From Mr B. R. Sinclair, MRPharmS
A friend of mine mentioned that his wife had been ill and was prescribed penicillin. Neither the doctor nor the pharmacist had thought to mention the alleged potential for an interaction with her oral contraceptive.
Later that day, he telephoned me to say that his wife had been refused sale of the emergency contraceptive in their local high street pharmacist on religious grounds and wanted to know if the pharmacist was allowed to do that. I said “yes”, and enquired where she, as ethically compelled, had directed them in order that they might obtain a supply. The pharmacist gave no such alternative. Living in a small town in Hertfordshire, the next nearest pharmacy turned out to be a 20-mile round trip.
It is time for the Royal Pharmaceutical Society to compel pharmacists to provide the emergency contraceptive or face disciplinary proceedings. Religious grounds are not acceptable for a supposed profession that has pretensions of being a vital component in the promotion of the nation’s sexual health. It is, quite honestly, embarrassing. There are many things I object to, but I do not let them interfere with my professionalism.
The Society should enter the 21st century, get off the fence, and face up to its ethical and professional responsibility.
Barry Sinclair
Glasgow
ethics...
From Ms T. O. Adeshina, MRPharmS
There is guidance from the Society on EHC and all pharmacists should follow it. It is expected that any pharmacist choosing not to supply EHC on grounds of religious or moral beliefs should advise the customer, in a decent manner, on an appropriate local source of supply.
If this is not done, then the pharmacist has failed in his or her duty of care and, therefore, becomes open to any disciplinary process if reported. This is what Mr Sinclair should be advocating, instead of saying that supply of EHC by pharmacists should be made compulsory. Pharmacy is not the only healthcare profession with such matters of conscience and nowhere are members of other professions told they must comply, or else.
Choosing not to supply EHC on religious or moral grounds is an individual matter. Those who so choose should not be penalised. I believe in not supplying EHC because of my Christian belief but I will not prevent any woman needing it from getting a supply and it is my duty to direct her to a local source of supply. If I fail to do that then I have failed in my duty to her as a pharmacist and should be disciplined.
However, I do not expect to be disciplined for making a decision based on my faith. This does not make me any less professional or responsible.
Temi Adeshina
London
From Mrs Z. K. Crowther, MRPharmS
Mr Sinclair seems to equate the provision of EHC with the nation’s sexual health. Since EHC does not give protection against sexually transmitted diseases, it is not the complete or only answer to sexual health problems.
Although an unplanned pregnancy could be inconvenient and distressing, it is a natural event, not an unhealthy one.
Pharmacists can still be dedicated and professional people even though they have conscientious objections to initiating a supply of EHC and they can still give professional advice on sexual health issues.
Perhaps Mr Sinclair’s friend’s wife did not give the pharmacist the opportunity to advise and reassure her, or suggest other sources of supply for EHC. If, after further discussion, that was still considered necessary, the reference book ‘Stockley’s drug interactions’ states: “The oral contraceptive/penicillin interaction is inadequately established and controversial … the total number of failures is extremely small.”
Finally, just as some hospitals do not provide an accident and emergency service, it is possible for some pharmacies not to sell EHC but still provide a valuable pharmaceutical service to the local community. Suggestions of compulsory sales and disciplinary action are excessive.
Zofia Crowther
Reading, Berkshire
"Although an unplanned
"Although an unplanned pregnancy could be inconvenient and distressing, it is a natural event, not an unhealthy one."
Surely as a pharmacist, the knowledge that natural cannot be equated with healthy should be readily apparent almost every time a drug is dispensed? Illnesses are (broadly) natural, and yet we train as pharmacists in order to supply drugs which will have the most damaging effects possible towards them. It also cannot be said that pregnancy and childbirth in particular are without risk; they carry an inherent risk due to the strain they place on the body and the effects they can have on pre-existing medical conditions. Knowing that other people can give birth safely does not mean that every woman can.
From Mrs R. Baker, MRPharmS
If his friend’s wife had conscientiously studied the patient information leaflet from her pack of contraceptive when she first went on it she would have been alerted to the fact that medicine can sometimes interact with the pill. If the prescriber had acted conscientiously he or she would have asked the woman if she was taking any other medicines (or accessed her medical records) at the time of prescribing the penicillin.
