Feedback for Proposed Revision of the Code of Ethics

1.
Pharmacy Technician  ·  Sept. 25, 2015

Hello I think it would be a good idea to respect the rights of all healthcare workers' consciences.

2.
Pharmacist  ·  Sept. 28, 2015

I agree to The Proposed Revision of The Code of Ethics

3.
Pharmacist  ·  Sept. 29, 2015

I support the revisions to the Code of Ethics

4.
Pharmacist  ·  Sept. 29, 2015

I agree to The Proposed Revision of The Code of Ethics. The draft is thorough and clear. The difficultly lies in monitoring members and implementing these changes. Thank you for the time and effort taken towards protecting our profession.

5.
Pharmacy Technician  ·  Oct. 17, 2015

The proposed codes of ethics for Pharmacists and pharmacy technicians focused on enhancing the conduct and behavior. They are to be developed more or less simultaneously focusing on patient, as far as possible. I believe they are all linked together and each code helps the cultivation of others. I would say code of ethics address more or less mental discipline of pharmacists and technicians as well. My own experience in community pharmacy has been as such if we could perfectly focus on the patient at drop off counter or pick up counter adding more compassion towards them, at the same time with diligent approach with right speech the patient focus interaction would have been more beneficial for the patient.

6.
Pharmacist  ·  Oct. 22, 2015

i support the proposed revision code of ethics

7.
Pharmacist  ·  Oct. 22, 2015

I completely agree with revised code of ethics.

8.
Pharmacist  ·  Oct. 22, 2015

In the proposed Code of Ethics I would stress a Health Professional's right to refuse service if it is contradicting his/her conscience, or his/her religious beliefs. This will protect a Healthcare Worker's constitutional right to Freedom of Belief (or Freedom of Conscience). Otherwise, in the future, Pharmacists and Pharmacy Technicians may be required to take part in, so called, "assisted suicides", if this is deemed as "good" or "beneficial" to the patient by future legislators etc.

9.
Pharmacist  ·  Oct. 23, 2015

I fully support the revised code of ethics.

10.
Pharmacy Technician  ·  Oct. 24, 2015

I am quite impressed with the document as it stands. It is comprehensive in that it can be applied to both Pharmacists and Pharmacy Technicians. In my recent experience I have found that there is still an inability of some to recognize Pharmacy Technicians as licenced and responsible professionals. If the document continues to address both professions in the same capacity within their scopes of practice it will hopefully help clarify some of this issue.

11.
Pharmacist  ·  Oct. 25, 2015

Two comments: 1) sections 2.13 & 2.16 appear to introduce the possibility that a person could be in conflict with one while observing the other. 2) section 4.21 could be interpreted that no advertising should be allowed since the purpose of advertising is to attract business.

12.
Pharmacist  ·  Oct. 25, 2015

I agree with the Proposed Revision of The Code of Ethics

13.
Pharmacist  ·  Oct. 25, 2015

In the proposed Code of Ethics I would stress a Health Professional's right to refuse service if it is contradicting his/her conscience, or his/her religious beliefs. This will protect a Healthcare Worker's constitutional right to Freedom of Belief (or Freedom of Conscience). Otherwise, in the future, Pharmacists and Pharmacy Technicians may be required to take part in, so called, "assisted suicides", if this is deemed as "good" or "beneficial" to the patient by future legislators etc.

14.
Applicant  ·  Oct. 25, 2015

The revision is quite detailed which allows for more clarity in describing the various principles. It is important the code continues to respect the moral & religious beliefs of members and allow for conscientious objection. To truly do this would be to not require a pharmacist to make a referral (if you morally object to something but still refer a patient for it, you are still involved in the process which has moral implications).

15.
Pharmacist  ·  Oct. 27, 2015

i supporst the proposed revision of the code of ethic

16.
Pharmacist  ·  Oct. 28, 2015

I read the proposed change to the conscientious objection. Here are my issues. 1) It is not being transparent with the patient. Secretly referring to a manager only involves more complexity. What if the manager wants to defer based on conscience? Ultimately, health professionals have a mind, reason and a conscience and covering it up turns people into robots. 2) What if the manager is not available? 3) having an alternate provider available is not always feasible in settings where there is only one pharamcist. 4) justice and harm go both ways. just as a patient can refuse a recommendation which may benefit them, a professional can refuse to follow through with a therapy which may harm a patient. This is patient care, not patient inconveience. 5) I support override the consience clause only in cases of an emergency. Most cases involving life, death and etics have time to resolve and often need to include more than two individuals. 6) referring is still assisting. Some people, based on the strength of their convictions, equate the two as treatment. Ultimately, every case is different and applying set rules to deal with every patient is unrealistic.

