Pharmacists: Just Say Yes

There's a weird debate raging right now in the U.S. If you're not an American, you're going to be baffled by this. Pharmacists want the right to refuse on ethical or moral grounds to fulfill certain prescriptions. Now, now, I know that if you're outside the U.S., you're checking your calendar to see if it's April 1. This isn't about Christian Scientists getting jobs in drugstores and then not selling any drugs (although that would be a great test case). Rather, it's about people with specific religious beliefs wanting to exercise those in a regulated environment to deny legal drugs or devices to people with a prescription from a medical doctor or another professional with a right to prescribe.

Here's The Seattle Times and The Seattle P-I on an information meeting by the state Pharmacy Board in Washington yesterday. The problem isn't someone abusing a drug--I'd like to hear the moral opinions of pharmacists who dispensed massive amounts of hydrocodone and oxycontin--rather, it's this event in the P-I's story: "For example, a pharmacist at a Seattle hospital in May refused to fill a woman's prescription for antibiotics because it came from a facility that provides abortions. The pharmacist cited religious objections, Luftig said."

Yeah, that's just great.

We are ostensibly still a civil society ruled by law, not religious leaders, anti-christs, or oligarchs. (I know, I'm trying to talk about our ideal state.) In a civil society, that which is legal should be obeyed. If you believe the law is unjust--which in the past has typically meant that a law had an onerous effect on a minority of people, such as segregation--then you work for its change through civil disobedience, lobbying, and electing new leaders. (Options outside that are not part of a civil society, such as assassination, intimidation, and outright disregard for law--such as stating that because you're president the law doesn't apply to you when you decide it doesn't.)

Pharmacists who believe that dispensing drugs that will prevent pregnancy (emergency contraception) is against their moral or ethical system will need to stop being pharmacists while they work to have laws changed to prevent those drugs from being legal or allowed to be prescribed. If we all, as a society, individuals to prevent legal access to legal medicine, then there is no slippery slope. It's all downhill. It means that a member of the Aryan Nation whose morals forbid providing medication to black people would have as many rights as a pharmacist who believed in encouraging abortion by withholding emergency contraception.

This is a harsh opinion, of course, but it's not out of line with the principles on which are society is founded.

Update: Some good exchanges in comments with someone diametrically opposed to me but who respects my opinion enough to engage, and I likewise. I disagree with him, but it's so refreshing to hear a frank opinion with logic behind it in this debate instead of seeing bloody fetuses contend with bloody hangers.

One point I didn't originally make above is that my big fear about pharmacists being allowed to pick and choose which drugs, which formulations, and which doctors or institutions for which they fulfill legal prescriptions is that it doesn't allow the average person to know reliably whether any prescription they are written may be fulfilled at any given pharmacy.

If regulations are passed that allow pharmacists to express moral judgments over dispensing drugs--rather than, say, safety or legal judgments that would involve them calling state investigators about overprescription or dangerous combinations a doctor was advising--then the questions will be:

Can a pharmacy choose to only hire pharmacists who adhere to a particular set of moral beliefs and will that involve a written pharmacoepia that they will adhere to?

Conversely, may a pharmacy choose legally to not hire a pharmacist who doesn't sign a pledge agreeing to dispense all legal medications with a legal prescription?

May a pharmacist change his or her mind without losing his or her job?

May a pharmacy post a notice, "This pharmacy dispenses all legal medications"?

Will a pharmacy be required to post a notice that reads, "This pharmacy may choose at its discretion to decline to fill any prescription on moral grounds?"

Will pharmacists be required to provide written moral objections for each prescription they decline? For instance, if a pharmacist (as noted in the P-I story) refuses to dispense drugs that aren't involved with a particular hot-button issue (let's say, birth control) when it's a prescription from an institution that they have a moral objection from, will they face repercussions? For instance, let's say I live in a tiny town, 100 miles from anywhere else, with a single drugstore. Let's say my pediatrician happens to perform abortions on the side. Let's say the druggist, presented with a prescription for critical antibiotics for my child says, "I cannot ethically give you those drugs because my morals prevent me from handling prescriptions written by Dr. X." What happens then?

