Tuesday, October 30, 2007

Pills: To Push or Withhold?

"Pope Benedict XVI said Monday that pharmacists have a right to use conscientious objection to avoid dispensing emergency contraception or euthanasia drugs _ and told them they should also inform patients of the ethical implications of using such drugs."


This is a controversy which has been going on for several years. On the one hand, the Vatican and conservative group would like to make it illegal for pharmacists to distribute drugs that they consider to be morally objectionable. On the other hand, many liberal groups are pushing to make it illegal for pharmacists not to fill prescriptions for such drugs.

Having recently read Luther's Eight Sermons at Wittenberg, I find that Luther's handling of the reform of worship there to shed interesting light on the struggle to control pharmacists. In 1521 and 1522, a group of reformers under the leadership of Andreas Karlstadt decided to impose Luther's ideas by force. At the time Luther was in hiding and did not play a part in this, but when he found out about it, he went to Wittenberg and said the following to the reformers:

"In both [things which are necessary, and things which are a matter of choice], love must deal with our neighbor in the same manner as God has dealt with us; it must walk the straight road, straying neither to the left nor to the right. In the things which are “musts” and are matters of necessity, such as believing in Christ, love nevertheless never uses force or undue constraint. Thus the mass [as practiced at this time] is an evil thing, and God is displeased with it, because it is performed as if it were a sacrifice and work of merit. Therefore it must be abolished. Here there can be no question or doubt, any more than you should ask whether you should worship God. Here we are entirely agreed: the private masses must be abolished. As I have said in my writings, I wish they would be abolished everywhere and only the ordinary evangelical mass be retained. Yet Christian love should not employ harshness here nor force the matter. However, it should be preached and taught with tongue and pen that to hold mass in such a manner [as it is now] is sinful, and yet no one should be dragged away from it by the hair; for it should be left to God, and his Word should be allowed to work alone, without our work or interference. Why? Because it is not in my power or hand to fashion the hearts of men as the potter molds the clay and fashion them at my pleasure [Ecclus. 33:13]. I can get no farther than their ears; their hearts I cannot reach. And since I cannot pour faith into their hearts, I cannot, nor should I, force any one to have faith. That is God’s work alone, who causes faith to live in the heart."

For Luther, the pastoral issue of including and loving all people (even those who hold views diametrically opposed to yours) trumps all. Reforms must be made, but never should a person be forced to act in a certain way.

I see a couple of implications as to how these ideas apply to the discussion of pharmacists filling prescriptions, regardless of whether or not to do so is immoral. First, those pharmacists who feel it is wrong to distribute certain drugs should not be required to do so. Second, those people who have been prescribed medication and wish to taken, should in no way be prevented from receiving their medication.

How would this work? Earlier this month in Illinois, a compromised was settled in which pharmacists can step aside and have someone else in their pharmacy fill an objectionable prescription, so long as there is always a way for a patient to receive medication.

It looks like both the Pope and the State of Illinois are taking a tip from Luther.


Lucas Johnson said...

Because the article and the post focuses on pharmacists, I don't necessarily know that pharmacists are "pushing" as the title of this blog post suggests. Because in general they are only following the doctor's direction, I think, "To Fill or to Withhold" might be more appropriate. Now doctors on the other hand...

Ben Colahan said...

Point taken; though "To Push" can also refer to pushing pharmacists to distribute pills.

Lucas Johnson said...

True, however in the context of the post presenting "to push" with "or withhold" implies that the pharmacists are doing the pushing.

I was actually thinking more about this, and it seems that pharmacies profit by selling drugs, even controversial drugs such as those used for emergency contraception and euthanasia, so they benefit from a doctor's prescription of these drugs. If pharmacists are filling prescriptions, are they "pushing" merely by being a part of the process and by indirectly profiting from it?

In addition, in filling these prescriptions, pharmacists must engage their time and experience and talent, all God-given gifts, in ensuring that no harm is done to the patient. If individual pharmacists think that these drugs are morally wrong, what it does it mean to be participating in a process and using their God-given gifts in a manner which profits from such sales, even if such drugs were not directly prescribed by the pharmacist?

I think you're right. Illinois seems like it may be onto something in allowing each individual pharmacy to seek the middle way of compromise and in not forcing pharmacists to participate in activities they may deem to be morally wrong.

caralynjayne said...

