Moral Dilema: Emergency Contraception

[Caverject]

You are a pharmacist that believes Plan B is an abortion like pill. You are presented with a prescription for Plan B. You refuse it, explaining to the patient your beliefs do not allow you to fill the prescription. The patient becomes upset and starts crying uncontrollably stating "She is going to die if she doesn't get this medication" You state to the patient that being pregnant is God's gift of life and she should be happy if she does get pregnant. She then responds and says she has Eisenmenger's Syndrome.

What do you do?

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[bananaface]

Ideal: look up the MOA of Plan B, correct my misperception, dispense
More realistic: refer to another provider
Irresponsible/unprofessional: not dispensing or referring

The patient is supposed to avoid prenancy with Eisenmenger's Syndrome.

 

[golf299]

As a pharmacist it is NOT your job to decide who gets to use what medicine! I am sick of people trying to force their beliefs on others. Unless there is an ADR associated with the Rx, there is absolutely no reason to refuse to fill the order. If you believe differently, perhaps you should take a job in an arena where subjectivity is permitted.

 

[Caverject]

Does not a professional career such as pharmacist allow for judgements? I know that if a patient walked into my pharmacy for Lipitor after not having it for 9 months, that I would refuse to fill and transfer it.

 

[bananaface]

Unless there is an ADR associated with the Rx, there is absolutely no reason to refuse to fill the order.

I confess to having answered the question too hastily.

Caverject, how long has it been since she has unprotected intercourse?

 

[golf299]

i agree with your lipitor example. however, that is not a moral decision that is being made, that is a pharmacologic decision that is in the best interest of the patient. there is a distinct difference between morality and professionalism. it would be unprofessional to not question the refill of a Rx for lipitor if it has been more than 9 months since the last fill. that has nothing to do with morality.

there is no way of making a convincing arguement that refusing to fill an Rx based on your individual belief is your right, or even a privilage you can wield. you are in the pharmacy to do a job, and do it effectivly so the patients health is ultimately improved. you are not there to play Dr. Morality as you see fit, and electing to do so is flat wrong.

 

[Caverject]

i agree with your lipitor example. however, that is not a moral decision that is being made, that is a pharmacologic decision that is in the best interest of the patient. there is a distinct difference between morality and professionalism. it would be unprofessional to not question the refill of a Rx for lipitor if it has been more than 9 months since the last fill. that has nothing to do with morality.

Great point.

bananaface: 24 hours

 

[ultracet]

there is no way of making a convincing arguement that refusing to fill an Rx based on your individual belief is your right, or even a privilage you can wield. you are in the pharmacy to do a job, and do it effectivly so the patients health is ultimately improved. you are not there to play Dr. Morality as you see fit, and electing to do so is flat wrong.

I believe in my state the law would disagree with you! So that to me is a fairly convincing argument (in my opinion) to fill at my personal discretion.

 

[bananaface]

bananaface: 24 hours

Cool. So, I am not past the efficacy the time limit of 5 days. In that case I would look up the MOA and fill, or refer to another provider.

(Notice that an ADR is not the only legitimate professional reason not to fill a prescription. )

This is one of those cases, like with HIV meds and anti-rejection meds, where not filling could create harm to the patient. Even though there is no obligation to fill, it is a situation in which you are at risk for becoming a legal precedent mandating one.

 

[ButlerPharm.D.]

I'm sure most of you as professional phase pharmacy students have taken some sort of class on healthcare ethics. I'm surprised that none of you have mentioned that Pharmacists do indeed have a "conscience" clause as do Physicians regarding acts that go against their beliefs. However, this does not mean that a RPh can simply deny a patient the morning after pill without the patient having some other alternative, whether that means having another RPh fill it or directing them to another pharmacy. I feel that often times cases like this are blown out of proportion because both patient and RPh don't deal adequately with the situation. If the RPh were to simply tell the patient that they are not able to fill it and then offer them some other recourse as to how they can get it filled, then I believe we would not hear quite so often about this type of issue.

