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Ethical decision making in pharmacy
Ethical Decision Making in Pharmacy This overoiew) the first in a series of articles on pharmacy ethics) describes the steps pharmacists should take in analyzing ethical problems. by Bruce D. Weinstein, PhD
Imagine the following scenario: Mary Moore* is a 76-year-old patient with hypertension. Her physician, David Darner, had previously treated her with diuretics and beta blockers, but had stopped the drugs because of side effects (orthostatic hypotension in the case of the diuretics). Darner decides to try Esimil (guanethidine) and prescribes 20 mg daily. Moore brings the prescription to her pharmacist, Paula Smith, but Smith is concerned about the potentially severe drug side effects. Smith believes that calcium channel blockers would be more appropriate. When she calls Darner and suggests this, the physician becomes irate. "This is not your area of expertise. You don't even know this patient. Leave prescribing drugs to me, and just fill the prescription." What should the pharmacist do? Different people will give different responses to this question. Some will say that she should attempt to get the prescribing physician to change the prescription order. Others will say that she should dis* Names are fictitious.
Steps in Ethical Decision Making After determining that you are faced with an ethical question: 1. Gather the clinically relevant facts of the case. 2. Identify all of the values that play a role, and decide which values are in conflict. 3. Propose possible solutions to resolve the conflict. That is, answer the question, "What could you do?" 4. Choose the better solutions for the particular case, justify them, and respond to possible criticisms. That is, answer the question, "What should you do, and why?"
AMERICAN PHARMACY
pense the medication but counsel the patient about the risks of severe side effects. Still others might say that she should simply refuse to dispense the medication. At stake is the pharmacist's duty to protect others from harm, the physician's and the patient's expectations that the prescription will be filled by the pharmacist, and the right of the patient to be provided with information needed to make treatment decisions. Whenever we ask "What should I do?" particularly with respect to the welfare and rights of others, we are asking an ethical question. If there are conflicting moral responsibilities, the situation becomes an ethical dilemma. This article and others to follow will examine the nature and scope of ethics as it relates to the practice of pharmacy by examining realistic clinical situations.
What Is Pharmacy Ethics? Ethics is the systematic study of what is right and good with respect to conduct and character. As a branch of both philosophy and theology, ethics seeks to answer two fundamental questions: (1) What should we do? and (2) Why should we do it? Ethics is concerned not only with making appropriate decisions about what we ought to do, but also with justifying those decisions. In other words, ethics seeks to provide good reasons for our moral choices. Pharmacy ethics applies ethical rules and principles to the practice of pharmacy. When we ask what a pharmacist should do in a particular case, we ask an ethical question. To justify our answer we appeal to the same rules and principles that apply to persons in society generally. 1 For example, the pharmacist'S obligation to protect patient confidentiality is merely an application of the rule that all of us have to carefully guard information that is entrusted to us. Sometimes, howSeptember 1993
Vol. NS33, No.9
ever, health care professionals are ethically required to assume risks not shared by laypersons, as when caring for persons with AIDS. 2 A professional incurs certain obligations not shared by nonprofessionals.
Pharmacy as a Moral Practice Pharmacy is a moral practice because pharmacists are concerned primarily with advancing the interests of patients and providing the services that patients want. Unlike members of
Resources in Pharmacy Ethics Books Beauchamp TI, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press; 1989. Beauchamp and Childress provide an indispensable analysis of ethical rules and principles in the context of health care. The fourth edition will be available soon. Weinstein Bruce D., ed. Ethical Issues in Pharmacy (Vancouver, Wash: Applied Therapeutics; forthcoming). This book will contain essays co-written by leading pharmacists and ethicists and will address such issues as pharmacists' relationships with the pharmaceutical industry, professional responsibilities toward chemically dependent colleagues, sexual harassment, and the right to health care. Encyclopedia Reich WT, ed. Encyclopedia of Bioethics. New York: Free Press; 1978. While slightly outdated, this work is a standard reference source and is available in most libraries. The second edition will be published in 1993. Journal American Journal of Hospital Pharmacy regularly features cases and ethical commentaries edited by Robert M. Veatch, PhD, professor of medical ethics and director, Kennedy Institute of Ethics, Georgetown University, Washington, D.C. Searches of the Literature The National Reference Center for Bioethics Literature at Georgetown University will run computer searches of the literature on any topic and mail them to you at no charge. Phone toll free: 1-800-MED-ETHX. Videotape "Ethics Perspectives" is a videotape for examining ethical issues in pharmacy, written and produced by David B. Brushwood, professor of pharmacy administration, University of Flordia; and Jesse C. Vivian, associate clinical professor of pharmacy practice, Wayne State University. It is available through most schools of pharmacy and is distributed by Upjohn.
