Perspectives of community pharmacists on conscientious objection to provide pharmacy services: A theory informed qualitative study

Abstract

Background:
In recent years, pharmacists have been opting out of certain pharmacy services, particularly, providing contraceptives, for moral reasons. No research has been conducted on the perceptions of community pharmacists toward conscience objection in a secular state with a mostly Muslim population.

Objective:
This study aimed to provide an in-depth understanding of the factors related to the beliefs of community pharmacists on conscientious objection to provide pharmacy services contrary to their personal beliefs based on the theory of planned behavior.

Methods:
Semistructured interviews were conducted with a purposive sampling of community pharmacists. A hybrid deductive and inductive qualitative analysis approach was used on the data that were recorded and transcribed verbatim. Constructs related to attitude, subjective norm, and perceived behavioral control were explored.

Results:
In total, 25 community pharmacists were interviewed. Factors affecting pharmacists' decision to provide pharmacy services when their personal beliefs included the desire to maintain moral integrity, beliefs about consequences for health care service, profit, patient pressure, precedence of professional values, and care for religious sources.

Conclusion:
Most of the community pharmacists were against the behavior of conscientiously objecting to provide pharmacy services in Turkey because of possible negative consequences on health care. The pharmacists who were willing to act based on their personal beliefs were expecting from various third parties to fulfill certain responsibilities to facilitate to adopt the behavior. This novel study highlights the urgent need for more research and training for community pharmacists serving patients in different socioeconomic contexts in both developed and developing countries.

Full text

RESEARCH
Perspectives of community pharmacists on conscientious
objection to provide pharmacy services: A theory informed
qualitative study
Gizem Gülpınar
*
,S¸ ükrü Keles¸ , Neyyire Yasemin Yalım
article info
Article history:
Received 23 December 2020
Accepted 21 March 2021
Available online 29 March 2021
abstract
Background: In recent years, pharmacists have been opting out of certain pharmacy services,
particularly, providing contraceptives, for moral reasons. No research has been conducted on
the perceptions of community pharmacists toward conscience objection in a secular state with
a mostly Muslim population.
Objective: This study aimed to provide an in-depth understanding of the factors related to the
beliefs of community pharmacists on conscientious objection to provide pharmacy services
contrary to their personal beliefs based on the theory of planned behavior.
Methods: Semistructured interviews were conducted with a purposive sampling of commu-
nity pharmacists. A hybrid deductive and inductive qualitative analysis approach was used on
the data that were recorded and transcribed verbatim. Constructs related to attitude, sub-
jective norm, and perceived behavioral control were explored.
Results: In total, 25 community pharmacists were interviewed. Factors affecting pharmacists’
decision to provide pharmacy services when their personal beliefs included the desire to
maintain moral integrity, beliefs about consequences for health care service, profit, patient
pressure, precedence of professional values, and care for religious sources.
Conclusion: Most of the community pharmacists were against the behavior of conscientiously
objecting to provide pharmacy services in Turkey because of possible negative consequences
on health care. The pharmacists who were willing to act based on their personal beliefs were
expecting from various third parties to fulfill certain responsibilities to facilitate to adopt the
behavior. This novel study highlights the urgent need for more research and training for
community pharmacists serving patients in different socioeconomic contexts in both devel-
oped and developing countries.
©2021 American Pharmacists Association
®
. Published by Elsevier Inc. All rights reserved.
Background
As the scope of medical practice expands, some health
care providers have begun seeking consensus on exemption
from providing services that contradict their personal be-
liefs.
1
One’s refusal to take any action by free will is
regarded as freedom, and the right of a pharmacist to
refuse to provide certain medicines and health care services
on conscientious grounds has been discussed in the liter-
ature.
2-10
Although the ramifications of conscientious objection (CO)
in health care have been investigated significantly, empirical
studies on the subject in pharmacy are few.
8,10,11
According to
the studies conducted in the United States, United Kingdom,
and Poland, many pharmacists are reluctant to provide con-
traceptives based on conscience,
2
,
3,12
because these medicines
contradict their religious beliefs.
7
Pharmacists’attitudes to-
ward the supply of emergency contraceptives (ECs) have
mostly been explored in an ethical or religious context in
Western countries compared with the Islamic world. In the
United Kingdom, 2.6% of pharmacists have been reported to
have objected to supplying ECs on moral grounds.
13
In 1999,
the year Walmart announced its decision not to dispense ECs,
it was the fifth largest pharmaceutical distributor in the United
Disclosure: The authors declare no relevant conflicts of interest or financial
relationships.
*Correspondence: Gizem Gülpınar, BPharm, MsC, PhD, Department of
Pharmacy Management, Faculty of Pharmacy, Ankara University, Emniyet
Mah. D€
ogol Cd. No: 4, 06560, Yenimahalle, Ankara, Turkey.
E-mail address: gaykac@gmail.com (G. Gülpınar).