If the pharmacist who dispensed the penicillin had acted conscientiously, he or she would have alerted the woman to the fact that there might be an interaction. Instead of castigating these people for not acting conscientiously, Mr Sinclair chose to castigate the one person who took her job seriously enough to think through the consequences of her action and who was not happy with the possible outcome.
What we need is to make more use of our consciences not outlaw them.
Rosemary Baker
Wirral, Merseyside
From Miss R. M. Dales, MRPharmS
Imposing sanctions on people due to their religious persuasion (ie, because of their life choices) has been commonplace for many centuries and, therefore, carrying this into the 21st century is far from a move forward as Mr Sinclair suggests. It would ensure that any persons with religious or moral persuasions or any view on how to live their lives that differs from that of the Royal Pharmaceutical Society are inhibited from joining the profession, making the profession unrepresentative of the society it serves.
A recent article in Student BMJ1 discusses the issue of conscientious objection and points out: “The United Nations Universal Declaration of Human Rights declares the universal right to freedom of conscience. The Human Rights Act affirms the right to freedom of thought, conscience and religion.”
The author writes: “The [General Medical Council] acknowledges the central role of personal, cultural, and religious values and beliefs in the lives of doctors and patients in its latest guidance on this issue.
“We may never all agree on what is the right thing to do in difficult clinical and moral situations. But we need more doctors, not fewer, who are willing to defend what they think is right.”
Are pharmacists different from doctors in some way that should allow them to be subject to different discriminatory sanctions?
R. Dales
Wakefield, West Yorkshire
Reference
1. Williams C. Conscientious Objection. Student BMJ 2008;16:235.
From Mr C. H. Mercer, MRPharmS
Barry Sinclair (PJ, 23 August 2008, p213) makes a good case for the involvement of all the profession in the services available from community pharmacy. He is to be applauded, in my opinion, for daring to challenge the alleged moral high ground of so many self-appointed guardians of moral and religious rectitude whose various diatribes have littered the letters pages of The Journal for so many years.
I would extend my objections for refusal to supply not only from religious and “pro-life” groups but also to include those companies that wish to distance themselves from such activities for fear of damaging backlash from their wider customer base.
If, as professionals, we are in the field of pharmacy service provision then we should all sign up for all of it with heads held high and not be allowed to cherry pick what does and does not suit our own moral, religious or economic agenda.
Chris Mercer
Doncaster
Do not confuse compulsion with professional obligation
If I was a conscripted soldier and I objected to shooting at the enemy during war, then I would be considered a conscientious objector; because I was being forced to commit an act I felt morally wrong.
If I was a professional soldier and I objected to shooting at the enemy during war, then I would be considered unprofessional and stopped from practicing; because no-one was forcing me to join a profession and receive a salary for something with a recognised part that you might consider wrong.
The public has a right to expect that they can access pharmacy services as much as they can be defended by our professional army. The scenario described shows a clear breach of care. If an alternative source of EHC is available, then fair enough - the pharmacist's right to object to supplying a contraceptive (and not an abortifacent) can be allowed.
Otherwise one day we'll hear about a patient who died when a pharmacist refused to supply their life-sustaining mediation, on account of her being a witch (as per Exodus 22:18).
From Mr J. R. Hill, MRPharmS
Even by not directly supplying EHC, pharmacists who object on grounds of religion are still facilitating the supply by referral to another source.
This passing the buck attitude towards EHC goes against the role of the pharmacist, who has a duty to provide the quickest, safest and most efficient route to medicines.
Jonathan Hill
Manchester
From Mr C. Boucker, MRPharmS
Those debating the supply of EHC appear to fall into two camps: those whose moral principles require them to opt out, but accept that others who disagree have every right to make a supply; and those whose moral principles suggest that EHC should be universally accessible and so every pharmacist should be forced to comply with their views.
Although I am happy to supply EHC, I support the least arrogant of these arguments.
Colin Boucker
Gloucestershire
From Mr A. M. F. O. El-Dabbagh, MRPharmS
R. Dales mentions the human rights of pharmacists. But people requiring EHC have human rights as well that entitle them access to the treatment when they wish it.
