Understanding pharmacists' values: A qualitative study of ideals and dilemmas in UK pharmacy practice

Social Science & Medicine 68 (2009) 2223–2230

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

Understanding pharmacists’ values: A qualitative study of ideals and dilemmas in UK pharmacy practiceq Ailsa Benson b, Alan Cribb b, *, Nick Barber a a b

Department of Practice and Policy, The School of Pharmacy, University of London, Mezzanine Floor, BMA House, Tavistock Square, London WC1H 9JP, United Kingdom Centre for Public Policy Research, FWB-WBW, King’s College London, Waterloo Road, London SE1 9NN, United Kingdom

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 4 May 2009

Pharmacy, like other health care professions, is both a knowledge-based and a value-based profession. However, the values that inform practice activities are rarely made explicit. We sought to identify the values drawn on by UK pharmacists through qualitative interviews on day-to-day practice activities focused around practitioners’ conceptions of ‘the good pharmacist’, good practice and their experiences of ethical issues and dilemmas. The study was based upon loosely structured, one-to-one interviews of 38 selected practitioners reflecting a range of practice roles and settings. The interviews were recorded, transcribed and analysed following the principles of grounded theory. The accounts of practice (of self and colleagues) in the data showed pharmacists to be very dedicated and conscientious. Practice was predominantly discussed and presented by practitioners drawing upon a scientific mode of rationality. Value and ethical judgements were typically presented within this mode, with more open-ended and complex discussion of values and ethics appearing quite rarely. Two core values generally drawn on in reported practice emerged from the analysis – these were, ‘the patient’s best interests’ and a value we labelled ‘respect for medicines’. Common dilemmas arose from conflicting values, for example competing obligations to different parties, sometimes brought to a head by the conflicting demands of ‘rules’ of various sorts. Reported dilemmas related to rule breaking, resource allocation, patient communication and teamwork. There was a tendency for practitioners to ‘fall back’, often unreflectively, on their own personal value judgements when addressing these dilemmas. However, in the main, the values and dilemmas reported clearly show the socially embedded nature of professional ethics and, thereby, contribute to the social science re-theorisations of professional ethics needed if work on ethics development is to be realistic. Ó 2009 Elsevier Ltd. All rights reserved.

Keywords: Pharmacy Values Ethics Dilemmas Medicines UK

Introduction Pharmacy, like other health care professions, is both a knowledge-based and a value-based profession. However, the values that inform practice activities are rarely made explicit. In this paper we aim to make a contribution to making pharmacy values more explicit through analysing the reported perceptions and experiences of a sample of UK pharmacy practitioners. We use ‘values’ in a very general sense to refer to those things which practitioners see as making pharmacy valuable or worthwhile. In particular we are interested in those aspects of pharmacy which are cited by practitioners as an indicator of something that is ‘good’ whether that be in relation to practice goals, practice conduct, or the character of

qThis work was funded by the Royal Pharmaceutical Society of Great Britain. * Corresponding author. Tel.: þ44 02078483151. E-mail address: [email protected] (A. Cribb). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.03.012

practitioners. We use ‘ethics’ as a lens through which to elicit and make sense of pharmacy values. We are also using ethics in a very general sense to indicate a concern with determining what ought to be done in practice. Dilemmas arise when there are potential or actual conflicts between different practice values and hence are useful for investigating the ‘value axes’ that matter to pharmacists. That is, in looking at the dilemmas that are experienced and reported by pharmacists we are seeing the often invisible values which shape their work coming to the surface and being made conspicuous through the conflicts they generate. Although these dilemmas are not always seen explicitly as ‘ethical’ dilemmas by the practitioners themselves, because they are conflicts of values and centre on the question of what should be done they inevitably have some ethical dimension. Specifically our aim is to use pharmacy practitioners’ accounts of professional ideals and practice dilemmas to uncover and help map the values underpinning their conceptions of good practice. This process of value mapping also makes a small contribution to producing the more socially embedded

