The Pharmacy Conscience Dilemma | Cristina Alarcon, BPharm, MBE

This transcript was generated automatically. Its accuracy may vary.

[00:00:12] Mike Koelzer, Host: Hello, Christina. Well, hello, Mike. Thanks for joining the, uh, business of pharmacy podcast. I'm in grand rapids, Michigan, and your way over in Vancouver, uh, Canada way on the west coast. And I was going to sit here and laugh at you for being so far north and having such terrible weather. But before I did that, I looked online and I saw that you've got great weather out there year round.

Yeah, 

[00:00:35] Cristina Alarcon, BPharm, MBE: this is. Beautiful city. I would say this is the most beautiful city in all of Canada. Really? No. And I've lived, uh, I've lived back east most, uh, for half of my life. And, um, you know, I must say moving out here has been a blessing. It's like paradise out here. That's 

[00:00:49] Mike Koelzer, Host: great. It looks, it looks beautiful.

Well, Christina, introduce yourself. and tell why you and I are talking today just outside of the range of just because you're a pharmacist, but what actually got us talking on this show together. 

[00:01:05] Cristina Alarcon, BPharm, MBE: Sure. Well, I've, uh, been practicing pharmacy for, I would say almost. 30 years now. I, uh, absolutely love my profession.

And, um, and so yeah, you I've, uh, not only do I have, um, a ma, um, sorry, a bachelor's in pharmacy practice, but I also went ahead and did a master's in bioethics. And, um, so you've asked me to talk a little bit about why, uh, pharmacists would wanna do a master's in bio. 

[00:01:32] Mike Koelzer, Host: Yeah, because I think of bioethics and I'm always thinking of things nowadays, like testing two babies and stem cell research and things like that.

But what got you into the interest in bioethics being a pharmacist? 

[00:01:51] Cristina Alarcon, BPharm, MBE: Well, first, I'd like to start off with, because most people maybe don't know what bioethics is, yeah. Right. Entails exactly or what it is. So there's actually, and I don't usually use Wikipedia, but there's a really good definition. So I'm gonna use it.

Um, so bioethics is essentially the study of ethical issues that emerge from advances in biology and medicine. Um, and it's, it's concerning. Ethical questions that arise in the relationships among life sciences. So biotech medicine, and medical ethics, politics, law, uh, as well as theology and philosophy.

Um, and, um, so why would I want, why would a pharmacist like myself want to get into the study of bioethics? So for me, um, the idea came as a result of. My passion for wanting to help others understand, um, the reasons why sometimes a pharmacist or other healthcare professional might not be able to participate in the provision of some service or, uh, or the dispensing of some drug.

And, um, And this came as a result of, um, policies changes that took place, at least in Canada. And I think in the US as well, um, in the mid nineties, uh, we had changes in our codes of ethics, uh, that sought to change from. Um, a virtue oriented VIR focused ethics to a, um, a patient centered outcomes focus.

So in other words, going from what you might call a dermatological ethics to a consequentialist ethics. Now, now those are big words and most people don't understand what they mean, but essentially a deontological ethics. It's a system that judges, whether an action is right or wrong, based on a moral code, uh, and not just based on the consequences of the action or the outcomes.

Hmm. Um, a utilitarian or consequential ethics states that any course of action can be taken as long as the outcome. Is what you want, or as long as the outcome is, is good in, in your mind is good. 

[00:04:04] Mike Koelzer, Host: So essentially that's, um, the ends don't always justify the means, is that right? So you might have an end, you're looking for exactly, but that doesn't mean that you can necessarily take every step.

That you want to, to get there. If it's crossing certain ethical 

lines, 

[00:04:23] Cristina Alarcon, BPharm, MBE: you know, as an example, there might be something I don't particularly want or like to dispense, but I, I hesitate. I now wouldn't say to the patient, well, I don't have it if I have it. Sure. Gotcha. So that wouldn't be it. Wouldn't be just to do that.

So, yeah. And, and so these changes in the, in the codes of ethics. Um, at first glance I didn't pay much attention. It was 1997 when I moved to BC from, uh, from the back east, from the Toronto Montreal area. Um, and I didn't pay much attention until, uh, there was a product that came on the market. I dunno if you remember, the morning after pill was.

Previously, um, dispensed as an overdose of birth control pills. Yes. And then now it was, uh, patented and marketed as a product called green at the time. Sure. And, um, so all of a sudden I relooked at my code and I said, oh, oh, there's stuff in the new code that is gonna be problematic for me because essentially it's saying that, um, a Pharmac.

Can have freedom of conscience and religion, but they must, uh, dispense if no one else is available to do so and things like that. So, gotcha. It was clear that there was no real, uh, respect for freedom of conscience. And when I say I want, I wanna just backtrack a little conscience because many people think of conscience and they go, oh my God, conscience needs.

It's a little voice in you that tells you you're guilty of something. Yeah. And that's not what conscience is. Um, Conscience essentially needs to be. Everyone has one. You can be religious or non-religious, it doesn't matter. Everyone has a conscience, the ability to have a dialogue with one's self and, um, and, and examine one's.

Course of action. So you're not judging the person in front of you or their acts, you're judging your own act. Sure. And the conscience needs to be formed and it doesn't necessarily have to be formed by a religious tradition. It can be formed by, um, you know, the experience of our elders, you know, of our, our parents, our, our forefathers.

