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Assistant Professor, Department of Pharmacology, College of Medicine, Pennsylvania State University, 500 University Dr., Mailcode H078, Hershey, PA 17033-2360, fax 717/533-2006, kjd136{at}psu.edu
Reprints: Dr. Karpa
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Abstract |
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 Top Abstract Exercising a Professional Right...Pharmacists in Clinical PracticeReferences |
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Key Words: emergency contraception, professional right of conscience
Published Online, June 27, 2006. www.theannals.com, DOI 10.1345/aph.1H334
In their commentary, Wall and Brown appear to have a personal axe to grind. Rather than argue their viewpoint based upon facts that can be substantiated and cited in current literature, they chose instead to berate pharmacists everywhere and to create a fictitious case scenario upon which they built their platform.
In stark contrast to their original intent, Wall and Brown successfully demonstrated their lack of knowledge of modern-day pharmacy practice and the positions of professional pharmacy and medical organizations, including the Academy of Managed Care Pharmacy, the American College of Clinical Pharmacy, the American Pharmacists Association, the American Society of Health-System Pharmacists, and the American Medical Association (AMA). Frankly, it is surprising that the American College of Obstetrics and Gynecologists (ACOG) chose to publish Wall and Brown's commentary, given that it is fraught with accusations, inconsistencies, and false information.
Although numerous holes exist in their arguments against pharmacists' professional right of conscience, the disparaging remarks and incorrect depiction of contemporary pharmacists' roles in the healthcare system are the most disturbing parts of their article.
The coauthors state in no uncertain terms that pharmacists are incomplete, unlearned professionals who have more in common with community retailers than with other "traditional learned professions." Furthermore, according to Wall and Brown, a pharmacist's job entails "exercising only technical supervision over dispensation of medications."
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Exercising a Professional Right of Conscience |
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For myself and others who share this belief, use of emergency contraceptives raises important ethical questions and concerns. Wall and Brown allege that pharmacists with moral objections to emergency contraceptives are misinformed or promoting personal moral or political agendas; however, these objections are also scientifically based, as it is not clear how emergency contraceptives prevent pregnancy. Furthermore, the efficacy of emergency contraception appears to vary, depending upon the timing of intercourse, the timing of ovulation, and the timing of emergency contraception administration. Thus, the precise mechanism of emergency contraception may vary from one individual or circumstance to another.
While Wall and Brown would lead readers to believe that emergency contraception's only mechanism of action is the prevention of ovulation, I believe that the available data suggest otherwise. In fact, emergency contraceptives could not be as effective as they have proven to be if they worked only when taken before ovulation. Additional potential mechanisms by which emergency contraceptives may work include: thickening of cervical mucus, alterations in sperm penetration or transport, or interference with fertilization, follicular growth, corpus luteum development, and/or implantation.2-9
Given the seeming ambiguity surrounding emergency contraception's mechanism of action, it is no surprise that some physicians choose not to prescribe these products and some pharmacists opt not to dispense the drugs for personal conscience reasons. It seems that, at the very least, emergency contraceptives may interfere with the potential viability of a fertilized egg, and some healthcare professionals object to aiding and abetting such an action.
Rather than embrace our differences and simply agree to disagree about moral and ethical dilemmas, Wall and Brown assert, "Pharmacists who refuse to fill legitimate prescriptions for medications because of their personal values and opinions should be held accountable for their actions. Such violations should be reportable to state boards of pharmacy, and pharmacists who engage in such activities should be liable for sanctions including the loss of their licenses, and employers should be able to use such behavior by pharmacists as legitimate grounds for terminating their employment."
To that, I ask, why the double standard? Physicians are not forced to participate in or perform actions that they find morally objectionable. Why should pharmacists be held to a different set of rules? Not only do pharmacy organizations support pharmacists' right of conscience, but the AMA does as well. Indeed, the AMA affirms in its policy and position statements that "no physician or other professional personnel shall be required to perform an act violative of personally held moral principles." Physicians are not required to provide medical services to which they are morally opposed; therefore, neither should pharmacists be held to "required or fired" standards.
Instead, a priori communication and safeguards should be established by pharmacists and physicians to avoid these types of conflicts. Pharmacists should be permitted to refrain from participating in activities that are personally objectionable; however, pharmacists' choice to do so should not become a barrier to providing legitimately and accurately prescribed medications to patients in a timely fashion.
Potential conflicts can be avoided when (1) prescribers direct patients to pharmacies that are willing to stock and dispense certain medications, such as emergency contraceptives, (2) the shifts of pharmacy staff members overlap, allowing one pharmacist on duty to complete prescriptions that another pharmacist finds morally objectionable, (3) pharmacists provide immediate referral to alternative dispensing pharmacies, or, as the AMA's own directive states, (4) physicians dispense "medication to their own patients when there is no pharmacist within a 30 mile radius who is able and willing to dispense that medication." Notice that, according to the AMA's own directive (adopted in response to and in support of the pharmacists' professional right of conscience), prior planning is also the responsibility of the physician.
Wall and Brown assert that pharmacists have a "duty to fill," period. According to the authors, "to refuse to fill legitimate prescriptions for purported `reasons of conscience' introduces an unjust and unacceptable level of arbitrariness into the health care system." They assert that allowing pharmacists to exercise a professional right of conscience is synonymous with allowing pharmacists to hijack the healthcare system.
If a pharmacist's role were merely to dispense lawfully prescribed medications, then automation could take over. However, pharmacists are the most accessible members of the healthcare team and, in rural communities, they may be the only accessible healthcare provider. The role of pharmacists is more than counting pills and putting them into a prescription vial; a pharmacist's role is to interface and collaborate with physicians and patients to improve healthcare outcomes—a role to which Wall and Brown seem to be completely oblivious.
