Tuesday, August 24, 1999

New drugs create ethical dilemma


Can pharmacists refuse to sell?

BY SARA J. BENNETT
The Cincinnati Enquirer

        Karen Brauer has always been clear about her beliefs.

        Any drug that keeps a fertilized egg from attaching to a woman's uterus causes abortion, she says, and those are medications the Lawrenceburg pharmacist refuses to dispense.

        For nearly eight years, Ms. Brauer melded her personal ethics and professional responsibility with little trouble.

        Then in 1996, Kmart fired her for refusing to fill prescriptions for a certain type of birth control pill. Ms. Brauer sued this month, saying her dismissal violated Ohio law.

        Her situation highlights a dilemma faced by pharmacists.

        With a new “morning after” contraceptive on the market, the French abortion pill RU-486 under consideration by the Food and Drug Administration, and Oregon legalizing prescriptions for physician- assisted suicide, pharmacists must balance a patient's need for legal medication with the rights of pharmacists who find those drugs objectionable.

        “There's a lot of soul-searching going on,” said John Cronin, executive director of the American Society for Pharmacy Law and general counsel for the California Pharmacists Association. “The only question that existed before was whether or not the drug was appropriate for the patient, or whether the patient would be harmed by using it.

        But now, when the intent of the treatment is to do something that causes ethical issues, it becomes more significant.”

        By most accounts, Ms. Brauer's situation is rare.

        Planned Parenthood of Southwest Ohio and Northern Kentucky has not received any reports of women seeking contraceptives who were turned down by pharmacists, said CEO Sue Momeyer.

        However, a small number of pharmacists, including one in California, have come under fire for refusing to sell Micronor and related birth control pills that prevent fertilized eggs from implanting in the uterine wall, Mr. Cronin said.

        Doctor-assisted suicide, drugs that induce abortion after a woman is several weeks pregnant, and the “morning after” pill — taken to prevent pregnancy in cases of rape or other unplanned sexual contact — could make conscientious objectors out of more pharmacists, Ms. Brauer said.

        “This is getting their attention,” she said. “(Chain stores) are going to have to rethink how they run their pharmacies, and pharmacists are going to have to rethink how they practice.”

Leader of group
        Ms. Brauer, a Roman Catholic mother of three, is vice president of Powell, Ohio-based Pharmacists for Life International, which represents about 1,500 pharmacists.

        She says she made clear her views on drugs such as Micronor while studying pharmacy at the University of Cincinnati, and Kmart hired her in 1989 knowing her beliefs.

        If customers asked for drugs to which she objected, she sent them to another Kmart pharmacist in her store or, if none was on duty, to another Kmart.

        In December 1996, when the other pharmacist was off duty at the Delhi Township Kmart, Ms. Brauer had to choose: dispense Micronor or lie and tell the customer that Micronor was out of stock.

        She lied, but the customer learned otherwise and complained. Kmart then asked Ms. Brauer to sign a pledge to fill all legal prescriptions.

        She refused and was fired. Steve Pagnani, a Kmart corporate spokesman in Troy, Mich., said he could not comment on Ms. Brauer's complaint, but said Kmart tries to accommodate employees' religious beliefs and make arrangements for pharmacists who decline to fill certain prescriptions.

        Ms. Brauer claims her rights were violated because Ohio law prohibits punishing a person for refusing to participate in medical procedures resulting in abortion.

        Further, she said, Ohio doesn't require pharmacists to fill every legal prescription they receive.

        Pharmacists do have more leeway than customers might think, said Wil liam Winsley, executive director of the Ohio State Board of Pharmacy.

        If a pharmacist thinks, for example, that a patient is addicted to a certain drug, the pharmacist may refuse to fill that prescription.

        Ms. Brauer says she also wouldn't stock or dispense certain diet drugs because she was concerned about addiction or potentially deadly side effects.

        In such situations, a pharmacist should call a patient's doctor, said Marvin Rorick, a neurologist at River Hills Health Care and president of the Cincinnati Academy of Medicine. Pharmacists should not simply turn patients away empty-handed.

        Doctors and nurses have long had to weigh professional duty against personal ethics, Dr. Rorick said, but the patient should come first.

        “A physician's obligation, I think, is to go a little further, even if they don't want to get involved, so to speak,” he said. “They should at least try to serve the need of the patient. I think in the case of (Ms. Brauer), she might have a moral objection to filling the prescription, but she should have seen that it was filled or found an appropriate pharmacist on duty to refer the problem to.”

        Increased discussion of this issue has some pharmacists arguing the need for laws specifically protecting their right of conscience to refuse to dispense drugs.

        South Dakota is the only state with such a law.

        Pharmacist organizations across the country are adopting “conscience” clause resolutions. The Ohio Pharmacists Association passed one in April, and the American Pharmaceutical Association has adopted one as well.

Early action suggested
        That organization prefers, however, that pharmacists address their concerns before a problem arises rather than wait until customers ask for controversial drugs, said Susan Winckler, group director of policy and advocacy for the association.

        Pharmacists could refer patients to colleagues who will serve them, as Ms. Brauer said she did, or they could tell physicians in advance which prescriptions they won't fill.

        While pharmacists get used to challenges raised by new ethically charged treatments, the people they serve may have to re-examine their attitudes, said California's Mr. Cronin.

        “The comparison that I like people to consider is, there are many physicians and nurses who will not participate in abortions or what they view as life terminating procedures, and no one challenges their right to do that,” Mr. Cronin said.

        “Yet when it comes to a pharmacist asked to dispense something that is functionally going to do the same thing, people tend to view that in a different light.”

       



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