The notion of pharmacists-as-moral-agents has been taking a hit in the media recently. Ellen Goodman writes that:
The pharmacist who refuses emergency contraception is not just following his moral code, he's trumping the moral beliefs of the doctor and the patient. "If you open the door to this, I don't see any place to draw a line," says Anita Allen, law professor at the University of Pennsylvania and author of "The New Ethics." If the pharmacist is officially sanctioned as the moral arbiter of the drugstore, does he then ask the customer whether the pills are for cramps or contraception? If he's parsing his conscience with each prescription, can he ask if the morning-after pill is for carelessness or rape? For that matter, can his conscience be the guide to second-guessing Ritalin as well as Viagra?
How much further do we want to expand the reach of the individual conscience? Does the person at the checkout counter have an equal right to refuse to sell condoms? Does the bus driver have a right to refuse to let off customers in front of a Planned Parenthood clinic?
A clarification might help dispel some of Goodman's concerns. I do not favor efforts to shield individual pharmacists from all professional repercussions of their decision-making. Rather, I support efforts to protect pharmacists and their employers from state requirements that pharmacists ignore moral considerations in their professional conduct. A robust civil society demands that associations be given space to create and maintain identities that diverge from -- and even defy -- the surrounding society's norms. (I've explored this idea more fully in an article posted on the right: The Good, the Bad, and the Ugly: Rethinking the Value of Associations.) If Walgreen's wants to create an environment in which: 1) none of its pharmacists are allowed to dispense the morning-after pill; 2) all of its pharmacists are required to dispense the morning-after pill; or 3) its pharmacists are given discretion to follow their own moral convictions in deciding whether to dispense the morning-after pill, the company should be empowered to make that choice. The choice should not be trumped by the top-down imposition of collective norms, nor hijacked by the conscience of an individual pharmacist. If a pharmacist refuses to dispense the morning-after pill, she can be fired, but she shouldn't be brought up before a state agency for discipline.
With this understanding, Goodman's parade of horribles falls flat. If Walgreen's chooses to tolerate a pharmacist who dispenses drugs based on personal facts about the customer, so be it. If Walgreen's chooses to tolerate a cashier who refuses to sell condoms, so be it. Customers can boycott, picket, etc., but they should not be able to invoke the identity-squelching trump of state power. (The argument applies even more powerfully, in my view, to the mom & pop pharmacy down the street.)
Dahlia Lithick takes on a slightly different angle, making the seemingly reasonable proposition that:
Where the burden can either fall on a pharmacist (who knows in advance of her own moral reservations and is in a position to provide a patient with suitable alternatives) or on an unknowing patient (who may well be pregnant, frantic, poor, and short on time), the burden must properly fall on the pharmacist. Patients cannot have their expectations of timely, professional service undermined by unanticipated bursts of conscientious objection. . . .
These solutions don't force individual pharmacists to undermine their personal religious views. They do place high costs on the drugstores, which would now need to implement fixes such as posted warnings, agreements with other pharmacies, and the hiring of extra pharmacists, even if they can ill afford it. If an individual service provider wants to reserve the right to deny services, they should be free to do so, and if a drugstore wants to employ such a person, they should also do so. But these celebrations of religious conscience should happen at their own cost and never at the expense of citizens requiring services.
My response to Lithwick's proposal is grounded in the distinction between positive and negative liberty. Throughout this debate, the fact that the state may not obstruct one's access to a product or service is equated with a norm that the state must ensure access to that product or service. If value pluralism means anything, we should be very careful when we allow negative liberties to give rise to positive liberties. Could women who want to use the morning-after pill be inconvenienced if a pharmacy allows its pharmacists to refuse to provide it? Certainly, but that's an understandable outcome of seeking a highly controversial product in a free market. Putting the burden on non-state actors to ensure that individual consumers are not inconvenienced in their pursuit of such products replaces the mediating structures of civil society with a one-size-fits-all consumerist conception of organizational identity.
Finally, Dan Markel at the new (and excellent) PrawfsBlawg asks the important question:
Why should conscience be given special protection? If you want to be in a particular business, then you have to realize that business is subject to certain state regulations ensuring equal access. Just as Denny's shouldn't fail to serve blacks, drug stores shouldn't deny medicine to some people when it is available to other people, when the relevant neutral criteria (ie, a prescription) link the two classes of people.