17.
Pharmacist  ·  Oct. 29, 2015

You quoted Maimonides and Hippocrates as justification for what apparently appears to be an unequivocable stand that members be required to co-operate in the procedures for Physician assisted death. For your information: HIPPOCRATES CODE: “Nor shall anyman’s entreaty prevail upon me to administer poison to anyone.” MAIMONIDES LAWS OF MURDER AND PROTECTING LIFE: “ Whoever causes the loss of a soul is considered as if he has destroyed the entire world”".” Dr. Jacob L. Freedman, psychiatrist: Determining ‘'” mentally competent” challenging.

18.
Pharmacist  ·  Oct. 31, 2015

I am in favour of the proposed revision of the code of ethics

19.
Pharmacist  ·  Nov. 1, 2015

I agreed to The proposed revision of code of Ethics.

20.
Pharmacist  ·  Nov. 1, 2015

The intent is good but does not address the issue of pharmacies owned and controlled by non-pharmacists who are not subject to the Code (this applies to both community and institutional settings).
If cost-cutting means inadequate staffing and/or unsafe practices in the name of "efficiency", how does the College propose to deal with those who employ pharmacists and technicians in these times of casual and contract jobs?
Perhaps it is time to revisit the regulations governing pharmacy ownership. The world has changed since the old charters were created.

21.
Pharmacist  ·  Nov. 2, 2015

I agree with the proposed revision of code of ethics and I comply to the professional responsibility principles in practice.

22.
Pharmacist  ·  Nov. 3, 2015

I support the proposed revision code of ethics

23.
Pharmacist  ·  Nov. 4, 2015

We would like to provide feedback on statement 3.14 which currently reads as, "3.14 Members ensure that their views about a patient’s personal life, religious beliefs, and other morally irrelevant factors such as: race, gender, identity, sexual orientation, age, disability, marital status and any other factor(s), do not prejudice their opinion of the patient and affect the quality of service that they provide to the patient."

We propose that the following statement be included instead, "3.14 Members ensure that they provide the highest quality of care to all patients, regardless of their personal views on a patient's various identities, such as: race, gender-identity, sexual orientation, age, disability, marital status, religion, and any other factor(s). At the same time, members will ensure that they: 1) Learn with and from patients to increase their understanding of patients’ identities and experiences; 2) Continually reflect on how a patient's identities can affect how they approach healthcare and; 3) Redress the inherent power imbalance between patients and providers."

We would be pleased to discuss further with the College if desired, please do feel free to contact us.

24.
Pharmacist  ·  Nov. 5, 2015

1."The Code of Ethics is applicable in all pharmacy practice, education and research environments including non-traditional practice settings which may not involve a healthcare professional/patient relationship." (Ref: p1).
The term "non-traditional practice settings" is vague and raises a concern as to what constitutes "traditional practice setting." As one reads through the document, there are abundant sections that would not even touch on an educational or research type of setting. As such, an unlevel playing field is created because in essence the Code will NOT be applicable to all members of the College.

The proposed revision is categorized into four main sections, all of which consider a "patient" environment. It will be difficult to try and apply these to the "non-traditional" practice settings where such patient involvement (beneficence, non-maleficence, respect for persons/justice, and accountability/fidelity) are not part of the practice. It may be advisable to define the term "traditional practice setting." If that is to mean "community pharmacy practice" and/or "hospital pharmacy practice" then ensure that this is so-defined.

