Friday, 30 April 2010

General Pharmaceutical council & conscientious objection

Though the first of the seven principles of pharmacist professionalism published by the GPhC is "To make patients your first concern", the GPhC's draft standards allow pharmacists to refuse to hand over items that they find distasteful to their beliefs such as emergency contraception. This 'conscience clause' sounds to me as though the first concern is the pharmacist, not the patient.

As this article from the BBC details, a pharmacist refused to hand over the contraceptive pill to a woman, who was told to come back the next day when a member of staff who did not have such objections would be available.

Similar goings on in the US; in 2004 a rape victim was refused emergency contraception in Denton, Texas by 3 pharmacists, who refused to dispense the prescription due to their religious beliefs. In 2005 a Milwaukee pharmacist berated a woman with a prescription for EC shouting “You’re a murderer! I will not help you kill this baby. I will not have the blood on my hands.” In the US, the legislative situation is complicated; conscience clauses are endorsed or forbidden by local state law or alternatively by pharmacy boards, and these laws/codes may apply either to the pharmacy or indvidual pharmacists. Three states have passed laws mandating pharmacies to fill valid prescriptions (with a further state - Illinois - legislating that pharmacies must dispense birth control pills if stocked); a further three have pharmacy board statements requiring pharmacists to dispense valid prescriptions (source: Guttmacher Institute and National Women’s Law Center, 2008).

Back in the UK, the GPhC's draft standards state "3.4 Make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers".

The draft standards are available at

A consultation exercise is running on the draft standards until 28th May 2010 at

The council should be urged to remove the 'conscience clause' which essentially gives pharmacists the arbitrary right not to dispense medication that has been legally prescribed by a doctor. Whilst conscience clauses may be acceptable in certain situations e.g. a pacifist stance upon conscription to the army, pharmacists are not conscripted. As LaFollette and LaFollette state in an excellent article in The Journal of Medical Ethics (J Med Ethics 2007 33: 249-254):
Some medical professionals want to follow their private consciences without having to sacrifice their livelihood. We understand that. However, since their actions standardly affect others, often profoundly, we should not straightforwardly let them act on that conscience, especially since in their roles they uniquely satisfy some public needs. We should not recognise—nor should medical professionals claim—an unqualified right of conscience.
(Thanks to Epsilon Clue for this one: The Washington Post reports on a 'pro-life' pharmacy which recently closed down due to a lack of customers).

Medical miracle - Man survives without food or water 'for decades'

I wish my first post wasn’t such a distraction from more serious happenings in India, such as religious backing for ‘honor killings’, but it looks like we got ourselves an all-singin'-all-dancin' medical miracle right here, splashed across all the news wires.

Prahlad Jani is an 83 year old Indian ‘yogi’ being examined in a hospital in Ahmedabad to uncover how he has apparently survived without food or water ‘for decades’. Mr. Jani describes himself as a Jain ‘breatharian’ who can sustain life on ‘spiritual life force alone’. During the six days he has been monitored (apparently around the clock, with cameras overseeing his every move), he has not passed urine or stool (ethical aside for doctors: how long to do you let your patient’s urine output to be zero without a fluid challenge? Six days?).

Now the Scottish philosopher and resolute deathbed atheist David Hume seemed to have a pretty robust position on miracles (see ‘An Enquiry concerning Human Understanding’ published in 1748). He rather reasonably defined a miracle as "a transgression of a law of nature by a particular volition of the Deity, or by the interposition of some invisible agent." As reports of miracles generally come to us from the testimony of others, a miracle can only be said to have occurred if the probability of the miracle was higher than the probability of these people being mistaken, or the probability that they wanted to please others with their testimony, or the probability of them being outright liars (the apparition of the ‘Virgin Mary’ at Fatima in Portugal, to three shepherd children, comes to mind). Since a miracle is by definition a violation of the laws of nature, the probability of which is so diminishingly small (else it would not be termed a miracle!), miracles do not in fact occur as the odds of human senses having been fallible, or of others’ desire to deceive us, are always higher than ‘diminishingly small’.

Of course, we are all familiar with stories of patients with severe spinal injuries who walked again to the amazement of his doctors, or even the cancer patient who was given days to live and is now completely clear of any cancer as proven by scans and blood tests. Many of these turn out to be false, but many other such amazing recoveries undoubtedly occur*

Such recoveries are, unfortunately (or fortunately?), not miracles, but errors of prognosis. Medicine is partially art, based on science of course, but it relies most immediately on probabilistic science rather than upon inviolable laws like those found in physics. Medicine does not generally establish for itself sufficiently rigid parameters that we could say ‘if X occurred, then that would go against medical science to the extent that it would be a miracle’. Even if someone grew back an amputated limb, which of course has never happened (and might I cheekily interject Emile Zola’s remark upon visiting Lourdes: “I see lots of crutches but no wooden legs”), we would have a (major) challenge for embryology and our fledgling knowledge of adult stem cells. Here medicine differs from cosmology or physics: if I were to witness the rising of two suns tomorrow, and had no reason to think my senses deranged, then I would have to concede that a miracle.

However, Mr. Jani’s condition is not scarcely a medical one. As he doesn’t take in any energy through food (but expends energy through movement and presumably generates some heat and noise); his continuing existence is in violation of the physical laws of thermodynamics. Such a violation would count as a miracle for me (and, I believe, Hume), if we knew enough about the conditions under which Mr. Jani was being observed, and could rule out bias or fraud. So, we need a peer reviewed paper, reporting a suitable study period (I recall IRA hunger strikers, who took water, would usually die after about 2 months), access to original monitoring footage for anyone who wishes to verify the data, and statements of conflict of interest of the team involved. This is standard practice for a medical case study.

Until that occurs (and I doubt very much it will), there can, disappointingly, be no miracle of the fasting holy man.

*(and can be claimed, whether true or false, by the Vatican for the purposes of the canonisation process, who now engage with ‘expert’ medical witnesses).