmacist states: At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy. I will consider the welfare of humanity and relief of human suffering my primary concerns. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. I will keep abreast of developments and maintain professional competency in my profession of pharmacy. I will maintain the highest principles of moral, ethical and legal conduct. I will embrace and advocate change in the profession of pharmacy that improves patient care. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. (Oath of a Pharmacist) The Code of Ethics for Pharmacists and the Oath of a Pharmacist bind pharmacists to follow the stipulations stated. But the code and oath leave much up to interpretation. The code and oath do not and cannot state specifically what course of action a pharmacists should undertake in every possible situation, even though they set a very clear and concise guideline. Therefore, the individual pharmacist needs to use his or her personal beliefs, guided by the guidelines set by the code of ethics and oath, to determine the best course of action for every

Wacholz 3 situation presented to them. Ethics form the cornerstone of an individual's beliefs. They affect essentially every decision the individual makes and help make distinctions between good and bad, fair and unjust, etc. Therefore, pharmacists need to use their ethical beliefs to make decisions. In the United States, legal judgments vary regarding pharmacy ethics laws and practices. Legislation in Washington, South Dakota, Mississippi, and Idaho provides protection for pharmacists who refuse to fill a prescription which they find ethically disagreeable, regardless of the reasoning behind their refusal. Other states, namely Tennessee, Florida, and Georgia, recently passed laws, known as conscience clauses, that protect pharmacists who refuse to dispense certain types of contraceptives. These conscience clauses show that many lawmakers believe pharmacists moral judgment exists as a central element of their professional activity. In contrast, legislators in Illinois and California recently passed laws that essentially force pharmacists to fill every prescription given to them, regardless of their ethical views. In most other states, no laws exist that specifically state whether a pharmacist can or cannot refuse to fill a prescription. Courts in these states determine the ethics of each case individually, with the outcome strongly influenced by the views of the presiding judges and juries. The variance of ethics laws prove that these topics exist controversially in the United States. This essay will first address the filling of prescriptions for birth control pills. As the name suggests, women use these drugs to prevent unwanted pregnancies. People have called these types of pills contraceptives because they can inhibit the creation of a female egg (ovulation), the fusion of an egg and sperm (fertilization), or the implantation of a female egg on the uterine wall of the uterus. "The Pill" or the morning-after pill refer to contraceptive birth control pills. (Cullins). All requests for birth control pills require a prescription. Therefore,

Wacholz 4 everyone who wants birth control pills needs to receive them from a pharmacist, which creates the conflict of pharmacists refusing to fill these prescriptions. Most pharmacists and pharmacies fill prescriptions for birth control as a matter of routine. But institutions and individuals who ethically disagree with the use of birth control sometimes refuse to fill these types of prescriptions. Usually they refuse these prescriptions because of religious or conscientious concerns. For example, a pharmacist of the Catholic faith might refuse to fill a prescription for birth control pills because the Catholic faith frowns upon using birth control. In other words, their ethical beliefs dictate the need to refuse these prescriptions. A typical misconception exists that pertains to birth control prescriptions. According to Dr. Bruce D. White, from his book Drugs, Ethics, and Quality of Life, "Some patients are under the impression that once they receive a [contraceptive] prescription from their physician, they have a "right" to have that prescription filled at the pharmacy of their choice" (90). But White also explains that "Traditionally, pharmacists and pharmacy students are taught that they have neither an ethical obligation nor a legal duty to fill every prescription that is presented at the pharmacy counter. They are taught, rather, that they have a 'right' - and even an obligation - to refuse to fill prescriptions when they have sufficient reason to do so" (92). In other words, Dr. White says that the cause of this conflict between pharmacist and patient stems from a difference in views. Patients typically believe they deserve the right to immediate prescription filling while pharmacy school curriculum encourages pharmacists to refuse filling prescriptions they deem medically and ethically inappropriate. This difference in perception can lead to conflicts which receive national attention. ABC World News reported what Mike Koelzer, owner of Kay Pharmacy in Grand Rapids, Michigan,

