Tuesday, March 3, 2009

Your Conscience Doesn't Belong in My Health Care

I was pretty excited to read the news Saturday that Obama has decided to void the health workers' conscience rule enacted by Bush. Of course the people who want to keep this rule in place have framed the decision as a pro-abortion move, and unfortunately the people who support removing the rule have engaged them at this level. This rule is really about so much more than abortion.

It's not enough that we need to research our primary care doctors and try to find one whose medical approach most closely matches how we would like our health care managed. But under this rule, we also need to research and seek out and equally appropriate pharmacy.

If my doctor decides to prescribe marinol, a synthetic marijuana derivative, as part of a pain management plan or as an anti-nausea drug, but my pharmacist doesn't believe in prescribing marijuana, where does this leave me, the patient? (This is not a hypothetical question, it has happened—though I wasn't the patient; I was the caregiver and had the lovely task of dealing with the pharmacy.)

Either I need to go back to the doctor (schedule another appointment, take more time off from work to go to the appointment, and add another $20 office visit co-pay) and get a different prescription, despite the fact that my doctor has already considered the options and felt that marinol was the best option, or I need to seek out a pharmacy that will fill the existing prescription.

In a metropolitan area, the second option (while still a hassle) is doable. That is, of course, assuming the pharmacist will give the prescription slip back to you. But in a rural area, a person may only have one or two options available.

The doctor is my health care provider, not the pharmacist. The pharmacist is a service provider and should not be able to dictate the direction of my health care based on his or her beliefs.

If the pharmacist has a moral objection to dispensing medications as prescribed by a doctor, then the pharmacist clearly chose the wrong career—because that is exactly what a pharmacist is supposed to do.

Aside from refusing to fill a prescription due to dangerous drug interactions, unfortunately common when different doctors are prescribing for the same patient, the pharmacist should fill any and all prescriptions.

Aside from the marinol example, which admittedly only a relative few people would encounter, there's also the birth control issue. I have actually been in a Safeway pharmacy in San Jose, CA that refused to stock or sell all forms of birth control, including condoms.

Granted, you don't need a prescription for condoms, not even they cherry flavored kind—but come on, they're condoms! If I were a randy teenager, do you really think the fact that you won't sell me a condom is going to stop me from doing whatever it is I wanted the condom for?


  1. I came across your blog via your Mexican Spice Rub, for which, thank you. I use those spices and herbs in roughly those proportions in most Mexican dishes, but somehow it didn't occur to me to mix up a batch in advance.

    And then I skimmed a few other posts, and felt compelled to comment to this one.

    Do you really believe people must make their professional skills and businesses available to everybody, even at the risk of their consciences? If I become a lawyer, MUST I represent an incestuous dad in his custody case, or a tobacco company defending a product liability suit or simply every case that walks in the door, even one that turns my stomach, even when there are plenty of other lawyers who would be happy to do it? If I become a doctor, MUST I assist in a suicide or perform an abortion or help an unmarried welfare mom of six become pregnant with octuplets, even if there are other doctors who will do it if I don't?

    And is it really the government's job to compel that kind of uniformity of thought? "You must believe as Congress or the Supreme Court currently dictates, or surrender your conscience to their whims, or you will be barred from this, that or maybe any occupation." Really?

    Your position seems to be that, if you undertake a career, then that career and you are at the service of everybody who wants to use you, with no freedom of conscience allowed.

    I think a less totalitarian principle might be something like this:

    I'm only entitled to demand that someone else satisfy my needs if I would have had those needs satisfied by the person's non-existence. Say Pharmacist Betty refuses to dispense marinol. Would I be guaranteed my marinol if only Betty didn't exist, had chosen a different career, or chosen to open her pharmacy in some other town? Since there is no GUARANTEE that some other pharmacist would have been available to serve my needs just because of Betty's non-existence, then the answer is No.

    Betty's mere existence as a pharmacist or her opening of a pharmacy in my town doesn't restrict anybody else from becoming a pharmacist there who WILL serve my needs, therefore I don't have a right to demand that Betty violate her conscience to serve my needs.

    If, however, government restricts the number of people allowed into the profession in order to limit competition, then those allowed in must serve everybody. So the Muslim taxi cab drivers who refuse to carry passengers carrying alcohol, since only a limited number of cab licenses are permitted in a jurisdiction and the demand for licenses exceeds the supply, must suck it up and violate their consciences to serve the customer or allow their license to go to someone who will. (The position of greater liberty, of course, would be ending the restriction on the number of licenses, which would be my preference.)

    But since entry into the field of pharmacy and the opening of pharmacies is not restricted, pharmacists may choose what products they wish to carry, just like Walmart or Ace Hardware.

    It isn't your health care that is impaired, it is your convenience in obtaining your health care. If Betty won't dispense what you want, someone else certainly will, maybe just not as conveniently. I don't think your convenience trumps someone else's conscience.

    As it happens, although I believe abortion is a moral wrong, I've been pro-choice (meaning I believe that it should not be a legal wrong) for many years, and don't have any personal objections to medical marijuana either. But I don't think I'm entitled to demand that everyone else surrender either their consciences or their professions to my beliefs.

    The world is not made a better place by demanding that everyone conform to one rigid set of beliefs before they contribute their productivity to society. How are women seeking abortions made better off by the closing of all Catholic hospitals, for example? They aren't. The only people who benefit from that are those whose ideological totalitarianism trumps everything. I ran across your post on Cheney's freedom of speech, so I know you are not one of those, otherwise I wouldn't bother to write.

