Ethics as subjective or relative to cultural norms
The participants’ opinions about what they ought to do (which, it is assumed, includes
what they ought to do morally) were varied, and this was something that became a
topic for discussion. The participants attributed such diversity to differences in
personality and upbringing, religion and professional standards, and understood
judgement as being an ‘individual thing’. Even so, participants discussed the value of
consulting colleagues to get a second opinion on difficult matters.
In practice pharmacists might not have access to colleagues when faced with an
ethical dilemma. This is most likely a problem in the community sector of pharmacy,
where pharmacists often work in isolation. Cooper’s research showed isolation
among community pharmacists led to lack of assistance and communication which,
could, among other things, lead to an inability to articulate the ethical values of the
profession.47
“[In] community [pharmacy] you might possibly be there on your own
where the decision has to be yours…[You] can obviously try and contact
friends and colleagues and things but in that situation you might have to
make that decision there and then on your own and base it on your
ethical beliefs as opposed to a general consensus.”
Pre-reg1
‘Personal morality’ and ‘professional ethics’
In one of the groups there was disagreement about the extent to which professional
judgement should be influenced by personal values. One school of thought was that
it was a pharmacist’s duty to separate herself from a situation in order to make a
sound decision.
“It’s a moral thing and sometimes you’ve just got to take that moral issue
away from yourself.”
Pharm3
This separation is between the patient and the personal value-judgements of the
pharmacist. In the focus group discussion some participants said they made value
judgements while some claimed they preferred to be value-neutral. For example,
when discussing the supply of EHC, one participant said,
“My daughter’s that age as well and ... Yes, she could be [having sex], yet
she may not be. I don’t know, but it’s not for me to moralise. And if they
come to me for the morning after pill and I’m in a position to give it then I
will do it.”
Pharm3
It is worth noting that this itself is an ethically motivated statement. The pharmacist is
using the word ‘moralise’ as if making a moral judgement is to be illiberal, intolerant
or unfairly judgemental. In the same way, the word ‘judgement’ was used negatively
in the focus group.
4.1.2. Rules
The theme ‘rules’ was prominent in the focus group discussions, with participants
understanding an ethical problem as one in which ethics came into conflict with the
law. Other studies provide further evidence that pharmacists are concerned about the
rules of the profession and the law.48
There were three ways in which participants reported themselves to behave when
faced with an ethical problem that involved rules. They can be classed as: following
rules in a considered manner; obeying rules to avoid getting into trouble; and
breaking rules, which included discussion of how rule-breaking could be justified.
Following rules in a considered manner
Acting in accordance with the rules was expressed by some participants in terms of
respecting the reasons behind the rules. It was clear that in some cases rules were
being followed for considered reasons. This is demonstrated in the following
statement regarding supplying EHC outside the product licence:
“I would be breaking the product licence and I haven’t got the right to
break the product licence.”
Pharm1
Obeying rules to avoid getting into trouble
One of the motivations for pharmacists acting in accordance with the rules was to
avoid getting into trouble. For example, when asked whether a pharmacist should
supply a controlled drug to a patient without prescription, this participant was
concerned about police involvement, asking fellow participants:
“What do the police do? Come in and look and go through [your
records]?”
Pharm2
In the context of supplying medication outside the product licence, the following
reason was given for acting by the letter of the rules:
“You have to be careful…I heard from someone, probably through the
grapevine, about a doctor prescribing [hydrocortisone cream] for a baby,
for the face. The skin peeled off and I think the doctor got into trouble for
it.”
Pharm2
Breaking rules
The data suggest participants were comfortable with rules, and were keen to act in
accordance with them. However, rules would be broken if the patient’s interests
conflicted with the rules and were regarded by the individual pharmacist as
sufficiently strong to weigh more heavily than the unfavourable consequences of
breaking the rule. The data show varying judgements of the point at which a patient’s interests were sufficiently great to motivate breaking a rule, and varying judgements
of the point at which rules were sufficiently strict to act as a disincentive for acting in
the patient’s best interests.
An example was given of breaking the rules to supply medication without a
prescription to a patient who had run out of her medicine.49
“[It] is, strictly speaking, illegal. But we’ll do it.”
Pharm7
Participants spoke of rule breaking as the responsible thing to do in some cases,
recognising the importance of professional autonomy, which was also spoken of as
professional judgement.
Justification for breaking the rules
Justifying breaking the rules was framed by participants in terms of acting
professionally. As professionals, pharmacists use their judgements in individual
cases where guidelines do not exist, or are regarded as inappropriate. This
participant is explicit that being able to judge when to act independently is one of the
roles of a professional:
“I suppose in a way we’re professionals because then we can, we make
our judgements, I mean if you are not then, you … just all play by one
rule.”
Pharm4
This statement points to the relationship between rules and professionalism;
participants expressed a tension between acting professionally by following the rules
and knowing when to act independently of the rules in the name of professionalism.
4.1.3. Key ethical concepts
This section is a summary of a systematic examination of participants’ understanding
of some key ethical concepts in their work, an examination that demonstrates the
complexity of some of the practical ethical problems pharmacists face, and exhibits
the patchwork nature of the application of ethics in pharmacy practice.
Individual patients’ interests
The subject of the patient’s best interests was mentioned several times during each
focus group discussion, with the phrase ‘patient’s best interests’ used by participants
to mean the interests of an individual patient as opposed to a collective group.
Participants spoke of patients’ interests as if acting in the patient’s best interest
ranked as the highest principle, though there is evidence that participants did not in
fact regard this principle as highly as they sometimes claimed.
“[I]t’s all a case of weighing up what you think’s best for the patient.”
(unknown)
The above quotation may be an expression of a prima facie principle that could exist
without consideration of additional competing principles. Other reports from participants showed that a patient’s interests were regarded as important, but not
always as the priority. The three factors that competed with an individual patient’s
interests were interests of the pharmacist (commercial and whether they would be
struck off), other patients’ conflicting interests, and legal obligations.
“It’s often a compromise … you know, the law, what’s best for the patient,
what’s best for you.”
(unknown)
The patient’s best interests extended to the long-term social interests of the patient.
In this context, ‘social interests’ means the non-health interests of the patient, which
include patient autonomy, social relationships, financial interests and general welfare.
When discussing the supply of EHC, participants considered the broad social
interests of the patient.
In some incidents in which the patient’s interests came into conflict with the law
pharmacists were prepared to act illegally. In fact, interests of the patient were the
most common reasons participants gave for breaking the law, though it is important
to note that sometimes the law was given greater priority.
“But with somebody who is terminally ill then you don’t want them
screaming out with pain just because you are being bloody minded about
not giving them a prescription [because it has been completed
incorrectly].”
Pharm1
How highly a participant ranked patient interests varied between individuals. Some
participants were willing to break serious laws (for example those surrounding the
supply of controlled drugs) for the sake of the patient, while others set the boundaries
lower.
Public interests
Concern for public interests was a relatively minor theme in the focus group
discussions, but the subject did arise in relation to National Health Service (NHS)
resources. For example, when asked about a vignette in which a doctor was selfprescribing
medication the pharmacist strongly suspects she is abusing, participants
said it depended on whether the prescriptions were private or from the NHS. There
was a sense in which participants felt they had a duty to report repeated selfprescribing
if it was at the expense of the NHS, presumably because NHS funds are
intended for the use of the public, justly allocated and endorsed through policy. The
following quotation comes from a participant commenting on her own experience of a
doctor self-prescribing medication the participant suspected she was addicted to.
“[If] she starts prescribing from hospitals she’s actually using the
hospital’s facilities … rather than going to her own GP for it, and after
about three months …I wasn’t happy with it anymore. …[This] person was
abusing the NHS system in a sense, you know, because I just think that
whatever you want you shouldn’t be abusing the NHS system by doing
your own thing.”
Pharm4
Speaking in response to a vignette:
“If it was NHS I wouldn’t [dispense something self-prescribed], obviously,
but if it’s private then, it’s private, …[isn’t] it? … I don’t see anything wrong
with it …[because the self-prescribing doctor is] paying for that.”
Pharm2
The factor influencing this decision seems to be that there are wider public interests
tied up with the NHS that do not exist with private prescriptions, and participants felt
a moral obligation to act in the interests of the public.
Confidentiality
Although the ethical dimensions of confidentiality were recognised by some
participants, there were occasions when the moral dimensions of the notion were lost
in favour of the regulatory demands for confidentiality, and there were incidences in
which confidentiality was overlooked entirely despite it being a relevant feature.
Confidentiality was understood as a professional obligation, or an institutional rule to
be followed. This is illustrated in the following quotation, in which a participant said
she would keep patient confidentiality because she had been specifically told
(presumably by the professional body or in an education programme) to respect
patient confidentiality.
“We’re specifically told that you know you shouldn’t break [the] patient’s
confidentiality.”
