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Board: Pharmacy must fill every rx

Discussion in 'Pharmacy' started by Hibiclens, Apr 14, 2007.

  1. Hibiclens

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    Disregard the morning after pill aspect of this column, I find the most frightening thing be that a pharmacy must order any prescription that is brought in. (The way I interpert the article is that it applies to all drugs, not just Plan B)

    Board: Druggists Must Fill Prescriptions
    By CURT WOODWARD

    Associated Press Writer

    SEATTLE — Druggists who believe "morning-after" birth control pills are tantamount to abortion can't stand in the way of a patient's right to the drugs, state regulators have decided.

    In a unanimous vote Thursday, the state Board of Pharmacy ruled that drug stores have a duty to fill lawful prescriptions despite an individual pharmacist's personal objections to any particular medication.

    Pharmacists or drug stores that violate the rules could face discipline from the board, which has the power to revoke state licenses.

    The Washington State Catholic Conference and Human Life Washington, an anti-abortion group, predicted a court challenge, saying the rule wrongly forces pharmacists to administer medical treatments they consider immoral.

    "I don't think pharmacists who adhere to traditional moral precepts are going to allow their conscience to be overrun by the Board of Pharmacy," said Dan Kennedy, Human Life's chief executive.

    Planned Parenthood spokeswoman Amy Luftig said the ruling "ensures that men and women will have access to their health care."

    "It also respects a pharmacist's personal beliefs, so long as that doesn't come before a patient's needs," she said.

    Sold as Plan B, emergency contraception is a high dose of the drug found in many regular birth-control pills. It can lower the risk of pregnancy by as much as 89 percent if taken within 72 hours of unprotected sex.

    Some critics consider the pill related to abortion, although it is different from the abortion pill RU-486 and has no effect on women who already are pregnant.

    The federal Food and Drug Administration made the morning-after pill available over the counter to adults in August.

    Under the new state rule, pharmacists with personal objections to a drug could opt out by getting a co-worker to fill an order. But that would only apply if the patient is able to get the prescription in the same pharmacy visit.

    Pharmacies would be required to order new supplies of a drug if a patient asks for something that is not in stock.

    Pharmacists are also forbidden to destroy a prescription or harass patients, rules that were prompted by complaints from Washingtonians, chairwoman Rebecca Hille said.

    The rule will take effect in mid-June, Health Department spokesman Jeff Smith said.
     
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  3. patmcd

    patmcd Senior Member
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    They are talking about refusing to fill based on a personal objection, not a professional one. Say if you think a patient's rx is an overdose you could still refuse to fill it.
     
  4. Hibiclens

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    From a business perspective is what I'm talking about it. Say a patient wants XYZ med that you know they can get at ABC pharmacy down the road...do you still have to order it in for them??? Even if ordering said product will result in lost $$$????
     
  5. PrePharm1980

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    There are prescriptions that lose money?

    If so, well if you really cared, then you would have to weigh out the benefits. If you lose money from this one sale, will you regain your money back from the customer's other sales? Is it worth it?
     
  6. WVUPharm2007

    WVUPharm2007 imagine sisyphus happy
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    Really, it all boils down to whose autonomy is more valued. In the end somebody is taking it up the ass. Either the RPH's autonomy is ignored or the patient's autonomy is ignored. Of course this is assuming the patient can't go to some other pharmacy nearby in an Urbanish state like Washington, too. Then they could respect the autonomy of the pharmacists who do not want to dispense while serving their own autonomy elsewhere.

    It really doesn't matter, anyway. Don't want to dispense Plan B? Don't stock it, patient still has to go elsewhere because it is an urgent med, problem solved.
     
  7. WVUPharm2007

    WVUPharm2007 imagine sisyphus happy
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    I actually read the whole thing...this really is asinine business practice. What if I partially dispense some obscure med I was forced to order and am stuck with $500 of unused drug because a law forced me to order and dispense it?
     