 

[tupac_don]

You are a pharmacist that believes Plan B is an abortion like pill. You are presented with a prescription for Plan B. You refuse it, explaining to the patient your beliefs do not allow you to fill the prescription. The patient becomes upset and starts crying uncontrollably stating "She is going to die if she doesn't get this medication" You state to the patient that being pregnant is God's gift of life and she should be happy if she does get pregnant. She then responds and says she has Eisenmenger's Syndrome.

What do you do?

What you do, is you tell her, that by law you can refuse the prescription and that your beliefs prevent you from dispensing it to her. But if she wants to do it nonetheless to go to another pharmacy or to an ER where they will give the pill to her. Even though you don't agree with abortion, you can't limit her options if she wants to have it at all cost. IF you want others to respect your beliefs you must respect beliefs of others too. This way you give her an option and there is no hard feelings. Hope this helps.

 

[tupac_don]

I'm sure most of you as professional phase pharmacy students have taken some sort of class on healthcare ethics. I'm surprised that none of you have mentioned that Pharmacists do indeed have a "conscience" clause as do Physicians regarding acts that go against their beliefs. However, this does not mean that a RPh can simply deny a patient the morning after pill without the patient having some other alternative, whether that means having another RPh fill it or directing them to another pharmacy. I feel that often times cases like this are blown out of proportion because both patient and RPh don't deal adequately with the situation. If the RPh were to simply tell the patient that they are not able to fill it and then offer them some other recourse as to how they can get it filled then I believe we would not hear quite so often about this type of issue.

Funny just read your post and we pretty much agree. I guess great minds think alike

 

[bananaface]

Pharmacists who feel that EC is morally wrong are much less likely to agree that referral is a part of their professional responsibility when refusing to fill.

We don't refer patients whose narcotic prescriptions we turn away. Rather, we assume that they understand that they can try their luck elsewhere. Is this really a moral obligation for referral when one refuses to fill? Or, would any obligation to refer have to be legally based on the consequences of a denial of service?

 

[ButlerPharm.D.]

Although it is becoming more widely accepted that RPh's should be covered by a conscience clause, the APhA flat out refused. The following is an excerpt from the 97-98 policy meeting, “Current APhA policy addresses the ability of a pharmacist to refuse to participate in certain activities which conflict with their professional judgment, but there is no policy that addresses decisions based on personal, moral opinions. Pharmacists choosing to excuse themselves from such a situation continue to have a responsibility to the patient—ensuring that the patient will be referred to another pharmacist or be channeled into another available health system. Exercising the authority to excuse themselves from the dispensing process, and thus avoiding having personal, moral decisions of others placed upon them, requires the same consideration of the patient—the patient should not be required to abide by the pharmacist’s personal, moral decision. Providing alternative mechanisms for patients in this situation ensures patient access to drug products, without requiring the pharmacist or the patient to abide by personal decisions other than their own." The act of refusal would me immoral if the RPh gave the patient no other recourse I.E. if your pharmacy was the only 24 hours pharmacy around and it's currently 10 P.M. I believe the act of refusal to be moral if you give the patient some other recourse. If you simply deny to fill the script and turn your back, that's immoral and you should be reported to the state board of pharmacy. However, I think that RPh's need to have a conscience clause in the APhA code of ethics because it would protect us from lawsuits. The APhA code of ethics is too vague in its definition that a Pharmacist should, "respect the autonomy and dignity of each patient", where a pharmacist "promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients." What the heck does that mean!!?!?!?! This is the whole point, if you side step the issue we're going to constantly be hit with lawsuits. When dealing with EC, the RPh must make available some other recourse or fill the prescription. Just as someone else has said, what really is the difference between filling a script for EC and birth control pills?

Pharmacists who feel that EC is morally wrong are much less likely to agree that referral is a part of their professional responsibility when refusing to fill.

We don't refer patients whose narcotic prescriptions we turn away. Rather, we assume that they understand that they can try their luck elsewhere. Is this really a moral obligation for referral when one refuses to fill? Or, would any obligation to refer have to be legally based on the consequences of a denial of service?

 

[baggywrinkle]

." The act of refusal would me immoral if the RPh gave the patient no other recourse I.E. if your pharmacy was the only 24 hours pharmacy around and it's currently 10 P.M. I believe the act of refusal to be moral if you give the patient some other recourse. If you simply deny to fill the script and turn your back, that's immoral and you should be reported to the state board of pharmacy.