Yes. Right. The, um, by reading good classics, by speaking to leaders in our community, there's many ways of forming that conscience. Right. So that's important 

[00:06:30] Mike Koelzer, Host: to get out there. Yeah. Right, exactly. So the code of ethics that you came across in Canada, were they saying that, were they saying that you had an obligation to transfer that to another pharmacy?

Or were they saying that your pharmacy had an obligation to. Dispense that 

[00:06:51] Cristina Alarcon, BPharm, MBE: it, it was that you had to refer. There was a, there was the requirement of referring. So if you, for example, would not dispense it yourself, then you had to refer to another person. Now, what people don't realize is referral is. Is akin to doing it 

[00:07:07] Mike Koelzer, Host: yourself.

It would be, if somebody, if somebody came to you and said, could you please give me your gun? Right? Because I wanna kill my neighbor. And we say, I don't do that. But the law is telling me that I have to tell you that I know there's a gun in the garage of the neighbors next door that's loaded. So you would 

[00:07:28] Cristina Alarcon, BPharm, MBE: still guilty.

Of participating in some way. Right. And you would still be, it sure seems that way to me, I think in a court of law, you would still be found guilty and, um, the Nuremberg trials, nobody likes to think about that, but yeah, there were doctors who facilitated, um, the execution of patients and just by giving the drug out or by even if they weren't infusing it themselves, Yeah, right.

So there's many situations in the world out there. Um, and I use the word secular, but I mean, it's, we are secular, we live in a secular world, so we are dealing with secular topics right now. Um, but yeah, so, so what I did essentially in my, when I did my degree in bioethics is I, I, I wanted to study all the codes of ethics across the country to see how they differed.

Stance on freedom of conscience. And, um, sure. So what I did is, yeah, essentially I found that there were 1, 2, 3, 4, Five out of the 10 provinces that said, yes, you must refer to any referral. Had to ensure that there was minimal inconvenience to the patient. So that would mean, um, that's very subjective, right?

So if you had to go down the street, that might be good. But if the patient was in a wheelchair and they had to go down the street, that might be really inconvenient, right? Yes. Um, So, of course, since that was in 2009, and since then, a lot of things have happened that I can talk a little bit about, um, And there have been extensive changes to all the codes for the better I have to say.

Um, so since the, um, the decriminal decriminalization of, uh, euthanization assisted suicide, which in my mind are even more serious than, uh Preveal. Yeah. Um, There have been extensive revamping of all the codes of ethics, a across the country. Some of them still require referral. Some of them still there's two of the S that still require referral specifically for, uh, what they call medical assistance in dying to the patient.

So a referral must be made to the patient. A couple of the other provinces are just referral. Referring the doctor to another pharmacy. Um, so that can be problematic. Um, and you think about it. I, I have a friend as an example, my friend Armando, that's not really his, his real name, but anyway, my friend Armando , um, he, we talked about this, you know, he says, look, I'm not against assisted suicide, but I worked at a pharmacy and I was, um, and they were gonna participate in provision of the drugs and he says, but I couldn't do it myself.

You know, I'm not against it, but I can't. Um, so a proper conscience clause should protect the integrity of, um, of a pharmacist in that situation. And, um, so I wanna backtrack a little bit and, and, and go back to, um, why I would've. Uh, went to the university of Nova, uh, in 2005 to start a degree in bioethics.

And yeah, so all this stuff was happening. Codes of ethics were, uh, changing. It was, uh, this creeping in of policies that I couldn't agree with. And, um, And I was speaking out in, in the media. I was interviewed on radio, uh, television here in Canada on, on these issues. And I saw that sometimes reporters, journalists would with all good intentions get my words or my meaning wrong.

And so I started thinking, you know, I've gotta start writing myself. So I started writing for the paper myself and, um, Yeah, but I needed to find a better way of explaining things because I was realizing I wasn't reaching people's property. I wasn't, it seemed like my words were escaping. They were sounding judgemental and that was, that's not the intent of an objection to something.

Sure. Um, It's not to judge the person that wants the service. In fact, they can still get it elsewhere, right? Yeah. Uh, it's not to Trump anybody's rights, but it's to, to help people understand that, um, you can't force someone. To do something they believe is wrong. Right. You know, you can always do it. You can always, you cannot always do all the good you'd like, but you cannot force someone to do something they believe is wrong, because you pervert their conscience.

You pervert that person. Right? Sure. Um, so then in, uh, 2005, when I was in the middle of all of this, um, as well as lobbying my college for many years to change that code of ethics, it wasn't just myself. There was a group of us, pharmacists who were quite concerned. And every year we presented at the, uh, college of pharmacist, AGM, trying to change that code, you know, change it so that it would be more respectful to freedom of conscience and religion.

Yeah. And without minor, I mean, a few, you know, a few successes here and there, but not, not much. Happening. Um, so in 2005, I heard of a new program at the university of Novar of all places in Spain, which is really, uh, my country of origin. I was born in Madrid. Yeah. Oh, um, yeah, so I thought, Hey, um, not, not because it was in Spain, I thought, which is a beautiful country.

But I thought, Hey, this is an opportunity because it so happened that one of the professors at this, uh, of this program is a pharmacist. Um, Jose Lopez Guzman, he's a pharmacist, uh, who has written books, one of them on, um, on conscientious objection in pharmacy practice. Um, in 1997, another one on, um, the morning after a pill, uh, theoretical.