    Protecting liberty of conscience is surely worth the inconvenience of "researching an appropriate pharmacy." As human beings, we do not exist only as objects to serve others' needs, and no one should be treated that way, including pharmacists.

  2. Hi AnnJo,

    Thank you for your thoughtful comment. I understand what you're saying and that was not at all the point I was attempting to make, and it seems I may have missed the mark.

    No, I don't believe any lawyer must represent any client that comes through the door. If that lawyer is a public defender, he or she may have less flexibility in choosing clients. But by and large, lawyers will have an initial consultation with clients to decide whether there is a case, whether it can be won, and whether they even want to represent the client. It's also an opportunity for the client to learn about the lawyer.

    If the client's case is not in the lawyer's field of expertise the client may be referred to a different attorney. If the lawyer decides the case is not winnable, the client is free to seek out another opinion. And if the lawyer has an objection to representing the client, the lawyer can refuse and the client can seek out other representation.

    The lawyer actually seems more analogous to the doctor, not the pharmacist, perhaps the paralegal, as the person who does research to support the case, files documents with courts, and assists the lawyer, is more analogous to the pharmacist. Should the paralegal have the freedom to refuse to file documents with the court because he or she has a moral objection to the case the lawyer has taken on? Sure, but the paralegal would probably lose their job.

    And no, I don't believe that every doctor should be required to perform procedures they find morally objectionable. And an initial consultation allows the patient to discover what the doctor's position is. The doctor can then choose to take on the patient and the patient can choose to work with the doctor, or they can both move on--much like the lawyer and client.

    However, if the doctor has a moral objection to, say for example, performing an abortion, it would probably be in the doctor's best interests to choose a specialty that doesn't include that procedure. Same for the lawyer. For the pharmacist, the specialty is being a pharmacist and dispensing medications.

    For me, you're correct, it was more an issue of convenience (and being in a metro area, it was a minor one at that), but for family members who live in rural areas, at least an hour from the nearest pharmacy and 2 1/2 hours from the clinic, it's more than a major inconvenience. Going back and forth from clinic to pharmacy means extra expenses for travel and office visits, and lost wages from taking time off from work, and even possibly losing your job (and whatever health insurance you might get with it).

    We clearly have a difference of opinion, and that's fine. I'm not trying to change your mind--just trying to express mine. My position is more that if the medication is legal to prescribe, and the pharmacy has agreed to dispense medication under that insurance or health care provider, which to my mind constitutes a type contract, they should not be able to refuse to fill certain prescriptions. If Walgreen's pharmacy accepts Blue Shield, they should dispense any medication prescribed by Blue Shield physicians.

    In the specific marinol example I used. It was prescribed by a Stanford oncologist, and it was refused by a Stanford pharmacy. In such a case, I would expect a pharmacy aligned with a specific health care provider to fill any prescription from an affiliated doctor. At the time, we were commuting 2 hours each way for treatment. (After much prodding from the prescribing doctor, the Stanford pharmacy did end up filling the refill prescription, but it was a different pharmacist on a different shift.)

    Maybe a middle ground would be not pharmacists deciding individually what they will and won't dispense, but the pharmacy as a whole. This would allow individual pharmacists to choose to work with pharmacies that reflect their personal moral positions.

    The pharmacy should be required conspicuously post what they refuse to dispense, allowing patients to easily decide where they can (or morally want to) take their prescriptions.

    And, if it is the only pharmacy around for a given distance, X miles, perhaps the pharmacy shouldn't have the option to refuse.

  3. Thank you for your response. My concern is to limit the degree to which government is able to punish people for withholding their participation in policies they find morally objectionable. Since government now controls so much of our health care system, and soon will control more or possibly all, people's consciencious objections need to be accommodated there, just as we have always done in the military. And that's what the rule did that Obama just rescinded: It required health care institutions that received federal funds to make reasonable accommodations to the conscientious objections of their employees.

    It's ironic that, even when we had the draft, and even in wars for our national survival, such as WWII, we found it possible to accommodate people's consciences, but we now allow "inconvenience" to override people's most deeply held beliefs, or require them to sacrifice their livelihoods.

    I know that there are many inconveniences and burdens that attend serious medical problems, having experienced them (more than our share, perhaps) in my own family, but I hope my own needs never leave me so insensitive to the essential humanity of others that I demand of them that they surrender it to serve me.

  4. I think one of the points on which we differ is that you want to limit the government's ability to punish people and for you, the removal of this rule is tantamount to punishment. I too want to limit the government's role, but I don't see this as a punishment--any employer should make "reasonable accommodations to the conscientious objections of their employees," not just pharmacies. The rub for me is that there's a law telling employers to do something that should be common sense.

    The other piece that bothers me is how I actually encountered this rule in action. I wasn't told, "I'm sorry, I cannot fill this prescription. Please come back when Bob is on shift." I was told, "No, we won't fill it."

    And I'm sorry, I absolutely do not agree with your statements about the military. Our military has not always made room for people's conscientious objections, and certainly not with the draft. I think the military is better about making room for objections in the day-to-day military today; but as for the draft, we haven't had one since 1973(?), so who can really say.

    I am sorry that you seem to feel my opinion makes me insensitive to the essential humanity of others, I just don't feel that the rule, as written and practiced, is the answer. As I said, there needs to be some middle ground.