Pre-reg1
This motivation for respecting confidentiality is to act within the rules; respecting
confidentiality does not seem to be a moral compulsion. Stories from participants
showed that the consequences of misunderstanding confidentiality in this way meant
the principle was open to being breached. For example, when discussing a scenario
in which a customer asks the pharmacist to identify a tablet he has found in the
bedroom of his daughter (a patient of the pharmacy practice), participants recognised
that confidentiality was one of the main principles at stake. Although they decided
they would not disclose the information themselves, despite knowing what the tablet
was, some said they would instead direct the father to a source of information that
would identify the medication for him. This falls short of the moral obligation to act in
order to preserve the confidentiality of the patient, and in fact would cause the same
effect on the patient as breaching confidentiality would. Whether it is appropriate to
breach confidentiality in this case (for example to prevent harm to the daughter), was
not discussed in the focus group. Rather, the discussion was about how to direct the
enquiring father towards information without oneself being the one to divulge the
information.
“[T]hey usually tell you to refer to a drugs information helpline, don’t they,
’cause they’re good at identifying [drugs].”
Pre-reg2
Conversely, participants at times took a very cautious approach to confidentiality,
reporting to guard it closely, to the extent of suggesting that even saying that certain
information was confidential might arouse suspicion and break confidentiality to an
extent.
“[I]f you say, ‘Oh I’m not at liberty to say’ or something she’s gonna think,
‘Ooh, there’s something wrong there.’”
Pre-reg2
When discussing whether to disclose patient information, participants often raised the
point that some information about a patient is also publicly available general
information. The following is an example of a pharmacist disclosing information about
a patient as a result of disclosing publicly available general information:
“I’ve actually had somebody phone up, asking me what a particular
tablet was for. [I told her]. But I was sorry afterwards, because it turned
out that her husband was having an affair and had picked up an STD
and… she saw the leaflet. I was sorry.”
Pharm3
Competence of patient
Competence was seen by participants as measurable by common sense and by the
Gillick competency test.50 Participants took a practical approach to assessing
competency and did not see age as necessarily being the deciding factor.
Competence of the patient was raised in relation to supplying EHC, since
competence is one of the criteria for supply. Some participants were happy to supply
EHC to girls under the age of consent as long as the patient was competent to make
the decision.
Age was not the measure of competence. Rather participants judged competence on
the fact the patient had the initiative to go to the pharmacist and to what extent the
patient seemed to be sensible. As one participant observed, some adults who ask for
EHC seem less competent than some of the girls who are under the age of sixteen.
“I’ve come across eighteen-year-olds who I don’t think …[are] competent,
but they’re eighteen, so… and I’ve come across really young [girls]
who’ve, you know, got their heads screwed on.”
Pharm3
4.1.4. Sub-section summary
These findings show that participants’ understanding of ethics in pharmacy is based
largely on commonsense, with participants referring to ethics as subjective and
relative to cultural norms. Expressing ethics in metaphorical terms may indicate a
certain lack of fluency in discussing ethics, despite ethics being a feature of daily
practice for pharmacists. The word ‘ethics’ seemed to take on several meanings,
being used sometimes to mean the Code of Ethics, sometimes regulation,
sometimes morality, and sometimes a tool and justification for breaking the rules.
The frequent reference to rules in the focus groups was striking, and an ethical
dilemma was sometimes understood to be a conflict between moral and legal
obligations, rather than a conflict between two moral obligations.
4.2 Survey results
The results presented here are from two types of questionnaires sent to community
and hospital pharmacists. Data were gathered from pharmacists in community,
hospital and primary care practice. Comparisons can be made between community
and hospital pharmacists’ responses but since the number of respondents from
primary care practice was too low (15) to make reliable inferences, the data from
primary care practice were not subject to statistical analysis.
Results are presented in such a way as to answer questions about the frequency of
occurrence of certain ethical dilemmas, how pharmacists deal with these ethical
problems, and whether there is any statistically significant association between the
sector pharmacists work in, the decisions they make and how important they regard
certain factors when faced with an ethical problem.
Results show general agreement in regard to what pharmacists would do in certain
situations within and across sectors. Differences between sectors lay in how much
consideration pharmacists gave to their own financial interests and the financial
interests of the company, trust or hospital they worked for.
The survey included scenario-based questions, which asked participants whether
they had encountered certain situations in their work. They were asked how often the
situation had occurred in the past year. Participants were then asked to indicate, from
a selection of options, what action they had taken in those circumstances or, if they
had not encountered the situation, what action they think they would take.
4.2.1 Frequency of occurrence of specific ethical problems
The following two tables detail the frequency of occurrence of specific ethical
problems. Results show that the most common were: receiving an unsigned
prescription; being asked for emergency hormonal contraception over the counter;
receiving a prescription lacking full information; a patient returning unused, in-date,
unopened medication; and a family member requesting confidential information about
a patient.
It is worth noting that community pharmacists claimed to have encountered more of
the presented scenarios than hospital pharmacists had. Pharmacists from both
sectors have responded to scenarios they have not encountered, and as such there
are many answers to hypothetical, rather than actual, situations.51
Table 1. Table showing the frequency of occurrence of each possible dilemma faced by community pharmacists. Percentages have been rounded to the nearest
1% and exclude missing data, or those who answered ‘don’t know’ or ‘N/A’. The median category has been indicated by highlighting in blue the appropriate
frequency count and percentage.
Table 2. Table showing the frequency of occurrence of each possible dilemma faced by hospital pharmacists. Percentages have been rounded to the nearest 1%
and exclude missing data, or those who answered ‘don’t know’ or ‘N/A’. The median category has been indicated by highlighting in blue the appropriate frequency
count and percentage.
4.2.2 How pharmacists deal with specific ethical problems
Using scenario-based questions, participants were asked to report what they had
usually done when they had found themselves in specific ethically-problematic
situations at work. One of the features of these scenario-based questions was that, if
participants had answered that they had never in fact been in that situation, they
were asked what they would have done in that particular situation. Percentages have
been rounded to the nearest 1% and exclude missing values and those who
answered ‘don’t know’ or ‘N/A’.
4.2.2.1 Opinion within sectors
Community pharmacy
The following results have arisen from scenario-based questions that applied to
community pharmacists only, and exclude void answers. Community pharmacists
were mostly in agreement over how to resolve most situations (divisions of opinion in
ratios between 8:2 and 10:0 are considered to be ‘mostly in agreement’). Consensus
was reached on whether to supply or not supply methadone to a patient who has
come in for his/her methadone the day after the date specified on the prescription
(98% refused to supply, and 2% agreed to supply). Pharmacists were mostly in
agreement over whether to dispense for an unsigned prescription for something like
paracetamol (80% would dispense; 20% would refuse to dispense) and whether to
dispense from an unsigned prescription for something like an opiod analgesic (81%
would refuse to dispense; 19% would dispense). Pharmacists were mostly in
agreement over whether to sell medication over the counter to a patient who does
not really need it (and who would also not be harmed by it) (13% would sell the
medication; 87% would advise against the sale) and whether to sell medication over
the counter to a customer who may be abusing the medicine (14% would sell the
product; 86% would refuse to sell it). When asked whether their personal beliefs
affect whether they would supply EHC over the counter 6% pharmacists reported that
their personal beliefs affect their decision to supply; for 94%, their decision is not
affected by personal beliefs. Pharmacists were mostly in agreement about what to do
if they suspected a doctor was abusing medication from NHS and private scripts. In
the scenario given, the doctor had not responded to verbal intervention from the
pharmacist. There were almost identical results from the scenarios relating to abuse
of NHS and private prescriptions; 80% would report the doctor abusing medication
using NHS scripts, 81% would report him/her for abusing medication using private
scripts; 20% would not report the doctor abusing medication using NHS scripts and
19% would not report the doctor for abusing medication using private scripts.
There was slightly more pronounced division of opinion over whether to dispense
clinically equivalent medication when the pharmacy is out of stock of the brand
named on the prescription (71% would not dispense; 29% would dispense the
equivalent). Opinion was split over whether to supply medication to a patient who has
made it known s/he will use the medication against guidelines (e.g. hydrocortisone
cream being used for the face), with 59% of the opinion the supply should be
refused, and 41% of the opinion the medication should be supplied. Over the matter
of a girl who appears under sixteen years of age requesting EHC in an area where
no PGD (patient group direction) is in place, opinion was divided over whether to
supply EHC or not, with making the supply, and refusing to do so. Locum
community pharmacists were divided over how to resolve the following problem: ‘As
a locum you are told the usual pharmacist does things a certain way, and are asked
to work in that way too. You regard this as unethical’. Opinion was divided with 21%
operating as normal for that pharmacy, and 79% refusing to work that way.
Hospital pharmacy
The following results have arisen from scenario-based questions that applied to
hospital pharmacists only, and exclude void answers. All respondents agreed that
medication should be dispensed as requested if a paediatric consultant were to ask
for medication that is outside SPC (Summary of Product Characteristics) guidelines.
There was also strong agreement over what should be done in the following
situation: ‘A member of the public comes to the pharmacy and asks for some
medication for someone else who is waiting at home (e.g. his wife, who is in great
distress). S/he tells you the person for whom the medication is for has used the
medication several times before and is very familiar with it. The wait for A&E is
extremely long.’ The majority (93%) would refuse the supply, while 7% would supply
the medication. On the matter of knowing a patient who has a condition that may
affect him/her while driving has not informed the DVLA (Driving and Vehicle
Licensing Authority), 8% would report the patient to the DVLA, 37% would talk to the
patient, knowing s/he is unlikely to inform the DVLA him/herself, and 55% would
inform a medical consultant.