Wacholz 5 said about birth control pills: "I feel they [birth control pills] are wrong. While something is legal does not necessarily make it right and also does not make it something that I want to participate in. In the same report, another pharmacist stated, "This country was founded on religious beliefs and the freedom to have those beliefs. Therefore, they should carry over to our jobs" (Stone). These pharmacists bring up an interesting point to the argument over a pharmacist's right to refuse prescriptions. Should society consider religion a legitimate argument for pharmacists refusing to fill birth control prescriptions? In the United States, a separation exists between church and state. In other words, the government cannot regulate religious activity and likewise, organized religion should enact no direct impact on government. Yet, based solely on their religious beliefs, these pharmacists refused to fill lawfully issued prescriptions. I need to bring up the fact that most laws that passed in the United States that protect pharmacists who refuse to fill prescriptions do not state that the pharmacist should specify certain reasoning behind their decision. These laws leave it up to the pharmacists' discretion as to why they disagree with the prescriptions they refuse. Pharmacists exist as highly educated medical personnel who underwent vigorous training in their respective field. Their job does not only involve following a doctor's prescription and counting pills; pharmacists constantly use their knowledge and best judgment to decide the appropriateness of the prescription prescribed by a physician. They perform a much more active role in the types of medicine that patients receive than the general population typically believes. A web site sponsored by the Sexual Information and Educational Council of the United States (SIECUS), comments that, "This type of legislation [Conscience Clause] is criticized by

Wacholz 6 both medical professionals and sexual and reproductive health advocates for permitting a pharmacist to interfere with the patient/physician relationship" (Judge Rules). Seemingly, if SIECUS could dictate how pharmacists could act, pharmacists would not be able to interfere with "what the doctor ordered." By reducing a pharmacists ethical decision and professional judgment to the status of interference, the Councils statement ignores a founding principal of the pharmacists role. The Code of Ethics for Pharmacists refers to the covenantal relationship between the patient and pharmacist" (Code of Ethics). SIECUS approach would severely limit the protection and support that pharmacists should provide, and would break the trust and confidence patients should feel as they acquire their medications. Informed consumers recognize that anyone can make a mistake and that pharmacists follow through on their professional obligations when they use their best judgment to reassess or possibly refuse to fill a prescription, even when written by a trusted physician. In short, the patients relationship with his or her pharmacist exists no less important than that with the physician. Based on this relationship, the pharmacists code of ethics dictates that he or she must engage every appropriate level of evaluation while filling every prescription. Those who criticize pharmacists judgment also criticize the pharmacists Code of Ethics, their practices, their determination to serve the best interests of patients, and essentially the whole field of Pharmacy. Claiming that pharmacists should not have a right to refuse to fill questionable prescriptions undermines the basic principles and ideals of the field. Patients need to understand that a pharmacist's job requires him or her to evaluate a prescriptions appropriateness, and so should not consider this vital service as interference. According to the American Association of Colleges of Pharmacy (AACP), "Pharmacistsprovide expertise about the composition of drugs, including their chemical, biological, and physical properties and their

Wacholz 7 manufacture and use. They ensure drug purity and strength and make sure that drugs do not interact in a harmful way. Pharmacists are drug experts ultimately concerned about their patients health and wellness" (AACP.org). Because of pharmacists' expertise in the field of pharmacy and immense knowledge of drugs, they should be able to refuse prescriptions they deem inappropriate. Another controversial topic concerning pharmacy ethics pertains to assisted suicide medicine. According to assistedsuicide.org, "[Assisted suicide is] helping a person to end his or her life by request in order to end suffering" (Humphry). In the United States, less popularity exists for prescriptions for assisted suicide medicine than prescriptions for birth control pills. Presently, only three states can practice assisted suicide treatments: Oregon, Washington, and Montana. No laws exist that directly address a pharmacist's interaction with assisted suicide, but the American Society of Health-System Pharmacists (ASHP), a national organization run by pharmacists and a great authority on the subject, has issued this statement. "We affirm the ASHP policy [9802] that supports the right of a pharmacist to participate or not in morally, religiously, or ethically troubling therapies. This Statement establishes a framework for pharmacist participation in the legal and ethical debate about the appropriate care of patients at the end of life" ("ASHP"). So even though no written laws directly protecting pharmacists who refuse assisted suicide prescriptions exist, the ASHP statement gives a guideline stating that pharmacists should have to the right to refuse assisted suicide prescriptions without any consequences. The topic of murder and ending someone's life creates many controversies, mostly because people's opinions on what exactly murder means differ. Obviously, assisted suicide pills exist controversially because not everyone believes that medical personnel should have the right

Wacholz 8 to help terminally ill patients end their lives early. Many pharmacists consider assisted suicide to contain similarities to murder and therefore ethically disagree with assisted suicide. Just as with the previous controversy, pharmacists who make this decision must be regarded as following their professional oath to serve the best interests of their patients. Society should not criticize pharmacists for this act of integrity, but rather honor the professional judgment which brought it about. An article written by William L. Allen, J.D. and David B. Brushwood, J.D., found in the Journal of Pharmacy and Law, summarizes well the dilemma with pharmacists and assisted suicide pills. The basis of the dilemma is the choice a pharmacist may be required to make between the duty to fill a legal prescription for a medication that is deemed appropriate by both the prescriber and the patient, and the duty to adhere to one's own belief that medication should not be used to end life. We contend that in filling a prescription, especially given the recent advances in pharmacy practice, a pharmacist is no mere bystander in drug therapy. Rather, the pharmacist is an active participant whose values, attitudes, and beliefs should be given consideration. (Allen 1) Their thoughts on the subject consistently align with the ideas stated in this essay. Even in the case of assisted suicide where a physician and patient agree on this course of action, a pharmacist should be "no mere bystander" and should be able to refuse to fill the prescription. This speaks directly to the many pharmacists who agree that medicine should not be used by patients to end their lives. Even though it may seem that any controversies regarding birth control pale in significance next to those surrounding assisted suicide, careful comparison reveals that the two

