Saturday, January 19, 2008

All Pharmacists Cannot Be Nancy Reagan

Not quite an explosion onto mainstream media, more like a dribble over the affiliates, it has recently made national news that the Indiana General Assembly is trying again to pass an old bill that would create/ease a pharmacist’s “right to refuse” service, in this case based upon religious belief (among other factors). While there are already several states that support this practice by law, there’s no time like the present to address the situation either with national interest or in all remaining states.

This is not a new issue. “Right to refuse” clauses or “conscience” clauses, specifically as they relate to abortion drugs, have been around since Roe v. Wade. Clicking here gives a great breakdown of all the states pushing legislation in one direction or the other over this topic. Clicking here shows the verbiage in the formerly proposed Indiana bills.

Okay, so we all know where the argument goes. On one side it’ll aim to say that if any pharmacists are allowed to do this, then what’s stopping them from exercising a “right to refuse” over any other drug beyond morning after pills or any other customers beyond pregnant or possibly pregnant women? After all, a law cannot name a specific product or group. The other side will claim that these pharmacists are providing a Samaritan human service by “refusing,” similar to a firefighter that rescues a baby from certain doom or a conscientious objector soldier who refuses to fire in war. I’d like to take the discussion out a little wider than abortion drugs, though.

Even if a “right to refuse” sounds new to you, toward your likes or dislikes, it is, in fact, a concept we deal with everyday. Most of us have seen the sign in the convenience store reading “No shirt, no shoes, no service.” We all know that any clerk, customer service rep., sales person, or manager is permitted to simply withhold service if you are belligerent, cussing, threatening, physical, lewd, or generally being a pain in the ass. I can refuse you service if you’ve broken a contract or failed to pay. Libraries can kick you out for talking, cinemas for the same, museums for touching works of art, airports for being on a list, former employers for claiming you were disgruntled, some hospitals for having the wrong insurance, lending bureaus for having poor credit, restaurants for bringing in food from competitors, bars for drunken behavior, amusements parks for not sitting correctly in the rides, government buildings for failing to produce proper I.D., or even beaches for not swimming inside the ropes. All of these exercised “rights to refuse” seem reasonable to most of us. They are so commonplace, in fact, that we might consider them a required component of running a business.

Additionally, there is the more top-down notion that an employer or corporation should not be able to FORCE you, as an employee, to do anything that is against your moral beliefs or religion. Banco Popular cannot force tellers not to worship on Easter Sunday. Blimpies cannot insist that Muslim counter workers eat bacon on their lunch hour during Ramadan. Circuit City cannot add “stab that Commodore 64 moron in the neck” to a salesperson’s job description, even if that employee is a once violent ex-con. Yes, if employers ask you and you refuse them, you won’t be long for that job, but that is also why we have the fallback of wrongful termination suits.

Given this dual tier, common sense familiarity with “rights of refusal” in the conscious mainstream, it’s a surprising wonder that when applied to pharmacists it would get such a rise out of people. Sure, the focus on that one set of drugs brings with it all the ire of the medical abortion debate, but people who’ve never cared one way or the other about the legality of non-spontaneous abortions have thrown a great many hats into this “conscience” clauses ring. And, it is a dangerous, morally relativistic ring.

Assume for the moment that I am against conscience clauses, that I want them eliminated either from pharmacies in particular, or from all businesses as they relate to the customer. Perhaps the strongest argument to rid the world of the “right to refuse” is that the practice is a form of prejudice or discrimination. Refusing to sell a person a product is reasonably similar to a cabby refusing to pick up a pregnant woman. Refusing to fill a prescription is oddly comparative to not giving African-Americans a homeowner’s application at an open house. Even if the practice itself is not intrinsically biased, it is a very easy practice to abuse for the sake of bias. So, in order to counter the idea that “right to refuse” is similar to prejudice, my opponents will claim the act is based upon the pill, not upon the customer. They’ll make the counter-argument akin to the particular product, not the consumer. That’s a rough road for them to take, given that these pills, like others, will overwhelmingly be purchased by women, and that they will ALL be purchased FOR women like pre-natal vitamins, estrogen pills, medications to ease menopause, vaginal healthcare products, and anything bombastically pink.

While the counter-argument might not be completely convincing, I, as the presumed opponent of conscience clauses have to account for and deal with it anyway. This generally ropes me down from my “discrimination” high horse and lands me on a platform of “domino effect.” That’s to say that I would need to change angles, take the next most obvious route, and instead argue that if a pharmacist is allowed to refuse any customer one set of pills, what’s to keep her/him and all pharmacists from refusing all kinds of services based upon all kinds of belief systems. Pharmacist Edgar might refuse my anti-HIV cocktail because he believes my impending disease to be a gay curse and further proclaims that homosexuality is a superlative sin. Pharmacist Tallulah might fill 400 milligrams of my 2600 milligram prescription because she believes doctors over medicate. Pharmacist Deepak might refuse to give me any service whatsoever because I mentioned, three conversations ago, that I was a divorcĂ©. Well, this is a great argument. It makes sense to so many people. Granted, opponents will claim such things will never happen and then we wind up in this junior high school debate spiral.