Um, I have the title here somewhere, but anyway, it doesn't matter. It's uh, yeah, the morning after pill, um, Pharmaceutical aspects, ethical and Gerrid aspects of it. Um, so that was, uh, amazing, I thought this guy is someone I have to meet. Um, I read his books of course, in Spanish, which was a little bit challenging for me.

and, um, And I thought, okay, I've gotta meet this guy. And so this was a perfect opportunity. I went to Spain. I actually, it was a course that was, um, meant for professionals already. So people who were working in their field, um, and I continued to work full time and had to travel to Spain at least three times a year and stay there for about 10 days at a time.

Is that right? To, um, yeah. And, um, you know, it allowed me to meet people from. From all over the world. Um, the Spanish, Asian world, of course, people who, you know, I was lucky enough to be able to present, uh, my paper in, in English. Um, the paper that I wrote, um, which again, explored the code of ethics, um, across the country, across Canada.

Right. And, um, and then in. In 2009, I published a paper and the annals of pharmacology, I actually sent out a paper to many, many journals. And this one really li liked the idea of, uh, of, of the topic of, um, the actual, the title of the, uh, of the article is the hijacking of, uh, moral conscience, a Canadian perspective.

And, uh, it was peer reviewed. Journal. So it was interesting to see the back and forth that goes on. Yeah, right, exactly. Uh, it was a lot of fun to work with, uh, the analyst of pharmacotherapy. And, um, but I have to admit that since 2009, that since that publication, I haven't. You know, I've been busy working full time, so right.

I haven't had a lot of time to write more articles except for stuff I do on my blog online. And that's about it. 

[00:15:29] Mike Koelzer, Host: Yeah. I, I know, I know what you mean by, uh, wanting to have something written versus, uh, interviews. Cause sometimes, sometimes even not. Intentionally, they can chop off things that just change the meaning of, of your, uh, intents.

Well, 

[00:15:44] Cristina Alarcon, BPharm, MBE: actually I have to tell you about one, one, uh, interview I had, it was, um, I mean, I had a few live interviews, which is kind of fun because you know, they're not gonna cut you off. Um yeah. Right. Or, or, or change your words. But I had one interview that was for the CBC, um, and it was recorded. It was televised.

And, um, so I bought a tape recorder for the interview and I said to the journalist, I said, you know, um, do you mind if I tape this? You know, oh yeah. And she was taking a little bit of that because I know what they do. Right. They just chop it off. Right. And they make you look really mean, or, or why don't you do what they made me look really mean?

And I thought, oh my goodness. I 

[00:16:23] Mike Koelzer, Host: had one time where the paper interviewed me and this was on some other subject. Right. But it was on, it was. Insurance for the elderly. Yes. And, um, some of the, some of the elderly, like my grandma, she didn't need any handouts because she had plenty of money from her husband passed away and things like that.

And then I said, well, a lot of people do need that help, but it came out where they cut off the part. You know, they cut off the part about a lot of people needing help and they just left in that, you know, Mike doesn't like old people kinda stuff. So you do have to be careful. Yeah. Yeah. So Christina, that was in 2009.

And so, yeah. So here, 10 years later, then how has it happened? Things impacted you either pro or con since that 

[00:17:09] Cristina Alarcon, BPharm, MBE: time in 2012 is when, um, youth and, uh, assisted suicide and euthanasia were decriminalized, uh, in Canada. And so all of a sudden people were like, you know, we didn't think this was gonna happen. Yeah. Um, and things started to change from that point on.

Um, and I was also able to get onto the, uh, the college's ethics advisory committee. I was appointed to the committee, um, in 2000, get the dates wrong. I think it was 2000. Sixth or 2005, uh, 2000 anyway, somewhere around there. I was on the committee for some years. And when decriminalization of assisted suicide and using HIV came along, uh, we were able to at least make a few changes that would allow for freedom of conscience.

And we still need to ensure the patient can get what they want, but just not. The wording has been changed. So that it's a, there's a little bit more leeway there. I mean, you know, when you think about it, one of the things that always strikes me is that, um, if you think about any other service in your pharmacy, uh, if you're a pharmacy owner or, or, you know, you can, there's certain.

Things, you just don't carry, you know, you may not have a certain type of Walker or a certain type of cane or exactly for those things. Um, there is no need to refer. I mean, the patient is really inconvenienced, very highly inconvenience sometimes. And yeah, there's no, uh, policy that says you must refer, but when it comes.

To the conscience of the pharmacist in, in the, the media areas of life. Um, it's, it's striking that, uh, that then we are seen as, um, there's, uh, the power imbalance is, is quoted. Essentially all of a sudden things are turned around. They say, well, no, for those things that are, you know, you're just being squeamish.

Um, You should refer, you should refer to them. In fact, even in Quebec, you must not only, not only do you have to refer, but you must call the pharmacy that you're referring to the patient to ensure that they're gonna provide it and then call the patient at home to ensure they've gotten whatever they wanted.

So, which again is like doing it yourself, right? 

[00:19:23] Mike Koelzer, Host: Yeah. It's, it's, it's interesting. It's interesting because if you, if you. Are a pharmacy owner and you decide not to carry a Walker. Let's say as your example was you. You might not be carrying it for a lot of reasons. You might not be carrying it because it's just a pain in the, a pain in the behind to get the Walker in and to put it together with the tools and screws, or it takes up too much room or there's a lot of things you don't like, but none of 'em, none of 'em go against your conscience.

