Conscience and Clinical Care Steven Miles MD Miles

Conscience and Clinical Care Steven Miles, MD Miles 001@umn. edu October 2016

Sexual Medicine: Contraception, Assisting Reproduction, Preventing Disease, Enhancing Sexual Experience

Deeply Held Values Where do pharmacists’ values fit in?

Conflicts of Conscience: • A nurse is asked to restrain and force feed a patient. • A doctor is asked to sedate a person with ALS while a respirator is discontinued. • The distress that occurs when one knows or believes that one knows the right thing to do but constraints make it difficult to pursue that choice.

A brief history of legal rights and sexual pluralism in health care.

Comstock Law: 1873 -1936 Whoever shall offer to sell, loan, give away, exhibit, publish, or possess • an obscene book, pamphlet, advertisement, print, picture, or drawing or • any article for the prevention of conception, or for causing abortion, • or shall advertise the same for sale, • or shall write or print any circular, book, or pamphlet stating how such articles can be obtained, • shall be imprisoned at hard labor for not less than six months nor more than five years for each offense… Anthony Comstock Postal Inspector Politician

Griswold v Connecticut-1965 • • Supreme Court rules that a law barring married people from using contraceptives is unconstitutional. “Would we allow the police to search the sacred precincts of marital bedrooms for telltale signs of the use of contraceptives? The very idea is repulsive to the notions of privacy surrounding the marriage relationship. ” Estelle Griswold The 1 st Amendment has a penumbra of privacy as protected "associations" that are not political in the customary sense, but pertain to the social, legal, and economic benefit of the members. • The 3 rd Amendment, prohibiting the quartering of soldiers "in any house" in time of peace without the owner’s consent, is another facet of privacy. • The 4 th Amendment states the "right of the people to be secure in their persons, houses, papers and effects, against unreasonable searches and seizures. " • The 5 th Amendment’s Self-Incrimination Clause create a zone of privacy by which government may not force a person to surrender to his detriment.

Loving vs State of Virginia 1967 • Supreme Court voids laws barring the inter-racial marriage of Mildred and Richard Loving. • Almighty God created the races white, black, yellow, Malay and red, and he placed them on separate continents. And but for the interference with his arrangement there would be no cause for such marriages. The fact that he separated the races shows that he did not intend for the races to mix. Trial Judge. “Surrounded as I am now by wonderful children and grandchildren, not a day goes by that I don't think of Richard and our love, our right to marry, and how much it meant to me to have that freedom to marry the person precious to me, even if others thought he was the "wrong kind of person" for me to marry. ” ML 2007

Eisenstadt v. Baird, 1972 • Supreme Court establishes the right of unmarried people to possess contraception on the same basis as married couples. • “If the right of privacy means anything, it is the right of the individual, married or single, to be free from unwarranted government intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child. "

Plan B • Emergency contraceptive to reduce chance of pregnancy after barrier failure, unprotected sex, or sexual assault. • Should be taken within 72 hours of unprotected sex • Efficacy of up to 89% quickly declines with time.

Monopoly: Power and Personal Values • Pharmacists have a monopoly controlling access to certain products. • In some areas, there may be only one pharmacy. • Should pharmacists’ personal values and public monopoly empower them to selectively control who gets access to legal products?

Cases • North Richland Hills, Texas, pharmacists refused to fill a prescription for birth control. • Denton, Texas pharmacist fired after refusing to fill a rape victim's prescription for emergency contraception. • Dallas pharmacist refused to fill a mother's prescription for her son's Ritalin.

Monopoly on Goods = Monopoly on Values? • Some Islamic Taxi Drivers with airport contracts do not want to transport persons who have alcohol with them. • Infringement of personal religion for fares, for drivers? • How does this compare to the pharmacy debate? • Is a ‘conscience clause, ’ empowering the devout drivers the solution? Some Muslim Cashiers at Target Refuse to Scan Pork Products

New York Times September 2016

Conscientious Objections?

Personal Conscience and Public Health • Health laws express public health priorities. • Should a doctor’s personal values (on vaccines, contraception) affect the dispensing of public health materials that it controls?

Frames for the debate: Autonomy Frame Conscience vs Conscience? In a diverse society, every one must accommodate legal choices for public preferences.

Civil Rights Act of 1964 • TITLE II--All persons shall be entitled to the full and equal enjoyment of the goods, services, facilities, and privileges, advantages, and accommodations of …premises of any retail establishment.

Minnesota Human Rights Act • It is an unfair discriminatory practice to deny any person the full and equal enjoyment of the goods, services, facilities, privileges, advantages, and accommodations of a place of public accommodation because of race, color, creed, religion, disability, national origin, marital status, sexual orientation, or sex, • Place of public accommodation: a business … whether licensed or not, whose goods, services, facilities, privileges, advantages or accommodations are extended, offered, sold, or otherwise made available to the public.