4.2.2.2 Opinion between sectors
Data from a total of eighteen scenarios that could occur in either a community or
pharmacy setting were analysed. Within these eighteen, there was mostly agreement
within sectors and between sectors about how they would resolve each ethical
problem presented. There were only two exceptions to this, which will be detailed
towards the end of this sub-section.
There was general agreement over the following: if further information was needed
about a prescription, most would contact the prescriber (97% community; 98%
hospital). If a patient returned unopened, unused, in-date medication, most would
dispose of it (87% community; 95% hospital). If a colleague was taking prescription
medicine from the controlled drugs cabinet, most would report the colleague (96%
community; 98% hospital). If there was reason to suspect a child patient was subject
to abuse at home, most pharmacists would know what procedure to take and would
go through the appropriate channels (89% community; 92% hospital). If the
pharmacist believed the patient would be more compliant with important treatment if
s/he was misled about some information, most would not withhold the truth but would
talk frankly to the patient (82% community; 90% hospital). If a colleague was
behaving unethically, most pharmacists would talk to their colleague rather than take
no action at all (94% community; 81% hospital). If that colleague continued to behave
unethically after the pharmacist had spoken to him/her, most would then report the
colleague (82% community; 92% hospital).
If a close family member of an adult patient requested confidential information about
that patient, most would not pass the information on (92% community; 94% hospital).
However, opinion was divided in both community and hospital sectors over whether
to pass on confidential information to a parent of a fifteen-year-old child, with 34%
community and 42% hospital of the opinion that the information should be passed on,
and 66% community and 58% hospital of the opinion the information should remain
confidential. Divide was greater again over the question of whether a pharmacist
should inform a member of the public of the identity of a tablet that did not belong to
them. Figures 1 and 2 below show these last two sets of results in cluster bar graphs.
Of all the results detailed in this subsection, none showed any association between
the answers given and the sector the pharmacist works in.
Figure 1 Clus tered bar graph showing percentages of hospital
pharmacists (n=53) and community pharmac is ts (n=164) who would
pas s on or not pass on confidential information to a parent about their
15-year -old child's treatment. Frequencies are shown in the bars.
Figure 2 Clustered bar graph showing percentage of hosp ital
pharmacists (n= 55) and com munity pharmacists (n=164) who would
inform o r not inform someone of the identi fication of a tablet that did not
belong to them if the pharmacist was able to iden tify the tablet.
Frequencies are shown in the bars.
4.2.3 How important certain factors are in making ethical decisions
Pharmacists were asked how much importance they gave to certain factors when
making decisions about situations such as those presented in the questionnaire. The
most marked of these was the consensus, both within each sector and across
sectors, that the patient’s health interests should be given a great deal of
consideration (the mean score across sectors was 89%). It is also worth noting that
across sectors pharmacists gave a great deal of consideration to keeping within the
law (the mean score across sectors was 67%). Pharmacists across sectors also gave
a great deal of consideration to whether they would be struck off (the mean score
across sectors was 52%), to keeping within the guidelines of the RPSGB52 (the mean
score across sectors was 50%), and to their reputation (the mean score across
sectors was 31%). Factors that were given ‘quite a lot of consideration’ were the
pharmacist’s relationship with the patient (the mean score across sectors was 41%)
and the pharmacist’s relationship with the prescriber (the mean score across sectors
was 37%). ‘Some consideration’ was given to the financial interests of the company/
trust/ hospital (the mean score across sectors was 47%), the patient’s non-health
interests (the mean score across sectors was 46%), and participant’s relationships
with pharmacy colleagues.
An association was found between the sector pharmacists worked in and how much
consideration they gave to their own financial interests (U=3634.5; n1=175; n2=64;
p=.003), with community pharmacists considering their own financial interests more
than hospital pharmacists did. There was also an association between the sector
pharmacists work in and how much consideration they give to the financial interests
of the company, hospital or trust they work for (U=3609.5; n1=175; n2=64; p< .0005),
with community pharmacists less concerned with this than hospital pharmacists
were. It should be noted that these results are derived from questions that varied
slightly between the sectors. Community pharmacists were asked how much
consideration they gave to the financial interests of the company they worked for,
hospital pharmacists were asked how much consideration they gave to the financial/
resource interests of the hospital or trust they worked for.
Figure 3 Cluster bar graph showing which factor community pharmacists (n=150) and
hospital pharmacists (n=51) considered the most important when making ethical
decisions.
Other factors community pharmacists specified as being brought into consideration
when faced with an ethical problem included: ‘maintaining team approach and policy
in dispensing decisions’; ‘maintaining high standards of practice’; ‘moral values’;
‘commonsense’; ‘balancing the patient’s needs against the rule of the law’; and
‘justification for actions’. Hospital pharmacists specified ‘commonsense’ and
‘workload pressures’.
5. DISCUSSION
There is general agreement across sectors about how frequently certain ethical
problems arise in practice. Within sectors there was a lot of agreement about what
ought to be done, and no statistically significant difference was found between the
answers community and hospital pharmacists gave in response to questions
concerning what the appropriate action would be in each situation.
The data from both the survey results and the focus groups suggest pharmacists
consider the patient’s health interests to be a very important factor in ethical decisionmaking.
It is worth noting that the patient’s health interests were ranked more highly
in the survey than any other factor, but that the patient’s non-health interests were
not ranked very highly. Many of the scenario-based questions asked in the survey would have included an element of the patient’s health interests, for example the
scenario in which the pharmacist would ideally have more information about the
prescription. It is arguably in the patient’s best interests that the pharmacist
dispenses only on full information, and most (97%) community and most (98%)
hospital pharmacists reported that they would request further information from the
prescriber in such a situation.
However, many of the scenarios in the questionnaire demanded the participant
consider his/her relationship with the prescriber, the patient and the public, and many
included a dimension of the social interests of the patient. It is worth noting that when
asked to rank the level of consideration they gave to certain factors when considering
an ethical problem, although the patient’s health interests take priority, regulation
seems to play a very important part in moral decision-making among pharmacists.
Pharmacists ranked their consideration of the law, RPSGB guidelines, their
reputation and the risk of being struck off more highly than the patient’s non-health
interests.
Concern for regulatory constraints is echoed in the findings from the focus groups,
which showed that sometimes pharmacists were prepared to break the rules in the
interests of the patient, but in some cases pharmacists acted in accordance with the
rules even if this was not necessarily in the best interests of the patient. The findings
from the focus groups showed that deferment to regulation occurred for at least two
reasons: out of respect for the rationale behind the rules, and because of fear of
getting into trouble.
Where the community and hospital sectors differed in their approach to ethical
problems was in consideration of the financial aspects of pharmacy. Community
pharmacists are under commercial pressure in a way that pharmacists in other
sectors are not, and given this it is perhaps not surprising that community
pharmacists were more concerned about their own financial interests than hospital
pharmacists were. Many (24%) community pharmacists give ‘some consideration’ to
their own financial interests. Findings from the focus group indicated that the
pharmacist’s own financial interests were not of great importance, though one
participant did note “We’re pharmacists, but we’re also businessmen” [Pharm1]. In
part this supports research by Hibbert, Rees and Smith, which showed that
community pharmacists experienced a conflict between business or economic
concerns and “professional responsibilities”.53 Hospital pharmacists are exposed to
different financial pressures, which is shown in the fact that community pharmacists
are less concerned about the financial interests of the company they work for than
hospital pharmacists were concerned about the financial interests of the trust or
hospital they work for.
However, since the scenario-based questions did not have scope for explanations for
the answer given, it is impossible to tell which factors influenced pharmacists’
decision-making in each scenario given. For example, the 80% community
pharmacists who would dispense paracetamol from an unsigned prescription, the
58% who would sell EHC over the counter to a girl who appeared underage, and the
41% who would supply medication against the product guidelines may have been
motivated by financial gain, or may alternatively have been more concerned about
the patient’s interests and the patient’s autonomy.
It is worth noting that while most (79%) community pharmacists were willing to
dispense from an unsigned prescription for something like paracetamol, most (71%)
would not dispense a clinically equivalent medicine if out of stock of the brand named
on the prescription. Not dispensing the clinically equivalent brand is not in the
patient’s best interests, since it makes no clinical difference, and it would have no
financial impact on the pharmacists. Compared with dispensing from an unsigned
prescription, this is a minor breach of rules, and so it is possible another factor is at
play. Pharmacists across sectors reported to give ‘quite a lot of consideration’ to their
relationship with the prescriber (the mean score across sectors was 36%). Cooper
suggests community pharmacists suffer subordination under doctors,54 which may
account for any reluctance for community pharmacists to go against the request of a
prescriber in such a situation.
There were interesting data on responses to scenarios relating to confidentiality.
Most pharmacists in each sector (92% community; 95% hospital) answered that they
would not disclose information about a patient’s treatment to a spouse or close family
member of that patient. This is in keeping with the RPSGB’s Code of Ethics, and
respects the principle of confidentiality. There may be some situations in which
unique circumstances justify disclosure, which may account for those who answered
that they did disclose the information. There was less agreement over whether
confidential information about a patient aged fifteen years should be disclosed to that
patient’s parent. In this case, 63% of community pharmacists and 59% of hospital
pharmacists answered that they would protect the confidentiality of the patient.