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association
journal homepage: www.japha.org
https://doi.org/10.1016/j.japh.2021.03.014
1544-3191/©2021 American Pharmacists Association
®
. Published by Elsevier Inc. All rights reserved.
Journal of the American Pharmacists Association 61 (2021) 373e381
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States.
14
One survey conducted among pharmacists in Oregon
and New Jersey revealed that more than half of the pharma-
cists expressed that provision should be made to allow refusal
to prescribe medications that are against their religious be-
liefs.
15
Another survey among pharmacists in Nevada revealed
that 6% of the pharmacists were not willing to dispense
controversial medicines to patients.
8
Some qualitative studies
have revealed that adolescents are reluctant to request EC
from pharmacists in the United Kingdom and United States
because of fear of stigmatization.
11,16
Aside from dispensing
ECs, medicines used for cognitive enhancement which are
known as pharmaceutical cognitive enhancers (PCEs)dsub-
stances able to improve some cognitive functions owing to
their action on the biochemical balance of the braindhave
triggered an important debate in philosophy and bioethics.
The substances most commonly included in the set of PCEs are
drugs used off-label by healthy people without specificdeficits
who want to improve their standards of intellectual and
cognitive performance.
17
A study investigating the attitudes of
professionals (pharmacists, doctors, nurses, lawyers, and ac-
countants) toward the use of PCEs in academic settings in New
Zealand showed that they felt ambivalent about the use of
PCEs if prescribed by a physician.
18
Turkey is the only secular state that is mostly Muslim.
19
The constitution of the Republic of Turkey has clarified
that the country is a secular state with full freedom of
religion. Although Turkish law and other social structures
involve elements of both secular Western and Islamic
Eastern cultures, Islam has a great influence on society,
especially in rural areas.
20
No comprehensive law exists in
the legal regulations on CO for health care providers in
Turkey. According to Article 3 of the Turkish Pharmacists
Deontology Code, a pharmacist cannot refuse to provide
services on conscientious grounds:
A pharmacist is obliged to pay maximum attention and
care, and prescribe for the patient, regardless of gender,
language, race, nationality, philosophical belief, religion
and sect, moral thought, character and personality, social
level, position and political thought.
21
However, like many other countries worldwide, a conser-
vative conjuncture based on moral concerns and personal
beliefs has become dominant in Turkey in recent years. The
most noticeable characteristic of this era is that belief-based
approaches have become more prevalent in health care
practices.
19
Most of the studies focused on controversial services
affecting the attitude of physicians and patients in service
providing in the Islamic world.
19,20,22-25
In recent years,
controversial services in medicine have become debatable in
decisions on pregnancy termination and end-of-life practices
(physician-assisted suicide, euthanasia) and in the provision of
health care services to transgender patients and to patients of
the opposite sex.
20,22,26
No study has been found to explore the
pharmacists’refusal to provide pharmacy services contra-
dicting their personal beliefs in an Islamic country. In addition
to having concerns about the refusal to dispense certain types
of medicines, an observation has been made in countries such
as the United States, United Kingdom, Canada, Australia,
France, Germany, Russia, India, and South Africa, where Mus-
lims live as a minority, that awareness and sensitivity toward
the content of haram substances [religiously forbidden sub-
stances to Muslims: alcohol and pork] in medicine have
increased.
27,28
The sensitivity to haram medicines in Turkey
has been relatively new.
28
The use of pork gelatin instead of
bovine in the production of capsule medicines by some Eu-
ropean drug manufacturers started the “halal-haram drug”
debates in Turkey in 2013, after the mad cow disease, or bovine
spongiform encephalopathy.
29
Although some of the phar-
macy professional bodies in Turkey announced that the only
matter of relevance is to maintain patients’health, conflicts of
opinion have begun among both physicians and pharmacists.
The recent tendency of community pharmacists in Turkey to
adopt belief-based approaches can be examined within the
framework of discussions held on CO.
Pharmacists’refusal to provide pharmacy services or to
dispense certain medications raises a particular concern for
patients living in more rural areas.
8
Some small towns in
Turkey have no more than 1 or 2 pharmacies, which may limit
patients’ability to find an alternative that they can reach by
walking or driving. For example, ECs pose a substantial barrier
to patients living in rural areas, given that it should be taken
within 72 hours of unprotected sex to prevent pregnancy.
Community pharmacists, like in other parts of the world,
are seen as some of the most accessible health professionals in
Turkey. Community pharmacists not only distribute medi-
cines, but also provide information about the effects, possible
adverse effects, dosing, application, and interactions of medi-
cines.
30
Even though this advisory role is included in phar-
macy law in Turkey,
31
pharmacists provide these services to
the public free of charge, as pharmacy counseling services are
not funded.
32
Consequently, the scope of pharmacy services is
mostly shaped on the basis of drug dispensing.