What's to distinguish racism or other bigotry from moral objections? In the comments, my agile disputant notes that if an Aryan Nation member won't prescribe drugs to a person of color, that discrimination laws would cover that, noting there are no discrimination laws that cover, say, abortion drugs. But I'm not sure that answers the question. If my religion says that left-handed people are an abomination, then when someone tries to sign for their drugs with their left hand and I object based on strongly held religious beliefs, how will I be prosecuted? And will it be a civil or criminal offense?

I'd like to know some answers to this. The ethical issue is being presented quite narrowly as "druggists don't want to give out abortion pills," but I don't see how you can construct in a commercial, civil, and legal solution that provides predicable medical access to drugs without answering these questions.

Bob Barr, Constitutional Hero

I never thought I would write these words: I have great admiration for Bob Barr. Most of his policy positions and his method of campaigning are abhorrent to me. But his out-of-office role as defender of the Bill of Rights is quite remarkable, especially when he stands up in front of Republicans and points out that that party should come after country.

There's a fundamental problem with Bush's stance on his role as executive, and that is that his faithful are (or perhaps were) largely defending him because of a host of reasons mostly related to personal trust or party affiliation, not law or reason. If Clinton had attempted this seizure of power from checks and balances, I'd be dismayed, too, even more so because Clinton was a lawyer, was a scholar.

Here's the key line from Dana Milbank's Washington Post story:

"Whether it's a sitting president when I was an impeachment manager, or a Republican president who has taken liberties with adherence to the law, to me the standard is the same," [Barr] said.

Concierge Care

I've been seeing a concierge practice doctor for several years now since he and his partner decided after the departure of two of their colleagues to form their own high-priced retainer service to opt for a middle-class one. I pay several hundred dollars a year for unlimited care from my doctor. This has been invaluable to me, although more useful when I was coordinating my cancer care in 1998 than in recent years. Until Ben's first cold several months ago, I had avoided any cold or flu that was more than a passing runny nose for two years. Now I've had several colds via Ben, and I don't blame him a bit.

Concierge medicine involves a doctor assuming only the risk to provide their service to a patient and the services of their office. This has caused Washington State's insurance commissioner to investigate the practice as he believes it might fall under the provision of an insurance company. I don't believe risk is really involved because the doctor is pledging his or her own services. My doctor's practice puts fees in escrow until after each month in which service is provided, thus limiting a patient's actual dollar exposure to $0.00 for any given month.

The New York Times is picking up on this trend quite late. The Wall Street Journal wrote about my and other doctors back in 1998, and I was quoted in the article. I have the same reaction as many of the folks on both sides of the concierge debate in this Times article: I love the access I have and I know my doctor enjoys his practice more. And I know that he is able to better keep up on developments in treatment and have his own life. Nobody said that being a good doctor should involve 80-hour or 100-hour weeks for your entire career.

The "lavish care" in the headline doesn't apply to most retainer-based doctors. Lavish means getting the doctor on the phone when you call, getting in the same or next day for an appointment, and spending 15 to 30 minutes with a doctor when you're there. Lavish. Right.

On the other side is the fact that the more doctors that retreat into retainer-based services, the fewer doctors available for general medicine. Retainer-based doctors have fewer patients in their practices. Because I can afford his fees, it means I get better health care than others who have to see whomever.

Of course, my reaction is that Medicare and other social support systems for healthcare should organize to build networks of retainer-based clinics that would allow patients to avoid expensive emergency room visits and save everyone in the system money. For fairly small fees, people with little or no money could be subsidized into better health care. Right now, hospitals eat huge bills (or pursue people with no money like they're the Erinyes) or people face financial ruin.

There is a lot of evidence that the lower you are on the income totem pole in the US, the worse you sleep and the worse your health. Because you make less money, the less you are able to improve your health through routine care and medication that might cost a fraction of emergency-room visits or late-in-the-process care. There's that telling scene in As Good As It Gets when Helen Hunt's son who has some kind of asthma-like disease is finally seen by a regular private-practice doctor paid for by Jack Nicholson: the doctor says, this is pretty easily treated as long as we're on top of it. This is not Hollywood magic.

