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Pharmacy colleges quash conscientious objection

Canada (2000)

A version of this article originally appeared in the BC Catholic.
Reproduced with permission.
Greg J. Edwards
Pharmacists are critically thinking individuals who integrate their values into their work life-and they are not mere robots who are glorified order-takers for physicians. We should be promoting such thinking, not punishing it.--Nancy Metcalfe, pharmacist

Pharmacists are said to be the most trusted professionals in medicine; they're conscientious; we rely on their discretion and their judgment; they have our confidence; we respect them; but do pharmacists respect themselves, let alone one another?

It's a good question, because in Canada, pharmacists, unlike doctors, find that conscientious objection is a bitter pill for their professional licensing organizations to swallow.

The pharmacists' governors pay lip service to a pharmacist's right to refuse to dispense products, but, in fact, a customer's convenience trumps a pharmacist's freedoms of conscience and religion: pharmacists are free to object but in the end they must refer or otherwise help customers get the objectionable product.

Manitoba is the only province that recognizes its pharmacists' right to object without having to refer a customer elsewhere. The Manitoba philosophy is that simply objecting to a practice isn't enough; that the freedom to refuse to participate in any way is essential to conscientious objection.

Despite this, however, Ron Guse, registrar of the Manitoba Pharmaceutical Association, dodged and weaved when asked whether his association would stand by pharmacists fired or refused employment because of their conscientious objection. In fact, not one Canadian licensing body contacted said that it would support a member in trouble for taking a pro-life stand. The associations' representatives say that any conflicts are the fault of owners or management. For example, conscientious objectors can be scheduled to work alongside pharmacist who dispenses any products without question.

Again, however, not one licensing body said it would stand by a pharmacist in trouble with management or owners.

Management can indeed make reasonable accommodation for dissenting pharmacists if they want to. UBC medical student Ellen Wasan works part time as a pharmacist at B.C. Women's hospital in Vancouver. She is not required to dispense offensive products. Others handle them.

Not all managers take a sophisticated attitude to dissent. Vancouver pharmacist Cristina Alarcon left the suffocating atmosphere of a hospital pharmacy for a private drug store where, she said, the mood is "like a breath of fresh air." She and her colleagues can express views and beliefs and practice them freely without fear of consequences.

Unions can support pharmacists who practice pro-life medicine, but very few pharmacists belong to unions. Consequently, their fights are lonely ones. Their licensing bodies are prone to intimidating them into conforming, especially if they don't have legal counsel.

Rather than dismiss some customers' complaints as vexatious, the Alberta College of Pharmacists is calling one of its members before it.

The B.C. Catholic has agreed to postpone publicizing this case, at the request of the pharmacist's lawyer, until it has been heard. Other Alberta pharmacists are waiting to see its outcome before they decide on which action they will take.

Constitutional lawyer Iain Benson has pointed out that Canadian case law supports religious freedom in the work place. But "pharmacists have yet to develop a serious approach to respecting conscience and religious beliefs. The kind of approach their 'official' spokesmen take would be laughed at by other groups "such as the Canadian Medical Association. Once the Canadian Pharmacists' Association develops a greater maturity, it will learn that law and ethics require more respect for pharmacists' consciences." [See Benson's critique of an article on law and ethics written by a member of the College of Pharmacists of BC Ethics Advisory Committee - Administrator]

Janet Epp Buckingham, legal counsel for the Evangelical Fellowship, agreed with Benson. "However," she added, "if an employer can argue successfully that dispensing contraceptives or abortifacients is an integral part of the job" and that to accommodate a conscientious objector "would be overly onerous" for him, he can discriminate in his hiring "on that basis."

On the other hand, Canadian law requires "reasonable accommodation" of employees' religious practices.

Pharmacist Alarcon, founder of Pharmacists for Life in B.C., wonders why medicine is fraught with so many inconsistencies. Beyond the fact that doctors are given full freedom of conscience, there's the fact that no pharmacy stocks everything.

Pharmacists are not obligated to go out of their way to supply or to refer for every product on the market, just, it seems, the morally offensive products, such as the morning after pill (MAP) and the abortion pill and birth control. Alarcon wonders why pharmacists have to refer patients for the morally offensive products, but not the others.

In November, for a third time in as many years, Alarcon is going to appeal to the B.C. College of Pharmacists to have it recognize its members' democratic freedoms of religion and conscience. [See Project Report 2001-01 on the conduct of the College's Ethics Advisory Committee - Administrator]

So far most objections are made against abortion drugs and birth control, which offend only a few, but, sooner or later, medicine will develop drugs and treatments and procedures that will offend a great many more pharmacists who will become interested in objecting at that time.

Killing the sick-known by many euphemisms such as euthanasia, doctor-assisted suicide, assisted suicide, mercy killing-is still murder in Canada, so it's remains a hypothetical issue for the most part. However, the MAP and the abortion pill (RU486), and birth control are with us.

Anti-pro-life feminists attack conscientious objection desperately, claiming that the MAP and RU486 are essential to women's health. However, even the most hard-hearted abortionist has to admit that abortifacients contain nothing that prevents, fights or cures disease: no antibiotics, no antivirals, just elevated doses of the hormones progesterone and estrogen, which make the womb shed or ward off the fetus or embryo-thus earning them the abortifacient label.

A doctor who asked not to be named said "the only health risk [to not getting the abortifacients] is pregnancy, which is a social risk, not a health risk: 'I won't have money to go to school.' 'My husband will find out, blah, blah, blah.' It illustrates just how stupid the health argument is."

In fact, should it need to be said, pregnancy is a very healthy state for the vast majority of women. What's more, if disease is a legitimate concern, as it is in a rape case, the victim doesn't go down to her local drug store: she goes to an emergency ward where "she's tested for HIV (AIDS), and screened and tested for other major sexually transmitted diseases, and then, sometimes, treated on the assumption that the rapist was infected."

