Conscientious objection in pharmacy

Should pharmacists be mandated to supply medicines such as emergency contraceptives despite their personal beliefs? 

CONSCIENTIOUS OBJECTION: The case for, by Leo Hamulczyk

It is often assumed that conservative people, either political and/or religious, have a desire to exclude service from various groups. They don’t. They simply do not want to participate in a service or supply a product which they see as immoral—or in plain language, wrong. This comes down to disagreements over right and wrong.

Everyone has a sense of right and wrong. The question is, where does one obtain their moral standards from? Are morals absolute or are they subject to change? And is there a higher standard or is societal consensus enough to determine right from wrong?

If consensus is enough, how much is required? Is it not possible for consensus to be reached by manipulation? And on this basis it becomes difficult to condemn historic atrocities (e.g. Nazi or Rwandan) as some had reasonably a high level of consensus.

People in every society generally agree that taking someone’s life is wrong and should be restricted to the most extreme of circumstances if done at all, so why should the life of an unborn child be taken for just any reason? That an unborn child is not a separate life, or person, from the mother cannot be justified.

From my various discussions over the years I continue to be surprised that, in general, the people who so vehemently support abortion tend to be the same people who claim that the death penalty is barbaric.

This is a double standard, and if the latter is wrong the former is also.

Only a small minority of abortions are performed because of concerns for the mother’s or child’s health.1 In these debates the “what if” question always arises. What if the woman was raped? What if the child has a deformity?

These questions can be safely ignored until the question which covers the majority of cases can be answered—that is, is it moral to take the life of someone for the sole reason that you don’t want them? This needs to be answered before the exceptional cases are addressed.

Considering the evidence

Gender transition is another contentious issue. We live in an evidence-based society: evidence-based medicine is the norm and virtually nothing in medicine or public health can be done without research and solid evidence backing it up.

Those who object to supplying gender-transition medications disagree that the notions that gender and sex can be separated, that gender can be fluid or non-existent, and that there is an ever-increasing number of genders can be supported by scientific evidence.

On what evidential basis do we accept that a person with no genetic abnormalities be accepted as the opposite gender based on their word (especially if they haven’t undergone gender transition surgical or medical treatment)?

The word of individuals has low standing as evidence, as seen in our inability as pharmacists to use patient testimonials to promote the products we sell. And, as a recent UK High Court decision has found, it is questionable whether minors have the capacity to consent to gender transition.2

Where does that leave the pharmacist with a conscientious objection to any of these services or the medications associated with them?

Secularity is often mistaken for an atheist or anti-Christian outlook. It is nothing of the sort. In a secular society, no ideology is favoured over any other and governing bodies should govern in a way that—as far as possible—is acceptable to all and protects the rights of all as far as is possible.

Thus, in a secular but democratic society, the only acceptable option with such high-tension moral issues is for the service or product to remain available but for those who disagree to be able to not participate in the supply.

When the Victorian government introduced legislation enabling voluntary assisted dying in 2017, it wisely included provision in the legislation allowing conscientious objectors the right to refuse to assist or support the patient, even to the point of refusing to provide information.

Unfortunately, the same government and others (e.g. Tasmania) refuse to give health professionals the same right when it comes to abortion.

The Victorian Abortion Law Reform Act 2008 states that the practitioner must “refer the woman to another registered health practitioner in the same regulated health profession who the practitioner knows does not have a conscientious objection to abortion”.3 This unfortunately makes such a practitioner complicit in what they consider to be an immoral act.

One medical practitioner suggested to me that providing a patient with access to a telephone directory or search engine may be seen as compliant with this law, given that the term “refer” is not defined in the Act, however this has not been tested in the courts to my knowledge. Also to be noted is that the Act does not prescribe a penalty for not complying.

Allowing for conscientious objection

Regarding the various forms of contraception, different people draw the line in different places as to where life begins. Some draw the line at any contraception whereas others may draw it at post-coital contraception, and yet others only at the termination stage.

There is no specific legislation dealing with conscientious objection to these medications, as well as medications for gender transition. However, in my opinion, a practitioner does not have to provide every product or service and may decide on which type of medications they choose to supply (or not).

The decision must, however, be made in a way as to not discriminate against a group, but rather not provide a certain range of services.

To conclude, a pharmacist should not be expected to provide a service or product they see as morally objectionable, nor to de facto participate in its provision.

Leo Hamulczyk is a hospital pharmacist in Bairnsdale, Victoria.

