Moral and ethical boundaries in healthcare

Over the last year that I’ve been writing about science and medicine, I have argued for protections for those who object to performing procedures or dispensing medications that they find morally reprehensible. The more I read and see about the issue, my feelings lie towards the “find another line of work” slant. I found this editorial in the WaPo the other day, and I’ve only just now gotten around to reading it.

Pharmacists refusing to dispense Plan B. Doctors refusing to prescribe Viagra to unmarried men. Fertility specialists refusing to artificially inseminate a gay woman.

These occurrences represent a provider, who is in a position of power, forcing their moral beliefs onto their patients. It isn’t right. But at the same time, I have a hard time condemning these people for refusing to go against their moral grain. I don’t think this dichotomy exists in any other field *but* medicine. Over time, medicine has evolved from a purely “healing” profession into something that deals with everything related to the human body and basic biology. As our knowledge and understanding of many different fields of science and social science blend with our knowledge of what has been traditionally labeled medicine (physiology, pathophysiology, microbiology, etc.), these responsibilities have changed.

The issue is driven by the rise in religious expression and its political prominence in the United States, and by medicine’s push into controversial new areas. And it is likely to intensify as doctors start using embryonic stem cells to treat disease, as more states legalize physician-assisted suicide and as other wrenching issues emerge.

“What constitutes an ethical right of conscience in medicine, and what are the limits?” asked Nancy Berlinger of the Hastings Center, a bioethics think tank. “This keeps getting harder and harder for us.”

I wish I had easy answers, but I don’t. I can see and understand both sides of the debate, but seeing and understanding isn’t the same as creating policies to protect both sides of those who are affected: the patient and the provider. My opinions on religion aside, I think that in reasonable circumstances, both parties must be accommodated as much as possible — but what about places where the population density is much lower, and there may not be another provider within a reasonable radius? Should the patient be made to suffer? Should the provider be forced to compromise their moral principles?

Again, I lean towards the provider compromising — people should not be allowed to force their beliefs on another. That’s the side of “religious freedom” that many seem to forget when they talk about people’s religious rights. It certainly cuts both ways.

While I was happy to see that Godwin’s Law did not apply to this article, slavery — the next best thing to Nazis — was invoked. And I don’t think the analogy was necessarily appropriate. Morality is a fundamentally gray area during the times in which a specific controversy exists. It is only with the passage of time that things become black-and-white — the controversy becomes “solved.” Slavery, for instance, has the benefit of that passage of time, so attaching something like medical ethics to it is a case of tying a very gray issue to one that is black and white. It’s breaking one of the rules of debate — though I can’t remember the fancy Latin name.

Some argue that health workers should not even be required to refer patients elsewhere for care they find objectionable.

“Think about slavery,” said physician William Toffler of the Oregon Health and Science University in Portland. “I am a blacksmith and a slave owner asks me to repair the shackles of a slave. Should I have to say, ‘I can’t do it but there’s a blacksmith down the road who will?’ “

In this case, if a provider is unwilling to participate in something they disagree with, I think they should be required to refer the person elsewhere, for the simple reason that they should not be allowed to force their beliefs on another, which they are tacitly doing through their inaction. Referrals protect the provider from directly violating their beliefs, and they protect the patient by allowing them to receive the care they need or desire. It’s as close to a win-win situation as one can get in this ethical morass.

As an aside, there are many who would say “to hell with morals, these providers should be doing their jobs!” as though “doing their jobs” is some absolute written in stone somewhere. It’s not. As with any other job, there are people from all walks of life in the medical profession, and regardless of what you might think of their religious beliefs, they must be protected. Because like it or not, what you think of another person’s set of morals is entirely irrelevant. That’s one of the things that makes this country great — and introduces these seemingly impossible ethical questions…

[tags]Medicine, pharmacy, ethics, morals, malpractice[/tags]

11 thoughts on “Moral and ethical boundaries in healthcare

  1. Very simple.

    Take care of it in the licensing procedures. As long as people’s beliefs are disclosed beforehand for what procedures they will and won’t do, that’s fine by me.

    For example:

    You either have Pharmacists, or Pharmacists – Limited. P-Ls will have letters following their license adding to what categories they will not dispense.

    There, that way people will have information on which pharmacies have full pharmacists, and which ones will refuse to provide certain goods, and there will be no confusion in the pharmacy market.

    And if employers decide that P-L’s aren’t as welcome in their business as a full pharmacist, or are worth less in the market due to lower ability to funtion, then that’s just a natural consequence of their self-selection in the market.

  2. While that solution seems like it’d be simple, pharmacists (and doctors and nurses and whomever else) would never consent to it.

    A declaration of what procedures/whatever will not be conducted posted prominently at the entrance to an establishment might be an interesting idea, but would probably be too objectionable to those people who have moral qualms. They get antsy like that…

  3. Well, =) people want their cake and the ability to eat it too. All I can ask is for full disclosure, ie, no middle-of-the-night suprises. Surely that’s fair for a free market, which is what the same people who believe in these restrictions would believe in, right?