Perhaps in this case some pharmacists regard the parents as having a right to know
about their child’s treatment, or perhaps some pharmacists believe it would be in the
patient’s best interests if the parents were involved. The RPSGB’s guidelines in the
Code of Ethics at the time of the survey stated that adolescents should usually have
the same rights to confidentiality as adults: “Pharmacists should be aware that
information about services provided to adolescents should not normally be disclosed
to their parents.”55
Opinion about confidentiality was divided further with the scenario in which a
member of the public asks the pharmacist to identify a tablet that does not belong to
him/her. Community pharmacists were almost equally divided between disclosing the
identity of the tablet (51%) and not disclosing its identity (49%); hospital pharmacists
were similarly divided, with 51% identifying the tablet and 49% not doing so. The
division here may be because of the uncertainty of the case. As with all the scenarios
presented, very little information was given to participants. In this case, factors that
might affect what the pharmacist decides to do include what the tablet is, whether it
is an illegal substance, what it is usually used for, where the person asking about it
got it from, and so on. There are strong arguments for disclosing the identity of the
tablet, and strong arguments for refusing to do so. A pharmacist may be obliged not
to tell the enquirer what the tablet is if, in doing so, this would breach the
confidentiality of one of her patients. On the other hand, to not tell the enquirer what
the tablet is could be dangerous. She may assume it is harmless when it is not, and
may take the tablet, causing harm to herself, or she may not have realised the tablet
was hers, and may miss vital medication as a result. This is a complex scenario for other reasons too, for example, it is arguable that the enquirer has a right to know
what the tablet is, since its identity is a publicly knowable fact.
These results show general agreement across pharmacy sectors about which ethical
problems occur most often, and how pharmacists deal with, or would deal with them
if they arose. The possible discrepancies that exist between sectors may be
explicable by the different settings pharmacists work in, the resulting exposure to
certain problems, as well as the associated inter-professional relationships in each
setting. Although the focus groups and relevant literature have provided some insight
into possible reasons behind the decisions made, there is scope for further
investigation. The results indicate where our attentions should lie both in terms of the
kinds of ethical problems pharmacists have to deal with most often, and the areas of
practice that might be worth further investigation with supplementary empirical
research.
5. IMPLICATIONS OF FINDINGS
The findings of this research are important for providing evidence that ethical
problem-solving is an important part of the ‘job description’ of pharmacists. While it is
already clear that ethics plays a significant role in the consciousness of the
professional body and regulator (RPSGB), there is evidence that ethics is also a
prominent feature at the practice level. As pharmacy has become increasingly
people-orientated, rather than medicine-orientated, practising pharmacy means not
only applying technical knowledge about medicines and physiology, but also using
skills to understand and work with patients as persons. Having discovered from this
research that pharmacists seem to take a commonsense and patchwork approach to
ethics, a natural line of investigation to pursue would be to determine the extent of
pharmacists’ awareness, knowledge and understanding of ethics.
In addition, the findings from this research invite a combination of philosophical and
empirical questions to determine how well ethical problems are being managed by
pharmacists, what implications this might have on the ability of the profession to carry
out its role in society and how well educated individual pharmacists are to carry out
this moral role. The three key questions to be asked are:
1) Are pharmacists right in the way they deal with ethical problems?
2) To what extent is it important that pharmacists make the right ethical
decisions?
3) How should pharmacists be educated in ethics?
This penultimate section unpacks these questions.
1) Are pharmacists right in the way they deal with ethical problems?
This research, along with Benson’s findings on the values of the profession,56 offers
some insight into the rationale behind the decisions being made by pharmacists. It is
clear that on many matters pharmacists are largely in agreement about what ought to
be done in certain situations, which may be derived from the pharmacy culture, or
may be a representative ‘slice’ of the cultural values of a wider community.
The answer to this question of whether pharmacists are dealing appropriately with
ethical problems will be complex, hotly contested and possibly indeterminable. Even
so, some matters are worth exploring, for example particularly contentious issues,
those deemed to be of great moral magnitude, or ethical questions emerging from
new technology or practice.
2) To what extent is it important that pharmacists make the right ethical
decisions?
There are two key points to address in order to answer this question. The first is
irreducible to any other research question, and it concerns the moral conduct of
pharmacists, regardless of any measurable impact this might have on patients or the
profession. There is an intrinsic, basic value to ethics, such that it is simply important
to do the morally right thing; the profession is on a very basic level obliged to ensure
its members are acting ethically.
On another level, we need to ask what impact decision-making has on patients and
the public. It has already been established that a patient’s needs are not just
physiological and that ethics is an element that runs through pharmacy’s daily
practice. Now we must ask, what is the impact of this on the service that is delivered
to patients? Further, does it matter how these decisions are made?
The findings from both the focus groups and the survey bring our attention to the
strong presence of regulation in pharmacy decision-making. While the patient’s
health interests were considered the most important factor when making ethical
decisions, the law and the RPSGB guidelines were also given ‘a great deal of
consideration’, and the patient’s non-health interests were only given ‘some
consideration’. This suggests that while pharmacists encounter ethical problems in
their daily work, their decisions are based primarily on concerns for the physiological
needs of the patient, and a duty to act within the regulations.
Intuitively, there seems to be an important moral difference between the pharmacist
who acts in accordance with the rules because she is afraid of getting into trouble if
she does not, and the pharmacist who agrees with the fundamental principles behind
the rules, or respects the process by which the rules have been set. Importantly, in
cases in which both the autonomous professional’s actions and the less autonomous
individual’s actions are compatible with the rules, the difference between the two is
very subtle, so much so that in most instances it is unlikely to have any measurable
impact on the patient or on the profession’s ability to deliver an excellent public
service.
In reality, pharmacists often find themselves in situations for which there are no clear
guiding rules. The autonomous professional with sound moral judgement will usually
handle such situations appropriately and ethically. It would be tempting to try to put in
place further regulation to guide any less autonomous individuals, or anyone who
may be mistaken in their moral judgements.
However, aside from the impracticalities of anticipating and regulating every possible
eventuality, there is an important distinction to be made between the pharmacist who
follows the rules habitually or for fear of the possible repercussions of breaking them,
and the pharmacist who occasionally breaks the rules for considered moral reasons.
The former may sometimes result in wrong action, while, if the judgement is right, the
latter will result in the morally right action. It is important to note that any breach of a
rule for moral reasons must be for the right moral reasons, and usually with the right
results; arguably, integrity is only ever any good when the moral agent gets it right.
3) How should pharmacists be educated in ethics?
Depending on the answers to questions 1 and 2 above, the profession may wish to
assess the formal ethics education pharmacists receive (during and/ or beyond the
MPharm). The broad aims of formal ethics education in vocational subjects tend to
be to raise awareness of ethical issues and the guidelines of the profession, and to
provide a structure to assessing ethical problems and making appropriate, justifiable
decisions.
Pharmacy schools now commonly include ethics as part of their educational
programmes, and ethics appears as part of the RPSGB’s Indicative Syllabus.57
Pharmacy ethics education differs from other ethics education in its content, but the
basic educational challenges are the same across other professional accreditation
programmes. There are many pedagogic questions that are generic to ethics
education, including what the purpose of ethics education is, how best ethics is
learned, and how ethical competency can be assessed and measured.
Recent graduates have, on the whole, received more formal ethics education than
previous generations of pharmacists, but ethical sensitivity and judgement are
sometimes regarded as wisdom that develops with experience. It would be
interesting to investigate the impact of formal education on pharmacists’ awareness,
attitudes and behaviour. Likewise, it would be interesting to investigate the impact of
experience, or a combination of experience and recent training (for example when
formal ethics education forms part of a later qualification). It would be worthwhile
investigating whether pharmacists’ approach to ethics in their work is influenced by
certain factors (e.g. age, number of years practising since graduation, extent of
formal ethics education).
6. CONCLUDING COMMENTS
The empirical research findings presented here form one level of investigation into
pharmacy practice ethics. Although not statistically representative of the pharmacy
population in the UK, the findings provide preliminary evidence of some of the ethical
problems pharmacists face and detail frequencies of occurrence of these problems.
The findings provide insight into what pharmacists understand ethics to be, what their
priorities are when dealing with ethical dilemmas, and how they resolve specific
problems.
The findings clearly indicate that ethics is an integral part of pharmacy practice, that
pharmacists approach ethics in a fairly commonsense way, often giving the patient’s
interests priority, and often influenced by regulation. The profession, and in particular
the RPSGB, must now consider exactly what it regards ethical conduct to be and
whether the decisions pharmacists make are in line with the ethical principles of the
profession. The newly revised Code of Ethics makes a significant contribution to
addressing this. In addition, an important question for the pharmacy profession is, to
what extent professional autonomy is a component for achieving its aims. All
professional codes of ethics are limited in their capacity to guide ethical behaviour,58
not least because a code of ethics may be regarded as a form of regulation. Formal ethics education may help further equip pharmacists with the ethical awareness,
knowledge and understanding needed to effectively manage the moral dimensions of
the profession.