  8. Hibiclens

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    Ummm....your first question in your post is priceless. That aside, anyone who has worked in a retail pharmacy knows there are some prescriptions that come up to the window that are better served that the patient goes elsewhere. I'm not talking life or death meds or anything that would harm a patient...I'm talking when a patient comes up to the window for lets say #7 Vfend for example that your pharmacy will never use the rest of the bottle. Now, Vfend is a life or death med but thats just one that came to mind dollar wise. Its should not be out of the question to have a patient check around town for a med they need. Don't respond back with best interests of the patient...I am well aware. They'd get it faster if they exerted some effort and your store wouldn't lose money. The way I see this law is that a patient hands you a presciption and says "I'll be in for it tommorrow"....you'd better have it. I'm not sure that is a good thing. Sometimes common sense should be able to prevail.
     
  9. Hibiclens

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    Bingo.
     
  10. Hibiclens

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    Now I will say...I have no idea how this law is truly worded, I am just going by the media reports...maybe it just pertains to Plan B...but thats not how the "article/other articles on the web" about it read.
     
  11. sdn1977

    sdn1977 Senior Member
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    I think this is pertaining to Plan B or other drugs which some pharmacists might have a "moral" objection to. So...I think your first statement of "disregard the morning after pill aspect" is the primary place you're being misled.

    The issue around the few drugs which are extremely expensive & rarely used (ie Vfend...) - although those are indeed life sustaining, they are not initiated normally in the outpt setting. Usually, inpt pharmacists will find the source for the drug before the pt is being discharged. This occurs routinely with fertility medications, expensive antineoplastics, unusual antibiotics/antifungals, etc...university & research hospital pharmacists are used to knowing who will carry what, how long it takes to get, who to talk to,etc...and this process is started well before discharge or before initiating tx because often insurance will require a PA....so this is not an issue.

    The law is not designed to force business to run at a loss - it is to force business to not "shut out" certain individuals or drugs from being dispensed due to moral objections - rather to have them address & facilitate these issues beforehand.

    Most states have these laws on the books now.
     
  12. Pharmguy07

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    Does this mean that an independent pharmacist couldn't choose to not stock Plan B?
     
  13. WVUPharm2007

    WVUPharm2007 imagine sisyphus happy
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    Yeah, but they would apparently have to order it if demanded...which seems pointless.
     
  14. Pharmguy07

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    That's absurd. I can see the argument that it's wrong for a pharmacist working for a retail chain to refuse to dispense something when it's stocked in that particular pharmacy, but independent pharmacists should be able to stock or not stock whatever they want (well retail chains too).
     
  15. sdn1977

    sdn1977 Senior Member
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    The law in CA is this - you don't have to stock anything, but with regard to medications ordered on an rx, if you don't have it, you must do your best to find it within a reasonable distance (this means call the 3 or 4 local pharmacies near you). You cannot keep the rx - you must return it to the patient. Ordering Plan B is not going to solve that pts issues that day, so our obligation is to help them find the medication.

    I often find I run out of Plan B over a long holiday weekend due to my location. But, I also know who else has it & I'm within close proximity to many pharmacies so it doesn't take me much time to locate it.

    I actually do this more often with Lovenox than I do with Plan B - I can anticipate Plan B, but I can't with Lovenox.

    But - yes, an independent in CA can choose to not stock Plan B if he/she wants. Most independents in my area choose not to stock Oxycontin.
     
  16. bananaface

    bananaface Pharmacy Supernerd
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    The law is not limited to controvertial medications. It will be summarized as part of an article on refusal to fill on the SDN mainpage whenever Lee gets around to posting it. Or, you can check out the full text of the law here:

    https://fortress.wa.gov/doh/hpqa1/HPS4/Pharmacy/documents/WAC246-869-010.pdf
    https://fortress.wa.gov/doh/hpqa1/HPS4/Pharmacy/documents/WAC246-863-095.pdf

    There are 2 links, as 2 sections of the WAC were revised.
     
  17. sdn1977

    sdn1977 Senior Member
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    This does not appear to go agains the concientious objection aspect of the law, but I'm not familiar with your laws, so I don't know if that is dealt with in a different section.

    It appears to just do what all the other state's laws do - return the rx or try to find an alternative pharmacy which might have it in stock. I may be missing something since this is just a small piece out of a larger portion of the law.
     