Vol. NS33, No.9
September 1993
other kinds of businesses, pharmacists are generally expected to place the interests of others ahead of their own. Indeed, this is one of the defining characteristics of the health care professions. Every encounter between a pharmacist and a patient implicitly raises ethical issues because a pharmacist must ask questions about how to promote the rights and welfare of the patient. Although every encounter between a pharmacist and a patient raises ethical issues, these issues do not necessarily present ethical dilemmas. A situation in which two or more choices are morally justifiable, but only one is capable of being acted upon at a particular time, represents a moral dilemma. 3 A pharmacist who has to decide between protecting a patient from harm and filling a prescription, as in the case above, is caught in an ethical dilemma, since there are moral reasons justifying each of two mutually exclusive options. To ask what one should do as a pharmacist is often to ask a legal question as well, but it is incorrect to reduce an ethical question to a matter of law. The assumption of this article will be that ethics, not the law, establishes the ultimate standard for evaluating conduct. 4 Because there is a moral obligation to obey the law, however, ethical analyses need to consider the relevant statutes and court decisions. How should pharmacists approach the ethical problems they encounter? It is helpful to use the following protocol.
Ethical Decision Making Ethical decision making begins with getting the facts straight. Thus, the ftrst step for making ethical decisions, in the clinical setting or anywhere else, is gathering the relevant facts. 5 In this case, the relevant facts are that the patient has a history of orthostatic hypotension as a side effect of the drug prescribed for her. Other drugs that do not produce this side effect are available. While orthostatic hypotension is not necessarily life threatening itself, the loss of consciousness associated with it may place the patient and others at great risk. To resolve an ethical dilemma, facts alone are not sufftcient. Ethical problems involve values as well as facts. 6 Identifying values is the second step of ethical analysis. An important value in this case is safeguarding the welfare of others, which gives rise to the moral rule: "Protect others from harm." Pharmacist Smith has good reason to believe that dispensing guanethidine will result in harm, not only to her patient, but also to those who may come into contact with the patient. Her moral commitment to do no harm justiftes her belief that it would be wrong to dispense the medication. If avoiding harm to others were the only important moral consideration in this case, pharmacist Smith would not be faced with an ethical dilemma, since it would be clear that she should not fill the prescription. Other values, however, AMERICAN PHARMACY
playa role here. One is the pharmacist-physician relationship. Pharmacists are rightly obligated to promote good relationships with the physicians with whom they work, and this obligation includes a responsibility to dispense the medications that the physicians prescribe. We now have the makings of a genuine ethical dilemma: Smith is bound to avoid harming her patients and others, but she is also committed to promoting a professional relationship with the prescribing pharmacist. To which moral rule, and thus to which group of people, does she ultimately owe allegiance? This brings us to the third stage of ethical analysis, generating options. We have already considered several options open to the pharmacist in this situation: • Dispense the medication but counsel the patient about the risks of severe side effects. • Refuse to dispense the medication and explain to the patient why. • Attempt to persuade the prescribing physician to change the prescription. Other courses of action are possible, but these are the most obvious ones. Which option is best from an ethical point of view, and why? To answer this question, we take the fmal step of ethical analysis, choosing an option and justifying it. If pharmacist Smith had to choose between competing loyalties, it would be difficult to hold that her fmal decision must be to respect the wishes of the physician. After all, it is the primary commitment to the welfare of patients that distinguishes pharmacy as a moral practice. Still, it might not be necessary for Smith to choose between the patient and the physician. She might call the physician back and discuss calcium channel blockers and their lower patient risk in this case. Sometimes ethical conflicts can be handled adequately by successfully exercising interpersonal skills rather than by making tough choices. Only if such an attempt is unsuccessful will the
pharmacist have to decide whether loyalty to the physician requires placing her patient and others at risk. This analysis suggests that some approaches to ethical problems in the clinical setting are more ethically defensible than others. Ethical analysis allows pharmacists to distinguish between better and worse approaches. It is sometimes the case that any option chosen will have unfortunate consequences (for example, the pharmacist's refusal to dispense the medication might upset the patient). But this is not the same as saying that there are no answers to ethical problems. Indeed, the circumstances pharmacists find themselves in often require some kind of decision or action, and, thus, in many instances, it is impossible to avoid making moral choices. Ethical analysis can lead the pharmacist to a reasoned and justifiable response to an ethical dilemma. Bruce D. Weinstein, PhD, is adjunct assistant professor of behavioral and administrative pharmacy, and associate director, Center for Health Ethics and Law, West Virginia University, Morgantown, W. Va.