The participants’ opinions about what they ought to do (which, it is assumed, includes
what they ought to do morally) were varied, and this was something that became a
topic for discussion. The participants attributed such diversity to differences in
personality and upbringing, religion and professional standards, and understood
judgement as being an ‘individual thing’. Even so, participants discussed the value of
consulting colleagues to get a second opinion on difficult matters.
In practice pharmacists might not have access to colleagues when faced with an
ethical dilemma. This is most likely a problem in the community sector of pharmacy,
where pharmacists often work in isolation. Cooper’s research showed isolation
among community pharmacists led to lack of assistance and communication which,
could, among other things, lead to an inability to articulate the ethical values of the
profession.47
“[In] community [pharmacy] you might possibly be there on your own
where the decision has to be yours…[You] can obviously try and contact
friends and colleagues and things but in that situation you might have to
make that decision there and then on your own and base it on your
ethical beliefs as opposed to a general consensus.”
Pre-reg1
‘Personal morality’ and ‘professional ethics’
In one of the groups there was disagreement about the extent to which professional
judgement should be influenced by personal values. One school of thought was that
it was a pharmacist’s duty to separate herself from a situation in order to make a
sound decision.
“It’s a moral thing and sometimes you’ve just got to take that moral issue
away from yourself.”
Pharm3
This separation is between the patient and the personal value-judgements of the
pharmacist. In the focus group discussion some participants said they made value
judgements while some claimed they preferred to be value-neutral. For example,
when discussing the supply of EHC, one participant said,
“My daughter’s that age as well and ... Yes, she could be [having sex], yet
she may not be. I don’t know, but it’s not for me to moralise. And if they
come to me for the morning after pill and I’m in a position to give it then I
will do it.”
Pharm3
It is worth noting that this itself is an ethically motivated statement. The pharmacist is
using the word ‘moralise’ as if making a moral judgement is to be illiberal, intolerant
or unfairly judgemental. In the same way, the word ‘judgement’ was used negatively
in the focus group.
4.1.2. Rules
The theme ‘rules’ was prominent in the focus group discussions, with participants
understanding an ethical problem as one in which ethics came into conflict with the
law. Other studies provide further evidence that pharmacists are concerned about the
rules of the profession and the law.48
There were three ways in which participants reported themselves to behave when
faced with an ethical problem that involved rules. They can be classed as: following
rules in a considered manner; obeying rules to avoid getting into trouble; and
breaking rules, which included discussion of how rule-breaking could be justified.
Following rules in a considered manner
Acting in accordance with the rules was expressed by some participants in terms of
respecting the reasons behind the rules. It was clear that in some cases rules were
being followed for considered reasons. This is demonstrated in the following
statement regarding supplying EHC outside the product licence:
“I would be breaking the product licence and I haven’t got the right to
break the product licence.”
Pharm1
Obeying rules to avoid getting into trouble
One of the motivations for pharmacists acting in accordance with the rules was to
avoid getting into trouble. For example, when asked whether a pharmacist should
supply a controlled drug to a patient without prescription, this participant was
concerned about police involvement, asking fellow participants:
“What do the police do? Come in and look and go through [your
records]?”
Pharm2
In the context of supplying medication outside the product licence, the following
reason was given for acting by the letter of the rules:
“You have to be careful…I heard from someone, probably through the
grapevine, about a doctor prescribing [hydrocortisone cream] for a baby,
for the face. The skin peeled off and I think the doctor got into trouble for
it.”
Pharm2
Breaking rules
The data suggest participants were comfortable with rules, and were keen to act in
accordance with them. However, rules would be broken if the patient’s interests
conflicted with the rules and were regarded by the individual pharmacist as
sufficiently strong to weigh more heavily than the unfavourable consequences of
breaking the rule. The data show varying judgements of the point at which a patient’s interests were sufficiently great to motivate breaking a rule, and varying judgements
of the point at which rules were sufficiently strict to act as a disincentive for acting in
the patient’s best interests.
An example was given of breaking the rules to supply medication without a
prescription to a patient who had run out of her medicine.49
“[It] is, strictly speaking, illegal. But we’ll do it.”
Pharm7
Participants spoke of rule breaking as the responsible thing to do in some cases,
recognising the importance of professional autonomy, which was also spoken of as
professional judgement.
Justification for breaking the rules
Justifying breaking the rules was framed by participants in terms of acting
professionally. As professionals, pharmacists use their judgements in individual
cases where guidelines do not exist, or are regarded as inappropriate. This
participant is explicit that being able to judge when to act independently is one of the
roles of a professional:
“I suppose in a way we’re professionals because then we can, we make
our judgements, I mean if you are not then, you … just all play by one
rule.”
Pharm4
This statement points to the relationship between rules and professionalism;
participants expressed a tension between acting professionally by following the rules
and knowing when to act independently of the rules in the name of professionalism.
4.1.3. Key ethical concepts
This section is a summary of a systematic examination of participants’ understanding
of some key ethical concepts in their work, an examination that demonstrates the
complexity of some of the practical ethical problems pharmacists face, and exhibits
the patchwork nature of the application of ethics in pharmacy practice.
Individual patients’ interests
The subject of the patient’s best interests was mentioned several times during each
focus group discussion, with the phrase ‘patient’s best interests’ used by participants
to mean the interests of an individual patient as opposed to a collective group.
Participants spoke of patients’ interests as if acting in the patient’s best interest
ranked as the highest principle, though there is evidence that participants did not in
fact regard this principle as highly as they sometimes claimed.
“[I]t’s all a case of weighing up what you think’s best for the patient.”
(unknown)
The above quotation may be an expression of a prima facie principle that could exist
without consideration of additional competing principles. Other reports from participants showed that a patient’s interests were regarded as important, but not
always as the priority. The three factors that competed with an individual patient’s
interests were interests of the pharmacist (commercial and whether they would be
struck off), other patients’ conflicting interests, and legal obligations.
“It’s often a compromise … you know, the law, what’s best for the patient,
what’s best for you.”
(unknown)
The patient’s best interests extended to the long-term social interests of the patient.
In this context, ‘social interests’ means the non-health interests of the patient, which
include patient autonomy, social relationships, financial interests and general welfare.
When discussing the supply of EHC, participants considered the broad social
interests of the patient.
In some incidents in which the patient’s interests came into conflict with the law
pharmacists were prepared to act illegally. In fact, interests of the patient were the
most common reasons participants gave for breaking the law, though it is important
to note that sometimes the law was given greater priority.
“But with somebody who is terminally ill then you don’t want them
screaming out with pain just because you are being bloody minded about
not giving them a prescription [because it has been completed
incorrectly].”
Pharm1
How highly a participant ranked patient interests varied between individuals. Some
participants were willing to break serious laws (for example those surrounding the
supply of controlled drugs) for the sake of the patient, while others set the boundaries
lower.
Public interests
Concern for public interests was a relatively minor theme in the focus group
discussions, but the subject did arise in relation to National Health Service (NHS)
resources. For example, when asked about a vignette in which a doctor was selfprescribing
medication the pharmacist strongly suspects she is abusing, participants
said it depended on whether the prescriptions were private or from the NHS. There
was a sense in which participants felt they had a duty to report repeated selfprescribing
if it was at the expense of the NHS, presumably because NHS funds are
intended for the use of the public, justly allocated and endorsed through policy. The
following quotation comes from a participant commenting on her own experience of a
doctor self-prescribing medication the participant suspected she was addicted to.
“[If] she starts prescribing from hospitals she’s actually using the
hospital’s facilities … rather than going to her own GP for it, and after
about three months …I wasn’t happy with it anymore. …[This] person was
abusing the NHS system in a sense, you know, because I just think that
whatever you want you shouldn’t be abusing the NHS system by doing
your own thing.”
Pharm4
Speaking in response to a vignette:
“If it was NHS I wouldn’t [dispense something self-prescribed], obviously,
but if it’s private then, it’s private, …[isn’t] it? … I don’t see anything wrong
with it …[because the self-prescribing doctor is] paying for that.”
Pharm2
The factor influencing this decision seems to be that there are wider public interests
tied up with the NHS that do not exist with private prescriptions, and participants felt
a moral obligation to act in the interests of the public.
Confidentiality
Although the ethical dimensions of confidentiality were recognised by some
participants, there were occasions when the moral dimensions of the notion were lost
in favour of the regulatory demands for confidentiality, and there were incidences in
which confidentiality was overlooked entirely despite it being a relevant feature.
Confidentiality was understood as a professional obligation, or an institutional rule to
be followed. This is illustrated in the following quotation, in which a participant said
she would keep patient confidentiality because she had been specifically told
(presumably by the professional body or in an education programme) to respect
patient confidentiality.
“We’re specifically told that you know you shouldn’t break [the] patient’s
confidentiality.”