2.Sections 1.7, 2.8 and 4.20
These sections will leave no room for the College to allow the sale of products from within pharmacies that are repeatedly at the forefront of debate in the professional blogs, columns, etc. as to efficacy. If there is no "evidence-based information" to show the efficacy (in keeping with requirements of approved marketed health products) of products such as homeopathic remedies, then the College must proactively prevent the sale of such products from pharmacies. That includes where a portion of premises (i.e., in a grocery store) is a pharmacy but the pharmacy attempts to sell them from the grocery area so as to avoid being deemed to be "sale from a pharmacy." If the entire premises is accredited as a pharmacy in order to allow the sale of scheduled drugs via all checkouts (including front checkouts such as is the case at Costco, far removed from any pharmacy oversight), then no such sale should be allowed.

Expecting members to abide by the Code also carries a responsibility by the College to ensure that this is done. Since no scientific evidence to efficacy is available for homeopathic products, by extension they cannot be condoned to be sold per the revised Code. The College, knowing such products are presently being sold, would be mandated to effect their removal.

Section 4.20 should be re-worded because "no potential benefit" can be argued to say that one can always allude to a "potential benefit" to a patient -- even if the placebo effect is considered (or, because no harm is reasonably an outcome, this equates to allowing the sale). The term "potential" would appear to be the word at issue, because in theory one can always argue there's a potential -- even if not based in science, or clinically-oriented. A "snowball's chance in hell" should not be seen as a "potential benefit."

3.Section 2.5
It would be advisable to include wording that supports the idea that in doing so in good faith, members are not to be "blackballed." In many jurisdictions, the terminology includes such wording as "Members should, without fear of reprisal, challenge..."

4.Sections 2.11, 2.12 (sexual behaviour/harassment)
The term "patient" should be defined. At present, the existing HPPC (RHPA) addresses these same areas and even there, the "patient" is not defined. The OCP has taken a benchmark to mean there is a clinical record of treatment (whether prescription, or OTC and then documented "for continuity of care" purposes), as required under Standards of Practice. Rather than get into debates over what constitutes a "patient" it would be much easier to define it for purposes of this document.

Section 2.12, as presently worded, would appear to be applicable in situations that are not "patient" oriented. (The word is not included). As such, that would include staff members as well, outside a "patient" relationship existing. If that was the intention, I applaud its broader application. The term "harassment" also has a pre-condition that when such actions are conducted, a person must first be made aware of the unappreciation of such conduct moving forward, before (upon a subsequent occurrence) it becomes harassment.

5.Section 2.14
The word "Member" should likely be "Members", or "A member..."

This section, as presently worded, would require all four subsections to be effected before a professional relationship may be ended (due to the use of "and" at the end of clause iii instead of "or" after each clause). However, it does not make an allowance for cases where a treatment contract has been entered into (e.g., methadone, substance abuse treatment) that contains its own clause where certain actions committed by a patient are to result in immediate cessation of the relationship. As such, wording should be included to take these types of contractual agreements into consideration so that the spirit and intent of such contracts are not compromised by first requiring four other conditions to be met. Perhaps adding revising the opening statement to: "Absent a contracted agreement between a member and a patient where breach of that agreement may provide for or constitute an ending of the professional/patient relationship, a member may only consider ending the professional/patient relationship when the member has met the following conditions:..."

6.Section 2.17
There is a typo ("polices") which should likely be "policies".

7.Section 2.20
It is unclear how this section, as worded, will allow for "Part B" pharmacists (still "members") to not have to remain "current" when they are not subject to "practice review" as they are not practising in a direct patient care environment. By very nature of the regulatory restrictions on a Part B member, the same level of clinical knowledge, etc. incumbent upon a Part A member is not required. While Part B pharmacists would ethically keep current in terms of whatever they are doing OUTSIDE a direct patient care setting, perhaps inclusion of "relevant to their practice environment" after "professional knowledge and skills" would be advisable.

8.Section 3.6
The term "individual" should be replaced by "patient" to remain in context with the subject matter preceding being specific to "patient."

9.Section 3.10
The word "expressed" should likely be "express". Privacy legislation generally uses the phrase "express or implied", rather than "implied or express (sic)". (Note: also applicable in section 4.35, where "expressed purpose" should be "express purpose").

10.Section 3.11
The term "minor" should be defined; it can involve various ranges of ages depending upon the specific legislation/document in which it is being used. Inserting clarification in brackets after the term (e.g., "under the age of ...") would clarify. Otherwise, members could impart their own definition as they see fit, and too much variance would occur.

