(Editorial) Pharmacists’ Rights of Conscience: Whose Autonomy Is It, Anyway?

Stephen Joel Coons

Clinical Therapeutics
Clinical Therapeutics

Extract
Patient autonomy is the foundation of the ethical principles that guide a health professional’s actions. It can be defined as “the right of individuals to make decisions about what will happen to their bodies; what choice will be made among competing options; and what they choose to take or not take into their bodies. ” By being a barrier to the patient’s receipt of a legally available prescription product, the pharmacist is not only denying the patient her autonomy but potentially causing her emotional and/or physical harm.


Coons SJ. (Editorial) Pharmacists’ Rights of Conscience: Whose Autonomy Is It, Anyway?. Clin Ther. 2005 Jun;27(6):924-925

Service or Servitude: Reflections on Freedom of Conscience for Health Care Workers

Sean Murphy

Protection of Conscience Project
Protection of Conscience Project

Abstract
The authors suggestion that patients should be able to access morally controversial services without compromising health care workers’ freedom of conscience is most welcome, as is their acknowledgment that “other options exist” when pharmacists decline to fill prescriptions.

However, the conflicting interests of patients and health care providers may be accommodated but cannot be balanced because they concern fundamentally different goods. Neither the concept of autonomy nor an appeal to the “needs” of the patient help to resolve conflicts in these situations, while fiduciary obligations cannot necessarily be invoked because they are not governed by fixed rules, and there can be no obligation to participate in wrongdoing.

The fact that post-coital interceptives can cause the death of an early embryo is at the heart of the controversy over the drugs. The authors’ advocacy of mandatory referral follows from their belief this is not wrong. Those with different beliefs do not share their conclusions. Conscientious objection does not prevent patients from obtaining post-coital interceptives from other sources. As the exercise of freedom of speech does not force others to agree with the speaker, the exercise of freedom of conscience does not force others to agree with an objector. Concerns about access to legal services or products can be addressed by dialogue, prudent planning, and the exercise of tolerance, imagination and political will. A proportionate investment in freedom of conscience for health care workers is surely not an unreasonable expectation.


Murphy S. Service or Servitude: Reflections on Freedom of Conscience for Health Care Workers (2004 Dec 20) Protection of Conscience Project (website).

The Limits of Conscientious Objection-May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?

Julie Cantor, K Baum

New England Journal of Medicine, NEJM
New England Journal of Medicine

Abstract
Several reports have detailed cases in which pharmacists have refused to fill prescriptions for emergency contraception. Should pharmacists have the right to refuse access to these medications? This Sounding Board article discusses arguments for and against the right to refuse and proposes a balanced solution to the problem.


Cantor JD, Baum K. The Limits of Conscientious Objection-May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?. N Engl J Med. 2004 Nov 04;351(19):2008-212.

(Correspondence) In Response

Bernard M. Dickens, Rebecca J. Cook

Journal of Obstetrics and Gynaecology Canada
Journal of Obstetrics and Gynaecology Canada

Extract

As neither our original Commentary on access to emergency contraception nor our letter response was suitable for fully referenced legal or ethical reasoning, we appreciate this opportunity to expand a little on the substance of both, addressing the points Mr Murphy raises.


Dickens BM, Cook RJ. (Correspondence) In Response. 2004 Aug; 26(8): 706-707.

(Correspondence) Access to Emergency Contraception

Sean Murphy

Journal of Obstetrics and Gynaecology Canada
Journal of Obstetrics and Gynaecology Canada

Extract

In a letter in the February issue of JOGC, Rebecca J. Cook and Bernard M. Dickens state, “Physicians who feel entitled to subordinate their patient’s desire for well-being to the service of their own personal morality or conscience should not practise clinical medicine” (emphasis added).
The statement is unsupported by their own legal references, and it has little to recommend it as an ordering principle in the practice of medicine.


Murphy S. (Correspondence) Access to Emergency Contraception. JOGC. 2004 Aug; 26(8): 705-706.

(News) Emergency contraception could lower abortion rate

Barbara Sibbald

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
Anti-abortion groups should welcome proposed new regulation allowing patients to access emergency contraception without a prescription, says the Society of Obstetricians and Gynaecologists of Canada. . . . Emergency contraception, or the “morning after pill,” is sold in Canada as levonorgestrel (Plan B). If taken within 72 hours of unprotected intercourse, it can prevent ovulation, or interfere with fertilization, or implantation. . .The Catholic Organization for Life and Family and other anti-abortion groups believe pregnancy begins with conception, not implantation. In a letter to Health Canada, the organization called levonorgestrel an “abortifacient.”.


Sibbald B. Emergency contraception could lower abortion rate. Can Med Assoc J. 2004 Jun 22;170(13):1903.