There's just things that are kind like, ah, they're kind of like. You might just be lazy. Maybe you don't wanna sell that Walker. Yeah, but no one says no one says to you, you you've, if, if you are lazy, if you're doing this, then, then you've got to have someone else do it. And you're like, you know why? But now when it's something even greater, when it's your own conscience, mm-hmm and.

And, and that's to argue or not even arguably that's, that's a bigger issue than, than laziness or maybe having space or something, but then all of a sudden you've got to be complicit with it. Uh, it seems backwards. It seems like they would say, you know, if it's just because you're lazy, then. Then then come on, come on.

Let's help them out and, and make and, and help find it, you know, but yeah. But, but it's, it's the opposite because it's, you're against it now help find it. So it seems backwards to me. 

[00:20:56] Cristina Alarcon, BPharm, MBE: Yeah, you're right. You're absolutely right. Um, it's and I, I know where it stems from, again, it's just the notion of power imbalance, which again, it's, it's, you know, um, It's a very socialist, uh, kind of ideological stance.

Mm-hmm um, if you go to some of the bioethical principles of, uh, in 1979 Bohan Shere, who were, uh, some of the first bioethicists to, to write on this topic, uh, they came up with some basics. Bioethical principles. And so there's the principle of non maleficence, which you shall do no wrong. The principle of beneficence, which you shall do.

Good. Um, the principle of justice and the principle of autonomy. So essentially what the codes, new codes of ethics have done is put the principle of autonomy. So patient's autonomy over and above. That of thou shalt do no harm or thal do good. And so autonomy is, um, is, you know, it's actually been twisted.

Uh sure. And, and, and, you know, you can talk of the whole ideology of choice as an example, you know, it's been twisted. I understand that patients, of course, have to have the ability to make their own decisions. And we're not saying we're not trying to take that away from patients. Yeah. Um, But to say that autonomy comes over nuns would be ridiculous.

If you think about, uh, for example, a drug addict comes in and he wants to get his stuff, you know, and you as a pharmacist, well, you don't wanna do harm. So you're, you are gonna practice nouns and you're gonna practice beneficence and you're not gonna give out the drugs too. Drugs at it. Right. Um, or you can think of many other cases where the Princip, the principle of autonomy, patient autonomy, wouldn't be put over and above that of the others.

Um, and, and your example of, you know, uh, uh, um, yeah. Products out there. You know, going back to, um, the fact that we can refuse to give out a certain service, like for, for example, right now we have expanded scope of practice. Um, sure. It's another area, you know, there's because of our expanded scope, there's more reason to ensure that we have freedom of conscience, because there's gonna be more dilemmas that come up.

Yeah. And, um, you know, pharmacists are doing injections, not all pharmacists are doing me reviews. I mean, is it exactly gonna be mandated? Um, So, are you gonna mandate that, uh, actually some corporations are, as you know, mandating some corporations, uh, pharmacy corporations have quotas that they, where they, um, so that , you get poor pharmacists who, you know, in order to meet the quota, they have to do things that are not necessarily ethical, like making the patients sign that they did a med review, which they never did.

Um, yeah. Right. So anyway, we can go on and on about there's a lot of other ethical issues obviously than just the ones I've brought up. When I spoke about the, um, uh, decriminalization of euth nation assisted suicide, I, I think I said 2012, it was actually, um, 20, uh, 16 is when, uh, assisted suicide and euth Inia were decriminalized in, in Canada.

And as a result of this, um, you know, people were all of a sudden, you know, the alarm bells were going off and. Things I had been seeing to the ethics, uh, committee and to, uh, the colleges, uh, that would come down the pike. I was warned that this might happen. And they said, nah, this will ever happen in Canada.

Um, you know, all of a sudden it came true and there's a lot of pharmacists out there who, you know, maybe they're not necessarily against it, but they certainly don't wanna be the ones participating in it. So all of a sudden, you know, they're implicated. I mean, every province is different. So in British Columbia, you still have to, I mean, the doctor has to contact the pharmacy directly.

So it's not the patient that will walk in with a prescription. Um, but. I can see it where, you know, there may be some pharmacies who will have kits available, right? So this is your euthanization kit. And for those patients who are gonna be doing it themselves at home, that kit could potentially be sitting there.

Um, you know, and you could never know who took it or who, or if that patient was forced to take the drugs. Right. Um, so. Yeah. So you as a pharmacist, maybe you're not necessarily against, uh, the concept of assisted suicidal or euthanasia, but you, you wonder, well, there's other ethical issues that will crop up in your mind, like who, uh, will someone force this patient to take these drugs or, uh, will they feel coerced because they feel like they're a burden to their family 

[00:25:45] Mike Koelzer, Host: as the many, many doctors that took place in the.

You know, the atrocities of World War II and so on, under Hitler, you think you're far away from that, but, um, society and, and laws gradually March up and before, you know, it, you're all, you're all in this together. 

[00:26:04] Cristina Alarcon, BPharm, MBE: Yes. And the thing is that, uh, the more we. The longer this is in place. The more it becomes normalized.

So exactly. And at a given moment, what ends up happening too is, um, I mean, I've heard pharmacists speak who have participated. Uh, they feel horrible about it, but they almost feel as if they've done something heroic and it's a little bit of a twisted way of thinking. Um, there's something that there's an ethicist, uh, Canadian ethicist.

