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Follow-up Letter from Cristina Alarcon et al to British Columbia College (Board) of Pharmacy

We wish to re-extend our thanks for your making the time to meet with us at the recent meeting. We recognize that for many of you, this entails taking time off paid work in order to serve the College, and therefore the public. As mentioned at the start of the meeting, we do not disagree with any of your core principles, we do value patient autonomy, we do take patient care seriously, and we believe that the College does well to ensure that public interest is represented. We also wish to thank you Marshall for your follow-up letter of May 17^th, in which you explain the positive course of action the committee has agreed to take in order to study this important matter further, and we are hopeful that some positive action will follow.

We are writing in order to clarify a few of the questions to which we did not have time to respond at length during the meeting on May the 3^rd.

For the sake of clarity, we set out below our recommended reformulation of Value VIII of the Code of Ethics – it involves the removal of the final clause, with the second explanatory note accordingly adjusted. It would thus read as follows:

Value VIII. A pharmacist ensures continuity of care in the event of job action or pharmacy closure.

Several concerns were raised which we did not manage to fully answer, and to which we add the following thoughts.

The first such concern mentioned is that this recommendation would create a situation where the pharmacist imposes their personal moral beliefs on autonomous patients. We would suggest that this is not the case. Rather, the pharmacist is merely indicating that they themselves are unable to provide the service. Ironically, the way that Value VIII is currently written actually does result in an imposition of morality – but this time of the patient over the pharmacist. This arises because if there is not another pharmacist available nearby to fill the prescription, the desires of the patient become binding on the pharmacist who is compelled by the Code of Ethics of the College (which is a subsidiary body of the state) to do whatever the patient requests. Far from being neutral and inclusive, Value VIII actually enables a patient to use the force of law to conscript the pharmacist into assisting the patient to reach the patient’s objectives in accordance with the patient’s morals. In seeking to protect the autonomy of the patient, the autonomy of the pharmacist is denied and coerced – this cannot be the best option. What is needed is a principled approach to develop a modus vivendi for everyone, patient or pharmacist, to the greatest extent possible; the current Code provisions do not do this, our suggested changes do.

Certain people may believe that they can live by different moral commitments in their private and professional lives, but many do not. As Mr. Archer mentioned in reference to the Meiorin^¹ decision of the Supreme Court of Canada which Geoffrey Trotter outlined, the inappropriate fitness requirement had the effect of basically requiring a female applicant to be a man – or at least to act like one. We would suggest that Value VIII as currently written requires those with conscientious beliefs which preclude them from being able to dispense certain prescriptions to act as if they did not have those beliefs while at work. This is to lose sight of the very nature of moral or religious beliefs – those who hold them feel obliged to live according to them in both the private and public spheres. If we consider our own beliefs, we will most likely recognize that this applies to each of us. If we believe that it is immoral to eat meat, or to consume alcohol, or to swear, we live by this belief both at home as well as at work. Those pharmacists with conscientious beliefs which make them unable to fill certain prescriptions are due no less respect than those who have no difficulty doing so.

Each of us might also consider whether, in the event that Euthanasia becomes legal in Canada (and the Bloc Quebecois was advocating for this in the previous federal Parliament), we would expect the College to not compel us to fill such a prescription. Under Value VIII as it currently reads, if there were no other pharmacist available, each of us, if presented with a prescription for a euthanizing drug, would be compelled to fill it even if we had a conscientious belief against causing the intentional (albeit consensual) death of our patient. Surely this example shows that Value VIII does not provide adequate protections to pharmacists.

With respect to euthanasia, we should look at the Belgian situation, and the fact that it appears that there is a greater probability that pharmacists will be involved in this practice than physicians. Based on the current euthanasia rate, each of Belgium’s 11,775 pharmacists has a 3% chance of being asked to supply drugs for euthanasia during one year of practice: 30% over ten years. It is interesting to note that, though physicians are the usual focus of attention in the health care sector when euthanasia is discussed, there is a higher probability that a pharmacist will be asked to facilitate the procedure. These estimates do not take into account factors that might increase or decrease the probability in different locations or in different kinds of medical practice or specialties, nor the possibility that the actual number of euthanasia cases may be two to five times higher than those reported.^²

This leads into another concern, which was raised by Mr. Lum: that our recommended adjustment to Value VIII could result in a suffering patient being denied what some may perceive as necessary care. This is indeed the “hard case” which is most troubling, although we would suggest that the prescriptions which some pharmacists would be unable to fill would rarely fall within this category. It may be valuable to have further discussion on the scenarios that Mr. Lum has in mind, and to consider whether the conscience of the pharmacist could also be respected in those situations. This inquiry aside, however, we would encourage the committee to also consider the “hard cases” on the other side.