If we allow a pharmacist to opt out of supplying EHC through conscience, this will open the gates to more judgemental practices: others might not supply contraceptives, condoms, treatments for chlamydia or mouthwashes that contain alcohol.
A. El-Dabbagh
Wickford, Essex
From Emeritus Professor J. C. Dearden, MRPharmS
I was saddened by the harsh comments of Chris Mercer concerning pharmacists who, for reasons of conscience, refuse to supply emergency hormonal contraception over the counter.
Let us be quite clear about what EHC is, and what it is not. It is not a contraceptive, since conception (or the risk of conception) has by definition occurred before use of EHC. EHC prevents the newly formed embryo from embedding in the wall of the uterus, and thus is an abortifacient. I am aware that there are those who argue that before embedding, one has “only” a fertilised ovum or embryo, and not a fetus. But a fertilised ovum is alive and, in my view, its destruction is just as wrong as is the abortion of a 20-week fetus or the killing of a child.
I believe the development of EHC to be a backward step in the history of civilisation, but one which has been easy to take because we have become conditioned to placing less value on life. Alexander Pope expressed it well in his “Essay on Man”:
Vice is a monster of so frightful mien,
As to be hated needs but to be seen;
Yet seen too oft, familiar with her face,
We first endure, then pity, then embrace.
John Dearden
Helsby, Cheshire
Difficult moral decisions
From Mr S. A. Malcolm, MRPharmS
John Dearden, in defence of pharmacists who refuse to dispense emergency hormonal contraception on the grounds of conscience, makes the scandalous claim that destruction of a fertilised ovum is as wrong as killing a child (PJ, 20 September 2008, p326).
As a pharmacist who is not opposed to EHC, I should be profoundly offended to be told that I am the moral equivalent of a child murderer. However, I have not taken offence because I do not think Professor Dearden believes this claim himself.
If he honestly believes this, how could he associate with colleagues who regularly assist in the killing of children? Why does he not spend every spare minute outside his local pharmacy with a banner, denouncing the crimes that are being committed within?
Professor Dearden’s choice of verse from Alexander Pope, which shows how we can slip from shock to complacency, is strangely apt. We have come to accept fundamentalist hyperbole because these days it seems to surround us.
But when difficult moral decisions are under discussion, we need to be careful and honest in our choice of language. On this occasion, Professor Dearden has been neither.
Stewart Malcolm
Bures, Suffolk
From Miss A. J. Smith, MRPharmS
About the time that the supply of emergency hormonal contraception was proposed to be switched to over-the-counter supply, the community pharmacy that I work in received a letter from a concerned customer, asking us how we could justify supplying EHC to the public.
In my letter of reply, I stated that in spite of my own personal beliefs, whether it is for or against supply, that it is the patient’s choice to take this medicine and I respect her decision to do so. This is still the case.
If a woman has decided that she wishes to take EHC, then her decision should be respected and supply made. Why should we, as pharmacists, refuse supply, causing the patient the inconvenience of having to find an alternative source of supply?
What if the alternative source also refuses? What if it is too late in the day to find another pharmacy open? Do we tell her to try elsewhere in the morning despite knowing that the effectiveness of the medicine will be reduced? Perhaps she will not bother to try elsewhere and hope for the best? Do these options ease our conscience?
Whatever medicine we supply to our patients it is, ultimately, their decision whether or not to take it.We, as pharmacists, are not there to judge our patients. It is not fair for us to deny them treatment because we do not agree with it.
A. J. Smith
Halifax
EHC and knowledge
Whilst I believe that religious grounds for refusing the sale of EHC is "not cricket" for pharmacists - we happily give methadone an addictive drug in substance misuse maintainance, I believe that religious grounds are a shield to hide behind for lack of knowledge. Barry Sinclair is right in that the Society should come of the fence and take a stand, making the provision of EHC compulsory for all pharmacists, making the knowledge of how to provide the service ingrained in the knowledge of a pharmacist.
I don't like doing quite a few of the things that I do in the course of a day, but I realise that my thoughts must be put aside for the greater good of humanity.
Regards
Bob Dunkley
Remove the option for refusal on grounds of faith
From Mr B. R. Sinclair, MRPharmS
Colin Boucker implies that it is more arrogant to provide immediate care for patients than it is to impose our own beliefs on them and delay access to their treatment accordingly.