Wacholz 9 topics raise questions with important underlying similarities. The basis pharmacists may use in forming their objections to either of these topic must be the same: ethics. The support and protection they should receive for their decisions in both cases also relies on another idea: professional integrity. Obviously, the topics of contraception and assisted suicide exist at the center of so much controversy because they both draw direct attention to the conflict between what decisions human can make and what decisions they should make. This basic discussion usually draws passionate supporters who will strongly defend their often opposing positions. People of each side usually view their opponents as misled and closed-minded. Ironically, the opinions and actions of every side of the rising debate rest on similar foundations: the reduction of human suffering, the protection of human rights, the wishes of a higher power. Pharmacists and many other medical professionals often exist in a central position in these controversies. But since the ethics of these topics are controversial and difficult to differentiate, pharmacists do not deserve to become the "middle man" for either side. Instead, a pharmacist who acts with integrity, who takes a difficult and controversial course of action, should be allowed the right to move forward in what seems the best direction. According to the Code of Ethics for Pharmacists, pharmacists should retain the right and obligation to use their professional judgment to determine what drugs will best treat their patients, even if their judgment conflicts with that of a physician. In the oath all pharmacists take upon entering their profession, pharmacists agree to look after the welfare of humankind. By dedicating years of time and resources to train for their profession, pharmacists prove their dedication to excellence and high ideals. No one member of the medical profession deserves

Wacholz 10 more credibility or voice when it comes to important controversies, but each individual who acts with integrity deserves his or her voice when it comes to important controversies. This essay presented two controversial pharmacy ethics topics and thoroughly explained and discussed them both: birth control pills and assisted suicide pills. This essay attempted to justify why, in both cases, a pharmacist should retain the unquestioned right to refuse prescriptions which they believe will not serve the patients best interest. Pharmacists perform much more than just fill prescriptions and count pills; they utilize a combination of medical knowledge and appropriate ethical beliefs shaped by a thorough medical education to provide their patients with the best available medicine. Based on all of these factors, and upon the uncertainties which surround these two issues, it becomes apparent that pharmacists who act with integrity should retain the right to refuse to fill any prescriptions which they find to be against the best interest of their patients.

Wacholz 11 Works Cited Allen, William L., David B. Brushwood. "Pharmaceutically Assisted Death and the Pharmacist's Right of Conscience." Journal of Pharmacy and Law. Spring (1996): 1. Web. "ASHP Statement on Pharmacists Decision-making on Assisted Suicide." American Society of Health-System Pharmacists. American Society of Health-System Pharmacists. 2008. Web. 17 Feb. 2012. "Code of Ethics for Pharmacists." pharmacist.com. American Pharmacists Association. 2012. Web. 16 Feb. 2012. Cullins, Vanessa. "Birth Control Pills." Planned Parenthood. Planned Parenthood Federation of America Inc. n.d. Web. 15 Mar. 2012. Harvey, Stephanie E., Ei-Lun Lu, Oscar Rivas, Julie Rodgers. "Do Pharmacists have the Right to Refuse to Dispense a Prescription based on Personal Beliefs?" New Mexico Pharmacists Association. New Mexico Pharmacists Association. n.d. Web. 16 Feb. 2012. Humphry, Derek. "Definitions of Euthanasia." Assisted Suicide. Euthanasia Research & Guidance Organization. 19 Jan. 2006. Web. 17 Feb. 2012. "Judge Rules Pharmacist Violated Code of Ethics - Shines New Light on Pharmacist Refusal Debate." SIECUS. SIECUS. 8 Mar. 2011. Web. 16 Feb. 2012. "Pharmacist Code of Ethics & Oath Pharmacy Pledge & Sworn Statement." US PharmD. US PharmD. 2012. Web. 1 Mar. 2012. Stone, Gigi. "Some Pharmacies Refuse to Fill Birth Control Prescriptions." ABC News. Yahoo! News. 8 Aug. 2008. Web. 16 Feb. 2012.

Wacholz 12 White, Bruce D. Drugs, Ethics, and Quality of Life. New York: The Haworth Press, Inc, 2008. Print.