Pre-reg1
This motivation for respecting confidentiality is to act within the rules; respecting
confidentiality does not seem to be a moral compulsion. Stories from participants
showed that the consequences of misunderstanding confidentiality in this way meant
the principle was open to being breached. For example, when discussing a scenario
in which a customer asks the pharmacist to identify a tablet he has found in the
bedroom of his daughter (a patient of the pharmacy practice), participants recognised
that confidentiality was one of the main principles at stake. Although they decided
they would not disclose the information themselves, despite knowing what the tablet
was, some said they would instead direct the father to a source of information that
would identify the medication for him. This falls short of the moral obligation to act in
order to preserve the confidentiality of the patient, and in fact would cause the same
effect on the patient as breaching confidentiality would. Whether it is appropriate to
breach confidentiality in this case (for example to prevent harm to the daughter), was
not discussed in the focus group. Rather, the discussion was about how to direct the
enquiring father towards information without oneself being the one to divulge the
information.
“[T]hey usually tell you to refer to a drugs information helpline, don’t they,
’cause they’re good at identifying [drugs].”
Pre-reg2
Conversely, participants at times took a very cautious approach to confidentiality,
reporting to guard it closely, to the extent of suggesting that even saying that certain
information was confidential might arouse suspicion and break confidentiality to an
extent.
“[I]f you say, ‘Oh I’m not at liberty to say’ or something she’s gonna think,
‘Ooh, there’s something wrong there.’”
Pre-reg2
When discussing whether to disclose patient information, participants often raised the
point that some information about a patient is also publicly available general
information. The following is an example of a pharmacist disclosing information about
a patient as a result of disclosing publicly available general information:
“I’ve actually had somebody phone up, asking me what a particular
tablet was for. [I told her]. But I was sorry afterwards, because it turned
out that her husband was having an affair and had picked up an STD
and… she saw the leaflet. I was sorry.”
Pharm3
Competence of patient
Competence was seen by participants as measurable by common sense and by the
Gillick competency test.50 Participants took a practical approach to assessing
competency and did not see age as necessarily being the deciding factor.
Competence of the patient was raised in relation to supplying EHC, since
competence is one of the criteria for supply. Some participants were happy to supply
EHC to girls under the age of consent as long as the patient was competent to make
the decision.
Age was not the measure of competence. Rather participants judged competence on
the fact the patient had the initiative to go to the pharmacist and to what extent the
patient seemed to be sensible. As one participant observed, some adults who ask for
EHC seem less competent than some of the girls who are under the age of sixteen.
“I’ve come across eighteen-year-olds who I don’t think …[are] competent,
but they’re eighteen, so… and I’ve come across really young [girls]
who’ve, you know, got their heads screwed on.”
Pharm3
4.1.4. Sub-section summary
These findings show that participants’ understanding of ethics in pharmacy is based
largely on commonsense, with participants referring to ethics as subjective and
relative to cultural norms. Expressing ethics in metaphorical terms may indicate a
certain lack of fluency in discussing ethics, despite ethics being a feature of daily
practice for pharmacists. The word ‘ethics’ seemed to take on several meanings,
being used sometimes to mean the Code of Ethics, sometimes regulation,
sometimes morality, and sometimes a tool and justification for breaking the rules.
The frequent reference to rules in the focus groups was striking, and an ethical
dilemma was sometimes understood to be a conflict between moral and legal
obligations, rather than a conflict between two moral obligations.
4.2 Survey results
The results presented here are from two types of questionnaires sent to community
and hospital pharmacists. Data were gathered from pharmacists in community,
hospital and primary care practice. Comparisons can be made between community
and hospital pharmacists’ responses but since the number of respondents from
primary care practice was too low (15) to make reliable inferences, the data from
primary care practice were not subject to statistical analysis.
Results are presented in such a way as to answer questions about the frequency of
occurrence of certain ethical dilemmas, how pharmacists deal with these ethical
problems, and whether there is any statistically significant association between the
sector pharmacists work in, the decisions they make and how important they regard
certain factors when faced with an ethical problem.
Results show general agreement in regard to what pharmacists would do in certain
situations within and across sectors. Differences between sectors lay in how much
consideration pharmacists gave to their own financial interests and the financial
interests of the company, trust or hospital they worked for.
The survey included scenario-based questions, which asked participants whether
they had encountered certain situations in their work. They were asked how often the
situation had occurred in the past year. Participants were then asked to indicate, from
a selection of options, what action they had taken in those circumstances or, if they
had not encountered the situation, what action they think they would take.
4.2.1 Frequency of occurrence of specific ethical problems
The following two tables detail the frequency of occurrence of specific ethical
problems. Results show that the most common were: receiving an unsigned
prescription; being asked for emergency hormonal contraception over the counter;
receiving a prescription lacking full information; a patient returning unused, in-date,
unopened medication; and a family member requesting confidential information about
a patient.
It is worth noting that community pharmacists claimed to have encountered more of
the presented scenarios than hospital pharmacists had. Pharmacists from both
sectors have responded to scenarios they have not encountered, and as such there
are many answers to hypothetical, rather than actual, situations.51
Table 1. Table showing the frequency of occurrence of each possible dilemma faced by community pharmacists. Percentages have been rounded to the nearest
1% and exclude missing data, or those who answered ‘don’t know’ or ‘N/A’. The median category has been indicated by highlighting in blue the appropriate
frequency count and percentage.
Table 2. Table showing the frequency of occurrence of each possible dilemma faced by hospital pharmacists. Percentages have been rounded to the nearest 1%
and exclude missing data, or those who answered ‘don’t know’ or ‘N/A’. The median category has been indicated by highlighting in blue the appropriate frequency
count and percentage.
4.2.2 How pharmacists deal with specific ethical problems
Using scenario-based questions, participants were asked to report what they had
usually done when they had found themselves in specific ethically-problematic
situations at work. One of the features of these scenario-based questions was that, if
participants had answered that they had never in fact been in that situation, they
were asked what they would have done in that particular situation. Percentages have
been rounded to the nearest 1% and exclude missing values and those who
answered ‘don’t know’ or ‘N/A’.
4.2.2.1 Opinion within sectors
Community pharmacy
The following results have arisen from scenario-based questions that applied to
community pharmacists only, and exclude void answers. Community pharmacists
were mostly in agreement over how to resolve most situations (divisions of opinion in
ratios between 8:2 and 10:0 are considered to be ‘mostly in agreement’). Consensus
was reached on whether to supply or not supply methadone to a patient who has
come in for his/her methadone the day after the date specified on the prescription
(98% refused to supply, and 2% agreed to supply). Pharmacists were mostly in
agreement over whether to dispense for an unsigned prescription for something like
paracetamol (80% would dispense; 20% would refuse to dispense) and whether to
dispense from an unsigned prescription for something like an opiod analgesic (81%
would refuse to dispense; 19% would dispense). Pharmacists were mostly in
agreement over whether to sell medication over the counter to a patient who does
not really need it (and who would also not be harmed by it) (13% would sell the
medication; 87% would advise against the sale) and whether to sell medication over
the counter to a customer who may be abusing the medicine (14% would sell the
product; 86% would refuse to sell it). When asked whether their personal beliefs
affect whether they would supply EHC over the counter 6% pharmacists reported that
their personal beliefs affect their decision to supply; for 94%, their decision is not
affected by personal beliefs. Pharmacists were mostly in agreement about what to do
if they suspected a doctor was abusing medication from NHS and private scripts. In
the scenario given, the doctor had not responded to verbal intervention from the
pharmacist. There were almost identical results from the scenarios relating to abuse
of NHS and private prescriptions; 80% would report the doctor abusing medication
using NHS scripts, 81% would report him/her for abusing medication using private
scripts; 20% would not report the doctor abusing medication using NHS scripts and
19% would not report the doctor for abusing medication using private scripts.
There was slightly more pronounced division of opinion over whether to dispense
clinically equivalent medication when the pharmacy is out of stock of the brand
named on the prescription (71% would not dispense; 29% would dispense the
equivalent). Opinion was split over whether to supply medication to a patient who has
made it known s/he will use the medication against guidelines (e.g. hydrocortisone
cream being used for the face), with 59% of the opinion the supply should be
refused, and 41% of the opinion the medication should be supplied. Over the matter
of a girl who appears under sixteen years of age requesting EHC in an area where
no PGD (patient group direction) is in place, opinion was divided over whether to
supply EHC or not, with making the supply, and refusing to do so. Locum
community pharmacists were divided over how to resolve the following problem: ‘As
a locum you are told the usual pharmacist does things a certain way, and are asked
to work in that way too. You regard this as unethical’. Opinion was divided with 21%
operating as normal for that pharmacy, and 79% refusing to work that way.
Hospital pharmacy
The following results have arisen from scenario-based questions that applied to
hospital pharmacists only, and exclude void answers. All respondents agreed that
medication should be dispensed as requested if a paediatric consultant were to ask
for medication that is outside SPC (Summary of Product Characteristics) guidelines.
There was also strong agreement over what should be done in the following
situation: ‘A member of the public comes to the pharmacy and asks for some
medication for someone else who is waiting at home (e.g. his wife, who is in great
distress). S/he tells you the person for whom the medication is for has used the
medication several times before and is very familiar with it. The wait for A&E is
extremely long.’ The majority (93%) would refuse the supply, while 7% would supply
the medication. On the matter of knowing a patient who has a condition that may
affect him/her while driving has not informed the DVLA (Driving and Vehicle
Licensing Authority), 8% would report the patient to the DVLA, 37% would talk to the
patient, knowing s/he is unlikely to inform the DVLA him/herself, and 55% would
inform a medical consultant.