You have your 24 hour pharmacist caught between a rock and a hard place.
The other half of the pharmacists obligation is to ensure that a prescription
is being dispensed for a "legitimate medical purpose" Failure to do so is also
grounds for being reported to the board.



A nurse practitioner recently sent me a prescription for Oxycontin with instructions to give 1 1/2 tablets on a Friday night. I refused to fill until I could clarify which indeed was the following Monday. Patients only recourse was to take prescription back or go to the ER. What about an apparent forgery or a stolen blank?

Refusing to fill until a prescription can be clarified is a standard tactic among pharmacists. Otherwise pharmacists are not only made fair game for every junky in a fifty mile radius, professional judgement is negated and we are reduced to simple dispensing machines. The day that happens the board can have my license. I will be happy to tell them where to put it.

 

[ButlerPharm.D.]

Your argument is a red herring; we're not talking about narcotic prescriptions or even those that you know to be falsified. It's quite clear what the pharmacist's recourse is in those situations. The question in this thread is what is a pharmacist to do in a situation where it is quite clear that the patient received the prescription lawfully and the medication is being taken for a legitimate medical purpose but for some reason the RPh objects to fill on a moral/religious basis? You seem to be focusing on narcotics and this thread has nothing to do with that. All Pharmacists should clarify/deny to fill narcotic prescriptions if they feel that they have been forged or obtained illegally. One thing I’d like to note is that even though you are talking about narcotics in your reply, your reply seems to focus on the legality of refusal whereas the thread is focused on the morality/immorality of refusing to fill a script for Plan B.

You have your 24 hour pharmacist caught between a rock and a hard place.
The other half of the pharmacists obligation is to ensure that a prescription
is being dispensed for a "legitimate medical purpose" Failure to do so is also
grounds for being reported to the board.



A nurse practitioner recently sent me a prescription for Oxycontin with instructions to give 1 1/2 tablets on a Friday night. I refused to fill until I could clarify which indeed was the following Monday. Patients only recourse was to take prescription back or go to the ER. What about an apparent forgery or a stolen blank?

Refusing to fill until a prescription can be clarified is a standard tactic among pharmacists. Otherwise pharmacists are not only made fair game for every junky in a fifty mile radius, professional judgement is negated and we are reduced to simple dispensing machines. The day that happens the board can have my license. I will be happy to tell them where to put it.

 

[baggywrinkle]

Your argument is a red herring; we're not talking about narcotic prescriptions or even those that you know to be falsified. It's quite clear what the pharmacist's recourse is in those situations. The question in this thread is what is a pharmacist to do in a situation where it is quite clear that the patient received the prescription lawfully and the medication is being taken for a legitimate medical purpose but for some reason the RPh objects to fill on a moral/religious basis? You seem to be focusing on narcotics and this thread has nothing to do with that. All Pharmacists should clarify/deny to fill narcotic prescriptions if they feel that they have been forged or obtained illegally. One thing I’d like to note is that even though you are talking about narcotics in your reply, your reply seems to focus on the legality of refusal whereas the thread is focused on the morality/immorality of refusing to fill a script for Plan B.

I wholeheartedly and respectfully disagree. The discussion is focused on the
ethics and morals of the individual pharmacist which is part of the foundation
of professional judgement. While I do not personally have a problem with dispensing ECT I have worked with excellent pharmacists who would and
have refused. In their professional judgement it is their duty to protect the patient which in their mind includes the unborn. While I might shake my head when a scandal arises as a result of this view I cannot in good conscience say anything against the pharmacist on duty at the time because it was not and will not be my name on the prescription. I will not interfer with that individual practitioners professional judgement because to do so will also interfer with my own ability to practice in a manner which will allow me to sleep at night. Recall in your training that pharmacy is both art and science. Secundum artem - judgement - is the difference between a technician and a pharmacist which allows the practitioner the ability to deal with shades of grey in a landscape of black and white. Remove professional judgement from the ECT issue and you impair the ability of the pharmacist to discern and take a stand against the falsified prescription, the lack of medical purpose by a physician-candyman for hire, or even insurance fraud. The common thread between plan B and narcotics abusers or fraud is not cut and dried without
the judgement of a trained experienced practitioner making a decision that a prescription is good and safe to fill or that it stinks on ice

The ability to decide is the only reason that Walgreens doesn't use dispensing machines where pharmacists used to stand. Once the decision is
made the pharmacist on duty must wear it both to court and defend it in front
of a board of his peers against the Standards of Practice at that time. That practitioner might choose wrong and be forced to answer for it later but *I* will always defend their right to make the decision and place their name on the log

{huff puff huff puff, getting down off soapbox}

 

[ButlerPharm.D.]