To change the subject slightly... or just going back to the opening quote regarding the Pope. While I understand the moral dilemma some pharmacists may face in distributing emergency contraception, I have trouble picturing the poor fellow at the pharmacy picking up his own euthanasia prescription. Not knowing much about the pharmaceutical industry or euthanasia "norms," I could be wrong, but I imagine euthanasia tends to happen in a hospital, not scrawled illegibly on a prescription to pick up at Walgreens.

In the case of emergency contraception, many prescriptions for this medication are provided by doctors after rape or incest. When this is the case, being challenged/judged at the pharmacy is simply cruel. And given the unfortuanate prevalence of these abuses, emergency contraception needs to be more available, not less.

It seems that if a pharmacist has an ethical dilemma in fulfilling their job description, they should perhaps explore other professions. I know that seems severe. But in most professions, if you cannot do what you signed on for, you are usually asked to leave.

Ben Colahan said...

As to the matter of pharmacists challenging/judging patient, I couldn't agree more. This is always the difficulty of freedom and grace--when you are not forcing people to behave in a manner that is appropriate, how can you be sure they won't abuse their freedom? The short answer is that you can't.
I would hope that pharmacists (especially ones who consider themselves Christian)would have the decency and compassion to not challenge/judge. I do not feel comfortable, however, approving of a law that makes it illegal for people to express an opinion or forces them to go against their religious convictions.

The idea of pharmacists leaving the profession is something I've been discussing other people. It seems to me that it would be unfair to ask pharmacists who entered the profession before these drugs were available to leave; however, I can see in future requiring new pharmacists to sign some sort of professional agreement that says they will provide what ever drug a doctor and patient have agreed upon. Thus the current dilemma would be only temporary.

Of course, I always have to ask the question, "How much should Christian ideals be played out in government?" Can governments and lawmakers navigate the difficulties of individual lives in the same way that a pastor must? Can the idea of uncompromising grace for ALL people really work when trying to rule a whole society in which there are people who have no qualms about harming others? I don't know...

caralynjayne said...

dammit! I wanted the last word! :)

Overall, for me this is a justice issue for the person who needs medicine. As with other slippery slopes, if a pharmacist may choose to not provide medicines, what is to stop doctors with similar opinions from eventually not prescribing them? Where can a patient get the medicine necessary if health care professionals get squeamish?

I also do not want to make laws that force opinionated pharmacists to go against their own beliefs. But the beliefs are their OWN, after all, and who are they to force their beliefs on patients?

And isn't it something to note that these questions always come up around medications for behavior-related issues, and not, say, allergies? Judgment towards the paitient is implicit in having a pause in providing medication at all.

As for leaving the profession, while there is something to be said for staying in a situation and hoping for change to emerge, when you find conflict with an unavoidable part of the job, I still think you should go. Soldiers who become pacifists don't stay in the military a second longer than they have to, hoping to change the nature of war. Pharmacists who can no longer confidently supply the prescriptions presented to them might think about it in a similar way, since the need for these medications is not going to end.

I have seen too many of my friends, married and single, enthusiastic participants and victims of abuses, be embarrassed and shamed by what they have to go through in order to take care of their bodies. This gets personal for me. I feel like the pharmacists are missing the point - they are providers of a service that can be a life-changing matter. Healthcare and all related professions need to be about the patients. If the patients' care is not our highest priority, we'll end up with a system... just like the one we have.

Ben Colahan said...

I promise I'll let you have the last word. ;)

I just want to be clear that I very much want to protect patients' rights. I tried to be explicit in my post that I would only support pharmacists abstaining from dispensing medication so long as it IN NO WAY HINDERED patients from getting the medication they need. Is the possible? I don't know. However, I am always wary of a dichotomy that requires one party to lose--my fear is that we are not thinking creatively enough about a problem because it is simply easier to vilify the other side. So my question for you is, do you think there is a way to protect patients' rights without forcing Catholic pharmacists to act against their beliefs or resign? The truthful answer may be "no," but I fervently pray that it is not.

caralynjayne said...

thank you for the invitation to Creativity!

I'll get back to you on this after all the reading we've been assigned! And maybe in person, too. I know that short-circuits the whole point of a blog... but I do have the tendency to get polemical, and I believe neither of us is trying to do that.