Access to emergency contraception

Rebecca J Cook, Bernard M Dickens

Journal of Obstetrics and Gynaecology Canada
Journal of Obstetrics and Gynaecology Canada

Abstract
The merits of non-prescription distribution of levonorgestrel as emergency contraception (EC), which is effective within 72 hours of unprotected intercourse, are contentious. The advantage of promptness and convenience of access may be offset by the absence of medical counselling. Opposition to EC based on the possibility of the drug acting after fertilization but before implantation departs from standard medical criteria of pregnancy. Physicians who propose to apply non-medical criteria, and use religious objections to abortion to deny prescription of EC, must publicize their opposition in advance, so that women may seek assistance elsewhere. When objecting practitioners, or facilities, become responsible for women for whom EC is indicated, such as rape victims, they are bound ethically and legally to refer them to reasonably accessible non-objecting sources of care.


Cook RJ, Dickens BM. Access to emergency contraception. J Ob Gyn Canada. 2003 Nov;25(11):914-916.

Human Rights Dynamics of Abortion Law Reform

Rebecca J Cook, Bernard M Dickens

Human Rights Quarterly
Human Rights Quarterly

Abstract
The legal approach to abortion is evolving from criminal prohibition towards accommodation as a life-preserving and health-preserving option, particularly in light of data on maternal mortality and morbidity. Modern momentum for liberalization comes from international adoption of the concept of reproductive health, and wider recognition that the resort to safe and dignified healthcare is a major human right. Respect for women’s reproductive self-determination legitimizes abortion as a choice when family planning services have failed, been inaccessible, or been denied by rape. Recognition of women’s rights of equal citizenship with men requires that their choices for self-determination be legally respected, not criminalized.


Cook RJ, Dickens BM. Human Rights Dynamics of Abortion Law Reform. Hum Rights Quart. 2003 Feb;25(1):1-59. Available from:

Effect of mifepristone and levonorgestrel on expression of steroid receptors in the human Fallopian tube

A Christow, X Sun, K Gemzell-Danielsson

Molecular Human Reproduction
Molecular Human Reproduction

Abstract
It is likely that mifepristone or levonorgestrel in the future will find extended use for contraceptive purposes. It is therefore essential to characterize the modes of action of these compounds. To assess the effect on the human Fallopian tube, 24 women with regular menstrual cycles and proven fertility, admitted to the hospital for voluntary sterilization by laparoscopic technique, were randomly allocated to a control or one of two treatment groups. Treatments were given with either a single dose of 200 mg mifepristone or 0.75 mg levonorgestrel in two doses 12 h apart, on day LH2. Surgery was performed on day LH4 to LH6. Steroid receptor expression was analysed by immunohistochemistry, Western blot and RT-PCR. In the controls, there was a higher concentration of progesterone receptors in the stromal cells in the isthmic region than in those in the ampullar region. Treatment with mifepristone increased the progesterone receptor concentration in epithelial and stromal cells and increased the estrogen receptor concentration in epithelial cells. No effect on steroid receptor concentration was found following levonorgestrel. The contraceptive effect of post-ovulatory mifepristone has previously been considered to be dependent on an effect on the endometrium. However an effect on the Fallopian tube could contribute to alter the peri-implantation milieu influencing fertilization and embryo development.


Christow A, Sun X, Gemzell-Danielsson K. Effect of mifepristone and levonorgestrel on expression of steroid receptors in the human Fallopian tube. Mol Hum Reprod. 2002 April 01;8(4):333-340.

Emergency contraception provision: a survey of emergency department practitioners

Reza Keshavarz, Roland C Merchant, John McGreal

Academic Emergency Medicine
Academic Emergency Medicine

Abstract
Objectives:
To determine emergency department (ED) practitioner willingness to offer emergency contraception (EC) following sexual assault and consensual sex, and to compare responses of practitioners from states whose laws permit the refusal, discussion, counseling, and referral of patients for abortions (often called “opt-out” or “abortion-related conscience clauses”) with those of practitioners from states without these laws.

Methods: Using a structured questionnaire, a convenience sample of ED practitioners attending a national emergency medicine meeting was surveyed.

Results: The 600 respondents were: 71% male, 29% female; 34% academic, 26% community, and 33% resident physicians; and 7% nurse practitioners and physician assistants. Many respondents (88%) were inclined to offer EC to those sexually assaulted by unknown assailants. More practitioners said they were willing to offer EC if the assailant was known to be HIV-infected rather than if the assailant had low HIV risk factors (90% vs. 79%, p < 0.01). More respondents would prescribe EC after sexual assault than consensual sex (88% vs. 73%, p < 0.01). The rates of willingness to offer EC were the same for practitioners in states with “abortion-related conscience clauses” and those from other states.

Conclusions: Most ED practitioners said they were willing to offer EC. Although the risk of pregnancy exists after consensual sex, practitioners were less willing to prescribe EC after those exposures than for sexual assault. “Abortion-related conscience clauses” did not seem to influence willingness to offer EC.


Keshavarz R, Merchant RC, McGreal J. Emergency contraception provision: a survey of emergency department practitioners. Acad Emerg Med. 2002 Jan;9(1):69-74.