US Out of WalMart

Does any small fraction of our population understand that WalMart is a scourge not because it offers low prices, but because it's destroying our healthcare system?

The company has 1.33 million employees. According to a leaked memo in today's NY Times on reducing health-care costs, 46 percent of those employees children are uninsured or on Medicaid. Because WalMart pays essentially poverty wages (legally), when they replace jobs in communities through their predatory practices that first drive out businesses through underpricing, they do the following:

  • Reduce money going into the community. They don't grow jobs, they replace them, typically higher-paid jobs within a town or city with lower-paid jobs often outside the tax boundaries.
  • Reduce tax revenue. Despite selling lots of merchandise, they often replace revenue rather than increasing it. Because people are paid less and the owners aren't local so that profit is spent local, money is sucked to Bentonville instead of spent in the area.
  • Burden the health-care system. Poverty wages and no health insurance guarantees offset health care costs to the local community, sucking more money away. The memo states bluntly, "Specifically, our coverage is expensive for low-income families, and Wal-Mart has a significant percentage of associates and their children on public assistance."
  • Tenure is a problem for them. They note that productivity doesn't increase with seniority and they don't like paying people more over time. This seems like a strange problem: hiring new workers incurs costs, and the longer someone works, the better they should perform on average, if not fired. Thus this "compensation" problem is a management problem.

This is sort of free-market capitalism at its worst: Because we as a country don't require health-care insurance for all employees of large companies, this allows a firm to offload its health-care burden. It's easy to argue that predatory underpricing shouldn't be regulated because the market will take care of it--and it often does--it's very hard to say that a company should force local communities to lose tax revenue and pay for health care.

This is not to say, by the way, that WalMart isn't paying anything for health care: 45 percent of their employees are covered. They spent $4.2 billion last year. Even so, a $17,500 per year job has a limit of $2,500 in out-of-pocket expenses or more, according to the Times article.

But it's another key to the broken health-care system that the increases in costs outpace inflation by a factor of three to five per year, and that this leaves more people behind instead of prompting massive reform by the affected businesses.

The Senate Dismisses Inflation's Power

By denying a Democratic move to raise the federal minimum wage from $5.15 an hour ($10,300 per year for a full-time job) to $6.25 over 18 months, the Senate Republicans have decided that on one hand, wages don't need to increase along with inflation's affect on decreasing buying power and, yet, on the other that business isn't increasing its revenues at least as fast as inflation. The most recent previous proposal by the marvelous and bilious Sen. Ted Kennedy was for a $2.15 increase (to $7.30) over 26 months, and this reduction picked up a vote.

A Republican counterproposal would have kept the $1.10 increase but required a remarkable array of horrible add-ons, such as allowing "flex-time," in which overtime one week could be made up through undertime another. These senators are pretending that people working these kinds of jobs have the easy flexibility that would allow the kind of schedules that employers would impose if no longer subject to week-based overtime rules. Jeesus.

Inflation increased 25 percent from 1997, the last increase in the federal minimum wage, to last month. Thus $6.25 would still be slightly short of inflation across that period. I live in Washington State, which requires a minimum wage of $7.35. This is still a ridiculously low wage: $15,700 per year. There are few communities in Washington in which a single person earning that wage and paying no tax on it would spend much less than one-third of their take-home on rent; in Seattle, you'd pay 75 to 100 percent of your take-home pay on rent.

Missing Piece in NOLA Left Behind Story

I've only seen this mentioned once in all of the coverage I've read of the descent to madness in New Orleans:

a) What percentage of New Orleans residents were estimated to be hard drug users before the evacuation?

b) What percentage afterwards?

People keep writing about a breakdown in order and so forth, and mention deteriorating mental health as one reason. The other is certainly withdrawal. There were no extra drugs in the city, and I imagine rich dealers fled along with the rest of the middle and upper class of the city.

If 100,000 people were left behind, which was the early official estimate (about 20 percent of 480,000 residents), and just 1,000 of them were drug users--thus estimating the drug usage in the city at 0.2%, laughably low for an urban town--then you have crazy people on the loose hallucinating, with the shakes, with uncontrollable behavior.

