Ethics and Pharmacy Practice Notes

Ethics and Pharmacy Practice

Case 1: Sarah and Don Hill

Sarah and Don Hill have four children under seven, three of whom have congenital heart defects requiring medication. They belong to a religious group that opposes medical intervention in life-threatening conditions. Despite their insurance covering the medications, they don't believe in interfering with fate. Under pressure from Don's employer (a family friend), they obtained prescriptions but do not intend to administer the medications, only filling them to appease the employer.

Ethics

  • Focuses on behavior, not thoughts or feelings.

  • Emphasizes action over opinion.

  • Based on individual behaviors towards each other in specific situations.

Morals

  • Principles of right or good conduct.

  • Differentiates between "right vs. wrong."

  • Based on core values (religious, spiritual, cultural, secular) that are generally not easily debated.

  • Develops within homogenous groups and may evolve over time.

Law

  • A system of socially-derived rules and regulations governing behavior.

  • Violation leads to predictable consequences.

  • Created by societies and constantly evolves to meet changing societal needs.

Ethics vs. Morals vs. Law

  • "The end justifies the means."

  • "The greatest good for the greatest number."

  • Distinction between "Good vs. bad."

  • "Hate the sin, love the sinner."

Ethics in Health Care

  • Examines specific, practical issues focused on behaviors and outcomes, not on feelings, opinions, emotions, or motives.

  • Moral and legal principles inform ethics but don't necessarily align.

  • Ethics, morals, and law may conflict.

  • Involves multiple stakeholders with multiple perspectives.

Key Ethical Principles

  • Beneficence

  • Justice

  • Non-Maleficence

  • Autonomy

  • Honesty (Truth-telling)

  • Fidelity

Beneficence

  • Acting in the best interests of the patient.

  • A pharmacist prioritizes the patient's well-being in professional practice.

  • Risk of paternalism.

  • Informed consent as a check on paternalistic beneficence.

Justice

  • Fairness, equitability, consistent application of rules/laws.

  • Use of predictable standards to judge behaviors, avoiding arbitrary differences.

  • Distributive justice focuses on fair allocation of scarce resources.

Non-Maleficence

  • "First, do no harm."

  • Balancing risks and benefits.

  • No use of patients as guinea pigs or for personal/professional gain.

  • Treatment of only what is medically necessary.

  • Avoiding conceptualizing ordinary processes, mild symptoms, personal problems, or risks as "disease".

Autonomy

  • Patient's right to self-determination (to choose what will be done).

  • Informed consent is crucial.

  • Capacity to consent must be present.

  • Considerations for competent minors.

  • Parental involvement in minors' decisions.

Honesty

  • Patients have a right to the truth.

  • Pharmacists have a duty to tell the truth and act with conviction.

  • Honesty is the foundation for trust.

  • Consider honesty in relation to business interests and the pharmaceutical industry.

Fidelity

  • Patients have the right to professional services that promote their best interests, not the professional's.

  • Avoid inappropriate or excessive prescribing.

  • Importance of inter-professional communication.

Don and Sarah Hill (Further Considerations)

  • What if the children were teenagers?

  • What if they were relatives?

  • What if the case involved immunizations or blood products?

  • Consider scenarios where the physician or employer inquires about medication adherence.

Informed Consent

  • Cornerstone of the medical system.

  • Patients have the right to full disclosure of all relevant aspects of care.

  • Patients must give explicit consent before treatment begins.

Determining Informed Consent

  • Ensuring all relevant information is provided.

  • Assessing the patient's capacity to understand the information.

  • Confirming the patient understands the information.

  • Ensuring the agreement to treatment is given freely, without coercion.

  • Verifying consent is for the specific treatment only.

Addressing Ethical Dilemmas

  1. Describe the nature of the dilemma from various stakeholder perspectives.

  2. Name the ethical principles in conflict.

  3. Explain why the principles are in conflict.

  4. Identify necessary additional information.

  5. Generate alternative solutions using ethical principles.

  6. Evaluate the outcomes of each alternative.

The Nature of the Dilemma

  • Recognize there are multiple sides to every story.

  • Identify stakeholders and their motivations/needs/agendas.

  • Consider your relationship to the situation and your own motivations/needs/agendas.

What Ethical Principles are in Conflict?

  • Differentiate between an ethical, moral, or legal dilemma.

  • Consider how different stakeholders interpret the ethical principles involved.

  • Assess the impact of moral or legal issues on each stakeholder's perspective.

Why are These Principles in Conflict?

  • Acknowledge that ethical problems are often not easily resolved.

  • Evaluate the magnitude of differences between stakeholders' perspectives and the possibility of compromise.

What More Information Do You Need?

  • Gather factual information.

  • Understand emotional factors.

  • Assess perceptions.

  • Consider history.

  • Identify prejudices/biases.

Alternative Solutions

  • Withhold personal judgment or criticism.

  • Brainstorm possible solutions.

  • Recognize that doing nothing is a possible decision.

  • Weigh and balance the probable impacts of decisions on all stakeholders.

  • Quantify the impact of decisions on stakeholders.

Evaluating Impact and Outcomes

  • Avoid letting "perfect" interfere with "good."

  • The least imperfect solution may be the best option.

  • Think ahead about the implications of decisions made.

  • Consider "Slippery slope" or "thin edge of the wedge" arguments.

Case 2: Jill, the Pharmacy-Owner

You are a pharmacy owner in a small town. Jill, your sole pharmacist, has an excellent rapport with clients and is an award-winning pharmacist. She wrote a letter to the town newspaper opposing same-sex marriage, calling it "deviant" and "sinful" and claiming homosexuality is a "mental sickness" that can be medically treated. She sympathizes with people who "get violent" about the issue because it will "ruin our society". Several customers congratulated her, and no one has complained to you.

Research in Pharmacy Education

  • Aggarwal et. al. (2002): A study of academic dishonesty among students at two pharmacy schools. Pharmaceutical Journal 269 (7219): 529-533.

  • Austin, Simpson and Reynen (2005): The fault lies not in our classes, but in ourselves a pilot study of academic dishonesty in Canadian pharmacy education. Teaching in Higher Education 10: 143-56.

Case 3: Signet Wilkinson

Signet Wilkinson, a pharmacist in a busy community practice, has a close relationship with her patients. Her cousin Fanny tells her about a new boyfriend, Joe Johnson, whom she is excited about. Signet is shown pictures of Joe. Later, Signet receives prescriptions for anti-retroviral drugs used to treat HIV for Joe Johnson. The person presenting the prescriptions resembles the photographs, but Signet isn't 100% certain.

Case 4: Quinn O'Driscoll

During a civil emergency caused by a flood, Quinn O'Driscoll, a pharmacist, works in one of the few viable pharmacies. Jason Dunbar, a 19-year-old patient with bone cancer known to Quinn, approaches him. Jason says his morphine tablets for pain control were destroyed in the flood and he needs more. His doctor is unavailable, hospitals are closed, and there is no electricity to consult computer records. Power is expected to be restored in a week.