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accounts of professional ethics that are needed if professional development and profession building related to ethics are to be realistic and to be based on more than the simple ‘deficit’ models of individuals that lie below the surface of many critical accounts of professional ethics. By ‘deficit’ models of individuals we mean those accounts that – often implicitly but sometimes explicitly – locate the explanation of gaps between ideals and practice in the shortcomings of individuals rather than in the wider systems of which they are a part. In such deficit models individuals are constructed as lacking some degree of understanding, skill or character which, if corrected, would close the ideal-practice gap. However, in more socially embedded accounts the explanatory focus shifts to interactions between individuals, working cultures, institutional structures and broader social systems and processes. This is a critical time to seek to understand pharmacy values and ethics. The nature of health care is evolving; for example, patients are now more active participants in their care (Blaxter, 2000). As health care roles and relationships become more complex, ethics arguably becomes even more salient (Kalvemark, Hoglund, Hansson, Westerholm, & Arnetz, 2004). Pharmacy is no exception. Although values and ethics can always be discerned in every health care encounter (O’Neill, 2001), the type and nature of encounters is changing, because pharmacy is in a state of transition. Pharmacists worldwide are increasingly seen as part of the clinical team, and are involved in the improvement of prescribing and medicines use. More recently in some countries, such as the UK, pharmacists can have prescribing rights. Consequently pharmacists are being faced with new responsibilities and new forms of patient involvement both of which require not only a new set of technical skills, but also the negotiation of complex roles and relationships and changing patterns of accountability. These changes, we suggest, mean that it is becoming ever more important to put pharmacists’ values and ethics under the social and scholarly spotlight. There is very little empirical ethics research – especially in the UK – that illuminates the values of pharmacy practice, or the way ethical issues are perceived and managed by pharmacy practitioners (Wingfield, Bissell, & Anderson, 2004). The earliest research into the values of UK pharmacy practitioners was through content analysis of, and key word identification in, professional documents of six health care professions, including pharmacy, together with a postal questionnaire to practitioners (Brown, 1988; Brown, Ellis, Linley, & Booth, 1991, 1992). The pharmacist practitioners in Brown et al’s research, from a list of choices, ranked ‘patient welfare’ as the most important indicator of the quality of practice. More recent research in Australia has also identified patient welfare as the core ethos underlying pharmacy practice (Chaar, Brien, & Krass, 2005). Method As a tool to try and gain an insight into the key values that our participants drew on, and perhaps struggled with, participants were asked about day-to-day practice in relation to conceptions of good practice and practice dilemmas. Specifically they were asked to reflect, through examples, on what made someone a ‘good pharmacist’ and to share and reflect upon work situations that had ‘pricked their conscience’, or made them feel uncomfortable, as well as situations where they had had to make a compromise and/ or where there had been alternative courses of action that made choices hard. A range of formulations of these key ideas were used in order to provide follow up prompts should interviewees not understand or identify with particular formulations. Purposive sampling was adopted so that those pharmacists interviewed reflected something of the variety of roles and persons within the UK. The final sample of 38 participants comprised 18 community pharmacists, 10 hospital and 10 ‘Others’ drawn from,

for example, primary care trusts, senior management positions (including policy making roles), and academia. This latter group is larger than would be expected in a representative sample but our choice was partly motivated by exploring the perceptions of pharmacists who, because of their seniority, role responsibilities and professional ‘overview’ may act as key informants and present us with some contrasting data. Participants from the pharmaceutical industry were excluded, as they are not only a relatively small proportion of pharmacists in the UK but they have very different practice activities. In addition to reflecting a wide range of UK pharmacy practice situations and roles, the participants were also drawn from a variety of geographical locations and reflected diversity in age, experience (less than 2 years to over 25 years), employment status (owner, employee, locum), gender (equal numbers), and ethnicity (four from minority ethnic groups). The participants were selected via a snowballing process that began with contacts of the project team and moved on through referrals both from participants and associated institutional gatekeepers. Data collection stopped when very similar accounts and themes were emerging from the interviews. The interviews were recorded and transcribed. The principles of grounded theory (Strauss & Corbin, 1998) informed the analytical process, with preliminary analysis following each interview as this facilitated the identification of themes for clarification in subsequent interviews. The analytical process involved the summarising, categorising and linking of significant selections of text (open coding), which were then grouped into larger sets (axial codes). A process of constant comparison was used within and across interviews and meant that both the axial and open codes were subject to frequent revision. At the time of data collection the research students ethics review process of the institution that hosted this research (which was undertaken as part of a PhD) was in the process of being established and we followed the interim arrangement for PhD research studies. In the case of research that was ‘non-sensitive’ (which included asking professionals to reflect on their own practices) and that did not involve accessing participants through NHS channels – permission was subject to the approval of the Chair of the Postgraduate Research Student Committee, which was obtained. As was also required we used formal protocols for informed consent and systematically followed the research ethics codes of conduct published by the Economic and Social Research Council, the British Sociological Association, and the Department of Health. Pseudonyms used for the extracts within this paper are appropriate to gender and ethnicity. While recognising the distinctive epistemological nature of interpretative research we took several steps to address concerns about reliability and validity. For example, the research sample was wide in terms of UK working contexts, roles and geographical area. The first nine transcripts were read and analysed by all the authors, and the subsequent ones were read and analysed by the first two authors. Emerging analyses were presented to pharmacy audiences and feedback was used to revise and refine the coding and the analytical categories. The themes discussed below are the ones that were strongly evident in the data. Unless otherwise stated data extracts are used that represent common themes. Our main aim is to analyse pharmacy values across the profession and we have not sought to separate out the different value orientations of different pharmacy roles, not least because the comparatively small numbers would make this process unreliable. However in places we have signalled some possible differences within the sample, most notably in the orientation of those pharmacists with ‘policy roles’. In the remainder of the paper we present our data analysis followed by a discussion. We only use a few indicative data extracts but hope to provide a sense of the data set and to illustrate the basis