References 1. Clouser KD. Bioethics. In: Reich WT, ed. Encyclopedia of Bioethics. New York: Free Press, 1978:115-27. 2. Emmanuel E. Do physicians have an obligation to treat patients with AIDS? N Engl J Med. 1988;318(25):1686-90. 3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press, 1989:4-6. 4. Callahan JC, ed. Ethical Issues in Professional Life. New York: Oxford University Press, 1988. 5. Ackerman TF, Graber GC, Reynolds CH, et aI., eds. Clinical Medical Ethics: Exploration and Assessment. Lanham, Md: University Press of America, 1987. 6. Veatch RM. Generalization of expertise: scientific expertise and value judgments. Hastings Center Studies. 1973;1 :29-40.
• Network with more than 4,500 pharmacy professionals from all over the country! • Earn up to 20 hours of CE credits-at about $12 per hour! • Sharpen your skills and kowledge with the latest information on patient counseling, health care reform developments, and pharmaceutical compounding! • Make and renew professional friendships at funfilled social events!
FOR MORE INFORMATION CALL
AMERICAN PHARMACY
1-800-237-APHA TODAY!
September 1993
Vol. NS33, No.9
Imagine the following scenario: Mary Moore* is a 76-year-old patient with hypertension. Her physician, David Darner, had previously treated her with diuretics and beta blockers, but had stopped the drugs because of side effects (orthostatic hypotension in the case of the diuretics). Darner decides to try Esimil (guanethidine) and prescribes 20 mg daily. Moore brings the prescription to her pharmacist, Paula Smith, but Smith is concerned about the potentially severe drug side effects. Smith believes that calcium channel blockers would be more appropriate. When she calls Darner and suggests this, the physician becomes irate. "This is not your area of expertise. You don't even know this patient. Leave prescribing drugs to me, and just fill the prescription." What should the pharmacist do? Different people will give different responses to this question. Some will say that she should attempt to get the prescribing physician to change the prescription order. Others will say that she should dis* Names are fictitious.
Steps in Ethical Decision Making After determining that you are faced with an ethical question: 1. Gather the clinically relevant facts of the case. 2. Identify all of the values that play a role, and decide which values are in conflict. 3. Propose possible solutions to resolve the conflict. That is, answer the question, "What could you do?" 4. Choose the better solutions for the particular case, justify them, and respond to possible criticisms. That is, answer the question, "What should you do, and why?"
AMERICAN PHARMACY
pense the medication but counsel the patient about the risks of severe side effects. Still others might say that she should simply refuse to dispense the medication. At stake is the pharmacist's duty to protect others from harm, the physician's and the patient's expectations that the prescription will be filled by the pharmacist, and the right of the patient to be provided with information needed to make treatment decisions. Whenever we ask "What should I do?" particularly with respect to the welfare and rights of others, we are asking an ethical question. If there are conflicting moral responsibilities, the situation becomes an ethical dilemma. This article and others to follow will examine the nature and scope of ethics as it relates to the practice of pharmacy by examining realistic clinical situations.
