Adding Further Restrictions to Permitted Use of Conscientious Objections

So far, it has been shown that while there is good reason to allow pharmacists the right to conscientiously object, restrictions should be in place (the conventional compromise or a variation thereof) to ensure that pharmacists’ integrity and autonomy are preserved as much as possible without jeopardising patient welfare. Contemporary policy and literature on this subject suggest some further limitations should be set so that only conscientious objections based on certain grounds should be considered valid. Increasing the limitations would be a further restriction of the pharmacist’s autonomy, which would come up against arguments in support of conscientious objections that are based on the premise that a variety of moral and religious beliefs ought to be tolerated. Further conditions for the acceptability of a conscientious objection are that the reasons for the refusal should be reasonable (Card 2007: 13), should not be based on prejudice (Wicclair 2014: 279), should be in keeping with the core values of the profession[1] (Wicclair 2000: 217 and Deans 2013: 53) and should be genuine (Meyers and Woods 2007: 20). This list, and each individual item on the list, presents a tall order. Looking at each in turn, one can see that none of these criteria is easily or completely achievable but nor is it futile to aspire to these requirements.

It is “not unreasonable to ask for reasons”, states Card (2011: 62), the “beliefs on which conscientious objection is based must be reasonable and should be subject to evaluation in terms of their justifiability” (Card 2007: 13). Under such a proposal, the reasons behind a conscientious refusal would have to be based on scientific knowledge and, where applicable, true or not implausible non-clinical claims.

Wicclair points out that the professional must have her clinical facts right (Wicclair 2006: 243) and just as important are non-clinical facts.

A position is most clearly unreasonable when the facts are incorrect or when a judgement is based on prejudice. For example, empirical research shows that some pharmacists are mistaken about some aspects of EHC and that views vary on the clinical action of EHC, which may affect the supply of EHC over the counter (Cooper et al. 2008a: 50). There is also evidence that pharmacists make their decisions about whether to supply based on their perceptions of women’s propensity to abuse EHC based on their age, wealth or locality (Cooper et al. 2008a: 50). Judgements about the non-clinical context include, for example, assuming the availability of EHC would lead to a rise in sexual promiscuity and irresponsible sexual behaviour (Barrett and Harper 2000: 205).

In many cases, there will be no evidence available to prove or disprove a nonclinical belief. Metaphysical beliefs (including religious) are almost immune to verification. As Marsh points out, “since many moral judgements stem from metaphysical or religious assumptions, this class of refusal [metaphysical] turns out to be rather common” (Marsh 2014: 314). There are very strong epistemic barriers to verifying metaphysical claims. While some metaphysical positions may be more plausible or more reasonable than others, there is great difficulty in validating or invalidating many metaphysical theories. Take, for example, Paul, a pharmacist who believes life begins when the soul is created, which is the point at which an egg and sperm unite to become the two-celled zygote. Paul understands that EHC is not an abortifacient, but he is correct in his belief that the use of EHC could destroy a zygote. Paul believes all humans who present themselves to him at his pharmacy are his patients. Subsequently, Paul believes the zygote constitutes a patient. In line with his professional code of ethics, Paul believes the interests of his patients are of prime importance. As such, Paul has a conscientious objection to supplying EHC.

Paul is unable to prove his claims are correct, but neither can his position be disproven. The problem with making it a requirement of conscientious refusals that the objector gives sound reason is, as Marsh argues, that it is either too easy or too difficult to satisfy (Marsh 2014: 313). Nevertheless, sound reasoning is so fundamental to how we justify decisions that the profession must surely strive to overcome epistemic difficulties wherever possible. Reasonableness tests are notoriously problematic, but in practice, the majority of accounts and narratives are accepted as being either reasonable or unreasonable, and therefore justification for decisionmaking is deemed achievable.

It has also been claimed that conscientious objections should be in line with the core values of the profession (Wicclair 2000: 217; Deans 2013: 53). The most basic problem with this approach is immediately obvious: how can we identify the core values? Some attempts have been made to do this (Benson et al. 2009), but there remains no definitive understanding of the core values. There will, however, be cases in which it is clear that an individual is acting against the values of the profession. As with the reason-giving requirement, it will be a matter of judgement within a real-life context whether a pharmacist could be said to be acting within the core values of the profession.

The requirement that the conscientious objection be based on core values of the profession is driven by a resistance to the conscience clause being an “anything goes” policy, such that when a pharmacist’s beliefs come into conflict with the values of the profession, the pharmacist’s beliefs are given priority. This presents something of a contradiction within the profession’s policies: the profession sets standards, presumably based on norms and values, which are collectively agreed by its members. At the same time, the profession permits an individual to act in a way that is contrary to those values (Deans 2013: 53). This could perhaps be avoided by recognising that one of the core values of the profession is respect for the integrity of the individual pharmacist. This would not eliminate conflict, but arguably conflicts of this kind inevitably exist within professions and do not present deep philosophical challenges.[2]

A requirement of genuineness has also been proposed, so that the objector has “a sincere scruple-based objection to the procedure” (Meyers and Woods 2007: 20). This is intended to eliminate refusals that are based on a non-moral aversion. This, again, may be hard to verify, though as Marsh points out, this may become evident when the individual is pressed to give justification for their conscientious refusal (Marsh 2014: 318-9).

Finally, Kantymir and McLeod suggest a middle ground of “reasonableness or genuineness plus”, which demands that the conscientious objector prove either:

  • 1. That it is reasonable, in particular, by showing that what grounds the objection is as likely or more likely to be true than what grounds the standard of care for patients
  • 2. That it is genuine, plus that it satisfies certain criteria

For option (2), the criteria are as follows: patients will still get the care they need in a respectful and timely fashion, any empirical beliefs on which the objection rests are not baseless, and the moral or religious beliefs on which it rests are not discriminatory (Kantymir and McLeod 2014: 21).

The strongest challenges this position faces are related to the applicability of such criteria: the interpretation, verification and practical management of imposing these standards.

  • [1] A similar criterion of goals of the profession has also been suggested (Wicclair 2006: 244).
  • [2] I thank Dien Ho for raising this point.
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