11.Section 4 ("custodian of the public trust")
The public trust does include public funding (e.g., ODB and use of public monies). So when a member commits fraud involving such public funds, it is not in the "best interests of their patients and society" since this inevitably leads to increases in drug plan costs and/or decreased coverage by limitations on inclusions of further drugs on such plans. Such actions should be included in the "A, B, C" of this section to reflect this reality, in addition to the important items listed under those sections.

12.Section 4.3
The meaning of this section does not appear to be conveyed by the wording. If the issue is a member using the specific absence of a type of behaviour from mention in the Code being "permissive" of such behaviour, then re-wording would clarify this: "...that because such behaviour is not expressly prohibited in a Standard of this Code, it is therefore deemed permissible."

13.Sections 4.11, 4.12
As per comments in #3 above, wording such as "without fear of reprisal" should be included in both these sections at the appropriate spot (typically, after the word "Members" such as "Members, without fear of reprisal, ...").

It would also be worthwhile to consider adding another bulleted item at this location, renumbering those that then follow, as 4.13:

"Members do not exhibit prejudice in any way towards other members complying with and components of this Code, including in particular sections 4.11 and 4.12."

14.Section 4.18
While this section states that members "recognize" this point, it does not go any further to say what should occur if a member identifies such actions where they are "employed by." So as such, a member could say they know it's going on but there's no duty to do anything further (as they would be fearful of reporting such regarding an employer). Nothing in this section requires them to do anything other than "recognize" it, if occurring.

15.Section 4.35
Mentioned earlier in #9: "expressed" should be "express". As well, consider replacing "benefiting financially" with "personal financial benefit".

25.
Pharmacist  ·  Nov. 5, 2015

In addition to previous submissions I have the following to add. Pharmacist employment discrimination: May severely limit opportunities. Some Community Pharmacy chains may not want to "get involved" in controversial matter if only for "image reasons" If not done "correctly" you are an accessory to manslaughter or murder. What is the ethical background of the people making final decisions for OCP?

26.
Pharmacy Technician  ·  Nov. 5, 2015

I strongly agree with revised code of ethics .

27.
Pharmacist  ·  Nov. 5, 2015

I totally agree with The Revised Code of Ethics

28.
Pharmacist  ·  Nov. 5, 2015

Although I highly doubt that my comments will result in any changes to the revised code of ethics, I consider it my moral duty as a health care provider to express my objections with the relevant explanation. Section 2.13 is putting at a high risk of losing their job and inflict serious mental/spiritual harm a significant minority of Ontario pharmacists, including myself. This section has nothing to do with ethics or science, but rather with an ideological agenda. The science of embriology (unlike humanist ideology) clearly states: The individual life of a multicellular organism, that of a human too, starts with the zygote. Every organism, humans too, in the course of their life undergo a series of successive transformations from the stage of zygote until death, during which the organism will appear differently, but it will remain the same being – human. This this the biological approach. All other approches of defining a human being will be either legal, or will bear professional preferences. That being said, what is a matter of fact to any biologist is that the unique genetical structure of the zygote is formed as a result of the fertilization of the human egg. This is a scientifical fact. Zygote, embrio and the growing child is not part of mother’s body, but is present in the mother as in an incubator, which is ideally suited for it’s early stages of development. The newly formed human being cannot be considered part of mother’s body neither immunologically nor genetically. The new human life is only geometrically part of the mother, but right from the very beginning it is another human being. From the point of view of biology abortion is forceful interruption of a human life. So, if science tells that abortion is murder – why do we go against science? Because of the humanist faith and it is in direct contradiction with science and other faiths. What else does the recent research tells us about abortion: A new study of the medical records for nearly half a million women in Denmark reveals significantly higher maternal death rates following abortion compared to delivery. This finding has confirmed similar large-scale population studies conducted in Finland and the United States. So, again, why would anyone be forced to participate directly or indirectly and against his/her will in a procedure that puts a woman under an increased risk of maternal death? Although it is quite saddening, it appears that even a professional organization supposed to stay out of such influence, can be influenced by the political ideology. Also, it is obvious that this code of ethics contradicts itself. We have the obligation, as the revised code of ethics states, to”keep our promise to act in the best interest of our patients and place their well-being first and foremost.” and the second foundational principle states we should do no harm. How does section 2.13 agrees with the scientifical knowledge that the termination of a human life at any stage of it’s development starting from zygote until death is murder and that abortion is increasing maternal death post-abortion?. Forcing the pharmacist to refer a patient to someone else who would agree to help terminate a human life seems utterly absurd. Therefore, these are the changes I propose to section 2.13