Who's now living in Australia who. Actually she's originally from Australia, but was in Canada for many years, Margaret Summerville, who spoke about the yuck factor, yuck factor. And she said that there's a certain yuck factor that we all have inside ourselves. And when you, uh, think about something, you, you, you, with your rational mind, you know, when you say, Hmm, I, I, I have this horrible feeling.

Feeling or horrible. Um, uh, there's something, it doesn't seem right. Doesn't sit right with me. Um, right. You have to listen to that gut instinct because it's there for a reason, this yuck factor. Um, right. So these pharmacists who have that yuck factor, and yet they feel that, you know, uh, because this is now legal, therefore it.

It's good because it's legal. Sometimes people equate legality with goodness and with right. You know, something 

[00:27:25] Mike Koelzer, Host: yeah. Right. Legal is right. You know, an example of that of course, is, you know, slavery in the US before the civil war was legal that's, but I wasn't right. 

[00:27:35] Cristina Alarcon, BPharm, MBE: Yeah. So, and there were people with a conscience who, who knew that, or who felt that way, but because it was so tied into the economy, they were unable to rid themselves of slavery for so many years.

Right. With the end of course, other reasons. Um, yeah. Right. You know, you can see this creeping in and saying, well, is this gonna become part of, is this our. Part of our side as well is gonna creep in also as part of the economy, because it's a lot cheaper to, you know, kill someone off than it is to keep treating them right.

If, uh, if their situation seems hopeless. Um, so I was going back to the pharmacist who, all of a sudden, they feel as if, as though they've done something heroic, they've gone against their basic instinct of not providing something that will terminate the patient's life. And, um, And they kind of need a pat.

They feel like they need a pat on the back, you know, that they've done this, this terrific act of hero heroism. And it's, it's a twisted view of, uh, of reality, you know. 

[00:28:34] Mike Koelzer, Host: Do you think that that move towards heroism is subconscious? They try to bring that out of themselves to get a pat on the back that they know they don't deserve, but it might somehow take away that yuck factor.

[00:28:49] Cristina Alarcon, BPharm, MBE: I think it's probably a way of ACE raging, their conscience. I said earlier, everyone has one. Everyone has this. Yeah. Um, ability to dialogue with one's self and, um, right. And think about what they've just done. Um, and also there's people who do participate in it, then they never wanna do it again, you know, because it's like, I can't do that.

You know? Uh, why can't they do it? They don't even know why they can't. Can't. 

[00:29:16] Mike Koelzer, Host: So this was all basically back in 2009. So for the last 10 years you made your statements, your studies and so on mm-hmm and then how, how does it either affect your life or how do you stay involved in and so on for better or for worse?

[00:29:33] Cristina Alarcon, BPharm, MBE: Okay, so what I've done, um, since the very beginning, I would say starting in the year 2000, and now we're at 2019, , uh, believe it or not is, um, You would've thought that this was a crazy thing to do, but I became sort of a public figure. Um, in a sense, I wanted the public. I wanted to. To be out there. Um, it was a means of actually protecting myself as well, because I thought if I'm out there, it's known that the college knows my stances.

Yeah. Right. Um, I debated, you know, on television. I, so, so things are known out there. And, um, since then, I've just, I've kept, I wouldn't say a high profile. Um, maybe less so. You know, opportunities have not arisen. Um, but also I haven't been seeking it necessarily. Um, I think we've accomplished a lot since, um, the youth, well, we've gone backwards in having youth assisted suicide, but we've accomplished a lot in a sense of.

Bring awareness out there and the laws still are not perfect, but, uh, they're better than they, they, the policies are, the college policies are not, are better than they used to be for sure. Uh, yeah, there's also a greater awareness. And for myself personally, I was lucky enough to have an understanding boss who allowed me to, I was not a business owner.

I've never been a business owner. Um, I practiced in the community setting for, uh, most of my career. I started out in hospital pharmacy for my first eight years of the career and then moved on to, uh, to community drugstore, no practice. And yeah, you think that that would be incompatible with all the stuff I've been doing?

Um, yet, um, if anything. You know, there's only positive things that have come out, uh, of my work. And I've also done a lot of writing. I write for the community in the healthcare network where I write on various topics through business. Sorry, not just business, uh, sorry, not just ethical, controversial issues, but also just business topics.

Um, and. Yeah. I just feel that there needs to be, um, a place for pharmacists to talk about these more needy issues. And yeah, sometimes because of the work I've done, I've had calls or emails, um, from pharmacists, from across the country. Um, young pharmacists, you know, just graduated. Yeah. Because they need advice, how to deal with an employer, for example.

And there's yeah. You know, where you need to have a good lawyer as well. you need to have a lawyer, um, because these issues are employment issues. Uh, and this is where pharmacists, we, tend to be quite afraid of speaking out. In fact, when I was. Lobbying for college. I was taken out to dinner by one of the college members and she said to me, you know, I said, why do you have so many rules and regulations?

You know, and why the ethics, uh, the code of ethics spells everything out. Like it doesn't make sense. You have to leave room for. Some thought, right? You have to . Yeah. Yeah. And, uh, she says, no, it's because, you know, pharmacists like to have everything spelled out, you know, they call us and say, what do I do in this situation?

What do I do in that one? Yes. And said, well, yeah, but we have a mind, you know, we're we're persons with, with minds, you know? And 

[00:32:54] Mike Koelzer, Host: So yeah. Pharmacists are our rule, our rule followers in general. Yeah. 