“Yes they will!

“No they won’t!”

“Yes they will, poopy head!

The spiral aside, domino effect is an understandable platform. I was vey careful NOT to discuss my political affiliations and points of view with the dentist right before he gave me a root canal. Sure, he picks up CNN on the same monitor with my dental x-rays, a monitor that during my exquisite torture only he could see and watch, but the last thing I needed was him taking out his election primaries dismay on my exposed, raw nerve. Duh! None of us like to imagine how that situation might turn out if we were forced to agree with all dentists’ political leanings before getting extra Novocain. We fear domino effect. We perceive it, acknowledge it, and prevent it. Recessions and depressions are domino effect. Nations falling to Communism was a domino effect. Why not pharmacists’ “right to refuse?” It’s a great argument. Don’t let any pharmacist refuse to give out any drug and we’ll never have to worry about all of them doing it with all drugs. Oh wait, where have we heard that argument before? Ah yes, gun control!

Here comes the dangerous moral relativism I spoke of. If I make the supposition that many of the people who’d oppose a pharmacist’s right to refuse skew to the political left by nurture, well then they are the same people that have been trying to convince right wingers there would be NO domino effect if we take away certain firearms. One cannot make the anti-domino effect argument for conscience clauses without opening up the door on overblown NRA assertions. By arguing this way that Donna should get her pill after she was raped, is to also argue that Manny the American ex-con gets his pick of AK-47 arsenals. Damn! So near, and yet so far.

Now, let’s go the other way. Let’s presume for the next moment that I am pro “right to refuse,” if even because I am simply pro anything with the word rights in it. Perhaps the easiest way to start this argument is with a future tense.

“So, one day, American doctors and psychologists and legislators decide that suicide is not a form of murder, but a patient’s choice. I, as a pharmacist, in good conscience am supposed to give them a big death pill? Am I as a pharmacist supposed to trust more in my nation’s ability to promote the common good than I am my own ability to spare a life standing right in front of me?”
There’s something basically human about the idea that doing one’s job well is defined by the limits to which we’d take it. We don’t think that a professional football player is any better if he keeps running to Montana after scoring the touchdown. In fact, we’d think he’s nuts. No reasonable person would claim that self-inflicted 17 hour workdays are anything but highly negative workaholism. Heck, we even give the most powerful job in the world, the U.S. Presidency, all kinds of limits, parameters, checks and balances and thereafter define a President’s “job-well-done” by how precisely s/he stayed within those strictures. Is it at all odd, then, that some doctors under the same Hippocratic Oath refuse to perform abortions or that some pharmacists under the Oath of a Pharmacist, an oath that includes a passage on ethical conduct, exercise their right to refuse? Isn’t setting limits part of a job-well-done? Are they really supposed to become a doctor or a pharmacist one year and then dole out every drug and every procedure that crops up in years to come no matter how radical or controversial? Do we not simply think they are better at their own jobs if they take the mental moment to say, “Stop, wait a second, let’s examine if this is really in congruence with my patient, my oath, and my knowledge?”

Opponents to this view on conscience clauses often go right for the frequented point of view, “What about the rights of the patients?” The law said they could have the prescription. The doctor who examined them lent all the professional weight of making out the prescription. The insurance company was even willing to pay for the prescription. Who is a pharmacist at the tail end of the service provider chain to say that a particular person should not be sold that particular prescription? Even more so, who is a pharmacist to countermand a medical doctor? The argument is the basic, tell-tale wisdom our parents taught us about rights. We were never to let the exercising of our own rights extend to the tip of somebody else’s nose. That is the historical difference between “rights” and “equal rights.”

So, this time, as the presumed pro “right to refuse” junkie, in accounting for the most frequented counter-argument, I dial my stance down a few notches from the lofty oaths and good job defense to now land these shoes on a platform of endless examples.

“What if women, once again, no longer had the right to refuse any random guy for sex?”

“What if Nancy Reagan never taught children to just say no to illegal drugs?”

“What if unions had never strengthened employees’ rights, many of which were based on the refusal to be abjectly abused?”

“What if the Boston Tea Party never took place?”

Insert your own pre-1964 examples here. There are a million of them. The new argument becomes the simplified idea that there is a lot of good demonstrated throughout history by both the practice of granting legally covered rights to refuse and, by extent, in listening to the very words that make up the phrase. Refusal empowers, it protects rights, it prevents catastrophe; it draws a line in the sand defining character, change, and perspicacity.

New opponents then jump in on this litany of examples with their contrasting case that states “none of those examples have anything to do with the sale of products and services.” They wish to assert that in order for equal rights to prevail through their infancy in a system of free enterprise, then at the very least we must make all products available to all consumers. We must collectively decide that the historic examples of “right to refuse” cannot apply to a product line or supply chain, to a service driven industry or person to person transaction. This leads again to the now familiar gambit,

“Sure we can.”

“No we can’t!”