Regarding the rural situation and other issues related to "access", it is important to note that some imagination and political will would likely resolve those difficulties. For example: it is unlikely that any community has only a single pharmacist or pharmacy and no other health care provider who could supply the requested drug. Such a situation is highly hypothetical, if not, as Sean Murphy of the Protection of Conscience Project put is succinctly, “mythical”. This was acknowledged in an editorial in January, 2001 by the editor of the Canadian Pharmaceutical Journal, entitled “Compromise” who observed that if any such place existed, they would have a lot more to worry about than getting the MAP. As the editorial suggests, a satisfactory resolution to this problem can be achieved with some creativity and flexibility.^³

We should also consider the many excellent and dedicated pharmacists who live in rural areas and may be the only pharmacist on duty at a given time. Value VIII as currently written gives them the following choice when presented with a prescription that they cannot fill due to reasons of conscience: either act consistently with your conscience, decline to fill the prescription, and face discipline by the college, or violate your conscience. This is an untenable choice for such a pharmacist to face. The result will be that many excellent pharmacists are unable to practice in rural areas as they are forced to either quit pharmacy practice, or to move to larger centers where they can ensure that they are not the only pharmacist practicing at a particular time. This will only exacerbate the public health challenge flowing from the lack of pharmacists willing to work in underserved communities. As was mentioned during the meeting, it also forces entire groups who hold particular conscientious objection concerns to leave pharmacy practice or avoid entering the profession in the first place. Surely it is in neither in the public interest nor the interest of the profession to maintain a policy that excludes members of those groups who would otherwise wish to serve in health care

At the end of the day, we agree with 99% of what is in the Code of Ethics. We take patient care very seriously, we love our work, and we support the role of the college in upholding the public interest. We also agree strongly with the value of patient autonomy. No pharmacist should be able to impose their beliefs on their patient, but neither should a patient be able to impose their beliefs on their pharmacist. That is how a free and properly open society should function in all areas of life - - and the relationship between medical professionals and patients, while different from some areas of ordinary commerce, is not free the need to properly accommodate diverse belief systems.

All of the Values of the Code of Ethics set a laudably high standard of care that pharmacists are to provide to their patients. This requires pharmacists to put the good of their patients above their own personal convenience or cost. The adjustment that we propose to Value VIII leaves all of those high standards in place, yet also seeks to better ensure that the dignity and rights of the pharmacist are affirmed along with the dignity and rights of the patient. This will serve to guarantee that the pharmacy profession in BC continues to attract the most diverse and committed professionals available. As was so eloquently put by pharmacist Ann Nadalini at the meeting, it is becoming more and more common for pharmacists of all practice settings to specialize in various aspects of healthcare. It should not be surprising then that not all pharmacists are experts in providing all types of requested services. It should also not be surprising that each pharmacist, as a conscientious, integral individual, would offer only those services he believes will be for the good of his patient, that patient meanwhile having the option to seek advice from the professional of his/her own liking.

We would be honored to offer whatever further assistance the committee may need in its deliberations, including reappearing before it to answer further questions, or to be invited to make further submissions with regard to specific concerns that the committee has with our recommendation. We encourage the College of Pharmacists of B.C. to take leadership in upholding the dignity of all pharmacists and in promoting diversity within the profession.

1 British Columbia v. British Columbia Government and Service Employees' Union [1999] 3 S.C.R. 3, [1999] S.C.J. No. 46 [Meiorin].

2 For further on this see: http://www.consciencelaws.org%5CExamining-Conscience-Background%5CEuthanasia%5CBackEuthanasia08.html/

*^* I would like to acknowledge and thank Geoffrey Trotter, UBC Law Graduate for his encouragement and his invaluable assistance, Prof Dr.Jose Lopez-Guzman, Professor of Pharmaceutical Deontology and Bioethics at the University of Navarre in Spain for his tutorship and his readiness to give very helpful advice, many thanks also to Sean Murphy of the Protection of Conscience Project for his support over the years, and a very special thanks and acknowledgement goes to Iain Benson, legal advisor and academic, for his ever insightful comments and assistance over long years.