I respectfully disagree. I've never heard of a RPh refusing to dispense narcotics because of a religious or moral obligation therefore one can not place both, dispensing of narcotics and EC, on the same level. NARCOTICS AND EC ARE NOT MORALLY ON THE SAME LEVEL AND AS SUCH CAN NOT BE COMPARED. I have heard of RPh's refusing to fill scripts because it's believed that the script has been forged, but again, different issue-legality not morality. I think many of you do not understand my argument. I'm saying it's fine for a RPh to morally object to dispensing EC but they need to give the patient another alternative-I.E. have other RPh on premises fill it, send them to another pharmacy. If the RPh DOES NOT GIVE THE PATIENT ANY OTHER RECOURSE THEN THEIR ACT IS IMMORAL WHETHER OR NOT THE REFERRAL GOES AGAINST THEIR MORAL BELIEF. And the discussion is not focused on the ethics and morals of "you" as a pharmacist, the thread is asking is it moral/immoral for a RPh to refuse, although it does boil down the RPh's judgment, we're asking the morality/immorality not whether you know people who have done and it respect them for it. I've known many RPh's who I respect, that doesn't mean they've acted morally.

I wholeheartedly and respectfully disagree. The discussion is focused on the
ethics and morals of the individual pharmacist which is part of the foundation
of professional judgement. While I do not personally have a problem with dispensing ECT I have worked with excellent pharmacists who would and
have refused. In their professional judgement it is their duty to protect the patient which in their mind includes the unborn. While I might shake my head when a scandal arises as a result of this view I cannot in good conscience say anything against the pharmacist on duty at the time because it was not and will not be my name on the prescription. I will not interfer with that individual practitioners professional judgement because to do so will also interfer with my own ability to practice in a manner which will allow me to sleep at night. Recall in your training that pharmacy is both art and science. Secundum artem - judgement - is the difference between a technician and a pharmacist which allows the practitioner the ability to deal with shades of grey in a landscape of black and white. Remove professional judgement from the ECT issue and you impair the ability of the pharmacist to discern and take a stand against the falsified prescription, the lack of medical purpose by a physician-candyman for hire, or even insurance fraud. The common thread between plan B and narcotics abusers or fraud is not cut and dried without
the judgement of a trained experienced practitioner making a decision that a prescription is good and safe to fill or that it stinks on ice

The ability to decide is the only reason that Walgreens doesn't use dispensing machines where pharmacists used to stand. Once the decision is
made the pharmacist on duty must wear it both to court and defend it in front
of a board of his peers against the Standards of Practice at that time. That practitioner might choose wrong and be forced to answer for it later but *I* will always defend their right to make the decision and place their name on the log

{huff puff huff puff, getting down off soapbox}

 

[bananaface]

Any question of ethics by definition involves morals. And, turning away narcotic precriptions is typically a matter of professional ethics. For example, many pharmacists feel that we have an ethical obligation not to knowingly condone the overuse of prescription narcotics, because doing so not be in the best interest of the patient. Likewise, some pharmacists feel that filling EC is not in the best interest of the patient.

 

[shivalrous]

Would the pharmacist necessarily be aware of the circumstances for emergency contraception? (i.e. in the event of rape or such).

I don't want to elaborate in an attempt to prevent any flame wars. But I hope people understand that things aren't written in stone...some cases of possible pregnancies are TRULY unwanted.

 

[TucsonDDS]

What would you do if your ER doctor had a religious believe against blood and therefor wouldn't transfuse your loved one. Granted this is unlikely to happen but it is the same senario. I would hope that as a pharmacist and a patient advocate you would either fill the presciption or refer the patient who would. It is not your right to force your beliefs on someone else. For a long time women in Afghanistan weren't allowed to show skin because it was against religious and ethical beliefs. Was that right? Let people chose for themselves and get off of your high horse.