[00:32:57] Cristina Alarcon, BPharm, MBE: Right. Um, so it's good to have rules. I'm not saying we, we shouldn't, but we can't be, have more rules than, than the Catholic church, you know?

yeah, yeah. Even there, you know, as, as a, as a Roman Catholic, you know, I know that that, that, that the church allows for freedom of conscience, you 

[00:33:14] Mike Koelzer, Host: know, so well, and not only, not only do they allow for the informed conscience to take precedence over any other. Any other thing that points to morality, the informed conscience is primary.

That then all of that, I think the key though, is that a lot of times people, uh, don't choose an informed conscience. They're really looking at their well, either uninformed conscience or enough. Enough information just to, um, maybe make a decision that they think might be best for them. 

[00:33:47] Cristina Alarcon, BPharm, MBE: Exactly.

So their, their reason they have to examine their, their reasons for their actions as well. All that 

[00:33:54] Mike Koelzer, Host: Let's ask this. So. I own my pharmacy. I've made a choice not to sell a lot of stuff. I don't, I don't sell real expensive cancer medicines that are gonna go outdated. I don't sell, uh, magazines in my store. I don't sell contraceptives in my store.

It's my store. It's my choice. I sell what I want to sell in my store. Yeah. Um, what if somebody were to work for me? And their conscience was that they don't want to sell anti-anxiety tablets because they say that the Bible says that we should not worry, that we should depend on God for our daily bread and not worry about tomorrow.

What if, what if. What if that person's conscience said that they don't wanna sell the, the Xanax and, and, uh, you know, these kind of medicines, do I have protection against that because does conscience only go to life and death issues or, or do I have to worry about that as a business person? That's 

[00:35:04] Cristina Alarcon, BPharm, MBE: a very, very good point.

Um, yes. As a business person, you should, uh, you should worry, uh, not worry, but you should be concerned. Right? We, we can't um, I mean, how can I say, look as employees. We also have to respect the business aspect. Um, mm-hmm we can't do things well, as an example, we shouldn't be preaching to patients. That's one of the things that, you know, always is always brought up, like you shouldn't be preaching to patients.

Yeah. We shouldn't make ourselves obnoxious. Um, In, in the case you mentioned anti-anxiety pills. Yeah. There's not just the Bible. There's a lot of psychiatrists now saying that, you know? Sure, sure. People end up getting addicted to a lot of this stuff. Mm-hmm you can think of antidepressants I've read.

Yes, exactly. Good books about, uh, written by psychiatrists who are concerned about some of the side effects and patients are not being forewarned about these. So, yes. I mean, I would take this employee aside and say, look, um, you know, and this is not a life and death situation, the patient. We should be telling the patient, the patient has a right to be informed of all options and of the possible side effects and the possible problems with these medications.

Um, I, you know, I have a friend who refused for example, to give out cholesterol pills because she was saying it was ruining people's hormones and really, and the guidelines were way too low. And, um, so she just didn't wanna spend Lipitor or anything related to that. Interesting. And, um, so. So, what do you do in a case like that?

You know, it's not a life and death situation, although you could say, you could say, well, the patient's not getting his, uh, cholesterol. He might end up having blocked arteries and die of a heart attack. right. Um, an argument could be, could be made for the opposite, you know, that he could end up with yeah.

The opposite with dementia, because. Yeah, they're looking at studies showing that it, uh, these drugs can, they can do more 

[00:37:06] Mike Koelzer, Host: Harm than good. And he might, he might die by accidentally lighting the house on fire or something like that. Yeah. All right. So what do, so what do you do as an owner then? Is there any protection for me as an owner?

If someone like me comes in as an employee and says, I'm not gonna do cholesterol, I'm not gonna do estrogen because I, I don't agree with that. They make this drug or how it treats the women and I'm not gonna do X, Y, and Z. So, is there protection for the business person in those cases? Yes. 

[00:37:37] Cristina Alarcon, BPharm, MBE: I mean, as a business person, you have to accommodate to the level of, um, undue hardship, but.

These are pharmacological issues that we are talking about now, are they conscience issue? Is it a conscience? It's definitely, it's not a religious issue as such. I mean, there's not, you can't say that, you know, in the Bible it says that you mustn't dispense analysis. Um, it does say trust in God. So as a business owner, you do have to speak to your employees, know, know their thoughts on these things, and then.

You do have to sit down some 

[00:38:07] Mike Koelzer, Host: guidelines. I can see that if I decided to work for an abortion clinic and all of a sudden, I said, I'm not going to answer the phone anymore, but I'm, I'm the secretary there. I can see, you know, it just seems like some things that the boss has, the business should have an ability to say that you're not doing, you know, you're not doing your job either.

So it's a tough one. 

[00:38:31] Cristina Alarcon, BPharm, MBE: It's a tough one. Um, I. Anything, any of our, how can I tell you? I mean, our decisions need to be evidence based, you know, so, and also again, taking into account that the patient is also a decision maker, right? So in this case, um, you are giving something to the patient. Um, but your action is not like, is not producing the effect of killing anyone.

Or not. 

[00:39:05] Mike Koelzer, Host: Okay, but, okay. So, but is that written in the conscious law about killing someone? Because we can say that birth controls in and of themselves and the mechanism of action talks about decreasing the lining of the uterus, which reduces the likelihood of implantation. So we can, we, we can be talking about this.