Section 2.13 Members can refuse to provide advice or product that will help terminate/result in termination a human life at any stage of it’s development (from zygote until death) on the basis of scientifical, moral or religious grounds. Although abortion and euthanasia are legal, we understand that it is ethically unacceptable to many practicing pharmaciststs. Therefore, members are required to notify patient that they are not providing these products and services and the pharmacist is not required to ensure there is an alternative provider, since it will cause a significant mental/spiritual harm to the member.

I am 100% confident that these changes will not be done and it is a clear sign that persecution against people who think differently started in Canada and true democracy and real human rights are under threat.

29.
Public  ·  Nov. 6, 2015

Congratulations on this proposed Code of Ethics! For several years I have provided one-on-one instruction/consultation for members of health care professions, including Pharmacy. I consistently use the Codes of Ethics from each profession to anchor all remediation/instructional service. Even if the need is for Communication skill development or understanding about boundary crossings, my approach is to base the skill development/learning on the foundation ethical principles (Autonomy, Beneficence ,Non-Malfeasance and Distributive Justice so that the link between the skill/knowledge and the ethical principles are clearly made.I also underscore the obligation of health care professionals as to their Fiduciary obligations to their patients, emphasizing the power imbalance and the vulnerability of patients within that relationship. Your proposals are comprehensive and clear regarding the expectations for Pharmacists to act ethically and professionally, using the ethical principles (timeless, able to withstand scrutiny) as a a basis for practice. Bravo and I especially like that each member will sign a commitment to ethical behaviour. I look forward to hearing the results of your Council's deliberation and the proclamation of a revised Code of Ethics.

Thank you

30.
Pharmacist  ·  Nov. 6, 2015

Hello- thank you for the opportunity to review and give feedback on the new code of ethics for our College.

Overall, the document should maybe define that where "patient" is stated in the Code, it includes both patients and substitute-decision-makers.

Re: P 2 paragraph 1- The most important feature or characteristic that distinguishes a healthcare professional from another type of professional is that: healthcare professionals are committed, first and foremost, to the direct benefit of their patients and only secondarily to making a profit. Pharmacists and pharmacy technicians are healthcare professionals Instead of "profit" suggest "personal gain". I do not think that profit ($) is the most applicable word to apply to our profession, and that personal gain, which encompasses status, recognition, in addition to money is a better description.

P2- When we become a regulated healthcare professional we implicitly enter into what is commonly referred to as a ?social contract with society?. I find this reference awkward. Perhaps the intent is the "social contract"? If there is going to be something in quotes, it should be referenced.

Re: the "ethical principles of healthcare"- There are many ethical principles that apply to healthcare. I suggest this introduction be reworked- to state that the OCP's Code focuses the the principles of: beneficence, non-maleficence, respect for persons/justice and accountability (fildelity) among the many that apply to the provision of health care.

Re: the definitions of the principles I do not agree with the all the stated definitions of the principles chosen.

Beneficence (to benefi) Beneficence is not to benefit. It is act with the best interest of the other in mind. The first sentence of the definition (P2-3) implies that our role is to benefit ourselves. Perhaps the intent was to state: The first foundational principle that forms enshrines our commitment to serve and protect the best interests of our patients.

Respect for persons/Justice In the biomedical ethics literature, these are separate principles with different meanings.
Respect for persons upholds our commitment to respect the intrinsic humanity of our patients, making them and their decisions worthy of respect, compassion and consideration. Importantly, this helps us build on the foundational relationship between the individual pharmacist and patient as decisions are undertaken, and emphasizes that all people are entitled to participate in decision-making to the extent that they are able. I believe that justice should be a separate and recognized principle in the Code. It upholds the premise of our contributions to the best interests of society. The principle of justice states that we will treat people in similar circumstances in similar ways.