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of our analytical categories. Following a brief review and overview of the way in which the respondents summarised the nature of the pharmacy role, we set out the range of practice dilemmas referred to by them. Although we are interested in mapping these dilemmas in themselves the core purpose of focussing upon them is because these self-reported dilemmas expose the ‘value axes’ which are salient in pharmacists’ self-reports.

Findings The pharmacy role and core values The data set provided a strong sense of the distinctive nature of pharmacy practice and how this distinctiveness arises from the role that the profession of pharmacy plays in health care and in society as a whole. Colin, in a typical account, summarises the role of pharmacy as follows: [the part of the health care] arena that pharmacy specifically takes up . is really quite unique and sophisticated. . It is about medicines. But not just medicines themselves: it’s medicines and the people that consume them, and the people that use them. So. it is the interaction of the medicines with the prescribers, with patients etc Missing from Colin’s words here are the concern for meticulousness and conscientiousness that appeared across the data set. The data were saturated with references to the ‘unique’ properties of, and risks of, medicines and the crucial role of the pharmacists in managing medicines reliably and safely. In short what we came to label ‘respect for medicines’ was presented as fundamental to the practice of pharmacy. Colin’s account also introduces the pivotal idea of the interaction between medicines and users, and in particular of the medicines–patient interaction. Len, also reflecting widespread accounts, sums up this focus on the medicines–patient interaction and at the same time highlights the interaction between pharmacists and (other) prescribers: Everything we do is around optimising therapy for the patient. . First do no harm is generally the rule and after that do good. . It’s weighing up the factors, and trying to reach a decision you think is in the patient’s best interests. . First of all, does the patient need the drug, is it the right drug . then it comes to dose, what dose shall we give that will be effective, but cause minimal problems in terms of side effects and so on . When I’m up on the wards I’ve already made those decisions [on the basis of the evidence] behind the scenes . that bit is done.. And . if I’m asked ‘Why are you recommending this particular .[by the consultant] I’d say, ‘Well, I can present this little bit of evidence, blah blah’, which I think is actually compelling and I’ve got a case to support it with, The specific work context inevitably affects the form of professional practice activities. The above extract comes from Len, a hospital pharmacist, but the first half of it reflects views also emphasised by those interviewed within community (retail) pharmacy. Len’s account is also helpfully illustrative of a scientific mode of rationality; and this is something that pervades our data set. Science based expertise, on this account, is used to protect and promote what was often referred to as ‘the patient’s best interest’ – the other ‘core value’ that emerged from our analysis as pervading the data. The category of ‘patient’ here reflects a conception in the data not just of a singular or individual patient but – at least on many occasions – ‘a body’, the beneficiary of the previously accrued, evidence-based knowledge possessed by practitioners.

