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Presented By: Lisa Chee Pharmacy Intern 2009-2010 Fall semester learning outcomes Spring semester learning outcomes Case study analysis Updating the Moodle website History of ethics in pharmacy Current ethics related issues Selection of case study for spring 2010 focus Research on Plan B- morning after pill (emergency contraception) Evolution from apothecary to pharmacy Controversial topics regarding emergency contraception and a pharmacists right to conscientious objection Pharmacy students knowledge on emergency contraception* Oregon assisted suicide law* Image to the left: represents that of old-day apothecary shops Image to the right: represents our modern day pharmacy The term apothecary was used in Europe during the mid 14th to mid 17th century between the Middle Ages and Renaissance An apothecary represented anyone who owned a shop or store that carried nonperishable commodities including spices, drugs, dried fruits and preserves An apothecary was responsible for dispensing herbal remedies that were prescribed by trained physicians They would grind seeds and herbs together with the aid of a mortar and pestle to formulate the physicians written prescription Additionally, in areas where physicians were not as accessible, apothecaries were also responsible for diagnosing illnesses and generating a treatment plan for their patients Apothecary Shops Contain endless jars filled with medicines and herbs ready for preparation Often times, a garden would be located behind the shop surrounded by medicinal herbs that are commonly used in the apothecaries’ practice Modern Day Pharmacies Filled with limited rows of medications that are already synthesized and ready for distribution Many are found located in large cooperation chains such as Target or Wal-Mart Few are privately and individually owned Duties between the two professions were made distinguishable during the 18th century and onward A typical pharmacist is expected to administer prescriptions according to a doctor’s written instructions and assisting customers with issues within their expertise As opposed to apothecaries, pharmacists are not allowed to prescribe drugs or diagnose patients whatsoever. Instead, they are given limited power to dispense and offer generic medical advice. We no longer focus on traditional herbal remedies, but more so on modern day treatments Emergency contraception that can prevent pregnancy when taken within 72 hours of sexual intercourse Potential to prevent up to 75% of unplanned pregnancies NOT similar to an abortion pill, which contains high dosages of mifepristone Plan B acts primarily by stopping ovulation (the release of an egg from the ovary) Plan B prevents fertilization, or the union of a sperm and an egg. If fertilization does occur, Plan B may prevent a fertilized egg from implantation (attaching to the womb). Mary is a pharmacy student on a rotation in a busy clinic downtown. Mary has worked with Dr. Jennings, her preceptor, for two weeks and gets on well with her. Alice, a patient presents to the clinic pharmacy to purchase Plan B (an OTC emergency contraceptive) to Mary. Mary is a Catholic and believes emergency contraception is abortion and amounts to the killing of innocent human life. This has happened once before and another pharmacist was able to help the patient. Even though there are others in the pharmacy who could dispense the Plan B pill, Dr. Jennings decides it is time to teach Mary her duties and asks her to participate in the dispensing and consults for the drug. Mary is dumbstruck by this request. Is Dr. Jennings reasonable in forcing Mary to participate in filling this script as part of her education? My Response: No. I believe that Dr. Jennings is not reasonable in forcing Mary to participate in filling this script as a part of her education. Personally, I feel that this one script that she chooses not to fill will not have a large affect in her education in any way because she is receiving the same education by filling other prescriptions. According to the Code of Ethics for Pharmacists, it states the following: ◦ Pharmacists should recognize the differing beliefs and values According to the Pacific University Introductory Pharmacy Practice Experiential Series Manual, it states the following requirements of preceptors: ◦ Preceptors may assign appropriate additional tasks, including but not limited to: learning the computer system, entering prescription and patient data, performing distributive functions, and/or counseling patients. ◦ Preceptors are expected to instill and demonstrate principles of professionalism and ethics. Do pharmacists have an absolute duty to fill every safe and legally prescribed script? My Response: In short, no, pharmacists do not have an absolute duty to fill every safe and legally prescribed script. According to a 2006 article in the Washington Times, titled “States move to legalize pharmacists’ right to refuse,” pharmacists working in the following states are legalized to deny certain care or prescriptions based on individual morals and beliefs: Arkansas, Georgia, Mississippi and South Dakota. Pharmacists working in the following chains are also allowed to refuse filling contraceptive prescriptions: Target, Walgreens, and Winn-Dixie. Note: Pharmacists who choose to deny a patient care must refer the customer to an alternate drug store where they are able to receive assistance. In the following eight states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico and Washington, the American Medical Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Academy of Pediatrics and American College of Emergency Physicians have passed laws allowing women to purchase the morning after pill without a physician’s prescription Do you think pharmacists should have the right to refuse to participate in these types of care? What defines “participation”? My Response: I believe that pharmacists should be able to have the right to refuse to participate in this types of care based on their moral and religious