4.2.2.2 Opinion between sectors
Data from a total of eighteen scenarios that could occur in either a community or
pharmacy setting were analysed. Within these eighteen, there was mostly agreement
within sectors and between sectors about how they would resolve each ethical
problem presented. There were only two exceptions to this, which will be detailed
towards the end of this sub-section.
There was general agreement over the following: if further information was needed
about a prescription, most would contact the prescriber (97% community; 98%
hospital). If a patient returned unopened, unused, in-date medication, most would
dispose of it (87% community; 95% hospital). If a colleague was taking prescription
medicine from the controlled drugs cabinet, most would report the colleague (96%
community; 98% hospital). If there was reason to suspect a child patient was subject
to abuse at home, most pharmacists would know what procedure to take and would
go through the appropriate channels (89% community; 92% hospital). If the
pharmacist believed the patient would be more compliant with important treatment if
s/he was misled about some information, most would not withhold the truth but would
talk frankly to the patient (82% community; 90% hospital). If a colleague was
behaving unethically, most pharmacists would talk to their colleague rather than take
no action at all (94% community; 81% hospital). If that colleague continued to behave
unethically after the pharmacist had spoken to him/her, most would then report the
colleague (82% community; 92% hospital).
If a close family member of an adult patient requested confidential information about
that patient, most would not pass the information on (92% community; 94% hospital).
However, opinion was divided in both community and hospital sectors over whether
to pass on confidential information to a parent of a fifteen-year-old child, with 34%
community and 42% hospital of the opinion that the information should be passed on,
and 66% community and 58% hospital of the opinion the information should remain
confidential. Divide was greater again over the question of whether a pharmacist
should inform a member of the public of the identity of a tablet that did not belong to
them. Figures 1 and 2 below show these last two sets of results in cluster bar graphs.
Of all the results detailed in this subsection, none showed any association between
the answers given and the sector the pharmacist works in.
Figure 1 Clus tered bar graph showing percentages of hospital
pharmacists (n=53) and community pharmac is ts (n=164) who would
pas s on or not pass on confidential information to a parent about their
15-year -old child's treatment. Frequencies are shown in the bars.
Figure 2 Clustered bar graph showing percentage of hosp ital
pharmacists (n= 55) and com munity pharmacists (n=164) who would
inform o r not inform someone of the identi fication of a tablet that did not
belong to them if the pharmacist was able to iden tify the tablet.
Frequencies are shown in the bars.
4.2.3 How important certain factors are in making ethical decisions
Pharmacists were asked how much importance they gave to certain factors when
making decisions about situations such as those presented in the questionnaire. The
most marked of these was the consensus, both within each sector and across
sectors, that the patient’s health interests should be given a great deal of
consideration (the mean score across sectors was 89%). It is also worth noting that
across sectors pharmacists gave a great deal of consideration to keeping within the
law (the mean score across sectors was 67%). Pharmacists across sectors also gave
a great deal of consideration to whether they would be struck off (the mean score
across sectors was 52%), to keeping within the guidelines of the RPSGB52 (the mean
score across sectors was 50%), and to their reputation (the mean score across
sectors was 31%). Factors that were given ‘quite a lot of consideration’ were the
pharmacist’s relationship with the patient (the mean score across sectors was 41%)
and the pharmacist’s relationship with the prescriber (the mean score across sectors
was 37%). ‘Some consideration’ was given to the financial interests of the company/
trust/ hospital (the mean score across sectors was 47%), the patient’s non-health
interests (the mean score across sectors was 46%), and participant’s relationships
with pharmacy colleagues.
An association was found between the sector pharmacists worked in and how much
consideration they gave to their own financial interests (U=3634.5; n1=175; n2=64;
p=.003), with community pharmacists considering their own financial interests more
than hospital pharmacists did. There was also an association between the sector
pharmacists work in and how much consideration they give to the financial interests
of the company, hospital or trust they work for (U=3609.5; n1=175; n2=64; p< .0005),
with community pharmacists less concerned with this than hospital pharmacists
were. It should be noted that these results are derived from questions that varied
slightly between the sectors. Community pharmacists were asked how much
consideration they gave to the financial interests of the company they worked for,
hospital pharmacists were asked how much consideration they gave to the financial/
resource interests of the hospital or trust they worked for.
Figure 3 Cluster bar graph showing which factor community pharmacists (n=150) and
hospital pharmacists (n=51) considered the most important when making ethical
decisions.
Other factors community pharmacists specified as being brought into consideration
when faced with an ethical problem included: ‘maintaining team approach and policy
in dispensing decisions’; ‘maintaining high standards of practice’; ‘moral values’;
‘commonsense’; ‘balancing the patient’s needs against the rule of the law’; and
‘justification for actions’. Hospital pharmacists specified ‘commonsense’ and
‘workload pressures’.
5. DISCUSSION
There is general agreement across sectors about how frequently certain ethical
problems arise in practice. Within sectors there was a lot of agreement about what
ought to be done, and no statistically significant difference was found between the
answers community and hospital pharmacists gave in response to questions
concerning what the appropriate action would be in each situation.
The data from both the survey results and the focus groups suggest pharmacists
consider the patient’s health interests to be a very important factor in ethical decisionmaking.
It is worth noting that the patient’s health interests were ranked more highly
in the survey than any other factor, but that the patient’s non-health interests were
not ranked very highly. Many of the scenario-based questions asked in the survey would have included an element of the patient’s health interests, for example the
scenario in which the pharmacist would ideally have more information about the
prescription. It is arguably in the patient’s best interests that the pharmacist
dispenses only on full information, and most (97%) community and most (98%)
hospital pharmacists reported that they would request further information from the
prescriber in such a situation.
However, many of the scenarios in the questionnaire demanded the participant
consider his/her relationship with the prescriber, the patient and the public, and many
included a dimension of the social interests of the patient. It is worth noting that when
asked to rank the level of consideration they gave to certain factors when considering
an ethical problem, although the patient’s health interests take priority, regulation
seems to play a very important part in moral decision-making among pharmacists.
Pharmacists ranked their consideration of the law, RPSGB guidelines, their
reputation and the risk of being struck off more highly than the patient’s non-health
interests.
Concern for regulatory constraints is echoed in the findings from the focus groups,
which showed that sometimes pharmacists were prepared to break the rules in the
interests of the patient, but in some cases pharmacists acted in accordance with the
rules even if this was not necessarily in the best interests of the patient. The findings
from the focus groups showed that deferment to regulation occurred for at least two
reasons: out of respect for the rationale behind the rules, and because of fear of
getting into trouble.
Where the community and hospital sectors differed in their approach to ethical
problems was in consideration of the financial aspects of pharmacy. Community
pharmacists are under commercial pressure in a way that pharmacists in other
sectors are not, and given this it is perhaps not surprising that community
pharmacists were more concerned about their own financial interests than hospital
pharmacists were. Many (24%) community pharmacists give ‘some consideration’ to
their own financial interests. Findings from the focus group indicated that the
pharmacist’s own financial interests were not of great importance, though one
participant did note “We’re pharmacists, but we’re also businessmen” [Pharm1]. In
part this supports research by Hibbert, Rees and Smith, which showed that
community pharmacists experienced a conflict between business or economic
concerns and “professional responsibilities”.53 Hospital pharmacists are exposed to
different financial pressures, which is shown in the fact that community pharmacists
are less concerned about the financial interests of the company they work for than
hospital pharmacists were concerned about the financial interests of the trust or
hospital they work for.
However, since the scenario-based questions did not have scope for explanations for
the answer given, it is impossible to tell which factors influenced pharmacists’
decision-making in each scenario given. For example, the 80% community
pharmacists who would dispense paracetamol from an unsigned prescription, the
58% who would sell EHC over the counter to a girl who appeared underage, and the
41% who would supply medication against the product guidelines may have been
motivated by financial gain, or may alternatively have been more concerned about
the patient’s interests and the patient’s autonomy.
It is worth noting that while most (79%) community pharmacists were willing to
dispense from an unsigned prescription for something like paracetamol, most (71%)
would not dispense a clinically equivalent medicine if out of stock of the brand named
on the prescription. Not dispensing the clinically equivalent brand is not in the
patient’s best interests, since it makes no clinical difference, and it would have no
financial impact on the pharmacists. Compared with dispensing from an unsigned
prescription, this is a minor breach of rules, and so it is possible another factor is at
play. Pharmacists across sectors reported to give ‘quite a lot of consideration’ to their
relationship with the prescriber (the mean score across sectors was 36%). Cooper
suggests community pharmacists suffer subordination under doctors,54 which may
account for any reluctance for community pharmacists to go against the request of a
prescriber in such a situation.
There were interesting data on responses to scenarios relating to confidentiality.
Most pharmacists in each sector (92% community; 95% hospital) answered that they
would not disclose information about a patient’s treatment to a spouse or close family
member of that patient. This is in keeping with the RPSGB’s Code of Ethics, and
respects the principle of confidentiality. There may be some situations in which
unique circumstances justify disclosure, which may account for those who answered
that they did disclose the information. There was less agreement over whether
confidential information about a patient aged fifteen years should be disclosed to that
patient’s parent. In this case, 63% of community pharmacists and 59% of hospital
pharmacists answered that they would protect the confidentiality of the patient.