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When justifying himself (and his role) to professional colleagues Len explicitly uses the language of evidence and scientific rationality but, by contrast, there is no explicit reference to any patient involvement in weighing up the harm/good balances that he discusses. In the following sections we will review reported practice dilemmas as a way of further highlighting and opening up the nature of pharmacy values. We have organised these dilemmas into four broad categories that relate to rule breaking, resources, patient communication and teamworking. Rules and rule breaking The ‘rules’ that shape UK pharmacy, and which were cited in the interview data, come in many different forms – the law, codes of ethics, organisational rules, policy guidelines etc. These rules were presented as constraining action, albeit in different ways and with different degrees of force. For example, the law provides constraints on action, but these constraints can compete with core professional values around responsibility for a patient’s best interest. In the following example Eve underlines her sense of obligation to patient welfare, although notably does so by citing another source of ‘rules’, the Code of Ethics: you’re not supposed to give an emergency supply on controlled drugs. In this instance, it was a regular customer. It was. night, I knew he’d been along to his surgery and they were closed. And I didn’t want him to be without his painkillers overnight, so I gave him, I think, one for the night and one for the morning, on the understanding he would bring the prescription in the next day, which he did. But, technically, I was infringing the Misuse of Drugs Act, you know, the worst area that you can. but there are times where that’s what you need to do. I mean, you’ve got the Misuse of Drugs Act, but you’ve also got your Code of Ethics, what is it? ‘The pharmacist. the welfare of others.’ So, I decided that, in this case, I was. to take more notice of the Code of Ethics than the Misuse of Drugs Act. The data showed many ways in which rules from different sources, but applicable in the same situation, can conflict, creating practical and ethical dilemmas and calling on professional judgement and decision-making skills. For example, the professional Code of Ethics in force at the time of the research (Royal Pharmaceutical Society of Great Britain, 2005) included guidance about the management of over-the-counter sales of Emergency Hormonal Contraception (EHC) within community pharmacy. Individual pharmacists hold a variety of views about the beginning and end of life; drawing on related personal, religious or other cultural values (Wingfield & Badcott, 2007). Some participants readily identified their personal, including religious, values about such matters, and how they chose to manage conflicts they experienced between their personal values and their professional responsibilities. This is not simply a matter of ‘conscientious objection’ from those who are opposed to EHC on religious grounds but can effectively work the other way around i.e. a practitioner’s personal values can make them more liberal than professional norms dictate. For example, Roshan chooses to exercise her independence: We’re meant to ask them a whole load of questions. You’re meant to take them to one side and go through everything. . And maybe I don’t do it properly, but I’m happy to know that this girl feels they need it, and they’ve been brave enough to come in and ask for it, and so long as I know that they’re not on any other medication, they’re not suffering with any other medical condition blah blah blah, I’m not judgemental to know whether they are sixteen or fifteen or nineteen. I don’t ask their age. .I

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don’t do that, . If I did not sell it. what would be the consequences? I’ve had girls come in ‘Oh, the pharmacist down the road, he won’t sell it to me.’ And then I say ‘I will sell it to you, because it’s really important to me to know that you don’t do nothing about it’. And if this girl has an unwanted pregnancy, what will her future be? What will happen to her? As well as exercising her own personal value judgements here Roshan – as is common in the data set – is arguably acting from feelings of empathy and from caring motives. But Roshan might, at the same time, be viewed as acting paternalistically i.e. she is keen to act decisively on what she judges to be the best interests of the clients. Employers also provide rules and guidance about procedures to be followed within their institutions. These can also sometimes conflict with practitioners’ values about, and vocational responsibilities to, patients. They [her employer] have said we have to push the bigger pack [of painkillers] and I won’t, because I personally don’t think it is right. . We’re also told to give the branded product if someone asks for it. We’re not to let them know there is a cheaper generic. I don’t think that is right, I think people should get the choice. . So, if somebody asks me for the branded product, I say ‘we’ve got our own version, and it’s exactly the same and it’s half the price. It’s up to you.’ I think they should have the choice. (Mary) The dilemma here concerns which relationship obligation – that is, obligations to a patient, or obligations to the business/ commercial needs of an employer – should be prioritised when only loyalty to one can be met. Mary manages this tension quite subtly while working in a community pharmacy chain. She also signals the limits to, and possible paradoxes in, professional paternalism. Mary’s desire to protect the interests of patients requires her to flag up choices about which they may be unaware and thereby to enhance patient autonomy to some degree. We heard similar comments several times and one pharmacist we interviewed had left retail pharmacy because of the perceived pressure to conceal possible choices.

Resource dilemmas Len spoke about the way personal knowledge of (proximity to) and empathy towards a patient can potentially lead to what some might regard as favouritism through a decision not to adhere to the rule: We’ve accepted [the Strategic Health Authority] criteria for this drug trial. . Under the guidelines we have agreed this person would not receive the drug, but in our opinion we think [he should receive it]. It’s very difficult to argue against [giving it] when you have seen the specifics of a particular case. Here, we see that the pervasive concern with an individual patient’s best interests is still present, however we also see that this is at least qualified by, and set against, a concern with rules designed to serve broader populations. Some of the participants interviewed worked in policy development/implementation roles in primary care, and had to face the dilemma of deciding which patients should receive treatment when not all can be treated. (It is worth noting again that our sample somewhat disproportionately represented these ‘policy roles’.) However for these respondents, distributive justice was typically reduced to a technical issue based upon scientific evidence about the costs and benefits of medicines: How do we define what services someone needs? You’ve got actually to say, well, yes, I can see that there’s a benefit there but