Accountability (fidelity) This relates to our obligation to keep promises and maintain trust in our relationships with patients. I think this is the section that relates more to us applying our specialized knowledge to improve patients' lives. That is what the public trusts us to do. The word "fiduciary" though it doesn't exclusively relate to money, does carry that implication, and so I would suggest not using it in our College's Code of Ethics. Instead, consider: Accountability recognizes our professional promise to maintain the trust of our patients and society, as we apply our knowledge and expertise, acting in their best interests. This principle holds us accountable, not just for our own actions and behaviours, but for those of our colleagues as well.

P3- Code of Ethics and Standards of Application The Ontario College of Pharmacists Code of Ethics is founded on the core ethical principles of healthcare: beneficence, non-maleficence, respect for persons/justice and accountability (fidelity). These principles are not "the core ethical principles of healthcare"- instead, consider saying "... Code of Ethics is founded on the principles of.....'

About the following Standards of Application? I liked the format of our last Code of Ethics; the current version I find unnecessarily lengthy. It becomes difficult to find the sections one might want to locate. For example, 1.2 would seem to encompass all of 1.3, 1.4, 1.5, and 1.7

2.1 Consider splitting into 2 sentences: Members refrain from behaviours/attitudes which could potentially result in Harm. In addition, members make every reasonable and conscientious effort to prevent harm to patients and society.

(suggest word change): 2.5 Members challenge the judgment of their colleagues or other healthcare professionals if they have good reason to believe that their those decisions or actions could adversely affect patient care.

2.17: I don?t know what this means. Are we saying pharmacy technicians are required ethically staff the departments or stores where they work?

3.11: Consider changing to encompass the extent of decision making allowed all people in Ontario regardless of age: Suggest: 3.11: Members respect the right of all patients to make decisions about their health care to the extent that they are able.

3.12: regarding substitute decision-makers (SDM?s), SDM?s are the people who must make decisions when a patient is unable to make it for his/herself. The ?incompetent patient? is just the person unable to make that decision for him/herself at that time. Suggest striking ?incompetent patient? from this statement and from 3.13. Instead, consider: 3.12: ?members recognize and respect the right of authorized substitute decision-makers to make decisions on the patients? behalf. 3.13: Members apply the known wishes/intentions of a patient where those wishes, through a personal directive were expressed before the person was incapable of making the decision.

In the Declaration page to be signed, instead of: I will protect my patients? vulnerability and respect their rights as autonomous persons. Consider, ?I will respect my patients? rights are autonomous decision-makers?. I don?t think I should be protecting my patients? vulnerability. What was the intention of this phrase?

31.
Public  ·  Nov. 7, 2015

This also apply to the other non medical providors operating under the prefix of dr

32.
Pharmacist  ·  Nov. 7, 2015

it is okay.

33.
Abortion Rights Coalition of Canada.  ·  Nov. 9, 2015

Dear Ontario College of Pharmacists,

I am writing on behalf of the Abortion Rights Coalition of Canada. Thank you for the opportunity to provide feedback on your revised Code of Ethics. I think it is excellent in most respects. There’s just one aspect I’d like to comment on – the issue of conscientious objection – and ask if you would please consider my suggestions.

Your Clause 2.13 states:

Members must, in circumstances where they are unwilling to provide a product or service to a patient on the basis of moral or religious grounds, ensure the following: i. their conscientious objection is conveyed to the pharmacy manager, not the patient; ii. there is an alternative provider available to enable the patient to obtain the requested product or service, which minimizes inconvenience or suffering to the patient.

However, allowing pharmacists to object on their own personal moral or religious grounds directly contradicts these two statements in your Code of Ethics:

In choosing to become a pharmacist or pharmacy technician we acknowledge our understanding and commitment to the professional role, recognizing it is not about us – our own personal or business interests – it is about the patient.

Members recognize that their patients’ best interests must always override their own interests or the interests of the business which the member owns, has a financial interest in or is employed by.

Allowing pharmacists to object also conflicts with many other principles in your Code of Ethics, such as:

We appreciate that our patients are vulnerable and may often be limited by personal and circumstantial factors… and there is an imbalance of power with the healthcare professional holding that power.

When we become a regulated healthcare professional we implicitly enter into what is commonly referred to as a “social contract with society.”

