The politics of conscience and health care

I’m trying to imagine what it would be like to walk into a pharmacy with a prescription for, say, a contraceptive and be refused because the pharmacist believes contraception is morally wrong. In most areas I would be just inconvenienced because I could speak to another pharmacist or take my business elsewhere. In some places, however, I might be standing in the only drug store in town, and then what?

I’m also trying to imagine what it would be like to be a pharmacist whose faith or church teaching opposes artificial contraception – which would lead me into acting unethically if I filled that prescription. Even referring the customer to another pharmacist could be considered a disguised form of cooperation. And then what?

Last fall the Bush Administration started a process that resulted in a rule that protects health workers, particularly those who receive Medicare or Medicaid funding, if they refuse to provide treatment that goes against their consciences. The new rule took effect on Jan. 20, the day Bush left office.

Six weeks later, the new Obama administration declared its intention to reverse that rule, opening a 30-day public comment period that ended April 9. Now the Department of Health and Human Services is reviewing the comments and, come June or July, is likely to rescind the “conscience rule.”

The debate, in effect, pits the rights of patients against the rights of care providers, especially when it comes to birth control, abortion and end-of-life treatment.

“There are two schools of thought,” according to Walter Fitzgerald, adjunct professor of pharmacy practice who teaches law and ethics at the Gatton College of Pharmacy at East Tennessee State University. “One says that (providers) should not be forced to do something in conflict to their religious or personal moral values. Another says that if you are given a license by the state and in essence have sworn an oath to serve fellow man, then you don’t have the right to object any longer, because of your professional obligation.”

Opponents of the Bush rule say it limits access for care to patients. Supporters of the rule say it safeguards the freedom of conscience for doctors, nurses, pharmacists and other healthcare professionals that dates back to the Hippocratic Oath and the First Amendment.

Opponents say that laws enacted during the 1970s (soon after Roe v. Wade legalized abortion nationwide), which allow providers to refuse treatment as long as they provide information and access by other means, have worked just fine.

Supporters of the conscience rule, such as David Stevens, executive director of the Bristol-based Christian Medical and Dental Association, say those laws are toothless, opening the door to a kind of “ethical cleansing” in the medical field, aimed at practitioners who oppose abortion.

“There’s a lot of discrimination going on,” he said in a phone interview last week. A recent survey found that almost one-fourth of the CMDA’s 15,000 members said they had been “discriminated against” because of their opposition to abortion. “They’ve been fired from jobs or failed to get a promotion or weren’t able to get into an educational program,” he said.

But no lawsuits are pending, according to Stevens, because the laws don’t provide for legal action.

Tennessee, like most states, has a conscience clause, allowing health workers to refuse treatment as long as patients can get treatment elsewhere. So far, Fitzgerald said, the matter of conscience hasn’t been a problem, at least not for pharmacists. That’s not the case in some other states. In Illinois, for instance, pharmacists must dispense.

“There, it’s mandated. You don’t really have a choice,” Fitzgerald explained. “We don’t have anything nearly that strong in Tennessee.”

He isn’t sure yet how rescinding the federal rule would affect Tennessee.

“Giving information or referral is not required by law (in Tennessee), but from an ethical standpoint, that would be expected,” Fitzgerald said. “If a pharmacist refuses to dispense RU-486, someone could make an argument that it’s contrary to state Board of Pharmacy rule, especially if it’s medically necessitated or in case of rape.”

But that leaves a very complex, sometimes messy scene.

“Even if the federal law says that you have to honor freedom of choice, we have to balance that against our (professional) rules,” he said. “We don’t have a clear-cut answer.”

That pretty well sums up the whole debate.

Johnson City (Tenn.) Press, 25 April 2009.