Sure, you have the looters laughing as they remove blue jeans and DVD players. Given that about 50,000 people were in two buildings (Superdome and Convention Center), and tens of thousands were in homes and businesses, who was left on the street?

Criminals knowing they could prey on others and steal. Drug addicts without access to drugs (and needing money if they could buy some). Mentally ill people who couldn't get themselves to shelter.

Let's not draw a lesson about society breaking down from this.

Take any city you live in. Pick an area bounded by the old town, the sports stadiums, the convention center, and a dangerous district with high crime and low income. These are often in a direct line or a square or triangle. Now picture everyone with money and cars having left town. Who would be left in your city? The desperately poor, the ill; the deranged, the street people, the criminals; the drug addicts.

The poor and the ill were abandoned in New Orleans. The other groups were lumped in regardless of degree of intent, risk, and sanity.

Society exists in part to protect people who can't protect themselves and in part to protect the majority of society that wants to live in peace from the smaller part of society that is incapable of doing anything but tearing it apart.

Someone Also Thought of Norquist

I had this thought this morning that the architect of smaller government (which hasn't happened under Bush) has always talked about shrinking government to the size where it can be drowned in a bathtub.

I wonder what he would have been saying about drowning and bathtubs had he been on a roof in New Orleans for this last week wondering why the money and organization that would have allowed him to be rescued had disappeared?

Norquist et al. haven't shrunk government one bit. They've reduced taxes on the wealthy while tacitly not criticizing the massive growth in non-entitlement spending on military and homeland security that has, apparently, resulted in zero additional preparedness and zero additional international terrorist attacks.

No modern Republican president has shrunk government while shrinking deficits. Only one Democrat has.

See Daily Kos for a good image and comments.

Inadequate

There's nothing I can say about the hurricane or the government's response that hasn't been said elsewhere.

My only hope is that the callousness of the Bushies and the inadequate, terrible, unsympathetic response on their part will finally alert the red states to understand that these millionaires and power-hungry zealots don't care a rat's ass for them.

Where will the money come from rebuilding? From the blue states, as it has for the south many times before. Where will the private donations come from? In largest portion from the blue states.

When will someone stand up Rodney King like and say, "Can't we all just get along?"

Thimerosal Linked to Autism (Not the Usual Conspiracy Theory)

Totally frightening article in Salon today about how the CDC, drug companies, and others suppressed clear evidence linking thimerosol to autism. Thimerosal is a mercury-derived preservative that used to be widely used. A friend with a fellowship at Oxford in 1990-1991 had me ship her non-mercury-containing saline solution from the US because the mercury-free version was unavailable in England at that time.

In the past, there has been a lot of bad science, supposition, and conspiracy theories that connect this preservative with increased rates of autism. Unfortunately for those of us who were skeptical, this Salon/Rolling Stone article that relies on information obtained via the Freedom of Information Act shows that beginning in the Clinton Administration, a determined effort has kept the good science, direct correlation, and actual conspiracies secret.

We have not had our son exposed to thimerosal because the CDC currently advises that it thinks it is safe but doesn't have the clinical proof to demonstrate that it's safe. Thus, we've been prudent, and asked our pediatrician about all the vaccines and immunizations to ensure that they are mercury-free. She only administers mercury-free vaccines for infants (because that's what they're ordering) and noted that one for when Ben is older currently includes it but it will be phased out by the time Ben needs it.

This is a chilling and horrible violation of the public trust that will lead to assured billions of dollars of lawsuits against the drug companies that apparently colluded with government to suppress this information as they simultaneously moved to remove thimerosal from their vaccines. If this article checks out over time, we've got a massive smoking gun.

Myself, I've always been concerned that the food supply and environmental factors were responsible for the rise in autism, as well as improved diagnosis and an expanded set of definitions that encompass autism. No longer.

The other part of this, of course, is that the people who say that once a kid is given a vaccine that they are autistic the next day--that doesn't appear to be born out by the evidence. As a toxin, mercury accumulates, so it might be a matter of weeks or more likely months.