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Pharmacists have also been given authority to bill Medicare for cognitive medication therapeutic management services that are provided to Medicare Part D beneficiaries. In fact, the AMA developed pharmacist-specific current procedural terminology codes to be utilized for this purpose. Therefore, Wall and Brown's assertion that "pharmacists exercise only technical supervision over the dispensation of medications that are prescribed by physicians" is simply false and demonstrates how grossly uninformed the authors are about the expanding roles of pharmacists.
Despite their apparent disdain for pharmacists, Wall and Brown contradict their own statements when they first allege that pharmacists are only retailers, having little in common with members of the traditional learned professionals (such as physicians), but subsequently state that they "do not expect pharmacists to fill prescriptions that contain obvious dosing errors or that pose a dangerous risk of interacting with other drugs." How is it that unlearned, incomplete professionals could be held responsible for catching physician mistakes and errors in clinical judgment? Unless, of course, pharmacists are not unlearned, as Wall and Brown argue, but rather are the acknowledged experts on the action of drugs. Is it possible, then, that pharmacists merely exercise technical supervision over dispensation of medication? I think not.
Unlike Wall and Brown's assertion that a patient's interaction with a pharmacist is one of a retailer-customer interaction, as opposed to an interaction between a healthcare professional and patient, inpatient clinical pharmacists have worked directly with physicians and patients for decades, providing services that are not associated with dispensation of drugs. Pharmacists have been recognized in 2 Institute of Medicine reports as essential resources for the safe use of medications.10,11 Pharmacist participation on hospital rounds has been associated with improved medication safety, and significant importance has been placed upon the collaboration between pharmacists, physicians, and patients.
Even in the outpatient setting, patients pay visits to pharmacists because pharmacists can truly provide them and their physician with a third-party objective analysis of drug therapy problems and potential solutions. Increasingly, a new breed of consulting pharmacists is offering patient consultations via provision of drug-disease management services. Patients schedule appointments with these consulting pharmacists, not because they are retailers (in many cases, consulting pharmacists have nothing to sell), but rather to improve their health through education and appropriate medication use. When these consulting pharmacists schedule patient appointments, a comprehensive medical history is obtained and laboratory results are analyzed. Many pharmacists also perform limited physical assessments including blood pressure monitoring and diabetic foot examinations. As pharmacists actively engaged in patient consulting services know, it takes only one successful therapeutic intervention for physicians to begin referring patients to the pharmacist, even sending complete patient charts and laboratory test results in advance of scheduled patient-pharmacist appointments.
For more than 2 decades, innovative pharmacists have practiced medication- and disease-state management with patients, often in conjunction with medical clinics. Many pharmacists have focused their attention on specific therapeutic areas such as anticoagulation, asthma, diabetes, hyperlipidemia, women's health, or smoking cessation. Numerous studies have been published, with more data accruing daily, illustrating the positive clinical outcomes for patients and the beneficial cost savings for the entire healthcare system when pharmacists are actively engaged in patient care.12-30 Pharmacist intervention outcomes are well documented in the areas of economics, improvement in health-related quality of life, enhanced patient satisfaction, and avoidance of adverse drug effects.31
The expanding roles filled by pharmacists have been created by the mere fact that many physicians may no longer be able to provide the level of patient interactions that they would like to provide. Managed care has forced physicians to see more patients, spending shorter periods of time during each patient encounter. It has been estimated that the average patient-physician interaction is shorter than 7 minutes—hardly sufficient time to address all the disease- and drug-management issues that arise. Through disease-state management programs, pharmacists have consistently demonstrated that it is possible to educate patients about their disease, improve medication use, and take preemptive steps to avoid future complications.
Importantly, in the context of pharmacist-managed drug/disease-state therapeutic programs, pharmacists are knowledgable, easily accessible healthcare professionals capable of delivering care that physicians simply do not have time to provide. Both pharmacists and physicians bring their own unique areas of strengths and expertise to benefit patients. Whether or not Wall and Brown like to admit it, patient outcomes are improving because of pharmacist interventions—a phenomenon that would clearly not occur if the pharmacists' sole responsibility was "technical supervision over dispensation of medication." Rather than acting in a territorial, hostile manner to pharmacists, Wall and Brown should embrace the knowledge and expertise that pharmacists offer.
Pharmacists are making and documenting therapeutic interventions, improving clinical outcomes, and creating a new level of economic savings for the healthcare system at large. Contrary to the allegations made by Wall and Brown, the data speak clearly. Pharmacists have exciting, expanding roles and are certainly not in the business of hijacking the healthcare system. It is important to keep in perspective that nearly 3.3 billion prescriptions are dispensed in outpatient settings every year, which averages roughly 9 million prescriptions per day.32 Of the billions of prescriptions filled annually, only approximately 12 pharmacist "refusals to fill" have been documented during the last decade. Overall, the system appears to be working much more often than it fails.
Healthcare professionals, including pharmacists, should not be forced to participate in activities that they find to be personally objectionable. Safeguards should be established within and among pharmacies and medical clinics to ensure that patients' needs can always be taken care of in a prompt fashion without violating personal beliefs.
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References |
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TopAbstractExercising a Professional Right...Pharmacists in Clinical PracticeReferences |
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Related articles in The Annals:
This article has been cited by other articles:
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  K. A. Calis, F. Pucino Jr, S. R Penzak, and F. A Lombardo Comment: Pharmacist Critique Was Ill-Informed Ann. Pharmacother., September 1, 2006; 40(9): 1697 - 1698. [Full Text] [PDF]
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G. G Briggs Comment: Pharmacist Critique was Ill-Informed Ann. Pharmacother., July 1, 2006; 40(7): 1474 - 1475. [Full Text] [PDF]
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