 

[ButlerPharm.D.]

Yes, I know this. What I meant but my earlier post was, I don't know of any pharmacists that would refuse to fill a script for a narcotic based on the fact that they find the use of narcotics to be morally/religiously objectable. I do in fact agree with you that it is the RPh's duty to deny refills if they are aware that the patient intends to overdose. It appears we are getting off topic, the original post asks, "You are a pharmacist that believes Plan B is an abortion like pill. You are presented with a prescription for Plan B. You refuse it, explaining to the patient your beliefs do not allow you to fill the prescription. The patient becomes upset and starts crying uncontrollably stating "She is going to die if she doesn't get this medication" You state to the patient that being pregnant is God's gift of life and she should be happy if she does get pregnant. She then responds and says she has Eisenmenger's Syndrome.

What do you do?" I agree with TusconDDS that as healthcare providers it is not our role to force our beliefs on others and by refusing to fill the script and not giving the patient any other recourse.

Any question of ethics by definition involves morals. And, turning away narcotic precriptions is typically a matter of professional ethics. For example, many pharmacists feel that we have an ethical obligation not to knowingly condone the overuse of prescription narcotics, because doing so not be in the best interest of the patient. Likewise, some pharmacists feel that filling EC is not in the best interest of the patient.

 

[bananaface]

What would you do if your ER doctor had a religious believe against blood and therefor wouldn't transfuse your loved one. Granted this is unlikely to happen but it is the same senario. I would hope that as a pharmacist and a patient advocate you would either fill the presciption or refer the patient who would. It is not your right to force your beliefs on someone else. For a long time women in Afghanistan weren't allowed to show skin because it was against religious and ethical beliefs. Was that right? Let people chose for themselves and get off of your high horse.

Performing a transfusion is withing the normal scope of practice of an emergency department physician. At hiring, they would be obligated to tell their employer if there were any aspects of the job they would refuse to do, including this one. The hospital, if properly notified would either refuse to hire the individual, or pad the staffing with other staff who can perform the duties expected of an emergency physician. In pharmacy, EC dispensing is not yet ingrained as a standard of practice.

Pharmacy is a profession that has has and is undergoing a shift in roles and responsibilities. Pharmacists are being asked to do things that to them were unthinkable at the time they entered the profession. I still know a few people who think that counseling is not something pharmacists ought to be required to do or offer, because it was not common when they entered the profession. It takes time for everyone to accept the new practice standards.

We cannot excise a portion of practicing pharmacists from the profession. They are here to stay and we have to work with them. Like baggywrinkle said: When you are dispensing, it's your choice. When they are dispensing, it's theirs. Take some comfort in the fact that autonomy does not excuse one from potential lawsuits, should a denial of service be followed by an unwanted pregnancy.

Last summer, I met a younger pharmacist who was under the mistaken impression that Plan-B was an abortifacient and had on prior occasions refused to dispense it on this basis. He felt that life begins at conception and had strict moral beliefs against abortion. We got into a rational discussion, where I could see that he was not going to be upset if I pinned down his reasoning. When I pointed out that the current literature listed the MOA as supression of ovulation only, he didn't believe me. So, I took a shot in the dark and asked him if he would consider revising his stance if he looked at the literature and was convinced otherwise. (Note the cautious wording.) He said that he would consider it, but appeared doubtful that the findings would change his mind. Not only does he dispense Plan-B now, but he does so on protocol. It just goes to show what you can do if you work with people instead of getting angry and condemning them and their belief system. It is far better to work with their assumptions. You have to pick your battles carefully, though. Everyone has different comfort levels when it comes to discussing the application of their moral beliefs.

 

[bananaface]

What I meant but my earlier post was, I don't know of any pharmacists that would refuse to fill a script for a narcotic based on the fact that they find the use of narcotics to be morally/religiously objectable.

I know of an independant pharmacy on Seattle's eastside which does not stock narcotics as a rule, because the owner feels that their potential for abuse as a drug class outweights their benefit.