actually it’s too much money. You’ve got to say ‘What’s the evidence?’ (Nat) But Colin shows a deeper appreciation of the nature of the problem: It is difficult to put in something whereby there is an equitable distribution. . Equitable to the population . not disadvantage any particular group . there are certain resource issues in terms of targeting health and social need . I don’t know that you can square these things. A more hidden, but common day-to-day resource dilemma related to the allocation of time to professional responsibilities. Time as a resource is a moral consideration, and decisions about its use reveal pharmacists’ values. Hospital pharmacists usually visit several wards to check drug regimens. Care of the elderly wards tends to have long stay patients on stable regimes which means less prescribing activity. As Guy says: Some wards get a very quick, casual service and I’m thinking possibly some elderly care wards and things like this, where they only get two or three visits a week. This ‘ward’ focus also illustrates one respect in which pharmacists do look beyond the interests of the individual immediate patient. But it suggests that the institutional regimes in which practitioners are bound up may themselves embody resource allocation values e.g. that the ‘elderly’ as a class of patients may risk being made a lower priority. Day-to-day practice activities, related for example to the supply of medicines, or monitoring of treatment, also provide resource dilemmas where a tension can exist between respecting the autonomy of the patient and professional responsibilities for effective use of resources, as Hal illustrated: If you know that somebody who’s getting a . medicine and regularly not taking it, you have to explore with them why they’re not taking it. [A particular patient] doesn’t take his warfarin . and has to be given [expensive] IV treatment .I’ve spent a lot of time with him but that is the lifestyle he has chosen [and he is not going to change]. Sometimes, as in this example, respect for the lifestyle of a patient is considered to restrict the pharmacist’s responsibilities for the effective use of medicines. In Hal’s comments we can see again how the two core values we have identified can come together. But we can also see that there other values in play and that Hal is having to manage his frustration about using his knowledge of medicines to ensure individual benefit because of his recognition – like that of Mary, above – of the importance of patient choice.

Patient communication: paternalism and respect Respecting, and understanding patient’s cultural values, is important both instrumentally and for ethical reasons. Len acknowledges the tension between exercising beneficence and respect for a patient’s cultural values: [Patient’s cultural and religious values are] the ones most often overlooked. . You may have a patient who doesn’t agree with animal products. .. If you think a drug is in the best interests of the patient but it happens to contravene their deeply held beliefs, should you be giving it or not? . I think there comes a point where if I really think that a drug is in the patient’s best interests, yet it contravenes perhaps what they would have wanted should they be competent, . then on occasion I may

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feel, actually, I think it is probably best to give this drug. . [The patient might] never get to know that they are given this drug. In this extract we again see the incredible power of the combination of what we have labelled ‘respect for medicines’ and the concern for the patient’s best interest. In this case the patient’s best interest is interpreted, as was most common, quite narrowly to refer to clinical benefit rather than to encompass a concern with patient choice. Indeed this narrow reading is taken despite the fact that the practitioner may be dealing with patient’s ‘deeply held beliefs’. Although one limit to this form of paternalism, indicated here, seems to be the possibility of being found out. Ken likes to share knowledge with patients although his account also emphasises his ‘advisory’ role: I love it when people ask more technical questions and I can show off a little bit of what I know. . I’ll go into the [dispensary] and get my Martindale, that great big fat book, I’ll slap it on the [shop] counter and say, ‘‘I bet you wish you hadn’t asked now.’’ And then we look at the book and I’ll give them .advice. Like Ken, Eve works within community pharmacy and likes to involve the patient rather than necessarily turning to the prescriber: A lot of the time you can resolve the problem with the customer . rather than jumping straight on the phone to the doctor. Hospital pharmacists working on wards typically have access to more clinical data about a patient than is usual within community pharmacy. In secondary care contexts where there is considerable emphasis on clinical frames of reference there is perhaps a greater risk that the patient may then be seen more as a body and less as a person (even if the latter is often in the guise of a ‘customer’ in community pharmacy settings). Hal’s comments illustrate this frame of reference: On the wards, the pharmacists will have a profile of the patient, look at what the patient’s condition is, look at the medication therapy they are on, see if it is appropriate medication . look to see if there are any drug handling issues that mean the treatment needs changing. Monitoring treatments to make sure they are going to plan. For hospital pharmacists, potential conflicts between professional and patient values and autonomy may be further complicated by other ethical concerns, such as judging a patient’s mental competence. Patients in the UK considered to lack mental capacity can have their rights overruled; sometimes colloquially referred to as ‘being on section’. Such vulnerable patients require special ethical attention and treatment with respect and dignity. As Wendy describes, dilemmas about treatment, and about the pursuit of desirable clinical outcomes, can come to a head in quite dramatic episodes in which pharmacy practitioners are intimately involved: There was a patient with chronic schizophrenia who was refusing her drugs. . she was having to be pinned to the floor and given a syringe. . Me and the medics were on one side and the nurses were on the other side. . the patient is on section, she ain’t got no rights. . this drug is the only drug that has got a chance of helping this lady.