  18. bananaface

    bananaface Pharmacy Supernerd
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    It does not seem to allow for consciencious objection. The text states that "Pharmacists have a duty to deliver lawfully prescribed drugs...except for the following or similar circumstances." It does not list moral objection in that list and specifies that a "good faith effort" must be made to fill each prescription. There is a press release on the DOH page stating that this is indeed a mandate to fill controversial medications: http://www.doh.wa.gov/Publicat/2007_news/07-044.htm Of course the DOH and the BOP are not necessarily on the same page. Governor Gregoire likes to butt in where she has no authority to speak, as did her predecessor, Gary Locke. He posted crap on rx.wa.gov encouraging residents to illegally import meds from Canada. There are even helpful links to Canadian mail order outfits. She kept his page up and has used it as a pulpit to promote a state sponsored pharmacy discount card which those who sign up are led to believe they can use to split bill when in fact they can only do this if in the Medicare D donut hole. She also badmouthed her own local pharmacist for not stocking Plan B, when in fact he wanted to dispense it but was prevented from doing so by a vote of the cashier's union in the store he was employed in. What a great relationship she has with the pharmacy community.

    I guess I should get back on topic. :oops:

    Here is a flow chart put out by the board:
    http://www3.doh.wa.gov/policyreview/Documents/WSR07-05-055CR-102.pdf

    The chart says that you can refuse to fill if it would cause you to lose assets. I suppose if the pharmacist would be willing to quit over it you could count them as an asset and argue it if the case came to court.
     
  19. bananaface

    bananaface Pharmacy Supernerd
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  20. sdn1977

    sdn1977 Senior Member
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    Unfortunately, there are a couple of misstatements. There are indeed some "official" statements - by ASHP, APhA, AAFP & AMA, Canadian Healthcare Association, Canadian Pharmacist Association & The Royal Pharmaceutical Society of Great Britian. The court cases applicable as well as these statements can be found on the National Reference Center for Bioethics Literature under Pharmacists and Conscientious Objection.
     
  21. Gabby Pentin

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    IMO, personal opinions on medication do not belong in pharmacy practice. I don't think it is up to us to determine what is in the patient's "best interests" morally speaking. I am morally opposed to giving stimulants to young children to "treat" "ADHD", but I don't think it is my place to refuse to fill them once I'm a pharmacist. Refusing to fill a medication for a patient does not make a moral impact nor endear the pharmacist to them, it just makes them mad. If a pharmacist hopes to make any change to patients' views of X (whatever X may be) it's not going to be made by refusal to dispense.

    I also don't have very much respect for pharmacists who are unaware of the way Plan B works, or who are so "pro-life" that they don't want to dispense a drug that might PREVENT an abortion.
     
  22. Dr JPH

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    This is completely and utterly innapropriate and unprofessional.
     
  23. Dr JPH

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    :thumbup: :thumbup: :thumbup:
     
  24. WVUPharm2007

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    I don't really care if you happen to think it is or isn't. You are just one biased individual. Some other guy thinks that it puts them out of having to make a moral decision that has no right answer. And, yeah, said imaginary guy is biased, too. I'm at least trying to find a middle ground. This issue is a lot like an appendix, everyone's got one and they are all useless.

    It's either some liberal dingus that wants to unequivocally make people do something they have severe reservations against doing - something they feel is as wrong as murder; or, some conservative dingus that wants to tell a raped girl that it's unethical to give her some damned Plan B. I'm not actually sure that ever happens though because usually the ED gives the patient some after she gives a police report and all...but that's beside the point. All of this what-if crap is in the super magical fantasy world anyway.

    I know the "medical" definition of pregnancy occurs after the mechanism of Plan B can do anything, but it still doesn't change the fact that many people think that life starts when the little sperm burrows into the little egg. I sure as hell am not qualified to tell people what morals they should abide to. Nobody is. On the other hand, the patient also has autonomy, and if her ideas about life coincide with the medical definition, her ideas should be respected, too. Personally, I don't think a person is "human" until they have developed a sense of self-awareness. That's just me. I don't claim to be right or wrong because abstract ideals are unprovable.