Many if not all tribal reservation pharmacies in this area refuse to stock narcotics. As I understand it, that is more of a decision on the part of the tribe, based on the idea that the rampant abuse of these substances causes harm to the community. But, the pharmacists working there certainly understand and respect the tribes' point of view on the subject.

Would you argue that one has a duty to stock narcotics? Would you argue that the pharmacist on the eastside has a moral obligation to dispense narcotics if he worked at a location where they were stocked?

 

[baggywrinkle]

I respectfully disagree. I've never heard of a RPh refusing to dispense narcotics because of a religious or moral obligation therefore one can not place both, dispensing of narcotics and EC, on the same level. NARCOTICS AND EC ARE NOT MORALLY ON THE SAME LEVEL AND AS SUCH CAN NOT BE COMPARED. I have heard of RPh's refusing to fill scripts because it's believed that the script has been forged, but again, different issue-legality not morality. I think many of you do not understand my argument. I'm saying it's fine for a RPh to morally object to dispensing EC but they need to give the patient another alternative-I.E. have other RPh on premises fill it, send them to another pharmacy. If the RPh DOES NOT GIVE THE PATIENT ANY OTHER RECOURSE THEN THEIR ACT IS IMMORAL WHETHER OR NOT THE REFERRAL GOES AGAINST THEIR MORAL BELIEF. And the discussion is not focused on the ethics and morals of "you" as a pharmacist, the thread is asking is it moral/immoral for a RPh to refuse, although it does boil down the RPh's judgment, we're asking the morality/immorality not whether you know people who have done and it respect them for it. I've known many RPh's who I respect, that doesn't mean they've acted morally.

I agree with you. The pharmacist may refuse to participate but may not
prevent the patient from seeking care i.e. tear the prescription up and toss
it. To do so is asking to be sanctioned.

Regarding narcotics/controlled substances; Back in the early eighties before methaqualone was pulled off the market you could see signs in windows of pharmacies WE DO NOT CARRY QUAALUDE because they were tired
of being robbed for it. It was highly unlikely that you would persuade the pharmacist to order it for you even though you had a valid prescription. In his professional judgement it was not worth the risk to even mess with it.

Regarding legislation of morality; it won't happen.

Regarding professional judgement; I respect your right to run your practice as you see fit. If you want to give a customer a lecture instead of plan B as one pharmacist in my community will then more power to you. Remember, dobbing people into the state board cuts both ways and if you do it you had best walk on water....

Regarding blood transfusion; the physician should disqualify himself from the case and call in someone else

 

[ButlerPharm.D.]

It's amazing to see that some people on this forum regard change as bad. Many years ago the patient never knew what the doctor was prescribing, the name of the drug was not placed on the label and it wasn't the responsibility of the RPh to console or answer any questions regarding the medication because of a little term I like to call Paternalism. Would you advocate that patients now not be made aware of their medications? It seems that you reference the past in order to answer a question of concern now, so would you advocate this? Let's answer the question of the morality/immorality of dispensing EC in terms of today’s roles and responsibilities because so much has changed in regards to the practice of Pharmacy over many years. That RPh that you know who doesn't stock narcotics, has he ever been visited by any agencies that have questioned his choice?

 

[bananaface]

It's amazing to see that some people on this forum regard change as bad. Many years ago the patient never knew what the doctor was prescribing, the name of the drug was not placed on the label and it wasn't the responsibility of the RPh to console or answer any questions regarding the medication because of a little term I like to call Paternalism. Would you advocate that patients now not be made aware of their medications? It seems that you reference the past in order to answer a question of concern now, so would you advocate this? Let's answer the question of the morality/immorality of dispensing EC in terms of today’s roles and responsibilities because so much has changed in regards to the practice of Pharmacy over many years. That RPh that you know who doesn't stock narcotics, has he ever been visited by any agencies that have questioned his choice?

Who here said that change was bad? Do you have an issue with us presenting alternative points of view, be they ours or others'? If we are going to approach any situation constructively, we need to understand all relevant perspectives. There is no sense in pretending that eveyrone in the profession is on the same page.

I am not aware of any agency running a smackdown on pharmacies that opt not to carry narcotics.