If this view is prevalent among pharmacists, then the profession is in deeper trouble than I imagined when I penned my original letter regarding emergency hormonal contraception.
His response was not the most hysterical. R. Dales wrote that compelling the supply of EHC was an assault on her human rights. Her blueprint for anarchy is to allow pharmacists to act at all times with regard to their “personal, cultural and religious values”.
Suppose, for example, I believe that homosexuality is an abomination or outside Abrahamic dogma, believe that treatment on the NHS of drug addicts, alcoholics, the morbidly obese, or even the elderly is morally wrong when its limited resources could be used in fighting cancer or caring for sick children. According to Miss Dales, I should be free to act accordingly.
Occasionally, I am approached by Muslims asking for advice on products that do not contain gelatin (I know what the Islamic Organisation for Medical Sciences recommendations are). Imagine if I were to approach them with a similar contempt and inform them that I did not agree with their beliefs and was unwilling to help, but would be happy to direct them five miles down the road. I would, quite rightly, be disciplined, although it is difficult to see what moral authority the Royal Pharmaceutical Society would carry while it supports pharmacists having the option of refusing to supply EHC.
It astounds me that religious pharmacists can fear their God enough to refuse sale of EHC but not enough to display the courage of their convictions and risk getting into trouble with the NHS by refusing supply on prescription. This displays the same hypocrisy that allows Christian pharmacists to refuse sale of EHC without a hint of irony while working on the Sabbath. I repeat my call for the Society to remove the option for refusal on grounds of faith.
Barry Sinclair GlasgowMissed the point
From Miss R. M. Dales, MRPharmS
Judging by the antireligious rhetoric introduced into the emergency hormonal contraception debate by Barry Sinclair (PJ, 27 September 2008, p360), I can only assume that he has a particular issue with any professional who has religious convictions.
It is obvious he has missed the point of my letter (PJ, 6 September 2008, p263), which was to compare our professional body’s stance on conscientious objection with that of another relevant professional body — the General Medical Council.
Because he does not agree with my reasoned argument that “we may never all agree on what is the right thing to do in difficult clinical and moral situations”,1 he dismisses it as hysterical.
Furthermore, Mr Sinclair misquotes me. The quote he describes as my “blueprint for anarchy” was, in fact, a recent quote from the Student BMJ used to illustrate the GMC’s stance that “we need more doctors, not fewer, who are willing to defend what they think is right”.1
Ruth Dales
Ossett, West Yorkshire
Reference
1. William C. Conscientious objection. Student BMJ 2008;16:235.
Taking God out of the practice of pharmacy
From Mr M. S. Prest, MRPharmS
Barry Sinclair (PJ, 27 September 2008, p360) will be delighted to hear of an amendment brought to the Human Fertilisation and Embryology Bill by MP Dr Evan Harris.1
If the amendment were carried, then the right of pharmacists to refuse sale or supply of emergency hormonal contraception, on grounds of conscience, would be removed by law.
The fact that such an amendment, if passed, would force me to cease work as a pharmacist on grounds of conscience is not the issue that troubles me most. Rather, it is the presupposition that holding to a worldview that excludes God from pharmacy practice is, by definition, morally neutral and beneficial to our patients.
If the practice of pharmacy is to be based on the views of only those who take God out of the equation, what is to be the basis of our professional standards and ethics?
I, for one, would rather pharmacists care for patients by listening to God’s declarations about right and wrong, rather than those of politicians or pharmacists, neither of whom are renowned for their moral perfection.
To use the words of Mr Sinclair, I am one of many pharmacists who do “fear their God enough” not to be coerced into an action that I believe to be morally wrong in God’s eyes. The commitment I have made as a Christian is to put Jesus first before all things, Dr Harris’s views included.
Michael Prest
London
Reference
1. Harris E. Patients to come before doctor’s beliefs. Available at www.evanharris.org.uk (accessed 6 October 2008).
EHC Suppply
Simple question,
would it be appropriate to supply the same EHC on an FP10 prescription by those who think its inappropriate?
If the answer is 'yes', then why bother having a debate on the issue.