Working in teams Our data set shows much evidence of effective and polite communication between the pharmacist and doctor, designed to protect the reputation of doctors while safeguarding the interests of patients (Lambert, 1996). Such situations involve competing

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values and obligations, and balancing these, so as to protect relationships between pharmacists and doctors, pharmacists and patients, and doctors and patients. Roy has worked out how he manages such conflicts: [A] patient in a hospital is under the care of one consultant, that is the person who they’re under the care of, and that’s it. If the GP is treating this patient then I’m on the periphery, I’m giving advice to the patient if they ask me the appropriate questions, I’m giving advice to the doctor if he asks me something. I’m not going to say to the patient, ‘‘This doctor’s told you something wrong.’’ I’m not going to say the doctor’s wrong. I’d tell the doctor he’s wrong, I wouldn’t tell the patient the doctor is wrong. I might say [to the patient], ‘‘I think there might be a problem about dose or side effects of this medicine [I want to sort it out with the doctor].’’ Several participants gave examples of potential ‘whistleblowing’ situations relating to the work of colleagues. There is professional guidance for pharmacists about raising concerns over the competence of others (Practice and Quality Improvement Directorate – Royal Pharmaceutical Society, 2005) but a decision to ‘blow the whistle’ on incompetent behaviour of colleagues is easier said than done. Nat, working in primary care, faced such a situation with a doctor: He was a private practitioner, medical practitioner, who we’ve have reports about, complaints . Seeing young girls, relatively young girls, late teens or whatever, giving them slimming pills. . So, we’re in a dilemma. We don’t contract this individual, as a qualified medical practitioner, he’s entitled to set up whatever practise he wants, in terms of delivering medicine and so on. But, the complaints had come through. . So we requested that this individual, this medical practitioner, meet with us . to say we weren’t actually very happy with the way he was practising and the advice he was giving, not a good standard of care. . what we said to him is ‘‘. we’re going to refer you to the General Medical Council.’’ And we didn’t do that as an idle threat, we actually did. Analogous ethical problems also arose in relationships with pharmacy colleagues. Nan found herself dispensing the fourth instalment of an incorrectly written controlled drug prescription. If Nan dispensed the medicine under these circumstances both she and her colleague could have undergone criminal prosecution under the Misuse of Drugs Act. I couldn’t refuse to do it. . had the inspector come in, I [and my colleague] could both have been in trouble. I don’t think it would be fair on the patient [to not dispense it]. . I wouldn’t have wanted to embarrass the other pharmacist by saying to the patient, ‘‘Look, I’m really sorry, but the pharmacist that took your prescription shouldn’t have done it.’’ (Nan)

Discussion As we noted in the introduction, there is a dearth of literature focussed on ethics in pharmacy practice and much of that which does exist employs quantitative methods and is based on ethics scenarios being put to the respondents (Wingfield et al., 2004). Although the situation is slowly evolving, with a trickle of qualitative studies emerging recently (see Cooper, Bissell, & Wingfield, 2007), Cooper et al. have recently re-stressed the ‘underresearched’ nature of the field. We would endorse this point and would also want to stress the potential and the value of research in this area. Most concretely empirical ethics research helps