Is that anywhere though, in the. conscience clause to protect the business, to say that it has to be a direct life and death matter, or is it just the, or doesn't it get that deep? No, it 

[00:39:39] Cristina Alarcon, BPharm, MBE: doesn't get that deep. Well, maybe it should. So that's it. Yeah, maybe it should. Yeah. I'm gonna play devil's advocate there with birth control because as you know, we call it birth control, but it's often used for many purposes.

Yeah. So, um, you know, I may disagree with the purposes. I think sometimes, you know, it's used as a band aid solution for women's problems that are not looked at. We don't look at their root costs and try to treat that, just put a bandaid solution to a lot of things. Yeah. Um, So the birth control pill for me is one of those, you know, it's a bandaid solution.

Um, and, uh, you know, Yeah, it can potentially, um, you know, thin the line of years and prevent implantation, but we, you know, I have no control over what that woman's gonna do with her body, right. So she may or may not go out and, and, and 

[00:40:28] Mike Koelzer, Host: have sex. I'm gonna play devil's advocate back and say, that is the.

It's indicated right for that. And so somebody might come in and also buy some other drugs that are used to clear out an abortion, uh, after the right after it's been aborted and so on. But those drugs, I would play devil's advocate and say, those are not indicated for that, but the birth control number one.

It's indicated for that. Yes. And also it's a mechanism of action for that indication. So I would say if you're looking for something in black and white, yes. It can be used for other reasons, but. In black and white, I would argue that's both the indication and the mechanism of action. Yes. So I would say that's one that I would put higher on the list of a possible conscience.

Objection. Yes. It's tricky though. It is tricky here. You and I are sitting here and we're both, we're both on the same side of this, but you can see that even those on the same side can say, where does it fall in, in line? So it's tough. 

[00:41:37] Cristina Alarcon, BPharm, MBE: I mean, I think ideally, um, a pharmacist who has any kind of objection to anything, it can, it can be, like you said, anxiolytics, it can be anti antidepressants, it can be birth control.

It can be cholesterol, whatever, whatever, uh, you know, ideally they shouldn't place themselves in a situation where they are the pharmacist, it would be much easier for them. If, and I, I say this, I speak from experience. Um, yeah. You know, I was lucky enough to. For almost 20 years to work in a pharmacy where, you know, we were at least three pharmacists in, in one shift.

Now when I became manager of that store in 2012, um, which I did from 2012 to December, 2018, um, then, uh, you know, I was able to set a few more, there was more of a new way for me to set some rules as to what we carried and didn't carry, um, sure. And I negotiated with my boss, uh, the ability of not carrying, um, plan B or the morning after pill, that was back in 2016, so right.

Which was really cool. And so we were able to negotiate some things. And I think that that's where you were saying, well, you are the, as a business owner, you need to talk to that employee and negotiate and see where, yeah. How far can the business accommodate this or does it make sense to accommodate this?

Um, you know, Uh, does it make sense at all? You know, I mean, anxiolytics again, it's not in fact not giving it to someone who needs them can be, can jeopardize the patient's health. Right. So, um, You know. Yeah. And, and the whole topic of, of, uh, you know, I, I believe in this of life from, from the moment of conception to natural death, you know, and, uh, yeah.

That's as a Roman Catholic and I, you know, I don't go back on that. Um, but obviously there's degrees of evil. Right, right. So there's so, so for me, um, birth control. Yeah. It's a, it's a certain degree. I wouldn't put it on the same. If you put it on the, on a scale, uh, euthanasia is suicide for me is, is more horrendous.

Uh, yes. Now you have to think, you know, think about. Sometimes I stop. And I think about why it is that pharmacy became the gatekeeper of birth control to begin with? Yeah. Because if you think about it, um, it doesn't need a pharmacist for dispensing and you know, you can have it in a machine for all I care.

I, you know, certain, you know, you, you don't. I know many pharmacists would disagree with me on this. They, they see as a therapeutic option, but however, if you read the side effects, which you know, are, you know, if you, you roll out all of the side effects in that little pamphlet, you go, whoa. You know, is this doing women more harm than good?

And I think we've become so accustomed to just dispensing that we no longer, even mindlessly. Um, dispense the, the drug company is happy that we are mindlessly dispensing and, um, I've actually written about the effects of birth control on even our water system. And everyone's talking about the ecology, you know, that's another topic for another show.

[00:44:53] Mike Koelzer, Host: Yeah. It's tricky though, because once, once you go down that road, then, then you can look at almost every drug of the negative that's true effects that it's having. Yeah, that's true. So I, I. I think both sides owe it to each other. And I see it from both angles because at one point I was an employee of my dad who's since passed, but I think both sides.

It is to each other to, um, to speak up. And I think that it's, it's tricky. I 

[00:45:19] Cristina Alarcon, BPharm, MBE: think you've just hit the nail. There needs to be the ability and opportunity to dialogue. 

[00:45:25] Mike Koelzer, Host: I don't think there's necessarily easy answers. It's not clean, it's not clean by any means, but I think that the conversation has to be at minimum.

The conversation has to be had. 

[00:45:35] Cristina Alarcon, BPharm, MBE: Yeah, exactly. And that's where, um, Yeah, I think that by even just having this opportunity to speak on this podcast, it gives us a chance to air out some issues that I think a lot. People may be thinking about, but not able to put in words, To articulate. And by articulating some of these thoughts, we're actually helping, I think I hope 

[00:46:05] Mike Koelzer, Host: and I agree, Christina, and I think that, I think one thing it helps people to do is know. There's even a language out there, years ago, I always thought that I was, I never felt right going into the pharmacy.