This contract requires that we keep our promise to act in the best interest of our patients and place their well-being first and foremost…

Respect for Persons/Justice: We demonstrate this when we respect our patients’ vulnerability, autonomy and right to be self-governing decision-makers in their own healthcare. The principle of “Justice” requires that we fulfill our ethical obligation to treat all patients fairly and equitably.

Accountability (Fidelity): [This] principle directly ties us to our professional promise to be responsible fiduciaries of the public trust ensuring that we keep our promise to our patients and society to always and invariably act in their best interests and not our own.

You may believe that your Code of Ethics still justifies conscientious objection by setting constraints around how it is exercised, so as to ensure the patient can still obtain the prescription and is not even aware that the pharmacist has a moral objection. But placing restrictions around CO means you are trying to minimize its harms. It’s a tacit acknowledgment that CO is contrary to normal practice, and intrinsically harmful and unethical. This should raise serious questions on whether CO should be allowed at all. There is also an assumption that such restrictions are a reasonable compromise that would be effective in practice. But are they?

My colleague Dr. Christian Fiala and I have published several articles on the topic of conscientious objection in reproductive healthcare. We make the case that it should be generally prohibited:

'Dishonourable Disobedience': Why Refusal to Treat in Reproductive Healthcare Is Not Conscientious Objection Christian Fiala and Joyce H. Arthur Woman - Psychosomatic Gynaecology and Obstetrics. 2014 http://www.sciencedirect.com/science/article/pii/S2213560X14000034

‘Why We Need to Ban ‘Conscientious Objection’ in Reproductive Health Care Joyce Arthur and Christian Fiala. RH Reality Check. May 2014
http://rhrealitycheck.org/article/2014/05/14/why-we-need-to-ban-conscientious-objection-in-reproductive-health-care/

The CO debate: ‘Conscientious Objection’ is still dishonourable disobedience. Joyce Arthur and Christian Fiala. bpas Reproductive Review. July 2014 http://www.reproductivereview.org/index.php/rr/article/1606/ Our position is that so-called “conscientious objection” is not actually CO at all and is a misnomer. A person in a privileged position of authority (there by choice) is imposing their personal beliefs on a vulnerable other in a dependent position (not there by choice). Pharmacists and other healthcare professionals (HCPs) have a monopoly on the practice of medicine, and they voluntarily entered a profession that fulfills a public trust. They know they have obligations to provide care to patients without discrimination, and that patients are completely reliant on them for essential healthcare and can’t go elsewhere. These factors make the exercise of CO in reproductive healthcare a violation of medical ethics and an abuse of HCPs' position of trust and authority. It is also discrimination because the vast majority of refusals in the healthcare profession relate to women’s reproductive health needs, specifically contraception or abortion. Your Clause 2.13 would largely lead to pharmacists refusing to dispense birth control and emergency contraception, or in future, Mifegymiso. Such refusals would be discrimination on the basis of gender, because they affect only women and some members of the LGBTQ community.

CO in reproductive healthcare violates the principle of public accommodation, which requires the discounting of individual conscience within a profession to prevent discrimination. In the same way that the U.S. Civil Rights Act prohibits business owners from refusing to serve black people, a HCP’s right of conscience while “on the job” should be limited to prevent discrimination and protect the rights of others. In the 2001 Supreme Court decision Trinity Western University v. BC College of Teachers, the court ruled that teachers who adhere to certain religious beliefs are free to hold those beliefs, but could not act on them in the classroom if it would result in discriminatory conduct. Likewise, pharmacists are free to hold personal beliefs against abortion and contraception, but would be guilty of discrimination if they acted on those beliefs in their practice by imposing them onto dependent patients.

I dispute that your constraints around the practice of CO are reasonable or would be effective. First, requiring an objecting pharmacist to refer the patient to another pharmacist does not actually ‘fix’ the objection, from the point of view of objectors. For some it might, but many objectors will refuse to take any action that they feel makes them “complicit” in contraception or abortion, because they strongly feel these are immoral. Indeed, a number of U.S. states allow pharmacists to refuse to refer or provide any information to patients. Cases where pharmacists refuse to refer or even confiscate the prescription occur not infrequently in the U.S. and have probably occurred in Canada as well. I believe these problems arise because the referral requirement is a fundamental contradiction of the principle of CO – it tries to protect pharmacists’ conscience up to the point where they are required to violate their conscience.

