Hostname: page-component-586b7cd67f-r5fsc Total loading time: 0 Render date: 2024-11-27T21:21:41.314Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  01 January 2021

Elizabeth Chiarello
Get access Rights & Permissions [Opens in a new window]

Extract

Commercialization of medicine is a growing trend that threatens to undermine physicians’ commitments to patient care in favor of personal financial interests. Bemoaned by Arnold Relman as early as 1980, growing for-profit sectors of health care have been reshaping medicine from a profession into a business, forming the foundation of what he terms a “medical-industrial complex” that threatens to undermine professional identity and reshape health care funding. Commercialization poses new ethical challenges for health care providers who have a financial stake in their health care decisions and may undermine their fiduciary duties to patients.

Certainly, commercialization has brought about new trends in medicine — one need only to look as far as the rise in for-profit hospitals, diagnostic laboratories, and proprietary nursing homes to see how opportunities for financial gain reposition physicians’ orientations vis-à-vis patients.

Type
Symposium
Information
Journal of Law, Medicine & Ethics , Volume 42 , Issue 4 , Winter 2014 , pp. 518 - 534
Copyright
Copyright © American Society of Law, Medicine and Ethics 2014

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Relman, A. S., “The New Medical-Industrial Complex,” The New England Journal of Medicine 303, no. 17(1980): 963–970.Relman, A. S., “The Health Care Industry: Where Is It Taking Us?” New England Journal of Medicine 325, no. 12(1991):854–859;“Medical Professionalism in a Commercialized Health Care Market,” JAMA 298, no. 22(2007): 2668–2670.CrossRefGoogle Scholar
Id. Relman (1980).Google Scholar
Chiarello, E., “How Organizational Context Affects Bioethical Decision-Making: Pharmacists' Management of Gatekeeping Processes in Retail and Hospital Settings,” Social Science & Medicine 98 (2013): 322–24.CrossRefGoogle Scholar
Denzin, N. K. Mettlin, C. J., “Incomplete Professionalization: The Case of Pharmacy,” Social Forces 46, no. 3(1968): 375–381.CrossRefGoogle Scholar
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,See Charmaz, K., Constructing Grounded Theory: A Practical Guide through Qualitative Analysis (Thousand Oaks, CA: Sage Publications, 2006).Locke, K., Grounded Theory in Management Research (Thousand Oaks, CA: Sage Publications, 2001).Locke, K. Golden-Biddle, K., “An Introduction to Qualitative Research: Its Potential for Industrial and Organizational Psychology,” in Rogelberg, S. G., ed., Handbook of Research Methods in Industrial and Organizational Psychology (Malden, MA: Blackwell Publishers, 2002). This approach, widely used by qualitative researchers in the social sciences, enables patterns and categories to emerge from the data rather than fitting the data to predetermined categories.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).Google Scholar
Freidson, E., Professional Dominance: The Social Structure of Medical Care (New York: Atherton Press, 1970).Freidson, E., Profession of Medicine; A Study of the Sociology of Applied Knowledge (New York: Dodd, Mead, 1970).Freidson, E., Professional Powers: A Study of the Institutionalization of Formal Knowledge (Chicago, IL: University of Chicago Press, ).Larson, M. S., The Rise of Professionalism: A Sociological Analysis (Berkeley: University of California Press, 1977).Google Scholar
Scott, W. R., Institutional Change and Healthcare Organizations: From Professional Dominance to Managed Care (Chicago: University of Chicago Press, 2000).Starr, P., The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1982).Weitz, R., The Sociology of Health, Illness, and Health Care: A Critical Approach (CengageBrain.com, 2009).Google Scholar
See Scott, supra note 7.Google Scholar
Haug, M. R., “Deprofessionalization: An Alternative Hypothesis for the Future,” Sociological Review Monograph 20, no. S1(1973): 195–211.Haug, M. R., “A Re-Examination of the Hypothesis of Physician Deprofessionalization,” The Milbank Quarterly 66, Supplement 2(1988): 48–56.Haug, M. R. Lavin, B., Consumerism in Medicine: Challenging Physician Authority (Beverly Hills: Sage Publications, 1983).CrossRefGoogle Scholar