    Do you have a listing of the pharmacy accreditation boards across states and where to give consumer feedback for each of those, so that we can look for and demand more disclosure?

  4. Before I get on my high horse I should profess my ignorance: do pharmacists have a right to countermand a legal and valid prescription issued by a doctor?

  5. Before I get on my high horse I should profess my ignorance: do pharmacists have a right to countermand a legal and valid prescription issued by a doctor?

    Absolutely. A prescription is like an order slip. It’s within a pharmacist’s right to refuse to fill an order. It is not within a pharmacist’s right to withold the prescription so it can’t be filled elsewhere, unless the prescription itself is suspect. (Forgery, altered, etc.)

  6. Absolutely. A prescription is like an order slip. It’s within a pharmacist’s right to refuse to fill an order. It is not within a pharmacist’s right to withold the prescription so it can’t be filled elsewhere, unless the prescription itself is suspect. (Forgery, altered, etc.)

    Hrm, then I can see why this is becoming a big issue. Why is this? If there is a potential medical problem with a legal, valid prescription, shouldn’t this be taken up with a doctor and not the patient? I am not sure why fulfilling a legal, valid prescription is compulsory. I feel like a pharmacist has the right to question a ‘scrip for medical reasons, not because they don’t believe in birth control.

    Taken to a ridiculous extreme, what if a pharmacist refuses to give medicine to a group of people they don’t like?

  7. Hrm, then I can see why this is becoming a big issue. Why is this?

    Because a pharmacist has a license to dispense, just like a doctor has a license to prescribe. A doctor could not, for instance, walk into a pharmacy and start dispensing medications. That’s illegal. Just like a pharmacist cannot start writing scripts for people, because they are not licensed to prescribe.

    It’s the pharmacist’s license; no one else’s. Just like a doc can refuse to prescribe if s/he chooses.

    If there is a potential medical problem with a legal, valid prescription, shouldn’t this be taken up with a doctor and not the patient?

    It’s usually taken up with both. We explain to the patient what the problem is, and we get in touch with the prescriber’s office as well. Sometimes we give the script back to the patient (if they ask for it), and sometimes they like us to keep it until whatever the problem is, is resolved.

    I feel like a pharmacist has the right to question a ‘script for medical reasons, not because they don’t believe in birth control.

    I’m inclined to agree, like I said. But since it’s the pharmacist’s license, they can refuse to fill something if they choose.

    Taken to a ridiculous extreme, what if a pharmacist refuses to give medicine to a group of people they don’t like?

    They’d be fired and probably prosecuted for whatever -ism they were committing.

    This isn’t purely a pharmacy issue, by the way. Doctors and surgeons face the same decisions, and have the authority to make similar choices. And I’m not sure it’s fair to take that freedom away from any of them.

  8. “This isn’t purely a pharmacy issue, by the way. Doctors and surgeons face the same decisions, and have the authority to make similar choices. And I’m not sure it’s fair to take that freedom away from any of them.”

    From my viewpoint not as a doc / pharm, I just want to know before I walk in if you’re not going to prescribe something that would be beneficial to me just because of whatever beliefs you hold.

    For example, doctors and pharmacists who practice, say, asian or homeopathic or whatever styles and would recommend that sort of stuff put it into their descriptions. Why not people who follow, say, Christianity or Muslim or whatever restrictions to their prescriptions?

  9. For example, doctors and pharmacists who practice, say, asian or homeopathic or whatever styles and would recommend that sort of stuff put it into their descriptions. Why not people who follow, say, Christianity or Muslim or whatever restrictions to their prescriptions?

    It’s rarer than you think. Just like a real MD practicing phony-baloneyhomeopathy“. You just read about the “bad” ones in the news. As a percentage, those are the teeny-tiny minority. In fact, I’ve not heard of an RPh refusing to dispense something outside the “Bible belt.” Take that however you will. ;)

    Do yourself a favor and don’t worry about it, because the odds of it happening to you are slim. And BC is so common, I think a pharmacist would be let go if they refused to dispense it because of the percentage of prescriptions that are filled are for some form of contraceptive.

  10. question: If a pharmacist feels that a prescription was altered, does he have the right to lecture me about federal law, make a scene in front of everyone, raise his voice and accuse me of a crime? I’m asking because my doctor wrote “brand name only” on the prescription, the pharmacist accused me of writing it myself. Then proceeded to tell me it’s a federal offense to alter prescriptions. I got out my car in the drive thru, went into the store and told him that I did not forge it and to call my doctor. He refused to call my doctor then proceeded to lecture me. THEN he gave me the generic prescription….

  11. I’m sorry this happened to you. It really gets under my skin when pharmacists behave in a non-professional manner, and it puts me on the defensive. Most pharmacists have good sense, but some don’t. Just like any other profession, I suppose.

    At my old pharmacy school, you could (and still can) get expelled for “unprofessional behavior” in and around the community. I’d say this qualifies, but unfortunately demand for pharmacists is so high, he’d just be reprimanded at that would be the end of it. (Any maybe that’s all that should happen the first time around, but he could probably get away with it ad nauseum since every pharmacy is desperate for more pharmacists…

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