Finally, if pregnancy is indeed a medical risk, the patient's doctor has to consider that the MAP contains highly elevated levels of the same hormones that rise naturally during pregnancy. In effect, by giving the abortifacient, he could be inducing a hormonal condition that the patient should be avoiding.

The woman's doctor would be "mimicking the same hormones but at higher levels and in synthetic form. Anything they suspect that pregnancy is going to hurt, the MAP is going to hurt," the specialist concluded.

Even though it does nothing to fight disease, the MAP is sold as an 'emergency' contraceptive. That it should be taken within 72 hours of sexual intercourse is the only urgent aspect of its use.

Two provincial governments have even allowed pharmacists to share primary responsibility for getting the MAP into women's hands. The former NDP government of BC and the Parti Quebecois government of Quebec have made pharmacists prescribers, not just dispensers, of the MAP.

Brenda Osmond, deputy-registrar of the BC College of Pharmacists, said that a pharmacist can opt out of prescribing the MAP by declining to take the course that qualifies pharmacists as prescribers. However, if a customer comes in with a doctor's prescription, he must dispense it or refer.

The Alberta College of Pharmacists said a pharmacist receiving such a prescription is "the secondary professional," secondary to the prescribing doctor: the doctor has full freedoms of conscience and religion, but the pharmacist doesn't, which is insulting" says Vancouver pharmacist Alarcon.

It's also oddly contradictory, she added, considering that pharmacy organizations are lobbying and jockeying for more responsibility and bigger roles in medicine, a stand supported by Roy Romanow, the federal government's commissioner looking into Canada's health care.

However, the MAP dispute may soon become moot if the drug industry succeeds in getting the approved as an over-the-counter medicine. The industry argues that it is no more dangerous than Aspirin, ignoring the moral objection that it causes very early abortions.

Abortion promoters tend to allay such concerns by defining life as beginning not at conception (fertilization) but at the point when the embryo implants in the womb.

Ironically, making the MAP so easily available could benefit conscientious objectors because they could simply choose not to stock it. Non-pro-life sales clerks could ring in the product, but since nobody can compel a retailer to handle a product, there is no justification for forcing pharmacists to do so.

The Canadian Pharmacist's Association has not taken its own stand on conscientious exemption. Instead, CPA spokeswoman Janet Becigneul said her organization has adopted a "model" statement written by another voluntary organization, the National Association of Pharmacy Regulatory Agencies (NAPRA), the very statement calling for referral that the Manitoba pharmacists rejected two years ago.

Pharmacist Nancy Metcalfe of Morden, Manitoba, made the proposal that led to the rejection of the following paragraph: "The individual pharmacist must pre-arrange access to an alternate source, to enable the patient to obtain the service or product that they need [sic]. Any alternate means must minimize inconvenience or suffering to the patient or patient's agent."

Euthanasia, as well as abortifacients, was very much an issue when Ms. Metcalfe made her appeal: "I believe that people have intrinsic value, be they one day or 90 years old. I consider any active action against their lives to be murder. Thus this is an extremely serious issue. Do we really wish to aid strong Canadians in killing weak Canadians? Where is our traditional commitment to protect life?"

Metcalfe said that in a recent letter to her, Ron Guse, registrar of the Manitoba Pharmaceutical Association said, "The patient's right to so-called service, in this case, the right to terminate another person, overrides a pharmacist's right to act on deeply-held beliefs. He doesn't seem to realize that choice is not a value in itself: it depends on what the choice is about."

Metcalfe said that she is unaware of any other service provider who is forced to inform a patient where a service can be procured. "Physicians inform me that they are not required to inform patients who will prescribe the morning after pill, or where the patient can abort her baby. So, why put this requirement on us?"

When the Manitoba pharmacists were debating this issue, Metcalfe's intervention was impassioned

"I ask that you, no matter what you personal beliefs are, support me in rejecting this coercive measure. I ask that you allow people like myself to act on our convictions in this critical area. And I'd also ask you to remember that a vote passing this NAPRA recommendation could well deprive people like me of our license to practice. You see, I will not direct people to a source of life-taking medication. I cannot collaborate in the modern holocaust."

Conscientious pharmacists are not barring access to legal drugs, she added, but objecting to and refusing to participate in their usage.

Federal legalization of drugs and procedures doesn't make them mandatory, just permitted, she argued, adding that history abound with practices that, while "legal", weren't "right".

"Blacks and women were not considered persons; and let us not forget the infirm, the handicapped, the communists, the Christians and the Jews of the Nazi era."

"If today, the government decreed that we could kill all handicapped people, would you cheerfully dispense medication?"

Metcalfe pointed out that it was NAPRA, not the law and not the government, that adopted the attitude that these products are legal and therefore mandatory for pharmacists to dispense.

Ms. Metcalfe did not expect her resolution to pass, but she did foresee the "hullabaloo" that followed. The convention couldn't decide the issue so it was passed it on to an ethics committee. A very public debate also ensued. [For example, see News Release, Letter to Winnipeg Sun, Letter to Edmonton Sun - Administrator]

In the end, much to her surprise, Manitoba registrar Ron Guse wrote her "a very nice letter," stating that the committee had decided that Manitoba's pharmacists do not have to dispense or refer if they object to a product.

And now "where I work the doctors are asking pharmacists whether they stock drugs under dispute and then they tell their patients which pharmacies stock them. Some doctors stock their own."

Metcalfe, who is a Mennonite, credited the "power of prayer for her success. Now she and many others are hoping that pharmacists in the other nine provinces of Canada choose the full freedoms of religion and conscience.