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.