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Monday, June 19, 2006

Comments

The problem with your analysis of the situation is that it fails to take into account the whole focus of modern medical ethics.

The central concept of modern medical ethics is patient autonomy. Patient autonomy, simply put, is the concept that the *patient* is the one who decides to accept or reject relevant medically-acceptable treatments or interventions. The role of the physician and other providers is to provide objective information on and access to those options, within the scope of their specialties.

In other words, the relationship between the patient and the provider is NOT a traditional "customer service" relationship Rather, it is based on a kind of Kantian ethic of obligation to treat the patient as an end in himself as not as a means to some other end.

Your analysis turns the whole issue of autonomy on its head. In your "customer service" view the *provider's* interests are primary, and the patient's secondary. In your view, the provider need not provide any particular treatment, or presumably even *inform* the patient that other treatments are available.

So, for example, a woman severely beaten and raped and taken to a hospital, might not even be informed as to the existence of "Plan B." In the customer service view, this would simply be a "customer service" issue fully under the legitimate control of the hospital administration. In the "customer serivce" view of medical ethics I suppose it would even be acceptable for a physician to refuse to tell a woman she was pregnant for fear that she *might* get an abortion. It would be acceptable for a physician withhold virtually any information or intervention merely on the basis of a "moral objection," and without even informing the patient that anything was being withheld. All of this would be within the scope of private "customer service" policies and the State would have nothing to say about it.

In effect we end up with "provider autonomy" in place of patient automony, in which the medical options presented to the patient are limited by conscience and moral feelings of the provider, whatever those happen to be. Indeed, there perhaps would not even be limits on what the provider could refuse to do.

We can certainly do it that way, but ultimately I don't think you'd like to live under that system.

Thanks for your thoughtful commentary, Jim.

I take your point about patient autonomy. However, surely there are some limits to this, both practical and legal?

Do I have the right to go to any health care provider and demand that they give me whatever services they are technically competent to provide, simply because I am the patient and therefore supreme?

Now, if I feel that there's a particular service that I should get, and my own physician disagrees and won't provide that service (for whatever reason), can (or should) the physician be compelled to do so? Or is my recourse to "shop around" for a doctor who is more amenable to my own point of view?

And here's a serious question: are those physicians who are technically competent to do so legally required to provide abortions to anyone who wants them, or are they free to decline to perform that procedure on moral grounds? I honestly don't know what the law says on this point, but I suspect in that particular case the physician is allowed a great deal of leeway (and if not, then I am of the opinion that they should be). Why should pharmacists be held to a higher standard?

I don't see the patient autonomy/provider autonomy as being an either/or situation. Each party is autonomous and neither can compel the other to act in any particular way.

Of course you touched on much broader issues than the original post at BlueOregon, which was a call to specifically require pharmacies to promptly fill any prescription no matter what. While standards may possibly be different for different types of patient care (an ER is legally prohibited from refusing treatment to anyone, as I understand it... including those who cannot pay... the same is certainly not true for many other kinds of health care service providers) in the specific case of pharmacies I stand by the assertion that they essentially provide a retail service and thus retail standards of service are not inappropriate.

(Which is not to demean at all the valuable expertise that pharmacists bring to the transaction.)

"I take your point about patient autonomy. However, surely there are some limits to this, both practical and legal?"

Absolutely. You can't just "demand" a medicine or a procedure or anything else. But a patient can demand to be given relevant information and appropriate treatment options.

My point about patient autonomy is that it is the foundational ethical concept around which everything else must be organized. If you want physicians or pharmacists to be able to refuse certain things on the grounds of conscience, that's great. I just want to make sure that is done in a manner consistent with patient autonomy.

"in the specific case of pharmacies I stand by the assertion that they essentially provide a retail service and thus retail standards of service are not inappropriate."

Well . . . they are just like retail stores, except that their activities are governed by ORS chapter 689 and god knows how many federal laws. There is no such thing as a "pharmacy" outside Oregon statutes. A "pharmacy" is a legal entity that exists only through the State's licensing process.

One of the main concerns of the State pharmacy board is the preservation of the public "health, safety, and welfare." So it seems to me that if the State board of pharmacy decided that the availability of a certain drug was important to the public health, safety, and welfare, they could require pharmacies to carry that.

Anyway, I don't want to blather on, but the point is that ALL of this pharmacy stuff is governed by federal and state laws and rules. Pharmacies may come in a retail wrapper, but they're all laws and rules inside, and all about patient health, safety, and welfare.

And in a conflict between YOUR health, safety, or welfare, and the conscience of the pharmacist, whose interest do you think should prevail?

Jim, fair points. Thanks again for continuing the discussion.

"And in a conflict between YOUR health, safety, or welfare, and the conscience of the pharmacist, whose interest do you think should prevail?"

Well, as the presumed consumer in this scenario, I naturally would prefer for my own interest to prevail.

But I wouldn't be entitled to have my own interest prevail, is I guess my whole point in this discussion.

If I've got a legal prescription from my doctor, I'll go to whichever pharmacy will fill that prescription. If pharmacy A won't (or can't, because they don't stock it) provide the meds, I'll find one that can and will. And I may not patronize pharmacy A any more, if I'm disappointed with their attitude/service.

But I wouldn't claim to have a "right" to have pharmacy A specifically serve me.

You're absolutely correct that the state has the authority to regulate pharmacies, and if they chose to they could by fiat require any particular med to be stocked by all pharmacies at all times.

But they don't, now, and the original article that I take issue with suggests that they should so regulate the industry (actually, it suggests much broader regulation than just one particular med, though they have a specific drug in mind).

I'm simply suggesting that it would be inappropriate for them to do so, as that would expand an unwarranted sense of entitlement -- which is the "slippery slope" I'm most concerned about.

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