33
Sancar and
Okuyan
34
showed that most of the community pharmacists in
Turkey are willing to provide advanced pharmacy services;
however, they listed some barriers that hinder them from
providing these advanced services. Pharmacists have also not
widely realized their potentially critical role in promoting
Key Points
Background:
No study has been found to explore the pharmacists’
refusal to provide pharmacy services contradicting
their personal beliefs in an Islamic country.
This study would be the first theory-driven study
examining factors associated with the perceptions of
community pharmacists on the refusal to provide
pharmacy services contrary to their personal values.
Findings:
Most of the community pharmacists were against the
behavior of CO to provide pharmacy services in
Turkey because of possible negative consequences
on health care.
The proponents of CO considered value conflict and
failure to fulfill certain responsibilities by the third
parties as barriers.
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rational drug use and effective drug management.
35
Non-
dispensing pharmacy services in Turkey cannot go beyond
information-giving in community settings. Only pharmacies
can sell medicines to consumers in Turkey.
32
The medicines
are classified into 2 groupsdprescription-only medicines
(POMs) and nonprescription medicines.
36
Nonprescription
medicines, which are licensed at national pharmaceutical
markets to be purchased without a medical prescription,
usually from community pharmacies, are used in self-
medication in Turkey.
30
As discussed, ECs, which are among
the controversial medicines, are classified as POM; however,
haram medicines or cognitive enhancers can be either POM or
nonprescription medicine, based on the constituting active
ingredient.
The aforementioned debates and concerns regarding the
refusal to provide pharmacy services suggest that these “new”
attitudes, which were not previously experienced, are begin-
ning to become established in community pharmacy settings
in Turkey. Understanding these new attitudes is important to
ascertain imminent changes in pharmacy. In this respect,
investigating community pharmacists’experiences in com-
munity practice within the framework of CO on the grounds of
personal beliefs is essential.
Explaining the influences on adoption of certain behaviors
is best understood within theoretical frameworks. Although
many theories, such as the theory of reasoned action,
37
the
self-determination-theory,
38
and the social cognitive theory,
39
have been proposed and tested to understand behaviors in
health care settings, the theory of planned behavior (TPB),
whose pivotal concept is the intention to perform the behavior
as an antecedent of the behavior itself, has gained increasing
popularity for its relevance to understanding the motivation to
adopt a particular behavior. As depicted in Figure 1, this
qualitative study employed TPB in answering a specific ques-
tion related to community pharmacists’CO in providing
pharmacy servicesda phenomenon that is governed by a
unique set of dynamics. This study would be the first theory-
driven study examining factors associated with the percep-
tions of community pharmacists on the refusal to provide
pharmacy services contrary to their personal values in a
secular state like Turkey, which has adopted mostly Islamic
values. This in-depth understanding of the factors that deter-
mine pharmacy service provision on conscientious grounds is
important for developing an ethical perspective on CO among
community pharmacists. A further aim was to contribute to
the discussion on CO in pharmacy literature.
Objectives
The aim of this study was to provide an in-depth under-
standing of the factors affecting the perceptions of community
pharmacists on CO in providing pharmacy services contrary to
their personal beliefs based on the TPB.
Methods
A qualitative method was employed, using semistructured
interviews for data gathering. Semistructured interviews were
considered most suitable, given that the subject is a sensitive
matter of values. Thus, participants should be unrestricted in
providing their answers.
Theoretical framework
TPB is a well-known social psychological theory of human
behavior, developed by Ajzen and Fishbein
37
to explain and
predict behavior of individuals in a specific context.
41
According
to TPB, attitudes (individual’s overall evaluation of a particular
behavior in the direction of positive and negative judgments,
beliefs, andemotions related to the behavior), subjective norms
(perceptions about the views of others) and perceived behav-
ioral control (perceptions of the difficulty of performing a
behavior) are predictors of that individual’s behavioral intention
(plan to perform behavior) and consequently determine the
likelihood of the individual carrying out that specificbehavior.
40
TPB has been widely used in literature on pharmacy practice to
explain pharmacists’behaviors, including vaccination, medica-
tion management, and adherence-related behaviors.
42-45
Study population
Purposive sampling was used to recruit community phar-
macists inTurkey. Inthe light of the abovementioneddiscussion,
the starting point of these belief-based approaches in service
provision was religious sensitivities of health care providers in
Turkey. Therefore, religious sensitivity thought to affect service
deliveryof participants was used as a parameter in the purposive
sampling. Participants included in the study were balanced in
terms of low or high religious sensitivity. Participants who were
adhering tothe 5 pillars of Islam
46
dfaith, prayer, charity, fasting,
and pilgrimagedwere considered to be highly religiously sen-
sitive.Initially,pharmacists whowere known to have high orlow
religious sensitivity by the research team were invited. There-
after, participants with high or low religious sensitivity were
recruited using the snowballing technique. The study did not
have a target sample size; rather, it aimed to recruit participants
until saturation was reached. Ongoing preliminary data analysis
was being conducted during data gathering.
Data collection
Semistructured interviews were conducted between
January and May 2019. The TPB constructs framed the different
items of the interview guide (Appendix 1). The interview guide
piloted with 3 participants to assess face and content validity.
