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Choice and responsibility

Two issues are prompted by the
Thursday proposal
by the Washington Board of Pharmacy which would allow local pharmacists to decide not to fill birth control or some other prescriptions.

One is this: What sort of business is a pharmacy: A retail store-type business, or a public service-type business?

The new rule proposal suggests the retail store analogy.

Consider a supermarket. Such a store carries thousands of items, a wide range of foods and other goods, but all of that is only a fraction of what it could in theory stock. It could, possibly, stock hundreds of additional foods, thousands of additional brands and companies. The choices are endless. But the store makes them, based largely, presumably, on what people want to buy, but maybe too on profit margins or bulk deals, or maybe in some cases even the biases of the owner or manager. It’s up to the store. We can impact their choices as customers, but that’s about it. You can extend the analogy to many other businesses, even to the newspaper which runs some stories and leaves others out.

That’s one model for the pharmacy: A store in which the owner can decide what to stock and what not.

That seems to be the framework contemplated by the proposal offered by the board – but seems is as much as we can say, since the language in the actual proposed rule is so vague. The major and key section of the planned change reads this way:

WAC 246-863-095 Pharmacist’s professional responsibilities. (1) Pharmacists and pharmacy ancillary personnel shall not obstruct a patient in obtaining a lawfully prescribed drug or device. If a pharmacist cannot dispense a lawfully prescribed drug or device, then the pharmacist must
provide timely alternatives for the patient to obtain treatment. These alternatives may include, but are not limited to:
(a) referring the patient or patient’s agent to another on-site pharmacist;
(b) if requested by patient or their agents, transfer the prescription to a pharmacy of the patient’s choice;
(c) providing the medication at another time consistent with the normal timeframe for the prescription;
(d) consulting with the prescriber to provide an alternative medication therapy;
(e) return unfilled lawful prescriptions to the patient or agent; or
(f) provide to patient or agent a timely alternative for appropriate therapy.
(2) Nothing in this rule shall interfere with a pharmacist’s screening for potential drug therapy problems, pursuant to the pharmacist’s professional responsibilities.
(3) Nothing in this rule requires pharmacists to dispense a drug or device without payment of their usual and customary or contracted charge.

What does it mean to say that a pharmacist “cannot dispense a lawfully prescribed drug or device”? It does’t say, but section 4-j does refer to a pharmacist not delegating a “Decision to not dispense prescriptions for any reason.” What reasons? Left unclear.

Only the discussion in news articles of the members, their supporters and critics, are really illuminative – and they make clear that the aim is to allow pharmacists to avoid dispensing some prescriptions if they personally disapprove (another way of saying that the prescription runs afoul of their consciences).

The provisions do specifically say that patients must be obstructed from getting a legally prescribed drug of any sort – but what if all the pharmacists in a community refuse to provide it?

There we get into the second model of the pharmacy: As a business which functions as a public service, a business which is there to make money (like all businesses) but which also has specific responsibilities to the public which must be met. Utilities – electric, telephone, water and others – fall into this category. So do hospitals (in a general sense, even if many are public or nonprofit). Pharmacies are tightly regulated the way most other medical providers, which generally put themselves out there as providers of a specific service, do.

The strength of the public service argument, and the weakness of the proposed regulations, is that many people come to pharmacies with a need for immediate help. Could a pharmacist ultimately become legally liable for injuries sustained through failure to provide service? (A doctor might.) Perhaps we could have “full service” and “limited service” pharmacies? (We discussed that some months back in a previous post.) At least that would give people fair warning before they hit an emergency situation.

The Washington State Pharmacy Association, the trade group, supports the proposed rule, but that’s hardly the whole story. A side note: The WSPA’s web site sports the slogan, “The Washington State Pharmacy Association exists to support and advance the practice of pharmacy to ensure that the public receives optimal pharmaceutical care.” A question: How is a rule allowing pharmacists to offer unannounced diminished service consistent with their support for optimal care?

This is a good time to discuss the question of public responsibility, but there’s a second point to consider here before we end this post.

What we have here – as evidenced today by the front page banner headlines in newspapers across Washington state – is a social and political issue, one extending far beyond the feelings of a handful of pharmacists.

Who, especially, is behind the press to deny certain types of prescriptions? What is their motivation? How do they see this playing out? Where has the opposition been – and where might it be going?

There’s a lot of depth here, and to this angle we’ll return before long.

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