I could simply argue that racial equality has become deeply entrenched enough to merit its top-down imposition, even at the expense of associational identity, but of course that wasn't the case at the time of the civil rights statutes' enactment. Or I could try and distinguish the substance of the two norms: I think race discrimination is bad and should be stamped out, while I'm not sure that universal access to all legal pharmaceutical products is a good thing, especially as technology brings the pharmacist into more morally controversial arenas, notably reproduction and end of life. But that essentially is a punt, for if I care about a robust civil society, my inclination is to let the marketplace of ideas work it out, not to have my favored norms enshrined as collectively imposed judgment. For the time being, I'll try and carve out a distinction between anti-discrimination laws, which ensure full participation in the civil society, and access to all pharmaceutical products, which embodies a particular norm contested by participants in civil society. (I anticipate the response, that access to reproductive care is essential to women's participation in civil society. I don't completely agree with that, but acknowledge it's a tough point for my case, especially if I'm averse to enshrining collective moral judgments.)
As you can tell, I'm working through these issues myself. It's an important area, and it's going to get more important. I'm open to other perspectives and reactions.
Rob
Thursday, April 14, 2005
Which side should we who affirm Catholic Social Thought be on: President Bush's side? The side of the 44 Republicans who signed the letter? Or is Catholic Social Thought indeterminate on this issue--and if it is, what's CST good for?
WASHINGTON (AP), April 14, 2005 -- President Bush's budget centerpiece to squeeze
billions of dollars from spending on health care for the poor ran into
jeopardy Thursday as 44 House Republicans signed a letter protesting
the cuts.
The lawmakers said reducing Medicaid spending over the next five
years by up to $20 billion as approved last month by the House ''will
negatively impact people who depend on the program and the providers
who deliver health care to them.''
[To read the whole article, click here.]
Michael P.
As many of you know, Margaret O'Brien Steinfels is, like her husband Peter Steinfels, a former editor of Commonweal; with Peter, she directs the Fordham Center on Religion and Culture. For her reflections on the Church at this time of interregnum--reflections that will appear in the May 6th edition of Commonweal--click here.
Michael P.
The movement to empower pharmacists to take moral responsibility for their professional conduct has run into an obstacle in Illinois. The governor has ordered all pharmacies offering contraceptives to dispense them promptly to customers, and has filed administrative charges against the downtown Chicago drug store where a pharmacist refused to dispense the morning-after pill. Apparently Planned Parenthood's protest rally worked.
Rob
Thanks to Gerry Whyte, of Trinity College, Dublin, for this item from today's Irish Times. Note that according to the report, the Roman Catholic Church is among the authors of the law:
France's parliament has approved a law that will allow terminally ill
patients to opt for death instead of further treatment, but which supporters say
stops short of permitting euthanasia.
In an overnight session, the senate adopted a text already approved by the
lower house that allows doctors to stop giving medical assistance when it "seems
useless, disproportionate or has no effect other than maintaining life
artificially".
The draft bill says terminally ill patients should have the right to ask for
treatment to be stopped, even if that leads to death, and doctors should respect
their wishes after verification with the patient and medical colleagues.
The law also suggests families should be able to request an end to life
support for unconscious patients, and says doctors can prescribe pain-stopping
drugs for a terminally ill patient, even if the medication increases the risk of
dying.
The authors of the law - supported by the conservative government, opposition
Socialists and the Roman Catholic Church - have said the bill does not copy
voluntary euthanasia which is legal in Belgium and the Netherlands.
They say it is distinct from euthanasia because it does not allow the doctor
actively to end the patient's life.
Wednesday, April 13, 2005
MOJ readers may be interested in clicking on some or all of the reflections below. From the April 22d issue of Commonweal:
John Paul II
Assessing His Legacy
Six writers from different faith backgrounds examine the legacy of John Paul II:
Notre Dame theologian Rev. Richard P. McBrien
looks at the strengths of his papacy, namely in John Paul’s “foreign
policy” (events outside the church) and its strides in ecumenism, and
also its weaknesses, such as the pope’s “hard-line course of
enforcement of doctrine and canonical discipline.”
Duke Divinity School theologian Stanley Hauerwas praises the pope’s Christological focus by comparing him to Mennonite theologian John Howard Yoder.
Fairfield University theologian Nancy A. Dallavalle
names the public face of the papacy as among John Paul’s gifts to the
church, but also notes that “this popular acclaim did not always
translate into popular conversion.”
Rabbi Irving Greenberg
highlights the pope’s resistance to communism, his validation of the
Jewish covenant, and his emphasis on the “culture of life.”
In addition to these authors, University of Dayton theologian Terrence Tilley assesses how John Paul went about preserving the faith, and Orthodox writer Jim Forest recounts a telling personal meeting he had with the pope early in John Paul’s pontificate.
From the April 22d issue of COMMONWEAL, by Catholic Theologian Richard Gaillardetz:
MY HOPE FOR THE NEXT POPE
Richard R. Gaillardetz
The death of Pope John Paul II
has unleashed an outpouring of grief and gratitude for a man who may
well have been the most widely recognizable human being of our time.
This pope’s virtually unparalleled charisma and productivity and the
length of his reign will likely rank his pontificate among the most
influential in church history. Studies on the contributions of Pope
John Paul II and his impact on the church will engage theologians and
church historians for decades to come.