What Is Pharmacy Ethics? Ethics is the systematic study of what is right and good with respect to conduct and character. As a branch of both philosophy and theology, ethics seeks to answer two fundamental questions: (1) What should we do? and (2) Why should we do it? Ethics is concerned not only with making appropriate decisions about what we ought to do, but also with justifying those decisions. In other words, ethics seeks to provide good reasons for our moral choices. Pharmacy ethics applies ethical rules and principles to the practice of pharmacy. When we ask what a pharmacist should do in a particular case, we ask an ethical question. To justify our answer we appeal to the same rules and principles that apply to persons in society generally. 1 For example, the pharmacist'S obligation to protect patient confidentiality is merely an application of the rule that all of us have to carefully guard information that is entrusted to us. Sometimes, howSeptember 1993
Vol. NS33, No.9
ever, health care professionals are ethically required to assume risks not shared by laypersons, as when caring for persons with AIDS. 2 A professional incurs certain obligations not shared by nonprofessionals.
Pharmacy as a Moral Practice Pharmacy is a moral practice because pharmacists are concerned primarily with advancing the interests of patients and providing the services that patients want. Unlike members of
Resources in Pharmacy Ethics Books Beauchamp TI, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press; 1989. Beauchamp and Childress provide an indispensable analysis of ethical rules and principles in the context of health care. The fourth edition will be available soon. Weinstein Bruce D., ed. Ethical Issues in Pharmacy (Vancouver, Wash: Applied Therapeutics; forthcoming). This book will contain essays co-written by leading pharmacists and ethicists and will address such issues as pharmacists' relationships with the pharmaceutical industry, professional responsibilities toward chemically dependent colleagues, sexual harassment, and the right to health care. Encyclopedia Reich WT, ed. Encyclopedia of Bioethics. New York: Free Press; 1978. While slightly outdated, this work is a standard reference source and is available in most libraries. The second edition will be published in 1993. Journal American Journal of Hospital Pharmacy regularly features cases and ethical commentaries edited by Robert M. Veatch, PhD, professor of medical ethics and director, Kennedy Institute of Ethics, Georgetown University, Washington, D.C. Searches of the Literature The National Reference Center for Bioethics Literature at Georgetown University will run computer searches of the literature on any topic and mail them to you at no charge. Phone toll free: 1-800-MED-ETHX. Videotape "Ethics Perspectives" is a videotape for examining ethical issues in pharmacy, written and produced by David B. Brushwood, professor of pharmacy administration, University of Flordia; and Jesse C. Vivian, associate clinical professor of pharmacy practice, Wayne State University. It is available through most schools of pharmacy and is distributed by Upjohn.
Vol. NS33, No.9
September 1993
other kinds of businesses, pharmacists are generally expected to place the interests of others ahead of their own. Indeed, this is one of the defining characteristics of the health care professions. Every encounter between a pharmacist and a patient implicitly raises ethical issues because a pharmacist must ask questions about how to promote the rights and welfare of the patient. Although every encounter between a pharmacist and a patient raises ethical issues, these issues do not necessarily present ethical dilemmas. A situation in which two or more choices are morally justifiable, but only one is capable of being acted upon at a particular time, represents a moral dilemma. 3 A pharmacist who has to decide between protecting a patient from harm and filling a prescription, as in the case above, is caught in an ethical dilemma, since there are moral reasons justifying each of two mutually exclusive options. To ask what one should do as a pharmacist is often to ask a legal question as well, but it is incorrect to reduce an ethical question to a matter of law. The assumption of this article will be that ethics, not the law, establishes the ultimate standard for evaluating conduct. 4 Because there is a moral obligation to obey the law, however, ethical analyses need to consider the relevant statutes and court decisions. How should pharmacists approach the ethical problems they encounter? It is helpful to use the following protocol.