Perhaps in this case some pharmacists regard the parents as having a right to know
about their child’s treatment, or perhaps some pharmacists believe it would be in the
patient’s best interests if the parents were involved. The RPSGB’s guidelines in the
Code of Ethics at the time of the survey stated that adolescents should usually have
the same rights to confidentiality as adults: “Pharmacists should be aware that
information about services provided to adolescents should not normally be disclosed
to their parents.”55
Opinion about confidentiality was divided further with the scenario in which a
member of the public asks the pharmacist to identify a tablet that does not belong to
him/her. Community pharmacists were almost equally divided between disclosing the
identity of the tablet (51%) and not disclosing its identity (49%); hospital pharmacists
were similarly divided, with 51% identifying the tablet and 49% not doing so. The
division here may be because of the uncertainty of the case. As with all the scenarios
presented, very little information was given to participants. In this case, factors that
might affect what the pharmacist decides to do include what the tablet is, whether it
is an illegal substance, what it is usually used for, where the person asking about it
got it from, and so on. There are strong arguments for disclosing the identity of the
tablet, and strong arguments for refusing to do so. A pharmacist may be obliged not
to tell the enquirer what the tablet is if, in doing so, this would breach the
confidentiality of one of her patients. On the other hand, to not tell the enquirer what
the tablet is could be dangerous. She may assume it is harmless when it is not, and
may take the tablet, causing harm to herself, or she may not have realised the tablet
was hers, and may miss vital medication as a result. This is a complex scenario for other reasons too, for example, it is arguable that the enquirer has a right to know
what the tablet is, since its identity is a publicly knowable fact.
These results show general agreement across pharmacy sectors about which ethical
problems occur most often, and how pharmacists deal with, or would deal with them
if they arose. The possible discrepancies that exist between sectors may be
explicable by the different settings pharmacists work in, the resulting exposure to
certain problems, as well as the associated inter-professional relationships in each
setting. Although the focus groups and relevant literature have provided some insight
into possible reasons behind the decisions made, there is scope for further
investigation. The results indicate where our attentions should lie both in terms of the
kinds of ethical problems pharmacists have to deal with most often, and the areas of
practice that might be worth further investigation with supplementary empirical
research.
5. IMPLICATIONS OF FINDINGS
The findings of this research are important for providing evidence that ethical
problem-solving is an important part of the ‘job description’ of pharmacists. While it is
already clear that ethics plays a significant role in the consciousness of the
professional body and regulator (RPSGB), there is evidence that ethics is also a
prominent feature at the practice level. As pharmacy has become increasingly
people-orientated, rather than medicine-orientated, practising pharmacy means not
only applying technical knowledge about medicines and physiology, but also using
skills to understand and work with patients as persons. Having discovered from this
research that pharmacists seem to take a commonsense and patchwork approach to
ethics, a natural line of investigation to pursue would be to determine the extent of
pharmacists’ awareness, knowledge and understanding of ethics.
In addition, the findings from this research invite a combination of philosophical and
empirical questions to determine how well ethical problems are being managed by
pharmacists, what implications this might have on the ability of the profession to carry
out its role in society and how well educated individual pharmacists are to carry out
this moral role. The three key questions to be asked are:
1) Are pharmacists right in the way they deal with ethical problems?
2) To what extent is it important that pharmacists make the right ethical
decisions?
3) How should pharmacists be educated in ethics?
This penultimate section unpacks these questions.
1) Are pharmacists right in the way they deal with ethical problems?
This research, along with Benson’s findings on the values of the profession,56 offers
some insight into the rationale behind the decisions being made by pharmacists. It is
clear that on many matters pharmacists are largely in agreement about what ought to
be done in certain situations, which may be derived from the pharmacy culture, or
may be a representative ‘slice’ of the cultural values of a wider community.
The answer to this question of whether pharmacists are dealing appropriately with
ethical problems will be complex, hotly contested and possibly indeterminable. Even
so, some matters are worth exploring, for example particularly contentious issues,
those deemed to be of great moral magnitude, or ethical questions emerging from
new technology or practice.
2) To what extent is it important that pharmacists make the right ethical
decisions?
There are two key points to address in order to answer this question. The first is
irreducible to any other research question, and it concerns the moral conduct of
pharmacists, regardless of any measurable impact this might have on patients or the
profession. There is an intrinsic, basic value to ethics, such that it is simply important
to do the morally right thing; the profession is on a very basic level obliged to ensure
its members are acting ethically.
On another level, we need to ask what impact decision-making has on patients and
the public. It has already been established that a patient’s needs are not just
physiological and that ethics is an element that runs through pharmacy’s daily
practice. Now we must ask, what is the impact of this on the service that is delivered
to patients? Further, does it matter how these decisions are made?
The findings from both the focus groups and the survey bring our attention to the
strong presence of regulation in pharmacy decision-making. While the patient’s
health interests were considered the most important factor when making ethical
decisions, the law and the RPSGB guidelines were also given ‘a great deal of
consideration’, and the patient’s non-health interests were only given ‘some
consideration’. This suggests that while pharmacists encounter ethical problems in
their daily work, their decisions are based primarily on concerns for the physiological
needs of the patient, and a duty to act within the regulations.
Intuitively, there seems to be an important moral difference between the pharmacist
who acts in accordance with the rules because she is afraid of getting into trouble if
she does not, and the pharmacist who agrees with the fundamental principles behind
the rules, or respects the process by which the rules have been set. Importantly, in
cases in which both the autonomous professional’s actions and the less autonomous
individual’s actions are compatible with the rules, the difference between the two is
very subtle, so much so that in most instances it is unlikely to have any measurable
impact on the patient or on the profession’s ability to deliver an excellent public
service.
In reality, pharmacists often find themselves in situations for which there are no clear
guiding rules. The autonomous professional with sound moral judgement will usually
handle such situations appropriately and ethically. It would be tempting to try to put in
place further regulation to guide any less autonomous individuals, or anyone who
may be mistaken in their moral judgements.
However, aside from the impracticalities of anticipating and regulating every possible
eventuality, there is an important distinction to be made between the pharmacist who
follows the rules habitually or for fear of the possible repercussions of breaking them,
and the pharmacist who occasionally breaks the rules for considered moral reasons.
The former may sometimes result in wrong action, while, if the judgement is right, the
latter will result in the morally right action. It is important to note that any breach of a
rule for moral reasons must be for the right moral reasons, and usually with the right
results; arguably, integrity is only ever any good when the moral agent gets it right.
3) How should pharmacists be educated in ethics?
Depending on the answers to questions 1 and 2 above, the profession may wish to
assess the formal ethics education pharmacists receive (during and/ or beyond the
MPharm). The broad aims of formal ethics education in vocational subjects tend to
be to raise awareness of ethical issues and the guidelines of the profession, and to
provide a structure to assessing ethical problems and making appropriate, justifiable
decisions.
Pharmacy schools now commonly include ethics as part of their educational
programmes, and ethics appears as part of the RPSGB’s Indicative Syllabus.57
Pharmacy ethics education differs from other ethics education in its content, but the
basic educational challenges are the same across other professional accreditation
programmes. There are many pedagogic questions that are generic to ethics
education, including what the purpose of ethics education is, how best ethics is
learned, and how ethical competency can be assessed and measured.
Recent graduates have, on the whole, received more formal ethics education than
previous generations of pharmacists, but ethical sensitivity and judgement are
sometimes regarded as wisdom that develops with experience. It would be
interesting to investigate the impact of formal education on pharmacists’ awareness,
attitudes and behaviour. Likewise, it would be interesting to investigate the impact of
experience, or a combination of experience and recent training (for example when
formal ethics education forms part of a later qualification). It would be worthwhile
investigating whether pharmacists’ approach to ethics in their work is influenced by
certain factors (e.g. age, number of years practising since graduation, extent of
formal ethics education).
6. CONCLUDING COMMENTS
The empirical research findings presented here form one level of investigation into
pharmacy practice ethics. Although not statistically representative of the pharmacy
population in the UK, the findings provide preliminary evidence of some of the ethical
problems pharmacists face and detail frequencies of occurrence of these problems.
The findings provide insight into what pharmacists understand ethics to be, what their
priorities are when dealing with ethical dilemmas, and how they resolve specific
problems.
The findings clearly indicate that ethics is an integral part of pharmacy practice, that
pharmacists approach ethics in a fairly commonsense way, often giving the patient’s
interests priority, and often influenced by regulation. The profession, and in particular
the RPSGB, must now consider exactly what it regards ethical conduct to be and
whether the decisions pharmacists make are in line with the ethical principles of the
profession. The newly revised Code of Ethics makes a significant contribution to
addressing this. In addition, an important question for the pharmacy profession is, to
what extent professional autonomy is a component for achieving its aims. All
professional codes of ethics are limited in their capacity to guide ethical behaviour,58
not least because a code of ethics may be regarded as a form of regulation. Formal ethics education may help further equip pharmacists with the ethical awareness,
knowledge and understanding needed to effectively manage the moral dimensions of
the profession.
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