    In a perfectly logical world both sides would come to realize that they are wrong....and right. What, you mean the entire world doesn't operate in a black vs. white dichotomy? Surely, you jest....

    The only solution I've come up with is the "giant dispensing machine of Plan B in the middle of town square" idea. Or you could ask pharmacists to self-identify themselves as dispensers and set up a national database. I really don't care if John-boy down the street refuses to fill EC. Send them down to me, I'll be happy to make a quick $30. Heck, I'm thrilled at the idea, in the long run it means more business for me. Hell, I don't even have to count it. The stuff comes in a nice little purple box all prepackaged for consumption.
     
  25. Dr JPH

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    As a healthcare professional it is your duty to provide the best care possible to your patients.

    A person who walks into the ER isnt refused care because they are gay, black, poor or otherwise.

    The job of a pharmacist is to provide medication to the patient while ensuring the health and safety of the patient.

    It is not the pharmacists job to determine medical therapy or refuse therapy based on moral objections. And certainly not to refuse to fill a prescription from another healthcare professional who already deemed that particular medication appropriate for the patient.

    If the dose is wrong, call the doctor. Other than that, fill the Rx.
     
  26. WVUPharm2007

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    Huh, is that all? The hell am I in school for 6 years for? You do bring up a good point, our role should be greatly expanded.

    Says who? Why are your morals superior to anyone else's? That's the fundamental problem here. Everyone assumes they god damn know everything. I have an OPINION on the matter, and it actually mirrors yours, FYI. But that shouldn't matter because I'm at least not pretentious to the point where I think my morals and ideas are intrinsically superior to everyone who disagrees with me.

    Hahahaha. Yeah, right. I'll refuse to fill any medication for any reason I please. I'm not your or anybody else's little robot lapdog.
     
  27. Dr JPH

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    Thats a pretty dangerous cowboy attitude.

    "I will do what I please because I am the one with the degree."

    No one said you were a robot lapdog but your position as a pharmacist comes with certain responsibilities, among which is to provide the medication to the patient as directed by a physician.

    Did I say thats all your job was? No. My wife went to school for 6 years as well and I know for a fact she can do more than count pills.

    When it comes to providing care to a patient each member of the health care team is responsible for their role in that care. Doctors, Nurses, Physical Therapists, Pharmacists, etc.

    No one is underestimating the importance of the pharmacists role, at least Im not. But if a patient needs to pass through a moral check by each member of the healthcare team in order to recieve appropriate care, we are going to have a lot of people not getting the medical care necessary.

    The argument "they can go to another pharmacy" is ridiculous. A patient shouldnt have to. What if they cannot?

    When a patient is given a prescription by a physician they are under the assumption that they need that medication. The patient and the doctor are trusting the pharmacist to ensure that the medication doesnt interact with other meds, the medication is filled for the appropriate strength and amount and that the patient is educated about the proper usage and side effects of the medication. No where in there is there room for a moral barometer.

    When it comes to patient safety and appropriate medical care there should be no "opinion". Diagnosis and treatment. Diagnosis based on signs, symptoms and lab data. Treatment based on published literature and approved medications & therapies. No opinions needed.

    Placing a patients well being AFTER your own moral objections or opinions is dangerous. The patient should always come first. Its people who forget that who end up with problems.

    It is not the pharmacists job...or ANYONES job...to judge a patient for anything...sexual orientation, race, religion, gender, pregnancy status or otherwise.

    A pharmacist will refuse to fill Plan B but will work in a store that sells cigarettes. Tell me where your moral objections are there? Or do the moral objections pop up just when there is an opportunity to exercise some form of control?

    WVU...you have a reckless attitude. It is going to get you into trouble someday.
     
  28. sdn1977

    sdn1977 Senior Member
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    Sorry - in this case you are completely WRONG - at least in the state of CA. We have a conscience objection clause within our pharmacy laws which give us the right to refuse to fill medications based on our convictions, no matter their basis. The only caveat is the objection is based upon the drug & only the drug - not the individual nor the circumstance.

    Therefore, if a pharmacist chooses not to dispense oxycontin so they are not subject to being held up for this one drug which makes pharmacies in this state vulnurable....it does not matter if a physician writes it for a drug addict or a cancer patient. The objection must be maintain completely across the board for that pharmacist for all reasons for that drug.