Anees Ahmed
Scunthorpe
EHC supply
It is permissable to refuse to supply on prescription as wel. I once worked with a pharmacist who had moral objections - so whenever a prescrption came in, she left me to deal with it.
Do we really gain anything by forcing people to do things they object to? The majority of pharmacists will take a reasonable view of such things. Extremeists are happily rare. Where someone breaks the code of ethics and does NOT supply information about where a supply or further information can be obtained then then they need to be taken to task - and if necessary disciplined.
No-one has a right to force their views on others
supply of EHC mandatory
I find the topic interesting and though I live in India I like to add my view in this topic.
Firstly what is a Pharmacy? A man or a group of man joined in an enterprise to earn some profit by selling some medicines as well as their expertise. In doing so they must obey the law of the land. Consumers come to a pharmacy, pay some money for medicines and services and the owner earns his livelihood. So in the business field you must be more attentive to the needs of the consumer and for doing so you should remain prepare to loose some of your personal beliefs. If you have a headache you are not supposed to spread your aches to your consumers. In such case you should close down your shop. If you have any personal belief which restrains you to do something that should be known to your consumers from the inception of your business. you must be attentive to the needs of the consumers and that is real professionalism. You can deny supplyinh any medicine if you professionally believe that it is not good for the consumer. No other option of denying a medicine is not a good professionalism rather I think it should treated as an offence if anybody denies a medicine despite having a stock.
Pradyot Biswas
supply of EHC mandatory
I find the topic interesting and though I live in India I like to add my view in this topic.
Firstly what is a Pharmacy? A man or a group of man joined in an enterprise to earn some profit by selling some medicines as well as their expertise. In doing so they must obey the law of the land. Consumers come to a pharmacy, pay some money for medicines and services and the owner earns his livelihood. So in the business field you must be more attentive to the needs of the consumer and for doing so you should remain prepare to loose some of your personal beliefs. If you have a headache you are not supposed to spread your aches to your consumers. In such case you should close down your shop. If you have any personal belief which restrains you to do something that should be known to your consumers from the inception of your business. you must be attentive to the needs of the consumers and that is real professionalism. You can deny supplying any medicine if you professionally believe that it is not good for the consumer. No other option of denying a medicine is not a good professionalism rather I think it should be treated as an offence if anybody denies a medicine despite having a stock.
Pradyot Biswas
EHC
Naaah!! I don't supply it because I can't be a***d to do the course <GG> but apart from this frivolous comment, the Society really has to to get to grips with ethical dilemmas that are facing pharmacsts in their everyday practice. If pharmacists are to be allowed not to supply EHC on religious or moral grounds, then the Society should say so, otherwise a statement should come out from the Society that all requests for EHC should be met without demur (after a proper consultation of course!!), and that a refusal by way of religious or moral beliefs is grounds for a referral to the Infringements Committee, and a fitness to practice inquiry.
This would not be a bad thing IMHO, as there will some pharmacist somewhere who would challenge a ruling by the Society that they have to supply EHC in appropriate circumstances despite any moral or religious beliefs they hold. The resulting court case would force the Society to make a firm ruling one way or another.
Whilst EHC to me is a side-show, substance misuse maintenance is not and here again the Society is being wishy washy. Some of you may recall the letter I wrote to the Jouranl a month or two ago about police officers trawling the CD registers. I won;t go into the details, but suffice to say that it means as much to me as does EHC to the most devout pharmacist, and that we both have to search our consciences for an answer. The Society could help us both by providing some guidance, instead of taking our money and sitting on the fence
Regards
Bob Dunkley Leeds
There are some very good
There are some very good points made, mainly on the side of Mr Sinclair.
If an NHS script comes in for a supply of EHC how will the pharmacists who object to supplying it as a pharmacy medicine get round it? The pharmacy is contractually obliged to supply any medication from an NHS prescription so to refuse this would be a breach of contract.
Emergency hormonal contraception is legal in this country and so it should be every pharmacists obligation to provide it if required. If they want the law changed then lobby their MP, lobby the health secretary, join a pressure group! Don't impose your 'conscientious objections' on your patients because at the end of the day they deserve more than that. They are doing nothing wrong and you are in no place to judge them. If you can't put the care of your patients first then perhaps you're in the wrong profession.