I would get like butterflies and stuff. And I never knew that that language existed about nervousness and anxiety and, and mm-hmm, , you know, this and that and, and just. Just being able to know that the language is out there with the words like maleficence and just knowing that there's a language out there helps people to name some of those feelings.

And, and, and sometimes we can't name 'em even too much better than just calling it the yuck factor. Yeah. But there is a language and people, people. Can and should be talking about it. 

[00:46:50] Cristina Alarcon, BPharm, MBE: Yeah. I mean, 

yeah. Again, you hit the nail on the head. just open up conversation. Don't be afraid of dialoguing with people who disagree with you.

Um, yeah. Uh, you know, I find it's the most enriching thing ever. Like I have friends who don't see me, I, I, with me on these issues at all, but yeah. You know, the fact that we're able to carry on, um, a conversation and. And try to see each other's point of view. Right. Um, you know, frankly, sometimes we're too caught up with ideology and, um, yeah, we're afraid because what are people gonna think?

You know, so yeah. You know, a big drug comp, sorry, a big, uh, corporation, you know, takes over little independent and all of a sudden now, you know, it becomes a problem now, you know, you are no longer able to have a accommodation because, you know, um, It's it's a becomes a political issue for them or becomes an ideological and.

It's unfortunate because where there's a will, there's a way there's a, there's a way to accommodate people who dissent from, from the norm. And I'm not talking about wacko ideas I'm talking about in, in my case, it's. It's any drug that does not respect life from the moment of conception to natural death.

I mean, yeah. You could also include in the middle of that. Well, anxiolytics or whatever. I don't know. Yeah. I don't know why it's hard to say that's opening up a can of worms in a little bit. Um, 

[00:48:23] Mike Koelzer, Host: yeah. It's um, It's hard to say, but the, but the conversation is good. 

[00:48:29] Cristina Alarcon, BPharm, MBE: Yeah. The conversation is good. And, and again, going back to, to other medication, I think as pharmacists not, I think I know as pharmacists, we are the primary educators of the patient on drug therapy.

Mm-hmm um, unfortunately that's been taken over a little bit by. Self, the self interest of drug companies who are now, um, doing direct to patient consumer marketing and which should never have happened. Right. And, um, sometimes the doctors are in on it too, because they have a cut. Right. So they're getting some compensation from the company.

So not all doctors, but some, um, so the pharmacist really has to remain neutral in terms of, of therapy on Lyrics antidepressants, even though maybe. Not pro some of these things. 

[00:49:13] Mike Koelzer, Host: And for the record, I don't have a problem myself with anti-anxiety or depressants. I was, no, that was just a point I was, that was just a point I was making and think you'd have to be.

And I think that even though I was playing devil's advocate about those, I think that life and death is certainly that's more clear cut. That's more clear cut. And I think it has to be more clear. For anybody. I mean, you look at some of the worst of the worst, you know, serial killers or whatever, and there's not much debate around whether they're gonna have potatoes or oatmeal, but, but, but certainly the conversation when it comes down to a life conversation of whether they're gonna be put to death or not, mm-hmm,

That gets people talking. And so even though I was playing devil's advocate, certainly the life death issue is the primary, uh, discussion point. It seems. 

[00:50:09] Cristina Alarcon, BPharm, MBE: Yes. And, and when you talk about capital punishment, I mean that, you know, there's a lot of. Of people out there, pharmacists included who would not want to prepare drugs for yeah, exactly.

Execution. Because, well, for many reasons, one of them might be that right. You know, sometimes mistakes are made, so right. Um, or they just think they just don't believe in execution. They believe in re trying to rehabilitate the prisoners. So, um, 

[00:50:37] Mike Koelzer, Host: again, well, I, I always like to think that I always like to think that.

Um, that we're doing you and I, uh, looking at conscience are doing the job of everybody, because at some point, at some point it's going to come up in someone's life, even though you don't, you don't know when it's gonna come, there's all kinds of stuff. That's coming down the road that as we talked about with someone's own grandma facing whether they should mm-hmm.

call their life short because of, uh, insurance, you know, rebates or whatever. 

[00:51:13] Cristina Alarcon, BPharm, MBE: Absolutely. And I'd like to just, uh, mention that there're actually two Canadian provinces. Obviously the ideal conscience clause. And I'm gonna just read it because it's so amazing. New Newfoundland Labrador, for example, they, uh, they state that accommodation for the objector must be provided by management, which is amazing that they even state that management develops.

And then it's management that develops a means to ensure the medication or services are provided. So it's not the object. That's ensuring. Right. Yeah. Um, so I think that's the, that's the key that you don't force the objector to be the one PR uh, doing the referral or the provision, but that someone else takes over that role.

In my case, it was my pharmacy assistant who would screen the prescriptions and not give me the ones I wasn't gonna fill. So Newfoundland Labrador and also Nova Scotia are the two that, uh, that have that kind of a statement in there. And I think that's really important and respectful.

[00:52:18] Mike Koelzer, Host: Yeah. That makes a lot of, it makes a lot of sense. Well, Christina, it was a pleasure having you on and we could go on forever, but I think this gave people enough to kind of wet their appetite 

[00:52:27] Cristina Alarcon, BPharm, MBE: a little bit. Wonderful. Well, thank you so much for having me on Mike. It's been a lot of fun. 

[00:52:31] Mike Koelzer, Host: My pleasure. Thank you very much, Christina.