Trustworthiness and Professional Ethics

V IEW POIN T

Trustworthiness and Professional Ethics Amy Haddad

Earlier this year, Kansas City, Mo., pharmacist Robert Courtney admitted to charges that he had adulterated, tampered with, and mislabeled the chemotherapy drugs Taxol (paclitaxel—Bristol-Myers Squibb) and Gemzar (gemcitabine—Lilly) prescribed for 34 patients with cancer. Courtney pleaded guilty to 20 federal counts in an agreement with the government that avoided a trial. As of this writing, more than 300 lawsuits have been filed against Courtney and drug companies the plaintiffs claim either knew or should have known their products were being diluted (the companies deny the allegations). In addition, Courtney’s wife, who has not been charged with any wrongdoing, has agreed to pay $1.85 million in restitution to patients victimized by the pharmacist’s actions, money over and above any courtordered restitution. The case has been receiving extensive national coverage. Individual pharmacists across the country and APhA have been inundated with questions from concerned patients about the integrity of medications and, by extension, the integrity of the pharmacy profession. Does an infamous case like Courtney’s have an impact on

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patients’ trust in pharmacists? If so, what effect does the revelation of such profoundly unprofessional conduct have on the public’s beliefs about the trustworthiness of the pharmacy profession? What important lessons in ethics does this case have for educators, managers, and practicing pharmacists. Trust between a pharmacist and a patient rests on the cornerstones of honesty and faithfulness, or the ethical obligation to keep promises. If one cornerstone is pulled away as a result of dishonesty, willful disregard of obligations, or failure to keep a promise— whether implicit or explicit— the foundation of trust is badly shaken. When a pharmacist interacts with a patient, whether offering advice on nonprescription drugs or accepting a prescription, he or she is making an implicit promise to uphold the basic standards of the profession. Among these basic standards is to not harm the patient and to promote good. In a research article beginning on page 594 of this issue, West et al.1 report on how patients form beliefs about pharmacists’ trustworthiness. Their preliminary findings provide some insight into what the public considers evidence

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that pharmacists can be expected to fulfill their obligations in a trustworthy manner. The study findings are intriguing in light of two aspects of the Courtney case: the man’s behavior and what the public knows about what pharmacists really do. As they explain in their article, West et al. convened two focus groups to determine what information people use in forming beliefs about pharmacists’ trustworthiness. They presented the participants with three scenarios: a dispensing scenario in which the pharmacist essentially fills the prescription and hands it to the patient and two pharmaceutical care scenarios in which “the pharmacist went beyond the traditional dispensing duty and changed the prescribed medication.” After the groups discussed each scenario, the group leader asked a series of questions relating to the trustworthiness of the pharmacist under the circumstances described. The results of these discussions, documented by West et al. in their article, indicate that patients’ trust is less solidly constructed in the area of pharmaceutical care than in situations they more readily associate with pharmacists. When considering the more sophisticated examples of pharmaceutical care practice, which involved therapeutic substitution or conferring with a physician, the group members felt they could not rely on the same evidence that indicated pharmacists’ trustworthiness in the more basic dispensing scenario. In the pharmaceutical care scenarios, communication style and interpersonal

skills took on increased importance over, for example, the clean appearance of the pharmacy, which was important in the dispensing scenario. The members of the focus groups, like most of the public, were largely unaware of the professional activities that fall under the heading of pharmaceutical care. The groups acknowledged that the examples of advanced practice involve an element of risk for the patient. Thus, pharmaceutical care requires that patients invest the pharmacist with a greater degree of trust than they necessarily do in what is still the most widespread model of patient-pharmacist contact. Trust is necessary for the therapeutic relationship to be successful. One of the criteria members of the public use when evaluating the ethical standing of the pharmacy profession is their knowledge of the behavior of individual practitioners. Patients’ evaluation of pharmacists’ trustworthiness not only takes into account actions but the total set of character traits that the focus group members, certainly on the basis of their personal experience with pharmacists, cited as characteristic of the profession. West et al. refer to these traits as “claims.” The focus group members stated that pharmacists need to be knowledgeable, honest, caring, and confident. In the language of ethics, character traits such as these are called “virtues.” Virtues are habits that are deemed morally good because they predispose one to do what is right. The patient’s willingness to trust his or her pharmacist is a reflection of what the

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public thinks about pharmacy’s collective character. Thus, the behavior of Courtney has had a double effect on the public’s understanding of the pharmacist’s role. On the one hand, the public gets a glimpse into an area of pharmacy practice that is generally out of their view—the preparation of complex chemotherapeutic agents. Hence, the public learns that pharmacists can practice independently in managing the preparation of lifesaving drugs specifically tailored to the needs of each patient. Overshadowing any beneficial impact this particular information might have for the profession, however, is the lesson that a pharmacist can indeed betray the gift of trust the public has bestowed on him for self-serving reasons and in a manner that directly threatens the well-being of his patients. The well-publicized misdeeds of even a few members of a profession can, in people’s perceptions, outweigh a long-standing record of upright and beneficial contributions. In other words, the unprofessional conduct of one pharmacist can tarnish the reputation of the profession as a whole. It remains to be seen

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how much the Courtney case will, in the long run, impact pharmacy’s standing with the public in the areas of honesty and ethical standards. Moving beyond the unethical actions of an individual to the profession as a whole opens up an additional set of trust-driven expectations on the part of the public. Traditionally, the public attributes certain characteristics to professions, including: n The profession must serve the needs of society rather than the needs of a special interest group, usually for the benefit of society, with an altruistic goal as opposed to a materialistic one. n The profession should have a group identity and group consciousness that can be recognized by others. n The profession should develop and enforce its own code of ethics, standards of practice, and peer review. Underlying these criteria are values that lead to commitment to social goals and to accountability for individual as well as for collective behavior. The public grants a profession a degree of autonomy and status because of its members’ specialized knowledge; in turn, the public requires that the profession

police its own. Actions such as those of Courtney fuel a widespread skepticism as to whether health care professions—in this case, pharmacy—are taking strong enough measures to monitor and sanction members who do not comply with standards of care. Therefore, a credible, forthright response by the profession is paramount to reengaging the public’s trust. In other words, the profession must show the public that, now that Courtney’s misdeeds have been brought to light, pharmacy and pharmacists will take the right steps to prevent such occurrences in the future. Some of the answers for preventing future egregious conduct lie in the Code of Ethics for Pharmacists, in that it is a prescription for ethical behavior. Codes are, after all, public statements of the values of the profession. Ethical decisions, however, are first made privately, on an individual basis. Thus, every pharmacist holds the key to reaffirming the public’s trust in the profession. So, what can we as a profession salvage from this unfortunate episode from the point of view of learning about ethical obligations?

Educators can use this case as a cautionary tale about the responsibilities of pharmacists for the actions of their peers and the welfare of patients and about the personal moral standards the functions require. Pharmacy managers can and should explore the systems and processes they have in place for the reporting of wayward colleagues or unethical conduct to determine whether they are workable and fair to all parties involved. Finally, the lesson for practicing pharmacists is that all of the rules and guidelines for ethical conduct are only words unless each individual has the moral courage to do the right thing at the right time. Amy Haddad, PhD, is professor, School of Pharmacy and Allied Health Professions, Creighton University, Omaha, Neb. See related article on page 594.

Reference 1. West DS, Wilkin NE, Bentley JP, et al. Understanding how patients form beliefs about pharmacists’ trustworthiness using a model of belief processing. J Am Pharm Assoc. 2002;42:594–601.

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