“Of course we can, poopy head!”

I don’t truly see, given the eventual degradation into poopy head byplay, how anyone can firmly stand on any of the common arguments for or against conscience clauses. Sure I don’t want to have to go to seven pharmacists to find one who’ll fill my anti-anal leakage prescription. But, you know what? I also don’t want my daughter to be forced to sell a house to a customer who’s cupped her ass in the real estate office. I don’t want to be coerced to do every damn thing my yutz employer might insist I try, yet I also do not want do any damn thing the customer thinks I should do whilst calling me a fuckwad and insisting that the customer is always right.

My take is two-fold. First, we have laws, with regard to equal rights, that provide we cannot disallow anyone from entering our businesses based on race, ethnicity, creed, etc. There are still African-Americans alive who remember not being able to go into certain lunch counters or play on certain baseball teams. This is not some figment of revisionist history. They sat at the back of the bus, drank from separate fountains, used different bathrooms, went to different schools, and altogether were treated as less than. Those laws provided a necessary component to a truer America, one that did something to rectify its own atrocities. I find it interesting that pursuant to the interpretation of these equal rights laws and the simultaneous interpretations of “right to refuse” legislation, that any customer might now be allowed, by law, into the neighborhood, via the front of the bus, through the front doors of an establishment, up and down the aisles, only to still be refused service at checkout. By “interesting” I mean, how is that different than 1942?

I think there is some through line to a logic which would imply that if a customer is allowed into your business, that same customer must be provided your service within that business. Would this not be a self-evident truth? So long as a customer is not tampering with product, disturbing the peace, or doing something else worthy of getting them thrown out (acts that are covered by other laws and therefore not needing “right to refuse” clauses), then that’s it. Your personal feelings about their choice of product are irrelevant.

Secondly, let’s remember, with regard to pharmacists, that prescription drugs are controlled substances. They are legal controlled substances, but nationally controlled nonetheless. All of the legislators, companies, lobbyists, scientists, doctors, researchers, voters, officers, and associations involved with deciding how a substance is controlled are far too vast for any one crusader to veto solo. They’ve determined the exact process a person must go through to obtain said substances and when a person does so IN GOOD CONSCIENCE only to be turned away, it completely undermines the masses it took to make such a grand decision structure in the first place. Pharmacists are not the leaders of their own little nation. They didn’t go to school to become Ivan the Terrible. I understand that part of the job is something that goes against the grain of your ethical make-up. Then why do you have that job? Is it true with every job? Can we “refuse” to do any work based on the notion that all jobs go against our religion?

If it’s going to be right against right, right to refuse verses consumer rights, then I believe they stack like this. The person in the role of the pharmacist can go anywhere, anywhere at all to practice their right to refuse. Simply sitting on the couch NOT giving out pills is an exercise of that right. It’s a non-act by nature. You can go NOT do anything, anywhere. On the other hand, your establishment is the only place that rape victim can go to exercise her rights, rights that were already violated at least once. Taking away her one place to practice her right in order to maintain ALL your many places doesn’t seem equal with regard to rights at all. For Americans, rights without equality mean nothing. Don’t take my word for it. Here are some other entries:

Druggists Refuse to Give Out Pill

Pharmacists Rights at Front of New Debate

The Right To Refuse Service

Should Pharmacists Be Allowed to Refuse Service

It seems to me that nobody can force a store to carry a particular product, distasteful or no. I can't make Target carry Super Juggs 2008: The Sleeze Expo Edition. I can't make Dillard's carry unitards for men studying ballet or Japanese import Music CDs. Each business decides upon its custom consist to maximize profit and to evoke an atmosphere attractive toward targeted clientele. In the case of controlled substances, however, targeted clientele is EVERYONE. We control controlled substances in a manner that impacts everyone. Everyone needs to go through the same process to get these products. Everyone is subject to the same punishments if they get these products any other way. Everyone is still liable after getting these products for subsequent abuse of said products. It's a web of necessities used as both control and deterrent. One doesn't need to jump through any hoops to order off of However, if one does choose to navigate the web or jump through the hoops to get the proper medications, webs and hoops that we all set up for society's benefit, then we cannot opt to penalize righteous care seekers for doing so in the end. We cannot make the act of obtaining something illegally, wrong, AND the act of obtaining something legally, wrong. Pharmaceuticals distribution is a business that has no particularly targeted clientele. Everyone gets sick and hurt and therefore everybody needs care. This indicates that business owners who opt-in to an industry that serves all people have opted out of the choice of what products to carry or to sell.


Anonymous said...

Thanks for such an articulate, thorough treatment of this issue. Good job.

Pockets said...

Thanks, 'Chap'. I do very much welcome other points of view. I simply get saddened to hear the same older points brought to the forefront again, and again, not because they've failed to get disproved, but because few realize they've gotten caught up in a circular logic. My only regret with this post is having had to go through so many echelons of reiteration on both sides to simply conclude, "An industry set up to serve everyone must serve everyone.” Sometimes it’s a long way to modus ponens.