Participants of the pilot study were not included in the sample.
Most questions were open-ended to allow the emergence of
relevant topics and themes without constraint. Probing ques-
tions were asked to clarify or expatiate on participants’com-
ments when necessary.
The in-depth interviews, which were conducted by the first
author (G.G.), lasted from 30 to 60 minutes. The interviews
were audio-recorded after obtaining participants’consent.
Data analysis
A hybrid deductive and inductive qualitative analysis
approach was used.
47
Utilizing an interview guide framed by
TPB and a priori coding of the data back to the TPB illustrates a
deductive approach, and the generation of codes and sub-
themes from the same central meaning units illustrates an
inductive approach. All the interview recordings were de-
identified by assigning a protocol number (The protocol
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number assigned to participants was coded as follows:
“Pharm”[for Pharmacist] and the sequence number of the
interviewee [e.g., Pharm1] and the line number of the quota-
tion [e.g., L.2]) and were transcribed verbatim. A rough reading
of the written interview texts was conducted to gain a general
understanding of the responses by the first author. The first
author started familiarizing herself with the data by reading
and re-reading transcripts, noting the participants’use of
particular words or thought patterns emerging from the data
(Step 1). This was followed by discussions among the first and
second authors. Initial coding was used to develop a list of
codes representing major conceptual categories within the
data. This master codebook was developed and refined by the
entire research team through biweekly meetings. The first and
second authors independently coded all the interview tran-
scripts and identified prevalent codes. Next, subthemes were
then created from the prevalent codes and memos regarding
the conceptual and theoretical ideas that emerged during the
course of analyses by the first and second authors (Step 3). The
research team (G.G., S¸ .K., N.Y.Y.) discussed and structured the
subthemes through biweekly meetings. The presence of
multiple investigators with different backgrounds in the
research team was used to foster reflexivity. All 3 authors have
an interest in public health. The first author is an academic
pharmacist with an interest in research exploring pharmacists’
behavior. The second author is an academic in the field of
medical ethics, whereas the third author is an academic
physician with an interest in medical ethics. The first author
verified the findings with the second and third authors
throughout the analysis process. This was done with the aim of
providing a context within which researchers’beliefs, per-
spectives, and assumptions can be revealed and contested.
Consensus was reached by discussion between all 3 authors
(Step 4). Through deductive coding, subthemes were grouped
in themes based on the constructs of TPBdattitude, subjective
norm, and perceived behavioral control. An example reflecting
this process is the grouping of the subthemes “beliefs about
consequences for health care service”and “beliefs about
maintaining moral integrity”were grouped in “attitudes to-
ward CO.”(Step 5). Findings were interpreted and discussed in
the light of reviewed literature to gain a comprehensive
perspective in line with TPB (Step 6). This study closely fol-
lowed the research principles described in the checklist of the
consolidated criteria for reporting qualitative research.
48
To ensure study rigor and trustworthiness, interviewers
used consistent pilot-tested interview guides and reflective
journaling to document their reactions after the interviews,
and the research team used negative cases as described in the
section on data collection. In this study, the interviewers
recruited the negative cases purposively. The negative cases
represented the pharmacists with low religious sensitivity
with the aim of understanding all aspects of CO in providing
pharmacy services if other types of concerns, such as refusal to
provide cognitive enhancers, which are not related to religious
beliefs, would be present.
Ethical consideration
Ethical approval was obtained from the Ankara University
Ethics Committee (approval date: 01/02/2019; protocol num-
ber: 09) before commencement of the study. Informed consent
was obtained from each participant.
Table 1
The demographics of the participants
Demographics n
Sex
Female 11
Male 14
Location of community pharmacy
City center 15
Outside city center 10
The class of the population served
Upper-class neighborhood 8
Working-class neighborhood 10
Poor minority neighborhood 7
Religious affiliation
Muslim 18
Atheist 2
Deist 1
Other 4
Total (N) 25
Atud e
Subjecve norm
Perceived
behavioral
control
Intenon to refuse to
provide pharmacy
services contradicng
personal values
Atudes toward CO
Healthcare service
Moral integrity
Perceived normave beliefs
Professional values
Paents’ demands
Religious sources
Physcians’ direcves
Perceived control beliefs
Value conflict
Expectaons from third pares
Refuse to provide
pharmacy services
contradicng personal
values
Figure 1. The theory of planned behavior framework adapted from Ajzen.
40
Abbreviation used: CO, conscientious objection.
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Results
Twenty-five community pharmacists were interviewed in
total (Table 1). The average age of the participants was 40
years, and the ages ranged from 32 to 60 years. Collectively, the
participants had a wide range of community pharmacy expe-
rience, ranging from 1 to 39 years. More than half of the par-
ticipants (52.2%) had been practicing Islam according to the 5
pillars of Islam. Four participants did not state their religious
affiliations; thus, they were classified as “Other.”