There are some patients who I might not like, who I might not think deserve treatment as much as the next because they smoked 40 a day for 40 years and didnt look after themself. But again its not my place to judge!
So get off your moral high horse and put your patients first.
Those who supply EHC have a conscience too
Stephen Goundrey-Smith (PJ, 4 October 2008, p385) hijacks, by insinuation, the concept of conscience and made it exclusive to religion as if only those who have religious beliefs are the only people who have a conscience.
Conscience is a point of view, not something belonging to the church or churchgoers. I do not believe that a pharmacist who supplies emergency hormonal contraception has no conscience.
Conscience is something we acquire by education and may change throughout our lives. People must understand that whenever a pharmacist sells EHC, he or she is not encouraging abortion, just as a pharmacist who supplies methadone or needles is not encouraging drug misuse. Things are not always in black and white.
Conscience is partly a dynamic process of perception that changes with the advance in science and knowledge. It should be subjected to the necessities of life and fulfilment of peace and stability.
Let us do what we do best as pharmacists:help patients and ease their distress rather than giving them a sermon and changing our pharmacy to a church.
Ahmed El-Dabbagh
Wickford, Essex
Pharmacists should not be bullied
From Dr I. H. Stockley, FRPharmS
I am concerned by the attitude of those who think that pharmacists should be bullied into supplying emergency hormonal contraception (“morning-after pill”) against their consciences.
Do these people not have a conscience about anything that they would expect others to respect? For example: animal cruelty, animal testing and experimentation, blood sports, the bombing of civilian targets or “carpet” bombing in wartime, capital punishment, child labour, child prostitution, child slavery, corporal punishment, ethnic cleansing, euthanasia, intensive animal farming, land mines, meat eating, political or religious censorship and oppression, slavery, torture, war, weapons of mass destruction.
If we have an ethical or religious conscience about any of these (or other) issues, we ought to give equal respect to other peoples’ consciences too, whether the particular issue seems absurd to us or not. A quotation, attributed to Voltaire, expresses the degree of mutual respect that a civilised and free society ought to extend to its citizens: “I may disapprove of what you say, but I will defend to the death your right to say it.”
Ivan StockleyLoughborough, Leicestershire
How is this bullying?
Playing God
I would like to pose the question to all those morally or religiously opposed to the supply of EHC over the counter; as a pharmacist are you not playing God already?
The supply of a large percentage of OTC drugs and POM has a direct effect on a person’s life. Some may argue a disease or complaint of some sort is a punishment or lesson from God, so are we not intervening with Gods will as pharmacists by treating these maladies?
I find the ability to refuse the sale of EHC contradictory to your duty as a pharmacist. I point you to the seven principles of the code of ethics, by not supplying EHC I believe you to be disobeying at least four of the seven;
As a current student of pharmacy, these are the ethics that are drilled into me in order to help me become a professional; the ethics that so many qualified pharmacists dismiss in order to obey their own beliefs.
By not providing the patient with the care they need you have the possibility to decide for them a detrimental effect on the rest of their lives: a child.
EHC
Today i had my law n ethics workshop, it really made me think about EHC. im studying pharmacy because i love chemistry n love talking n caring for ppl...Pharmacy is the perfect combination!!!im very hapi i made the rite choice .
Regarding to the post above mine, y shuld i support smething im nt hapi wiz?? supposedly, im imposing my beliefs on the patient. indirectly the patient is doing the same thing to me!!!Y? shuld i agree, just cz i chose to be pharmacist, therefore work comes first before religion!!!
to be honest wiz u, when i see young gurls for EHC...im like wats happening in zis world....smething needs to be done very quickly....i guess every1 has the rite to chose!!we shuld respect that!
EHC
EHC
In reply to Miss Gokools post, firstly I would like to point out that by becoming a pharmacist you agree to do things that you may not be happy with. For example, you may need to treat a patient with a liver disease caused by drinking, you can not refuse just becasue you believe drinking is wrong.
I would also like to mention that it is not just young girls who require EHC, it is women of all ages, religions and ethnic backgrounds. Most of the time the reason they require EHC is because of an accident.
Being a pharmacist is not just a job, it is a profession. That means you should be acting professionally in all aspects of your life from day one of the MPharm course, I regret to mention that this is something you do not appear to be doing.