Ethical Decision Making Ethical decision making begins with getting the facts straight. Thus, the ftrst step for making ethical decisions, in the clinical setting or anywhere else, is gathering the relevant facts. 5 In this case, the relevant facts are that the patient has a history of orthostatic hypotension as a side effect of the drug prescribed for her. Other drugs that do not produce this side effect are available. While orthostatic hypotension is not necessarily life threatening itself, the loss of consciousness associated with it may place the patient and others at great risk. To resolve an ethical dilemma, facts alone are not sufftcient. Ethical problems involve values as well as facts. 6 Identifying values is the second step of ethical analysis. An important value in this case is safeguarding the welfare of others, which gives rise to the moral rule: "Protect others from harm." Pharmacist Smith has good reason to believe that dispensing guanethidine will result in harm, not only to her patient, but also to those who may come into contact with the patient. Her moral commitment to do no harm justiftes her belief that it would be wrong to dispense the medication. If avoiding harm to others were the only important moral consideration in this case, pharmacist Smith would not be faced with an ethical dilemma, since it would be clear that she should not fill the prescription. Other values, however, AMERICAN PHARMACY
playa role here. One is the pharmacist-physician relationship. Pharmacists are rightly obligated to promote good relationships with the physicians with whom they work, and this obligation includes a responsibility to dispense the medications that the physicians prescribe. We now have the makings of a genuine ethical dilemma: Smith is bound to avoid harming her patients and others, but she is also committed to promoting a professional relationship with the prescribing pharmacist. To which moral rule, and thus to which group of people, does she ultimately owe allegiance? This brings us to the third stage of ethical analysis, generating options. We have already considered several options open to the pharmacist in this situation: • Dispense the medication but counsel the patient about the risks of severe side effects. • Refuse to dispense the medication and explain to the patient why. • Attempt to persuade the prescribing physician to change the prescription. Other courses of action are possible, but these are the most obvious ones. Which option is best from an ethical point of view, and why? To answer this question, we take the fmal step of ethical analysis, choosing an option and justifying it. If pharmacist Smith had to choose between competing loyalties, it would be difficult to hold that her fmal decision must be to respect the wishes of the physician. After all, it is the primary commitment to the welfare of patients that distinguishes pharmacy as a moral practice. Still, it might not be necessary for Smith to choose between the patient and the physician. She might call the physician back and discuss calcium channel blockers and their lower patient risk in this case. Sometimes ethical conflicts can be handled adequately by successfully exercising interpersonal skills rather than by making tough choices. Only if such an attempt is unsuccessful will the
pharmacist have to decide whether loyalty to the physician requires placing her patient and others at risk. This analysis suggests that some approaches to ethical problems in the clinical setting are more ethically defensible than others. Ethical analysis allows pharmacists to distinguish between better and worse approaches. It is sometimes the case that any option chosen will have unfortunate consequences (for example, the pharmacist's refusal to dispense the medication might upset the patient). But this is not the same as saying that there are no answers to ethical problems. Indeed, the circumstances pharmacists find themselves in often require some kind of decision or action, and, thus, in many instances, it is impossible to avoid making moral choices. Ethical analysis can lead the pharmacist to a reasoned and justifiable response to an ethical dilemma. Bruce D. Weinstein, PhD, is adjunct assistant professor of behavioral and administrative pharmacy, and associate director, Center for Health Ethics and Law, West Virginia University, Morgantown, W. Va.
References 1. Clouser KD. Bioethics. In: Reich WT, ed. Encyclopedia of Bioethics. New York: Free Press, 1978:115-27. 2. Emmanuel E. Do physicians have an obligation to treat patients with AIDS? N Engl J Med. 1988;318(25):1686-90. 3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press, 1989:4-6. 4. Callahan JC, ed. Ethical Issues in Professional Life. New York: Oxford University Press, 1988. 5. Ackerman TF, Graber GC, Reynolds CH, et aI., eds. Clinical Medical Ethics: Exploration and Assessment. Lanham, Md: University Press of America, 1987. 6. Veatch RM. Generalization of expertise: scientific expertise and value judgments. Hastings Center Studies. 1973;1 :29-40.
• Network with more than 4,500 pharmacy professionals from all over the country! • Earn up to 20 hours of CE credits-at about $12 per hour! • Sharpen your skills and kowledge with the latest information on patient counseling, health care reform developments, and pharmaceutical compounding! • Make and renew professional friendships at funfilled social events!
FOR MORE INFORMATION CALL
AMERICAN PHARMACY
1-800-237-APHA TODAY!
September 1993
Vol. NS33, No.9