Attitudes toward CO
Beliefs about consequences for health care service
Participants mentioned that there might be possible out-
comes of CO if it becomes a legally recognized right. Participants
expressed that a law might end up with discrimination and
stretching the interpretation in practice. Most of them
mentioned that violence in health and injustice in access to
services mightoccur. Some of the participants indicated that the
qualityof health care service delivery will be affected because of
a stretch in the implementation of the law, which may lead to
difficulties in setting standards in the profession. Some reported
that there might be a ghettoization in the end. They referred
that stretching the laws might result in restricting a certain
group of people from accessing pharmacy services that do not
align with pharmacists’personal beliefs:
This time, there might be separation. Will women and men
take services separately? So it’s better to introduce the rules
of Sharia? Ohh…What a shame! (Pharm13/L.116e117)
Pharmacy services must be provided in a standard manner.
If such a law is enacted, a pharmacist might say one day,
“You grow a beard, so I won’t give you this medicine.”
Maybe one may say “You’re wearing a mini skirt, it’smy
right not to give you the service because of my religious
belief”[…]. Let me say more […] might say “I am an Alevi; I
do not give medicine to Sunnis.”This can go on…Even in
our oath, it says that I have to provide my standard service
regardless of religion, language, race, or sect. If we break
this rule, we lose the essence of modernity. The profession
of pharmacy will be over. (Pharm20/L.176e183)
Beliefs about maintaining moral integrity
The proponents of CO indicated that a law on CO might give
them personal freedom to exercise their personal values:
The pharmacist is also an individual; after all, he has his
own conscience and moral values. So does he have the right
to refuse? Yes he does. (Pharm5/L. 34e37)
Perceived normative beliefs
Caring about professional values
Participants who did not agree with provision of pharmacy
services based on conscience, argued that it was against pro-
fessional codes:
[…] then, you shouldn’t work as a pharmacist […]. For
instance, you can’t say to a diabetic about pork insulin, “I
can’t provide it to you.”Hence, then you have to close up
the pharmacy, go to a prayer room and contemplate. This is
what you have to do. You can’t do it [pharmacy] by thinking
of sin or good deed. [Pharm19/L.40e55]
Caring about patients’demands
Patient-related factors seem to have an impact on the
behavior of community pharmacists. Even some participants
did not feel pressured to provide pharmacy services on moral
grounds; they stated that they were unable to provide these
services because of patient-related factors, including patients’
hesitations in interacting with the opposite sex and using
haram medicines. Pharmacists citing patient-related factors
emphasized that some patients were hesitant when receiving
services because of their personal and cultural beliefs. There-
fore, participants could not provide counseling and had to direct
the patient to their staff following the patient’s request:
When a woman comes and asks for something, I tend to
answer the question she asks…However, if she still wishes
to receive services from our female technicians, I feel I have
to direct her to our female employees. (Pharm15/L.86e90)
Caring about religious sources
Pressure from the willingness to practice in line with reli-
gious sensitivities has a considerable influence on the behavior
of pharmacists. Participants who did not agree to provide
certain types of pharmacy services had some religious concerns.
Some indicated that they wanted to protect their religious
values and refused to give contraceptives or provide counseling
to the opposite sex. Others were afraid of committing sin. Some
of them sought external help when they felt confused:
We asked to the Fatwa Council (a council that issues
authoritative religious rulings by Islamic jurists in Turkey)
about these drugs containing alcohol. They mentioned that
“Everything that ethanol touches is impure. Therefore, if
you add ethanol in a drug combination, even if you evap-
orate all the alcohol, we cannot say this is halal”So, I cannot
sell, if there is an alternative! (Pharm16/L.87e89)
Religious sources do not always prevent the provision of
pharmacy services on conscientious grounds. Interestingly,
another group of participants embracing religious values did
not refuse to provide pharmacy services by interpreting reli-
gious sources (Qur’an, Sunnah, etc.). Different types of atti-
tudes in practice can be encountered because of differences in
interpretation of religious sources. Some participants said that
they agree to provide haram medicines, citing the orders of
some religious sources:
The haram point of this (he means alcohol)isbecauseit
makes you drunk! I have looked them up from our religious
sources and now I know that is not sinful when you use
alcohol for therapeutic aims. Alcohol is forbidden when it
renders people unable to think healthily, even to a level
where they lose consciousness of themselves. When you use
an alcohol-containing antiseptic, it doesn’tgetyoudrunk.