    That is why some pharmacists will not dispense plan B, cytotec or oxycontin, among others. I know many pharmacies in CA which do not carry nor will order any CII drugs at all - why???? It makes them vulnurable. Does the pt have to go to another pharmacy? Yes, by all means they do & can without problems. Those of us who choose to not stock something, based on morality, vulnurability or cost know exactly who in our area does indeed stock those medications & we refer the patients there. That is all the law requires in our state.

    We are not governed by the rules which require an ER pt to be seen (altho there is plenty of ER dumping in my area) & your arrogance in making our decisions for us is inappropriate, altho it may indeed be the case in PA.

    Fortunately, I do not live in PA and I am not subject to the influence you expressed. So - before you hand down your holier than thou attitude about what we should and shouldn't do - be sure you have your facts correct about what we can and cannot do!

    For WVA, the choice for a pharmacy to just not stock the medication is a non-confrontational approach to solving the issue with a moral dilemma and one which would work in my state if all pharmacy employees felt the same (which is highly doubtful, but we can use that for argument's sake).

    However...for the issue of Plan B - for those over 18, it no longer requires a prescription nor a pharmacist in any state. So, for those pharmacists who choose not to sell it, a technician can sell it without the pharmacist being involved at all - just like one of the most ridiculous laws we have on the books which are the PSE laws (which, hopefully, will be overturned after the next election takes place).
     
  29. Dr JPH

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    I am well aware of what you can and cannot do. In fact, thats why this whole thing is an issue to discuss, right? If you COULD NOT refuse then we wouldnt be talking about this. I thought that was clearly understood. :rolleyes:

    What you SHOULD do is remember that the patient should come first, not your personal opinions.

    The woman seeking Plan B is your patient...not some clump of cells that may or may not be present in her body.
     
  30. sdn1977

    sdn1977 Senior Member
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    If you are so aware of what we can and cannot do, why did you make the statement?::rolleyes:

    "And certainly not to refuse to fill a prescription from another healthcare provider who has deemed that particulare medication appropriate for that patient."

    It is not in your area of expertise to tell any pharmacist what he/she SHOULD or should not do. That is left up to them. If they feel they should not dispense, for any reason they choose, they are free to do so in CA. Your opinion, the patient's opinion does not come befoe the pharmacist's opinion.

    The reason this is being discussed here at all is there are apparently some states who are choosing to try to develop laws which go beyond that which is accepted within the profession - which is the pharmacist's right to choose to not fill an rx.....as I'm sure you wife knows well if she has followed nationwide court cases. The WA law does not address it entirely as written and to me, on the surface, does not disallow the moral conscience clause. But, state board clarification will be required to more clearly define what this vague & poorly written law actually will mean.

    For those pharmacists who do indeed have a strong moral, economic or safety reason for deciding to dispense or not dispense any medicaiton - they SHOULD and fortunately, in CA, DO have the ability to refuse to dispense without any influence on what your medical or moral decision was to write that prescription.

    Your comment on my statement that the pt must only be advised to go to another phamacy is "ridiculous" only reflects your opinion which is fortunately not shared by the CA state board of pharmacy because that is indeed what is written & it works quite well. Since we are the largest state in the country with the most pharmacists and pharmacies, I think this might work in most places as well (with the exception of VERY rural places - not WV! - see ..... I caught myself WVA;) ).

    Your comment "no where is there room for a moral barometer" indicates to me either you don't share your wife's belief in the fact that there is indeed a moral barometer, which is vocalized by our national professional organizations......or, perhaps she doesn't share them or neither one of you are even aware of them. I've certainly known more than one pharmacist who really doesn't have a clue as to what is expected professionally, but since she is not posting on here, we only have what you attest her knowledge of the issue to be. Unfortunately, your knowledge is not complete.

    Washington seems a bit slow to develop these laws since most of them were put in place last summer & fall and now that Plan B is otc - it is a moot issue.