CONSCIENTIOUS OBJECTION: The argument against, by Safeera Hussainy

As a pharmacist, you are bound to a Code of Ethics which is separate to your own ethical beliefs.

That Code acknowledges that as a health professional, you should not gatekeep on behalf of patients. Patients should be able to make their own informed choices, with all appropriate choices available in front of them.

Instead of gatekeeping, you are in a position to help them arrive at a decision that best suits their needs.
The best way for any health professional to help a person arrive at this optimal decision is to give them evidence-based information.

This means that you need to have the latest information at your fingertips, and can present the pros and cons of any treatment, whether that is emergency contraception or an abortifacient medicine—and understanding and being able to explain, for example, that emergency contraception (EC) is not an abortifacient.

When you arm a patient with that information, they feel empowered to make the best decision for themselves. When you do not, significant harms may ensue.

Imagine yourself as a person who requires a medication. When you go to see your pharmacist or your doctor, you will go with the expectation that you’ll be treated with respect, and without judgement, and with a reasonable expectation that you’ll be able to access the medication.

Perhaps the pharmacist does not want to dispense your medication because it is not vegan; or as a vaccine hesitant person, your medical practitioner refuses to vaccinate you.

If you’re denied or outright refused that medication, how would you feel?

Now imagine yourself as a person who identifies as a woman, has had unprotected sex and requires an abortifacient or emergency contraception. How would you feel to be denied that medication and told to continue your unwanted pregnancy?

Many of us have had situations where we have encountered incompetence from a healthcare professional: if they haven’t diagnosed us with the right condition, or it’s taken years to get a diagnosis (often the case with endometriosis, which is often managed with the oral contraceptive pill).

This is frustrating. But imagine not just incompetence, but refusal to help you manage your condition.

Avoid doing harm

Pharmacists also need to consider the harms which may ensue if a patient is denied the best medication for them. Perhaps they believe that refusing EC or an abortifacient is the best decision for that patient, regardless of the patient’s feelings.

This blocks access to information and potentially life-saving treatment. Emergency contraception, for example, is recognised by the World Health Organisation as a life-saving commodity.

If you stop that access, that patient may go on to have an unwanted pregnancy. Australia has one of the highest teenage pregnancy rates in the developed world, and about one in three pregnancies overall are unwanted or unplanned. By refusing contraception or EC, you contribute to this health burden.

This is particularly the case in rural and remote Australia, or other instances where there may not be another provider to refer patients to.

Some pharmacists also feel morally compromised by referring a patient onto another provider, and do not wish to do so.

Not all pharmacists are accredited to provide MS Two-Step, for example, the combined regimen for medical abortion. As a patient, if you are in an area where you need to travel to access this medication as a result of being refused by the local pharmacist, you may have to travel 50 to 100km—and you might not have the capacity to do that.

You may end up on the road to surgical abortion; you may end up trying to source the treatment yourself.

This comes with enormous stress and anxiety, particularly if you want to keep this discreet and don’t want to involve other people, such as family members or an abusive partner.

Even in a more populated area, you may need to do a ring-around to different pharmacies—and the answer still may depend on the individual pharmacist you encounter in person. In the case of EC, the time-sensitive nature of the treatment is also a problem, as with MS Two-Step.

Consider the bigger picture

There are significant health and financial impacts from completing an unwanted pregnancy: it has been shown that the health of the child is affected—for example, higher rates of nutritional deficiency.

In the instance of gender transition drugs, I understand that the rate of suicide is high in this group, and that these drugs can again be life-saving as part of a suite of supportive measures.

Take a step back and consider the human body as a complex machine, involving different functions and organs. These include the sexual and reproductive system—and the issues we’re talking about here relate to that organ system.

If you look at it from that perspective, rather than overlaying it with a moral perspective about what led the patient to need these medicines, you’ll be able to handle these situations with greater ease and comfort. If your own morals conflict with the idea of EC or abortion and you can separate your personal beliefs from your professional practice, that’s okay.

Pharmacists have their own religions and beliefs, and have the right to practise them within their personal lives—but not their professional lives, as it impacts others who they serve.

The most you can do is say that, “This conflicts with my personal beliefs, and I will have to refer you on”.

When you refuse to dispense, or worse, refuse to refer based not on clinical guidelines but upon your own moral code, you may think that you are saving a life or doing God’s will.

What you are actually doing is giving greater weight to salving your conscience than supporting the wellbeing of your patient, whose moral code may be entirely different to your own.

Dr Safeera Hussainy is a pharmacist and is Adjunct Senior Lecturer at the School of Primary and Allied Health Care, Monash University

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