beliefs, and depending on the patient’s situation. These topics are currently and possibly will always be controversial. However, by forcing pharmacists to abandon their morals imposes a heavy toll on the pharmacists themselves. According to Merriam-Webster’s online dictionary, the term ‘participation’ means “to take part, to have a part, or to share in something.” A pharmacist can and should be able to exercise independent judgment Professionals should not forsake their morals as a condition of employment ◦ Ethics and law allow physicians, nurses and physician assistants to refuse to participate in abortions and other reproductive services Conscientious objection is integral to democracy ◦ Pharmacists should be able to refuse to participate in acts that conflict with personal ethical, moral or religious manners because this is an essential element in a democratic society. ◦ In Oregon, we acknowledged this freedom with the Death with Dignity Act (1997). This act allowed pharmacists and other health care providers to prescribe lethal medications to terminally-ill Oregonians to end their lives via voluntary self-administration (Cantor, et al. 2). You are the only pharmacist in 100 miles, how would you handle this situation, since you cannot refer the prescription to someone else? My Response: ◦ Two Cases: raped victim vs. non-raped victim If the patient is a rape survivor, I feel that I will fill the medication. Even though I may be uncomfortable, psychologically, I would not want the patient to bear a child that is unwanted and ends up experiencing long term abuse and neglect from the mother. If the patient was not raped, but I was the only pharmacist within 100 miles, my best solution is to dispense the medication and provide care to the patient, even though I may be uncomfortable doing so; however, for future cases, I would make sure that there is at least one other pharmacist working with me who is comfortable with completing such a task. If not, I would make it a task to find a job at a different pharmacy that has legally accepted pharmacists to deny dispensing Plan B based on moral values and beliefs. What should Mary do in this situation? My Response: Based on my research, I believe that it is important for a preceptor and a pharmacy student on clinical rotations to be on good terms; however, in this situation, I believe that Mary should not be forced to dispense a medication if she is uncomfortable in doing so. Mary should be able to freely express her opinions with her preceptor and be confident enough to discuss how uneasy it makes her feel to complete such a task. As mentioned in some of the articles above, if a pharmacist is uncomfortable with dispensing a medication, they are able to pass the job onto another pharmacist who is. Therefore, Mary’s preceptor has no right to force her into dispensing Plan B. More so, Mary is not even a pharmacist, she is simply a student on rotations, a student interested in gaining pharmaceutical experience. 301 pharmacy students at University of Arkansas were surveyed As a result, this studied concluded that misinformation regarding the morning after pill method of contraception was common and that attitudes varied widely towards the use of Plan B. These results also concluded that pharmacy students in Arkansas could benefit from additional training on emergency contraception. According to Ertelt, the American public in general is “very misinformed about what emergency contraception is, how to use it, and how to access it (1).” Assisted suicide is and will always be covered by insurance; however, the Oregon Health Plan will not cover treatment plans including medications such as emergency contraception for rape victims or treatment drugs for cancer patients to slow the rate of cancer growth and increase life expectancy This is another issue that I would have loved to further researched on if more time has been permitted Dr. Marc Marenco ◦ Director of Pacific Institute for Ethics and Social Policy Katlyn Haggstrom ◦ Program assistant for Pacific Institute for Ethics and Social Policy Katie Lardy ◦ Assistant director and pathways coordinator Dr. Jeff Fortner ◦ Assistant professor at Pacific University’s School of Pharmacy Ackerman, Todd. “Emergency Contraception: Science and Religion Collide.” News and Perspective: Annals of Emergency Medicine. 47.2 (2006): 154-157. Cantor, Julie., and Ken Baum. “The Limits of Conscientious Objection- May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?” The New England Journal of Medicine. 04 Nov. 2004. Web. 28 Oct. 2009. <http://www.nejm.org>. Ertelt, Steven. “Pro-Life News: Morning After Pill, Oregon Assisted Suicide, Mexico, India, Abortion.” www.lifenews.com. 23 June 2008. Web. 09 May 2010. <http://www.lifenews.com/nb139.html>. Grealis, Catherine. “Religion in the Pharmacy: A Balanced Approach to Pharmacists’ Right to Refuse to Provide Plan B.” The Georgetown Law Journal 97 (2009): 1715. Iwasaki, John. “Assisted Suicide Law: Now for the Rules.” Seattlepi.com. 09 Feb. 2009. Web. 04 April 2010. <http://www.seattlepi.com/local/399431_death10html>. “Pharmacists Consientious Objections with Their Duty to Serve: Duties Inherent in Professional Ethics.” Medscape Today Article 45.4 (2005): 434-436. Ragland, Denise., and Donna West. “Pharmacy Students’ Knowledge, Attitudes, and Behaviors Regarding Emergency Contraception.” American Journal of Pharmaceutical Education 73.2 (2009): 26. Shipman, Becky., Jeff Fortner, Yvette Holman and Rita Barton. Introductory Pharmacy Practice Experiential Series Manual 2009-2010 Academic Year. Oregon: Pacific University School of Pharmacy, 2009. Smythe, Lynn. "Apothecary: Ancient Origins of Our Modern-Day Pharmacists." Associated Content - Associatedcontent.com. 04 Oct. 2007. Web. 20 Feb. 2010.<http://www.associatedcontent.com/article/396703/apothecary_ancient_origins_of_our_moder nday.html#content_footer>. “States move to legalize pharmacists’ right to refuse.” The Washington Times. 22 Aug. 2006. 14 Oct. 2009 <http://www.washingtontimes.com/news/2006/aug/22/20060822-102306-9590r/ >.