Lesbian Woman Sues Fertility Clinic. • Physician refuses to provide intrauterine insemination to a lesbian woman because of his religious objections. • He said that he would not inseminate any single woman, and that it was not sexual orientation discrimination. • Court found against physician on grounds that he discriminated by violating a law (all people get services equally) of general applicability. • North Coast Womens Care v Benitez. Calif. Supreme Ct 2008

Pharmacist Conscience Clauses: 2007 • IL, NJ bar pharmacists from refusing to fill prescriptions on moral, religious or ethical grounds. • Ark, GA, ID ME, MS, SD, TN, ID allow pharmacists to refuse to dispense various contraceptives. • CA: pharmacists may refuse to dispense contraceptives if their employer approves and the pt can access her Rx in a timely manner. • CO, FL: No pharmacy or employees may be held liable for refusing to dispense contraceptive supplies, procedures or information if their refusal is based on a moral or religious objection. • http: //www. ncsl. org/default. aspx? tabid=14380 • ALWAYS CHECK CURRENT LOCAL LAWS

Idaho Pharmacist Denies Anti-Bleeding Medication Because Woman Might Have Had an Abortion • 2011: a woman brought a prescription for Methergine, a drug that stops uterine bleeding regardless of cause, to Walgreens. • The pharmacist, suspicious that the bleeding may have been from an abortion, asked the clinic nurse practitioner why the patient needed it. The NP refused to answer citing the patient's confidentiality. • The pharmacist refused to dispense medication because she suspected an abortion. The pharmacist also refused to refer the bleeding woman to another pharmacy. • Walgreens disciplined the pharmacist. • The State Board did not punish pharmacist because Idaho Pharmacy Act does not require a pharmacist to fill a prescription.

The Affordable Care Act • Requires health insurance to cover contraception. • Some church based organizations, charities, hospitals and churches object. • No political outcry about coverage of • blood products for Jehovah Witness bodies, • requirement for health insurance of Christian Science groups, • coverage for chemotherapy by naturopathic stores.

Hobby Lobby. Supreme Court ruled that • corporation with religious owners cannot be required to pay for contraception insurance. • 13, 000 employees must pay for contraception. Should employers disclose corporate owners’ religious views to employees, to customers. Should employees be compelled to accept a work environment constrained by their employers’ beliefs. • Does this facade disclose that it is a sectarian mission?

Whose conscience is it? Practices • 98% of adult sexually active Catholic women have used contraception. • 83% of Catholic women who attend church weekly use contraception. • (NSFG, 2008) Policy Preferences • 65% of voters support requiring health insurance to cover birth control. No difference between Catholic/non Catholic voters. • 59% said health insurance of religiously affiliated employers should cover birth control.

St. Joseph’s Hospital, Phoenix-2009 • 27 -year-old pregnant woman to ER with heart & lung failure. Doctors conclude they could only save her life by aborting 11 -week-old fetus; patient consents. • St. Joseph’s bound to the Ethical and Religious Directives for Catholic Health Care Services of the U. S. Conference of Catholic Bishops. Those directives forbid abortion – even to save the life of the mother. • Sister Margaret Mc. Bride, a longtime administrator, convenes the ethics committee that votes to approve the abortion, saving the woman’s life. • Bishop excommunicates and demotes Mc. Bride and says that St. Joseph’s may no longer call itself Catholic. (The excommunication is revoked two years later. ) • • “Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save, ” said hospital officials in a statement. St. Joseph’s is a member of Catholic Healthcare West.

2012: Catholic Healthcare West becomes Dignity Health • Dignity Health is a secular nonprofit health care system and no longer be a sponsored ministry of the Catholic Church. • Dignity Health would operate Catholic and non-Catholic hospitals. • Catholic hospitals must follow the church’s moral and social teachings. • http: //www. catholic-sf. org/news_select. php? newsid=4&id=59532

Storman v Washington • Private pharmacy had religious objections to providing morning after medication (they believe it was an abortifacient). • Law said that legal drugs had to be provided in a timely manner and permitted a pharmacist to refuse as long as another pharmacist was in the story to fill. • Federal Appeals Court supported the law, said this did not require pharmacists to violate personal faith or take life.

Wisconsin: Abandonment • Pharmacist disciplined for refusing to fill or • transfer a woman's birth control prescription. Pharmacy Examining Board: Engaged in practices that endangered the health, welfare or safety of a patient • Departed from standard of care ordinarily exercised by a pharmacist. • Failed to inform managing pharmacist that he would not transfer a prescription for oral contraceptives • Failed to inform patient regarding her options for obtaining a refill.

American Pharmacists Association • Recognizes the pharmacist’s right to exercise conscientious refusal. • Supports systems to ensure patient’s access to legally prescribed therapy without compromising the pharmacist’s right of conscientious refusal. When this policy is implemented correctly, and proactively, it is seamless to the patient, and the patient is not aware that the pharmacist is stepping away from the situation. • APh. A policy does not support lecturing a patient or taking any action to obstruct patient access to clinically appropriate, legally prescribed therapy.

RESOLVED, That our AMA • support laws requiring individual pharmacists or pharmacy chains to fill legally valid prescriptions or immediately refer to an alternative dispensing pharmacy. • … work with state medical societies to adopt state legislation to allow physicians to dispense medication to their own patients when there is no pharmacist within a thirty mile radius who is able and willing to dispense that medication. ”

Steven Miles, MD Slides available on request. Miles 001@umn. edu