Conflicts of conscience: From the Drug Store to the Clinic

1. Conflicts of conscience: From the Drug Store to the Clinic Steven Miles, MD Miles001@umn.edu

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

3. Deeply Held Values Where do pharmacists’ values fit in?

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

5. Comstock Law: 1873-1936 • Whoever shall offer to sell, loan, give away, exhibit, publish, or possess • an obscene book, pamphlet, print, advertisement, 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

6. Griswold v Connecticut-1965 • Supreme Court rules that a Connecticut Comstock law prohibiting married people from using contraceptives was unconstitutional because it violated the "right to marital privacy." Estelle Griswold

7. 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

8. 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."

9. Frames for the debate: - Conscience vs conscience. - Business in diverse society.

10. 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.

11. Monopoly on Goods=Monopoly on Values? • Pharmacists have a legal monopoly on the right to dispense certain goods and services. • In some areas, there may be only one pharmacy. • Should pharmacists be able to use personal values to selectively dispense goods that society empowers it to collectively control?

12. Cases • North Richland Hills, Texas, 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.

13. RESOLVED, That the AMA should • Support laws requiring pharmacists or pharmacy chains to fill legally valid prescriptions or to provide immediate referral to an alternative dispensing pharmacy without interference • Work with state medical societies for laws to: • protect patients’ ability to have legally valid prescriptions filled, • 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.

14. 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 drivers? • Infringement of the rights of fares? • How does this compare to the pharmacy debate? • Is a conscience clause the solution?

15. 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?

16. 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.

17. 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 . . . whose goods, services, facilities, privileges, advantages or accommodations are extended, offered, sold, or otherwise made available to the public. Note: This includes a pharmacy, hospital, or a private clinic.

18. Wisconsin, pharmacist was 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. Wisconsin: Abandonment

19. American Pharmaceutical Association • "recognizes the individual pharmacist's right to exercise conscientious refusal and • supports the establishment of systems [e.g. transferring a prescription to a partner, giving it to another store, or handing a patient a toll-free hotline number, such as one set up by proponents of emergency contraception] to ensure patient access to legally prescribed therapy without compromising the pharmacist's right of conscientious refusal."

20. Outside the drug store

21. Mandatory Flu Shots for Kids? • Mandatory flu shots in Japan reduced: • pneumonia and flu deaths by 10,000 /yr • all cause mortality by 37-49,000 deaths /yr. Vaccine 2005;23:1540-48 N Eng J Med 2001;344:889-96 Deaths Vaccination

22. Biased Health Information • From a Minnesota Health Department pamphlet that doctors were required to give to women considering an abortion. • At the time, medical authorities from the NIH to major non-sectarian physician groups agree that there was no abortion breast cancer association.

23. Other issues • End of life care— • Withhold treatment • Demands for futile care • Non effective therapy • Insulin for a diabetic child? • Naturopathy for a person with cancer? • No blood products for a person with a curable disease? Naturopath charged with cancer patient's death Brian O'Connell was charged with manslaughter after he unsuccessfully treated Sean Flanagan who suffered from Ewing's sarcoma, a form of cancer. Flanagan was desperate he went to Mountain Area Naturopathic Associates. He had tried chemotherapy, radiation therapy, bone marrow transplants and surgery and put his last hope in O'Connell's herbal medicine, nutrition and physiotherapy. Seventh Day Adventist publication

24. Slides Available Steven Miles, MD Miles001@umn.edu