(Pharm15/L.51e54)
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Caring about physicians’directives
Some participants expressed that they did not have the
right to refuse to provide medicine if the physician prescribed
it. They were unwilling to interfere with physicians’directives:
If the doctors find it appropriate, I think pharmacists
shouldn’t object […]. If the patient wants to get a halal
treatment, he should talk to his doctor first. I have no right
to object to a prescription. (Pharm8/L.246e250)
Perceived control beliefs
Value conflict
Participants contending with their conscience while
distributing medicines because of religious sensitivities can
face ethical dilemma to prioritize their personal values over
profit-making. Owing to this ethical dilemma, some partici-
pants do not agree to provide pharmacy services, whereas
others choose to serve unwillingly. Some of them expressed
that their commercial concerns were at the forefront because
of their desire to make profit during the distribution of
contraceptives:
We are having troubles with the morning after pills. Un-
fortunately, we sell them because we have commercial
concerns [...] We’re doing it unwillingly [...]. This is my
personal dilemma [...]. As you know, birth control is haram
(prohibited) in Islam. (Pharm21/L.71e72)
One participant shared his views on an ethical dilemma
about not distributing haram medicines based on his personal
values:
It’s written in the package insert of the X product […]. If
there is an alternative, I think I should recommend the
alternative. Sometimes there are no alternative products in
this regard, which keeps us in a dilemma. (Pharm18/
L.39e42)
Beliefs about expectations from third parties
Participants who were the proponents of CO were expect-
ing various stakeholders (pharmaceutical companies, gov-
ernment, physicians) to fulfill their responsibilities in
respecting religious sensitivities of professionals and com-
munities to facilitate ease of behavior. For example, some
mentioned that drug companies have a responsibility to pay
attention to religious sensitivities in drug manufacturing or
marketing. This failure of necessary responsible behavior by
pharmaceutical companies leads some pharmacists to feel the
moral pressure to cope with the issue personally. Some par-
ticipants requested drug companies to stop supplying haram
medicines to the Turkish drug market:
[…] for instance, I wouldn’t say anything if Company A did
it. Because the owner is not a Muslim […]. I accept their
production and marketing of haram drugs within their
religious perspective. However, when the same company
takes the haram drug to the Turkish market, I want them to
take our sensitivities into account. If the company is espe-
cially Muslim, Turkish [...] it also hurts me much.. Then I
think in like manner, “If you are marketing these drugs as a
Muslim in our country, then I won’t distribute your medi-
cines.”(Pharm16/L.75e81)
Some participants reported that physicians’attitudes affect
their behavior. They mentioned that physicians, drug com-
panies alike, have a responsibility when prescribing:
I think doctors make the biggest mistake in this matter…If
a drug contains alcohol, I expect that they shouldn’tpre-
scribe it, but they do. (Pharm16/L.305e313)
Most of the participants who are proponents of CO
expressed that a law on CO would help them provide phar-
macy services that align with their personal beliefs. They
expect the government to enact a law on CO:
[…] I think this law would be nice. Religious consciousness
of the society will develop. Since we have a commercial
concern, we actually reassure our consciences without
believing it and say, “When it comes to medicine, it
wouldn’t be a sin if we gave it to the patient. It’s all about
the health.”If the government authorizes pharmacists in
this way, everyone can do what they want. (Pharm16/
L.142e146)
Discussion
The results revealed that the perspectives of community
pharmacists in terms of the scope and impact of CO using the
TPB. As hypothesized, examining constructs related to atti-
tude, subjective norm, and perceived control beliefs provided
insight into community pharmacists’behaviors related to CO
to provide pharmacy services.
Beliefs about the negative consequences of not providing
pharmacy services on health care service had an impact on the
behavior to not adopt CO. Some of the participants believed that
pharmacists in Turkey should not be granted a legal right to
exercise CO when providing services because this would cause
discrimination in health care or the right might be stretched in
implementation in favor of pharmacists’personal beliefs.
Similarly, according to McLean et al.
49
study, a tendency exists
among health care providers to slightly stretch the imple-
mentation of abortion laws in certain instances and to make
such tweaking of the law ethically justifiable to themselves. In
this context, where laws provide personal freedom in certain
cases, it should not be forgotten that laws are liable to introduce
ambiguities regarding how laws should be interpreted and
implemented. In contrast, few participants argued that a law in
favor of CO should be supported, as it will provide pharmacists
the personal freedom to follow their personal values. Several
studies have discussed pharmacists’rights to refuse to provide
contraceptives on conscientious grounds.
3,13,50-52
Others sug-
gested that the use of robotic systems in distributingmedicines
would be the best solution because their choices are not based
on moral values.
6
The debate on a better law on CO will
therefore continue regardless of what kind of law is passed. As
discussed earlier, enactment of a law on CO, which might pro-
tect the moral integrity of a person, may indirectly result in
negative consequences due to a stretch in the implementation
of laws. Therefore, ethical codes on restricting the refusal of
G. Gülpınar et al. / Journal of the American Pharmacists Associatio n 61 (2021) 373e381
SCIENCE AND PRACTICE
378
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pharmacists to serve their patients based on their personal
values must be established and strictly implemented.
Perceived normative beliefs had an impacton the behavior of
pharmacists in refusing to provide pharmacy services. On ex-
amination of literature on CO, generally, patients’demands,
physicians’directives, religious sources, and professional values
are considered as external factors that have an effect on the
behavior of health care providers.