In the midst of this widespread mourning it is
inevitable that the world will also be looking to the future. By the
time this article appears we may already have a new pope. Over the
weeks and months ahead there will be much discussion regarding items
that ought to appear on a new papal agenda. Many will hope for a
spiritual clone of John Paul II, a pope who will continue to encourage
a robust and evangelical Catholicism capable of confronting the
insidious relativism of our age. Others will wish for a pope with the
courage to change Catholic teachings they find troubling. We will
surely hear more, as we probably should, about issues that still rankle
the church politic (at least in North America): women’s ordination,
mandatory priestly celibacy, and homosexuality.
I harbor my own “wish list” for our new pope. Yet
perhaps our hopes and prayers ought to leave more room for the work of
the Spirit and focus less on issues and more on papal vision. For my
part, I shall be content to pray that our new pope might allow two
insights affirmed throughout the documents of Vatican II to inform his
vision for the church: First, the Word of God is addressed to the whole
church. And second, living in history as a faithful follower of Jesus
requires an eschatological humility.
. . .
This is no liberal fantasy for
a democratic church, but a quite traditional longing for a genuine
community of discernment that dares to introduce its decisions as did
the church of Jerusalem: “It is the decision of the Holy Spirit and of
us...” (Acts 15). It is a longing for a church that raises up leaders
who recognize that leading and listening are not mutually exclusive.
. . . I hope for a pope who has a healthy dose of
eschatological humility. Eschatological humility treasures divine truth
as it is mediated through the received faith of the church but also
recognizes that we do not so much possess divine truth as it possesses
us. The revelation of God’s love comes to us first, not in doctrinal
formulae, but as a person, Jesus Christ, who is for us “both the
mediator and the sum total of revelation” (Dei verbum, 2). As the
council taught, the church is “always advancing toward the plenitude of
divine truth” (Dei verbum, 8). A pope with eschatological humility
would know that in the final consummation of all things in God, our
confident dogmatic assertions will be seen, not as erroneous, but as
inevitably impoverished before that ineffable mystery that is God. Such
a pope would not hesitate to give testimony before the world to the
truth so treasured by followers of Jesus, but he would readily
acknowledge that although the church is “guardian of the deposit of
God’s word, and draws religious and moral principles from it...it does
not always have a ready answer to every question” (Gaudium et spes,
23).
Eschatological humility comes with understanding as
well what it means to belong to, and to lead, a church that is
pilgrim-a church that is confident it has set upon the right path and
wishes to share that way with others but that knows it has not yet
arrived (Lumen gentium, 48). A pope with eschatological humility would
know that this pilgrim church need never fear reform and renewal, for
it is only by reform and renewal that the church will hobble forward on
its journey (Unitatis redintegratio, 6).
Let us pray for a pope who believes that God’s Spirit
abides in the church as in a temple and speaks in and through that
church’s corporate discernment. Let us pray for a pope who speaks with
a conviction chastened by the modesty befitting a pilgrim. Such a pope
would truly merit the ancient title, servus servorum Dei, “servant of
the servants of God.”
[To read the whole piece, click here.]
The new issue of The Christian Century magazine has an article by Allen Verhey of Duke Divinity School on Terri Schiavo and the nutrition/hydration issue. Because Verhey tries to present arguments from Christian premises on both sides, as sympathetically as possible, the article may be useful as a teaching tool.
Verhey presents the argument for maintaining nutrition and hydration:
"Terri might not count for much as the world counts, but she surely counts as among 'the least of these' in Jesus’ parable. 'In as much' as you gave food to the hungry or drink to the thirsty, Jesus said, you did it 'as unto me' (Matt. 25). . . .
"If we fail to see life as a good, as a benefit to her, we have evidently accepted an unbiblical and Cartesian dualism of body and soul, reduced the self to its powers of rationality and choice, and reduced the body to a mere container for what’s really important and valuable."
Then he presents the argument on the other side:
"Christians regard life as a good, to be sure, but not as a second god. Remembering Jesus and following him, we can hardly make our own survival the law of our being. Christians may refuse medical care so that another may live. They may refuse medical procedures that may lengthen their days but do nothing to make those days more apt for the tasks of reconciliation or fellowship.
"It is not shocking that Terri would have suggested she would not want artificial nutrition and hydration if she were in a persistent vegetative state. That decision must be honored if we would respect Terri’s Christian integrity. . . . If we regard the preservation of her biological life as a benefit to her, then we have evidently adopted an unbiblical vitalism, reduced her to her body and her body to a mere organism."
He characterizes the issue between the two competing arguments: "Both sides agree that Terri is to be treated and cared for as an embodied self. They disagree about whether the greater risk is that she will be reduced to her capacities for rational choice or that she will be reduced to a biological organism."