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researchers and policy makers to ‘know what is going on’, which is important because calls for developments in pharmacy ethics depend upon some understanding of the status quo. At a more sociological level empirical research can also be drawn upon to help stimulate and formulate explanatory accounts of why pharmacy ethics is the way it is. Furthermore, we would argue, insights from empirical research can contribute to fundamental re-theorisations of the nature of professional ethics which have both academic and policy implications. We believe that our findings and analyses contribute to understandings of professional ethics in all of these ways. First, they help to fill an empirical gap in relation to pharmacy ethics; second, they help to demonstrate the crucial contribution of social science approaches to ethics; and third, and more specifically, they suggest ways in which theorisations of professional ethics, and calls for ethics reforms, need to be ‘sociologised’ and thereby reframed and moved away from simple deficit models of individuals. We will discuss each of these in turn. Our data set and analysis helps to illuminate the value-laden nature of pharmacy practice, including those aspects which, as we discussed in the introduction, are sometimes discussed in the literature as if they were value neutral. The findings show the central importance of the two core values of ‘respect for medicines’ and ‘the patient’s best interest’ and the technical-rational interpretation that is frequently given to these values. Our analysis of the whole data set shows that these two values lie behind and help to illuminate much of this data including the many practice dilemmas reported to us. ‘Best interest’ here is typically equated with the professional assessment of the clinical benefit derivable from medicines; an equation which carries with it a tendency towards paternalism. More generally the language in which ethics is discussed within our sample is broadly ‘rule-oriented’ – where rules are just narrowly technical-rational, but also legal and procedural. The theme of ‘rules’ and the tensions between different sets of rules (or standards, procedures, professional expectations) occurs across the data set. It illustrates quite clearly that pharmacy practitioners are not slavish rule-followers but have to exercise a degree of independent agency and professional judgement. However, even accounts expressed in terms of ‘rule breaking’ testify – by definition – to an approach which is rule-oriented. On the whole, in the accounts we have, professional judgement is required to balance the conflicting demands of different kinds of rules. But on occasions (e.g. in the example of Roshan and EHC) there is clear evidence of practitioner’s relying on their personal value judgements in a way that is out of line with professionally prescribed norms. Although all of the data relating to rule following and rule breaking shows the practitioners to be highly conscientious and thoughtful (especially with regard to protecting the interests of patients) there is comparatively little evidence in the data set of self-conscious reflection on values or of extended ethical deliberation about dilemmas. It is important to stress that professional paternalism is not intrinsically a bad thing i.e. it is always possible to ask whether or not paternalism is justified from case to case (Kleinig, 1984). The pharmacy practitioners we interviewed were undoubtedly beneficent and saw their scientific and technical knowledge and approach as powerfully geared to the ends of serving and safeguarding the health of patients. However the exercise of paternalism, although grounded on beneficence, tends to give primacy to the practitioner’s professional and personal values rather than those of the patient (Fulford, Dickenson, & Murray, 2002). Most people would now accept that cultural and religious needs in patient care should be respected (Henley & Schott, 1999) but the research reported here indicates there may sometimes be failures to give sufficient weight to such matters.

By contrast, there is some evidence, in certain cases, of practitioners recognising the value of patient choice, and of them interpreting the notion of ‘best interest’ to accommodate a respect for patient choice and lifestyle. In these cases the tendency towards paternalism is thereby qualified. A respect for the patient’s values can be demonstrated through seeking to understand what is important for them (Fulford et al., 2002) as well as involving them in care decisions (Coulter, Entwistle, & Gilbert, 1999). Some of our respondents also sought to show respect for patients through sharing technical expertise with them and thus bringing them into more of a partnership role. In addition it is clear that practitioners do not always have individual patients as the focus of their concern, with certain professional roles, in particular, focussed on protecting or promoting the good of groups of patients. Indeed in many instances the relevant focus broadens out beyond patients altogether and colleagues, employers etc. can become a key locus of concern. Nonetheless what we have identified as the core values indicate certain general emphases within the data set. These emphases should not be surprising. Pharmacy is defined around medicines and framed by the discourses surrounding medicines, particularly scientific-technical discourses and linked discourses about the production of clinical benefit. Pharmacy itself is generally regarded as a scientific profession; for example, pharmacists in the UK are registered as Pharmaceutical Chemists. There is inevitably a tendency for decision-making to follow a scientific mode of rationality; that is one that draws on knowledge and technical expertise, measurable standards and practice routines (Fish & Coles, 1998). In framing decisions and providing solutions for practice dilemmas values judgements will inevitably be made but, crucially, these are often hidden under the guise of technical neutrality (Wright, 1987). Recent policy emphasis on the importance of scientific rationality, most notably the evidence-based medicine movement, may strengthen this tendency. It is also apparent that pharmacy practitioners routinely face ethical challenges and dilemmas, albeit they may not be described, or seen, by them in these terms. Furthermore it appears that many such ethical challenges are not the result of exceptional circumstances, still less of poor practice, but are simply an inevitable product of the continuing balancing acts that practitioners have to achieve between a range of legitimate, but diverse, considerations. The systemic nature of these dilemmas is indicated by the fact that the dilemmas we uncovered in pharmacy practice correspond in broad terms to those identified in studies of other health professions and also in Cooper’s recent research focussed on community pharmacists (e.g. see Çobanoglu & Algier, 2004; Cooper, 2007) This characterisation of pharmacy values and ethics helps to specify the status quo and to identify possible scope for change and developments in ‘value literacy’ (Cribb & Barber, 2000). However, we suggest that this kind of empirical research has more fundamental implications for theory, policy and practice in pharmacy ethics. In identifying some broad tendencies and dispositions in the data set (summarised in the idea of ‘core values’) we do not want to suggest that these tendencies are somehow intrinsic to, or a necessary part of, the psyche of pharmacists. Rather, as the above analysis indicates, the values we have been discussing arise in substantial part from the dominant discourses on medicines that surround and construct pharmacy and the multiple social and institutional cultures and practices in which pharmacy is embedded. Empirical accounts offer the possibility of placing ethics within this broader sociological frame of reference. It is important to note here that we are entirely agnostic about the causal relationships between personal biographies and professional orientations. We are not making (and are not in a position to make) any claims about whether certain kinds of people end up in certain kinds of professions, or the extent to which, or depths to which, the