    For those students who are in pharmacy school - this is the time to learn what boundaries, if any, you won't cross and find ways to maintain your own moral compass or perhaps, more importantly, respect colleagues who have a moral compass which does not allow them to dispense, and still help the patient with their medical issue at hand. Doing that does not necessarily mean filling the rx yourself & you should feel comfortable with that decision without the judgment of others, especially prescribers who feel just because they wrote the rx, we'll blindly fill it.
     
  31. Dr JPH

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    Do your job and take care of the patient.

    Dont pass judgement.

    Its that simple.
     
  32. sdn1977

    sdn1977 Senior Member
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    NOT! next???
     
  33. Dr JPH

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    Oh grow up. :rolleyes:

    I have greater hope for others to act appropriately as Healthcare PROFESSIONALS.

    Perhaps my thoughts of treating pharmacists as equal partners is naive and unfounded. Afterall, someone who alters the course of prescribed treatment simply because they want to isnt someone I want involved in the care of MY patient.

    You shouldnt do something simply because you have the right to do it. Compromising a patients care is something I take seriously. I wish you did too.
     
  34. sdn1977

    sdn1977 Senior Member
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    Sir - I am indeed grown up & old enough to be your parent. I've probably been in practice longer than you've been alive, so I've seen about every kind of physician & pharmacist there is to see.

    I'm not only extremely professional with all those I come in contact with, I'm also respectful of those whose opinions are not like my own. Therefore, although I choose to not just dispense, but also prescribe Plan B for those under 18, dispense Cytotec to induce abortions and dispense Oxycontin, in spite of the possibility of personal harm, I also respect my colleagues right to choose not to do so.

    I in no way choose to alter the course of treatment you decide on, however, in the state of CA - let me be very plain with you since you are having a hard time understanding this - a pharmacist can choose to not participate in that patient's course of treatment if he or she chooses not to do so. Your opinion on the matter is of no consequence - legally or morally for that pharmacist since he/she can follow their own conscience. This is not just a protected right by law, this is a professional choice which is advocated and encouraged by our professional organizations....which I've indicated in a previous post.

    No one is compromising patient care here. We have in this state ways to protect the pharmacist's professional & moral ability to make their choices without compromising patient care. No pharmacist makes these choices just because they have the right to do it - these pharmacists truly live their moral beliefs - just like OB-GYNs who choose not to do abortions. It is their choice!

    You are making assumptions which are unfounded and unjustified AND making disparaging comments on how seriously I take my professional responsibilities. I take them very seriously and have enjoyed decades of trust, respect and friendship of not just healthcare colleagues, but also patients.

    I would not in any way tell you what to do - but, have you ever sat down with your wife to have this discussion? Does she ever have a circumstance in which she chooses or works with someone who chooses not to fill an rx based on a personal moral code which she does not share?

    Of course, in your own ethics classes you've covered this (I know a bit about medical education since my daughter is an MSIII), but pharmacists also have these courses & in the last year - our situation, particularly surrounding Plan B has become public. It was unfortunately tied up with a poorly operating corporate culture professionally, which clouded the issue.

    But - in 30 years....this is not the first time this situation has come up. My own first circumstance with this occurred 28 years ago when I was asked to compound nitroglycerin IV solution - which, you may not realize, is not that old commercially. Almost all my colleagues would not agree to compound this, however, I was able to develop a meeting with our cardiovascular surgical group, our anesthesiologists and our cardiologists to come up with parameters for compounding, dosing, guidelines for nursing so this could come about - all to the benefit of patient care & before this product was even available!

    So, Sir, please - do not talk to me about professionalism and comromising patient care. I have known this first hand far longer than you. Your approach to those of us who are not in your field might be more productive if you chose not to TELL us what we SHOULD or SHOULD not do because ultimately, we will do what we want to do - either with you or in spite of you.
     
  35. acetyl

    5+ Year Member

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    I think I'm stay outa this one, this time. I'll be the popcorn eating spectator learning about California law.
     
  36. sdn1977

    sdn1977 Senior Member
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    Get the large tub:D .
     
  37. genesis09

    genesis09 Senior Member
    10+ Year Member

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    At least in CA, you don't have a governor, like in IL, who hates your profession.
     

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