Tuesday, June 17, 2008

"Pro-Life" Pharmacies?

According to this article in The Washington Post (free registration may be required; HT Salvo), a small but growing number of drugstores are refusing to stock or sell contraceptives:

The pharmacies are emerging at a time when a variety of health-care workers are refusing to perform medical procedures they find objectionable. Fertility doctors have refused to inseminate gay women. Ambulance drivers have refused to transport patients for abortions. Anesthesiologists have refused to assist in sterilizations.

The most common, widely publicized conflicts have involved pharmacists who refuse to fill prescriptions for birth control pills, morning-after pills and other forms of contraception. They say they believe that such methods can cause what amounts to an abortion and that the contraceptives promote promiscuity, divorce, the spread of sexually transmitted diseases and other societal woes. The result has been confrontations that have left women traumatized and resulted in pharmacists being fired, fined or reprimanded.

In response, some pharmacists have stopped carrying the products or have opened pharmacies that do not stock any.

The concerns raised by those pharmacists are among those I discuss in my upcoming article in Salvo 6 (due out in early September). I think they are legitimate, though not enough to rule out all contraceptive use, still I find such "Pro-Life" drugstores interesting. As the article notes, there are two conflicting issues here: One is the right of a business to decide for itself what to sell (and pharmacies are businesses), which seems to be pretty fundamental. Just because a customer wants a business to sell something doesn't mean the business has any legal obligation to do so (though they obviously have an economic incentive). In an urban context where, presumably, anyone seeking contraception should have little trouble finding another drugstore that does stock them, this seems pretty indisputable. But what about in a rural context where there may only be one pharmacy within 20 miles, or where all the pharmacies in a county might conceivably adopt such a "Pro-Life" practice?

"We may find ourselves with whole regions of the country where virtually every pharmacy follows these limiting, discriminatory policies and women are unable to access legal, physician-prescribed medications," said R. Alta Charo, a University of Wisconsin lawyer and bioethicist. "We're talking about creating a separate universe of pharmacies that puts women at a disadvantage."

The article also quotes bioethicist Nancy Berlinger that "If you are a health-care professional, you are bound by professional obligations...You can't say you won't do part of that profession." But I can't see how this is true. Doctors routinely practice only one form of medicine or refuse to perform procedures that they consider unethical or dangerous. A pediatrician could not be held liable for refusing to perform brain surgery, nor should a gynecologist be required to perform abortions if she is morally opposed to them. Why should a pharmacist be any different? Granted, if they stocked contraceptives and simply refused to give them to certain customers, that would seem to be a form of discrimination and would likely be illegal. But to choose not to stock certain products seems within their rights, at least as long as customers have another option within reasonable driving distance.


Timothy Mills said...

Great post, Ken. Having based my own pro-choice stance on, well, the importance of choice, I think it would be hypocritical to turn around and deny people the same rights just because they disagree with me.

My inclination for pharmacies is to leave it (mostly) to the market. Religious conservatives can avoid pharmacies that carry contraceptives. Liberals can avoid pharmacies that refuse to carry contraceptives. Rural residents without adequately-stocked pharmacies can simply shop online. (If these products are not available online for legal reasons, then we run into a problem again.)

I do have a question, though. Obviously doctors are free to train in whatever specialty they wish, and cannot be compelled to practice in a field where they have insufficient expertise. I'd also say that a doctor with expertise can exercise personal discretion in performing cosmetic (ie, medically unnecessary) procedures. But where do we draw the line? Is it okay for doctors to refuse to perform blood transfusions if they are Jehovah's Witnesses? To refuse to treat menstruating women because they believe they are unclean?

(I'm not trying to be clever with this question - I honestly don't know where that line should be drawn. What are your thoughts?)

Ken Brown said...

That's a great question. I'm thinking if it's a legitimate religious or ethical objection, and they are consistent about it, they should have the right to rule certain things out, as long as it doesn't endanger the life of a patient.

What makes this particular issue difficult is whether contraception counts as "medically necessary." On the surface, it seems the answer must be no--indeed, hormonal contraception was actually the first legal medication ever prescribed to healthy people. But in our culture it is now perceived as a medical necessity, so how does or should that impact the government's treatment of it? I'm not entirely sure.

A related issue that might help bring the issue into focus (or just make it more confusing!) would be if a Scientologist pharmacy decided not to stock anti-depression medications. Would that be within their rights, or are anti-depressants medically necessary? For some people they do seem to be necessary, and I don't really think it's the pharamacist's job to determine whether that is so for a given patient (it should be between the patient and their doctor), which is why they would have to give them to everyone or no one (who has a prescription). But if those who need them can get the drugs elsewhere (from another pharmacy in town, or online), perhaps the freedom of the pharmacist warrants such a compromise. Again, I'm not sure.

majorsteve said...

Ken, there are two parts to this issue. One is legal: What can a pharmacist or doctor be compelled to do or be sanctioned for doing via the legal system. The other is a moral and ethical issue. The problem with the legal issue is that it gets very complicated and varies among different states. This part generally requires lawyers, courts, judges, juries, legal precedent, etc. to be properly (legally) sorted out. The problem with the moral ethical side of the issue is that it depends on whose morals and ethics you're talking about. The pharmacist may think it's immoral and unethical to sell contraceptives while the customer may think it's unethical NOT to sell them. I don't think there is a way to prove who is right.

Ken Brown said...

The pharmacist may think it's immoral and unethical to sell contraceptives while the customer may think it's unethical NOT to sell them. I don't think there is a way to prove who is right.

As far as I can see, that's the main reason people should have the freedom to decide for themselves, as far as that is possible. That includes both the freedom to buy contraceptives if you wish, and the freedom not to have to sell them at your store if you do not. Sorting all that out is, like you say, a difficult legal problem, but I don't see why it should require that every pharmacy follow the same policy.

Another illustration might help. Some people believe they should eat only (or mainly) organic food; other people consider it a nice idea but impractical or too expensive. Now, should all grocery stores be compelled by law to stock organics because of this (moral) disagreement, or should they have the right to decide for themselves what to sell, whether that be some organics, none, or nothing but organics? After all, if costumers dislike the choice the store has made made they (usually) have options: complain and/or shop somewhere else. I don't really see why a pharmacy's choice whether or not to sell contraceptives should be any different (agian, provided they are consistent about it, not merely refusing to sell them to some customers but not others).

majorsteve said...

We are in agreement on this. If the courts decide that contraceptives are a medical necessity then I think they are wrong. I know they are. In fact, I can prove it. But that's not likely to make any difference. The government needs to just get out of the way as much as possible.