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subjectivities of individuals are ‘taken over’ by their professional roles. Rather we are making the conceptual point that the values of pharmacy practice cannot be understood in a purely aggregative way (i.e. as constituted simply by the personal values of the community of pharmacy practitioners), because the values of pharmacy practice necessarily arise from the cultural and structural location of pharmacy roles in society. The study reported here can be seen as making a small contribution to the development of a more socially embedded approach to bioethics (De Vries & Conrad, 1998; Zussman, 2000; Cribb, 2005). Those authors who have called for a socially embedded bioethics have a constellation of demands in mind including a greater awareness of how what counts as a salient ethical issue is socially constructed and of the ways in which action is socially and institutionally structured, as well as an interest in the empirical investigation of ethics and in the discursive construction of ethical concepts including, for example, ‘benefits’ and ‘harms’ (Light & McGee, 1998). An empirically informed awareness of these factors means that we are less likely to accept readings of professional ethics which are purely individualistic or voluntaristic, and – without denying the existence or importance of agency – will be more likely to play up the social structures and processes that need to be addressed if ethics change is to take place. The findings on, and analyses of, the experiences of dilemmas also serve to show that many of the ethical tensions experienced by pharmacy practitioners are not clashes within an individual’s personal value set but are rather the product of pharmacists being located in complex social fields with diverse, and sometimes competing, role expectations (e.g. arising from commercial pressures in community pharmacy, or from the combination of population-oriented policy roles with individual-oriented ones). Many of these dilemmas therefore have an inherently structural dimension to them and cannot be completely resolved at the individual level or satisfactorily tackled by enhanced ethics education (although strengthened value literacy may enable practitioners to understand the value implications of their social locations better). Recognising the structural dimension of dilemmas moves us beyond simple deficit models of individuals and, we believe, helps to develop conceptions of ‘moral distress’, already usefully extended by Kalvemark et al. (2004). Whereas moral distress used to be primarily conceptualised as relating to the tension between vocational dispositions and institutional constraints (e.g. Raines, 2000), Kalvemark et al. (2004, p.1074) have urged consideration of ‘the context of the ethical dilemmas’ and re-defined distress as a product of an inability ‘to preserve all interests and values at stake’ (2004, p.1083). We would wish to add that distress can, at least in many cases, usefully be seen as a psychological parallel of, and side effect of, inevitable structural stresses built into health care roles such as those within pharmacy. Overall, we contend, there has been too much emphasis in the professional ethics literature, on both philosophical and individualistic constructions of values and ethics. While in no way wanting to diminish the importance of these things we believe that empirical analyses of professional ethics provide a useful basis for a more ‘socioligised’ conception of professional ethics and for a focus upon the social construction of role-related values and ethics. Conclusion As we signalled in the introduction a range of developments mean that ethical issues are becoming increasingly salient to pharmacy professional practice. Familiarity with ethical language and concepts – e.g. the ‘four principles of health care ethics’ as elaborated by Beauchamp and Childress (2001) and much

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discussed within the applied ethics literature – appears to be limited. This may support a tendency to ‘fall back’ onto a reliance on paternalism and a technical-rational mind-set that sees the supply of medicine as a solution to a specific patho-physiological problem. This research (and other similar research e.g. Deans & Dawson, 2005) has already fed into a revised approach to the professional Code of Ethics (Royal Pharmaceutical Society, 2007) and the new Code adopts a less technical-rational and more open-ended and principle-based approach to ethics. However, given the evidence that Codes of Ethics are often not used (Chaar et al., 2005) there is still a considerable challenge for the profession not only in ensuring that the new Code of Ethics is attended to, but also in finding more fundamental mechanisms to build professional structures and cultures which combine greater literacy about values and ethics with the high levels of professional commitment witnessed in this research study. An important part of this process of profession building, and ethics development, we would suggest, is to build empirically informed and socially embedded approaches to professional ethics. These approaches must take as much interest in the social processes of role construction as they do in individuals’ actions within professional roles.

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