Sex Values and Pharmacy Steven Miles MD Miles

Sex, Values and Pharmacy Steven Miles, MD Miles 001@umn. edu

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

Deeply Held Values Where do pharmacists’ values fit in?

A brief history of legal ‘coming to terms’ with controversial sexuality.

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 Comstock law barring married people from using contraceptives was 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. ” 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, in prohibiting the quartering of soldiers "in any house" in time of peace without the consent of the owner, is another facet of privacy. The 4 th Amendment affirms the "right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures. " The Fifth Amendment, in its Self-Incrimination Clause, enables the citizen to create a zone of privacy which government may not force him to surrender to his detriment. … Estelle Griswold

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. "

Frames for the debate: -Conscience vs conscience. -Pharmacist in a pluralistic society where diverse values are protected.

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 Legal Power and Personal Values • Pharmacists have a legal monopoly on the right to dispense certain goods. • In some areas, there may be only one pharmacy. • Should pharmacists be able to use personal values to selectively dispense goods that society allows it to collectively control for the benefit of a diverse society?

Cases • North Richland Hills, Texas, phamracists 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

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

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, 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

The Federal Battle • President Bush: • health care workers (MDs, RNs, Clerks) hospitals and insurance companies can refuse to provide services, information or advice to patients on subjects such as • abortions, contraception, blood transfusions and vaccines counseling if they are morally opposed or if that service that violates a "religious belief or moral conviction. ” • President Obama: narrowed this to abortions and sterilization.

St. Joseph’s Hospital in Phoenix • A 27 -year-old pregnant woman rushed to hospital with heart and lung failure from pulmonary hypertension. Doctors conclude they could only save her life by aborting 11 -week-old fetus; patient consents. • St. Joseph’s, a Catholic institution, is governed by the Ethical and Religious Directives for Catholic Health Care Services of the U. S. Conference of Catholic Bishops. Those directives forbid abortion for any reason – even to save the life of the mother. • Sister Margaret Mc. Bride, nun and longtime administrator at St. Joseph’s, convenes the hospital’s ethics committee. It votes to approve the abortion, saving the woman’s life. • The Bishop excommunicates and demotes Mc. Bride and says that St. Joseph’s may no longer call itself Catholic. • “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.

Wisconsin: Abandonment • Pharmacist disciplined Pharmacy Examining Board: for refusing to fill or • Engaged in practices that transfer a woman's birth endangered the health, welfare control prescription. 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.

Idaho Pharmacist Denies Anti-Bleeding Medication Because Woman Might Have Had an Abortion • November 2011: a woman took a prescription or Methergine, a drug that stops uterine bleeding regardless of cause, to Walgreens. • The pharmacist, suspicious that the woman's uncontrolled bleeding may have been from an abortion, asked the 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 woman may have had an abortion. The pharmacist's 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.

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 to provide immediate referral to an appropriate alternative dispensing pharmacy without interference • support laws to protect patients’ ability to have legally valid prescriptions filled. • discuss with relevant associations to guarantee that, if an individual pharmacist exercises a conscientious refusal to dispense a legal prescription, a patient’s right to obtain legal prescriptions will be protected by immediate referral to an appropriate dispensing pharmacy. • in the absence of all other remedies, 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. ”