8,23,50,51,53,54
In our study,
pharmacists who were serving poor minority neighborhoods
were more likely to encounter patients’preferences for gender
concordance. Boucher et al.
23
have showed that patient’s
requirement or preference for gender concordance reflects
physicians’behavior. Another study conducted in United Arab
Emirates has revealed that women did not accept obstetric and
gynecologic consultations by male physicians in Islamic envi-
ronments.
53
Therefore, even the physicians had no problems
regarding consultation of opposite sex, in which case, patients’
demands affect their behavior. In Lumpkin’s
54
study, pharma-
cists reported that if physicians prescribed Plan B tablets, they
would not be willing to interfere with their directives. In this
study,religious values have beenshown to be a predictorof CO to
providing certain typesof pharmacy services, suchas dispensing
contraceptives, haram medicines, and counseling to opposite
sex. This finding was consistent with the previous
studies.
8,13,50,51,54
However, a unique finding in this study was
that religious values do not always prevent the provision of
pharmacy services on conscientious grounds, although the
pharmacists may be highly religiously sensitive. This finding
appears to be associated with variations in the interpretation of
religioussources. A fulldiscussion on thesources of Islamiclaw is
beyond the scope of this paper. A brief overview, however, will
aid the reader by introducing the sources of Islamic law for our
subsequent discussion. The sourcesof Islamic law include (1) the
Qur’an, held to be the literal word of God revealed to the Prophet
Muhammad, (2) the Sunnah, which represents the recorded
sayings and actions of the ProphetMuhammad (the compilation
or the records of the Sunnah are called Hadith).Learned scholars
providefurther interpretation of the rules dictatedby the Qur’an
and Sunnah in Islamic law via Ijtihad. Fatwa issued via Ijtihad is
used to provide nonbinding opinions to address the needs of
people in different places and times. Differences in interpreting
the rules of Islam might introduce inconsistencies in deciding
how to behave in line with religion in health care practice.
22
This
inference might be expanded to other religions, such as Chris-
tianity, where problems on consensus in understanding the
rules exist. In this study, the tendency to interpret religious
sources against CO mightbe due to professional values provided
with professional education in a democratic and secular state
independent of religious values in Turkey.
In our study, prioritizing professional values as a subjective
norm affected pharmacists’behavior on the refusal to provide
pharmacy services negatively. Almost half of the participants
were against the refusal to offer pharmacy services on con-
scientious grounds and felt that this attitude was incompatible
with professional codes. Savulescu and Schuklenk
55
consider it
unprofessional for a pharmacist to refuse to provide oral
contraceptives on conscientious grounds. In another study
conducted in the United States, pharmacists considered it a
violation of the professional code to reflect personal beliefs in
professional practice.
8
This finding was consistent with other
studies expressing the importance of relegating personal
values to the background during service delivery.
54,56
The value conflict between giving priority to personal values
and making profit while providing services was observed as a
barrier to adopt CO to provide pharmacy services. Many phar-
macists who are proponents of CO in practice felt compelled to
supply medicines contrary to their personal values for com-
mercial reasons. On the contrary, pharmacists working in chain
pharmacies in many countries can refuse to distribute medi-
cines easily if these medicines contradict their personal be-
liefs.
3,57-59
These differences in attitude regarding refusal to
distribute medicines on conscientious grounds may be due to
individual concerns of pharmacists in Turkey to ensure the
commercial continuity of their pharmacies, because theyare the
sole managers and owners of their pharmacies. Gülpınar et al.
32
found that community pharmacists in Turkey felt compelled to
provide the medicines even if they doubted their effective-
ness.
33
In fact, another study revealed that pharmacy owners
advise patients about contraceptives in longer durations than
pharmacists working in chain pharmacies.
10
Therefore, future
studies may be conducted to understand whether being the
owner of a pharmacy and being an employee may influence the
decision to adopt the behavior.
In our study, beliefs about expectations from third parties
had an impact on pharmacists’behavior in CO to provide
pharmacy services. Participants believed that third parties have
various responsibilities in the context of CO. Some pharmacists
mentioned that physicians should ensure that they prescribe
halal medicines. Literature mentions similar responsibilities for
physicians.
60,61
Some pharmacists emphasized that pharma-
ceutical companies should considerthe religious sensitivities of
the community in their manufacturing and marketing activities.
This finding was consistent with those of previous studies.
60-62
When third parties fail to fulfill their responsibilities including
paying attention to religious sensitivities in drug
manufacturing, prescribing, and enacting laws on CO, pharma-
cists experience barriers in adopting the behavior. Some phar-
macists believe the absence of a lawon CO was a barrier to their
moral integrity. However, these barriers can interestingly be a
driving force for the pharmacists to refuse to provide pharmacy
services. In this regard, pharmacists felt the moral pressure to
refuse to provide pharmacy services when third parties do not
pay attention to cultural codes of the country in their activities.
For example, pharmacists were justifying their behavior of not
distributing haram medicines by attributing it to the pharma-
ceutical companies do not manufacture halal alternatives.