Your restrictions on the exercise of CO bring up other troublesome practical and ethical issues, which I believe would contribute to making your policy unworkable:

The objector must convey their CO to the pharmacy manager, not the patient: It is difficult to imagine that the patient, in many cases, won’t realize something is wrong, and start to question the pharmacist or feel worried or uneasy. The fact that a “Code of Ethics” is recommending subterfuge by trying to hide the pharmacist’s objection from the patient is troubling and should alert you that something is fundamentally wrong with allowing CO in the first place. Second, even if another pharmacist is available to fill the prescription, it can still cause an unnecessary (although hopefully short) delay. But if the patient must be referred to another pharmacy entirely, the jig is up and she can be left feeling humiliated, angry or upset. Further, the patient will be far more inconvenienced, to the possible extent of being unable to fill the prescription if she’s unable to travel to another pharmacy. Delays in prescribing emergency contraception are especially critical and can mean the difference between avoiding unintended pregnancy and having an abortion or unwanted birth. These are very serious consequences, yet they are glossed over by your apparent assumption that this restriction on CO will work effectively in practice.

The objector must ensure an alternative provider is available: There is no consideration given to the many occasions and pharmacies where there is only one pharmacist on duty, or for cases where other pharmacists at the same store may also be objectors, or for small towns and rural areas where only one pharmacy exists. Such circumstances can result in a complete denial of care with resulting harms to the patient, potentially serious ones. Second, the implication is that the objector will have to fill the prescription in such cases despite their personal or religious beliefs. However, if they hold their beliefs strongly (as almost all would), they would likely still refuse to do so despite your Code of Ethics. You cannot expect objectors to suddenly sacrifice their beliefs when you’ve already given them permission to compromise their duties in order to practice their faith. Once non-rational elements like personal beliefs are allowed to dictate the care of patients, evidence-based medicine and ethical codes cannot compete, and can no longer effectively limit the practice or expansion of CO.

Your Code notes that in exchange for its “social contract with society,” the pharmacy profession is given the autonomy to govern ourselves as a self-regulating profession with all the privileges and statuses afforded [to] regulated healthcare professionals.” Self-regulation is a privilege granted to HCPs by the Medical Profession Act, and more broadly is a privilege granted by the public itself. It is based on public trust, which means this privilege can be revoked if abused. If we cannot trust certain HCPs to fulfill their professional obligations by providing the most appropriate care or medicines that are available and legal, then those HCPs do not deserve an unencumbered right to self-regulation.

In conclusion, I would urge the Ontario College of Pharmacists to please take the following steps to ensure that pharmacists fulfill their duties to patients:

  1. Revise Clause 2.13 to prohibit members from refusing to provide a product or service to a patient on the basis of moral or religious grounds.
  2. If the College feels they cannot prohibit members from exercising CO, implement clear monitoring and enforcement guidelines for objectors. For example, they should be registered and be required to complete a report for every refusal. They should never be allowed to work alone, but always alongside another non-objecting pharmacist. Other disincentives such as allowing employers to prioritize hiring of non-objectors, and paying objectors less, could also be considered to gradually reduce the number of objectors in the field.
  3. In cases of violation, ensure that objectors are disciplined appropriately with consideration given to the extent of harm done to the patient. For example, if the patient ultimately became pregnant and had to have an abortion because of a pharmacist’s refusal to prescribe emergency contraception, the pharmacist should lose both their license and their job.
  4. Implement new eligibility criteria at universities and schools of pharmacy, so that students who wish to train to become pharmacists are ineligible from entering the program if they would object to prescribing contraception (at least). Prescribing contraception is an integral and very common service, so there is absolutely no excuse for pharmacists to not dispense it. Those who cannot fulfill basic job requirements have no right to enter that profession.
    Thank you very much for considering my views.
34.
Ontario Pharmacists Association  ·  Nov. 9, 2015

The Ontario Pharmacists Association (OPA or the Association) welcomes the opportunity from the Ontario College of Pharmacists (OCP or the College) to comment on the proposed revisions to the Code of Ethics.

Read the rest of OPA's submission here.

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