McKinlay, J. B. Stoeckle, J. D., “Corporatization and the Social Transformation of Doctoring,” International Journal of Health Services 18, no. 2(1988): 191–205.CrossRefGoogle Scholar
Freidson, E., Professionalism: The Third Logic (Cambridge, UK: Polity, 2001).Google Scholar
Macklin, R., Enemies of Patients (New York: Oxford University Press, 1993).Ubel, P. A., Pricing Life: Why It's Time for Health Care Rationing (Cambridge, MA: MIT Press, 2000).Relman, A. S., “The Trouble with Rationing,” New England Journal of Medicine 323, no. 13(1990): 911–913.Google Scholar
See Relman, (1980), supra note 1.Google Scholar
See Freidson, , Profession of Medicine (1970), supra note 6.Google Scholar
See Denzin, Mettlin, , supra note 4.Google Scholar
See Weitz, , supra note 7.Google Scholar
Abraham, J., “The Sociological Concomitants of the Pharmaceutical Industry and Medications,” in Bird, C. Conrad, P. Fremont, A. Timmermans, S., eds., Handbook of Medical Sociology (Nashville: Vanderbilt University Press, 2010): 290–308.Bell, S. E. Figert, A. E., “Medicalization and Pharmaceuticalization at the Intersections: Looking Backward, Sideways and Forward,” Social Science & Medicine 75, no. 5(2012): 775–783.Google Scholar
Goodrick, E. Reay, T., “Constellations of Institutional Logics,” Work and Occupations 38, no. 3(2011): 372–416.CrossRefGoogle Scholar
Fligstein, N. McAdam, D., A Theory of Fields (New York: Oxford University Press, 2012).CrossRefGoogle Scholar
Strauss, A.et al, “The Hospital and Its Negotiated Order,” in The Hospital in Modern Society, ed. Freidson, E. (New York: The Free Press of Glencoe, 1963): 147–169.Google Scholar
I have addressed this in part elsewhere. See Chiarello, supra note 3.Google Scholar
See Starr, , supra note 7.Google Scholar
Except clinical pharmacists who increasingly round with physicians.Google Scholar
Although this is changing with the advent of retail clinics in pharmacy.Google Scholar
Bodenheimer, T. Pham, H. H., “Primary Care: Current Problems and Proposed Solutions,” Health Affairs 29, no. 5(2010): 799–805.CrossRefGoogle Scholar
See Abraham, Bell, Figert, , supra note 17.Google Scholar
See Denzin, Mettlin, , supra note 4, and A. Birenbaum, “Reprofessionalization in Pharmacy,” Social Science & Medicine 16, no. 8(1982): 871–878.In the Shadow of Medicine: Remaking the Division of Labor in Health Care (Rowman & Littlefield, 1990).Google Scholar
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.Google Scholar
See Chiarello, , supra note 3.Google Scholar
Edelman, L. Suchman, M., “The Legal Environments of Organizations,” Annual Review of Sociology 23 (1997): 479–515.>Heimer, C., “Competing Institutions: Law, Medicine, and Family in Neonatal Intensive Care,” Law & Society Review 33, no. 1(1999): 17–66.Jenness, V. Grattet, R., “The Law-in-Between: The Effects of Organizational Perviousness on the Policing of Hate Crime,” Social Problems 52, no. 3(2005): 337–359.CrossRefGoogle Scholar
DiMaggio, P. J. Powell, W. W., “The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields,” American Sociological Review 48, no. 2(1983): 147–160.CrossRefGoogle Scholar
See Relman, (1980), supra note 1.Google Scholar
Lipsky, M., Street-Level Bureaucracy: Dilemmas of the Individual in Public Services (New York: Russell Sage Foundation, 1980).Maynard-Moody, S. Musheno, M., Cops, Teachers, Counselors: Stories from the Front Lines of Public Service (Ann Arbor: University of Michigan Press, 2003).Google Scholar
Conrad, P. Schneider, J. W., Deviance and Medicalization: From Badness to Sickness, Expanded ed. (Philadelphia: Temple University Press, 1992).Google Scholar
See Chiarello, , supra note 3.Google Scholar
See Starr, , supra note 7.Google Scholar
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.Google Scholar
Abbott, A., The System of Professions: An Essay on the Division of Expert Labor (Chicago: University of Chicago Press, 1988).CrossRefGoogle Scholar
Berger, P. L. Luckmann, T., The Social Construction of Reality: A Treatise in the Sociology of Knowledge (Garden City, NY: Doubleday, 1967).Google Scholar
Pseudonym for a large, chain pharmacy.Google Scholar
Chen, P., “For New Doctors, 8 Minutes Per Patient,” New York Times, May 30, 2013.Google Scholar
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).(last visited November 12, 2014).' href=https://scholar.google.com/scholar?q=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+(last+visited+November+12,+2014).>Google Scholar