Justifying the refusal to provide pharmacy services by citing
failure of third parties in performing their responsibilities cre-
ates a practically important questiondis it possible that phar-
macists’action to refuse to provide pharmacy services by
prioritizing personal values can be considered as an effort to
alleviate the feeling of guilt under the guise of imposing re-
sponsibilities upon others? The answer can be given in 2 ways.
First, assigning the responsibility to others can literally be
associated with a search for the right to freedom, or, second, it
can also be an implicit feeling of guilt that occurs when refusal
to provide a legal obligation is considered an incompatibility
with the universally accepted professional codes. If the latter
assumption is true, no gray zones providing “reasonable
compromise”for resolving such conflicts should exist. On the
Perspectives of community pharmacists on conscientious objection to provide pharmacy services
SCIENCE AND PRACTICE
379
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other hand, scientists support the view of a compromise be-
tween the needs of patients and the morals of pharmacists.
14
Brock offered 3 conditions that permit physicians and phar-
macists to refuse to provide service that is against their con-
science.
12
On the other hand, some argued that the search for a
suitable compromise would not be acceptable between the
proponents of the 2 extreme views.
63
This study shows that
when conflicts exist between personal and professional values,
a possible impulse may exist inherently within pharmacists,
which may lead them to seek possible solutions (enacting law,
manufacturing halal alternatives, and not prescribing haram
medicines) in order not to adopt the behavior of not providing
pharmacy services.
Study limitations
We acknowledge the limitations of this study. First, using a
priori theory in qualitative research has advantages and risks.
The main advantage to using theory was the organization of
data through preformed constructions providing richer and
deeper insights into participants’behavior and its social
context.
64
There remains, however, to be a risk of researchers
fitting their insights into the established framework. Second,
one participant refused to be voice-recorded. Therefore, script
notes were taken, and the interviewer took postinterview
notes. This might have resulted in data loss. Third, some of the
pharmacists who had high religious sensitivity were not
comfortable being voice-recorded, which might have caused
them to be unable to provide information fully. Fourth, the
sample was limited to pharmacies in Ankara, the capital city of
Turkey. Thus, the study results cannot be generalized to the
entire population. Further research should be conducted in
rural areas of Turkey, which may differ in patients’demand
and damage that patients might encounter when pharmacists
refuse to provide service. Finally, this study applied some core
principles described by Amin et al.
65
to enhance trustworthi-
ness of analysis and interpretation. However, additional prin-
ciples, such as the use of other data gathering techniques for
triangulation, peer debriefing, and member checking were not
possible given time, resource, and logistics constraints.
Conclusion
The findings of this study provide useful information on
pharmacists’refusal to provide pharmacy services based on
prioritization of personal or professional values and the factors
affecting their personal experiences. Most of the community
pharmacists were against the behavior of CO to provide
pharmacy services in Turkey because of possible negative
consequences on health care. The proponents of CO consid-
ered value conflict and failure to fulfill certain responsibilities
by the third parties as barriers. Understanding the whole
process of CO to provide pharmacy services by the provided
framework might expand the arguments on CO.
Acknowledgments
The authors would like to thank Dr. Mohamed Ezzat Kha-
mis Amin for his helpful comments and suggestions on earlier
versions of this paper.
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Gizem Gülpınar, BPharm, MsC, PhD, Senior Researcher and Lecturer, Depart-
ment of Pharmacy Management, Faculty of Pharmacy, Ankara University, Ankara,
Turkey
S¸ ükrü Keles¸ , PhD, Assistant Professor, Department of Medical History and
Ethics, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
Neyyire Yasemin Yalım, MD, PhD, Professor of Medical Ethics, President of
the Turkish Bioethics Association, Ankara, Turkey
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Appendix 1
General outline of the interview guide that was framed based on the theory of planned behavior
Theme/TPB component Question
Opening questions How would you consider a pharmacist’s refusal to provide any pharmacy services due to personal beliefs?
Which practices do you think can be covered?
Behavioral beliefs Have you ever avoided giving some pharmacy services because of your personal beliefs?
Have you been asked to do so?
How did you feel? (If yes to the previous question)
What are your opinions on the consequences of refusing to provide pharmacy services because of personal beliefs?
What are your thoughts about a legal right not to provide pharmacy services on the grounds that they contradict your personal
beliefs?
What happens to patients when they cannot get the service they wanted?
Normative beliefs What external factors/individuals/groups do influence your refusal to provide pharmacy services due to personal beliefs?
Do you have any expectations from external factors about this issue?
Control beliefs What circumstances would enable you to refuse pharmacy services due to personal beliefs?
What circumstances would hinder you from refusing pharmacy services due to personal beliefs?
What do you think should be the next step if a pharmacist does not provide services because of his or her personal beliefs?
G. Gülpınar et al. / Journal of the American Pharmacists Associatio n 61 (2021) 373e381
SCIENCE AND PRACTICE
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