Medical versus Fiscal Gatekeeping: Navigating Professional Contingencies at the Pharmacy Counter

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These data were gathered as part of a larger study on institutional influence on pharmacists' ethical decision-making. Specifically, I examined how legal, political, and organizational factors interacted with pharmacists' personal beliefs to influence care provision. I designed the study to focus on decisions about providing Emergency Contraceptive Pills (ECPs) that had received significant public and scholarly attention at the time of the study, but other ethical concerns such as those addressed here emerged over the course of research. I collected a maximum variation sample of pharmacists in four states with different “pharmacist responsibility laws” that dictate whether pharmacists can use moral justifications to refuse to provide care, see Kuzel A. , “Sampling in Qualitative Inquiry,” in Crabtree B. F. Miller W. L. , eds., Doing Qualitative Research (Thousand Oaks, CA: Sage Publications, 2000).

Patton M. Q. , Qualitative Evaluation and Research Methods (Newbury Park, CA: Sage Publications, 1990). I selected four states that varied by law and geographic region – California, Kansas, Mississippi, and New Jersey. Within each state, I selected one conservative and one liberal metropolitan county (determined using presidential voting records from 1980–2008) and within each county I selected retail and hospital pharmacists. Retail pharmacists included those working at three major national chains that were consistent across the states, and privately-owned independent pharmacies while hospital pharmacists included those working at Catholic, secular, and group (such as HMO) locations. The sample consisted of 24 hospital pharmacists, 40 chain pharmacists, and 31 independent pharmacists. Pharmacists varied by age, gender, and race/ethnicity. The benefit of a maximum variation sample is its ability to capture a full range of perspectives rather than the average perspective that would more likely be generated by a probability sample. This enables a solo researcher to assess similarities and differences across contexts. I recruited pharmacists by phone and conducted interviews in person using a semi-structured interview instrument that focused on how pharmacists identify and resolve ethical issues in daily practice, how they make decisions about providing ECPs, and how they would resolve hypothetical ethical challenges. Interviews lasted between 24 minutes and 3.25 hours, yielding a total of 123 interview hours. After having the interviews professionally transcribed, I coded them using grounded theory analytical techniques that involve coding, memo-writing, and theoretical sampling,

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For elaboration on the research design and analytical techniques used for this study, see Chiarello, supra note 3 and Chiarello E. , “Pharmacists of Conscience: Ethical Decision-Making and Consistency of Care,” Dissertation, University of California, Irvine, 2011, available at <http://gradworks.umi.com/34/72/3472822.html>(last visited November 21, 2014).

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See Denzin Mettlin , supra note 4.

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I have addressed this in part elsewhere. See Chiarello, supra note 3.

See Starr , supra note 7.

Except clinical pharmacists who increasingly round with physicians.

Although this is changing with the advent of retail clinics in pharmacy.

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See Abraham Bell Figert , supra note 17.

See Denzin Mettlin , supra note 4, and A. Birenbaum, “Reprofessionalization in Pharmacy,” Social Science & Medicine 16, no. 8(1982): 871–878.

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Pharmacy education has become longer and more clinically-focused, now requiring a 6-year PharmD (doctorate of pharmacy) that includes one year of clinical rotations. Pharmacists are also taking on primary care duties by providing immunizations, managing chronic conditions, initiating care via collaborative practice agreements with physicians, and dispensing behind-the-counter drugs over which they exercise primary discretion. In conjunction with pharmacists' own efforts, health care has become increasingly pharmaceutical based and the number of drugs on the market have proliferated, making it difficult for physicians to keep up with the rapid changes in drug therapies.

See Chiarello , supra note 3.

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See Chiarello , supra note 3.

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The “count and pour” refer to counting pills and pouring liquid medicine into bottles and the “lick and stick” refer to the process of adhering the label.

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Pseudonym for a large, chain pharmacy.

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Compounding pharmacists are specialty pharmacists who prepare customized drugs to meet patients' needs. While all pharmacies do some forms of compounding, most compounding occurs in a few pharmacies that specialize in this practice. See <http://www.pharmacist.com/frequently-asked-questions-about-pharmaceutical-compounding>(last visited November 12, 2014).