In this final chapter, I will summarise the main findings of this thesis, offer several
conclusions and consider the implications of this research for not only pharmacists and
pharmacy practice but also healthcare and society more generally. I will identify
possible limitations to the thesis, indicate areas of further research and provide further
reflexive insights into the research.
It is hoped that this thesis has provided unique and important insights into the nature of
ethical issues in UK community pharmacy and that these offer a significant
contribution to the pharmacy literature. The main conclusions of this thesis are that
community pharmacists encounter a range of ethical problems in their work but that
these often involve the routine, legal or procedural minutiae of community pharmacy
practice. As such, it may be more appropriate to consider these as quasi-ethical
problems rather than dilemmas since they often involved an ethical value and a legal,
procedural or financial issue rather than rival ethical values or normative conflicts. The
centrality of law for many pharmacists in this study was striking and law appeared not
only to be synonymous with ethics for many but it also defined and decided many
problems identified in pharmacists’ practice. The concept of ethically passivity
emerged as an appropriate description of pharmacists who were ethically inattentive,
concerned with self-interest and who did not engage in ethical action. However,
aspects of the community pharmacy environment, such as pharmacists’ isolation from peers, professionals and public, subordination to doctors and routinized work,
appeared to precipitate ethical problems and contribute to ethical passivity.
Before considering a number of specific conclusions, limitations and ethically relevant
potential changes to pharmacy practice from this thesis, I want to first of all reflect
upon the overall research process and consider several additional insights that will
offer a transparent and reflexive account of this research.
7.2 REFLEXIVITY
This thesis has involved an attempt to be reflexive about the research process and in
chapter one, for example, I indicated how my own experiences of community
pharmacy practice influenced the research and research questions and, in chapter three,
how decisions, changes and revisions to the research process occurred. In this section,
however, I want to focus upon a number of additional experiences from the research
and reflect upon how these reflexive concerns had relevance to the overall research
process, too.
In particular, I want to address the issues of my own development during the research
and also how the findings from this thesis could be located within my own
understanding of ethics and pharmacy practice. As noted in chapter one, I do not
subscribe to the notion of value neutrality in the research process and believe that it is
important to recognise how my own educational and professional background and
assumptions about ethics and the construction of knowledge have shaped and,
significantly, been shaped by this research.
Developing the first point about how the findings of this research could be
accommodated in my own experiences, a reflexive concern emerges - and one that
may be apparent to a reader comparing, say, chapter one with chapter four of this
thesis, for example – that my own ethical concerns as a practicing pharmacist did not
appear to be reflected in those of the cohort pharmacists interviewed. It may be
questioned, therefore, whether I was surprised or even disappointed in finding
legalistic and procedural ethical problems amongst many of the cohort pharmacists, for
example, or in often identifying only basic forms of ethical argumentation and
justification. To return to the analogy with Conrad’s Heart of Darkness briefly
(although I will make further comparisons at the end of this thesis), was there a
concern similar to that experienced by Marlowe, when he realises that his search for
Kurtz revealed something less than he had expected? He admitted that:
There was a sense of extreme disappointment, as though I had found out I had
been striving after something altogether without a substance. (Conrad 1902
p.67)
For Marlowe, this disappointment arose because of the disparity between what had
been reported about Kurtz and what he actually saw. To some extent, this perception
mirrors my own concerns and surprise and this may have arisen because my review of
the empirical pharmacy ethics research literature had revealed studies that had not
asked questions such as: how do pharmacists understand ethics issues, and were there
different approaches to resolving such issues in their work? What the published
literature did not indicate, for example, was whether pharmacists were forthcoming or
not in their responses and their ability to talk about ethical concerns. Hence, an initial sense of disappointment did arise in relation to some of the interviews in this research
since several were very difficult to conduct in terms of eliciting the participating
pharmacist’s experiences of ethical concerns in their work and to having them reflect
upon how they dealt with problems. Although this will be considered later in terms of
study limitations, I did consider using not just prompting about possible areas of
ethical concern but actual hypothetical vignettes. Looking back at this decision in the
research process, despite the difficulty of some interviews, I believed it was important
to continue to ask what did pharmacists understand by, and experience as ethical issues
in their work, and that this was justified since it revealed hitherto unidentified issues
such a legalistic conception of ethics and self-interest.
In the earlier interviews, my sense of disappointment with an interview was perhaps
more noticeable but I attributed this to anxiety about my research skills, manifest in a
number of concerns: since my research background prior to this had been quantitative,
laboratory-based pharmacy studies, I was worried that my skills at qualitative
techniques such as semi-structured interviewing might have led to interviews being
difficult; I also recall feeling an impatience and that I wanted obvious themes to
emerge following interviews, which in hindsight I think resulted from an anxiety about
the analytical stage of the research since this, again, was not a research approach I had
previously used. Looking back over the research process, these anxieties were
probably misplaced and occurred as a result of my initial inexperience: later interviews
did not necessarily lead to increased responses from interviewees, despite my
becoming more confident and experienced at interviewing as the research progressed,
for example, and, as the next reflexive concern hopefully indicates, understanding how the theoretical literature was of value in interpreting and analysing the interview data
was an important stage in the process for me.
In addition to my developing skills in qualitative techniques during the research
process, a further reflexive concern involved my increased theoretical understanding of
the ethics literature. In particular, I want to consider how this knowledge informed but
was also informed by, the research and data over the course of the three years of this
research. I was conscious at the early stages of the research (before beginning
recruitment and interviewing) of holding onto a more rigid understanding of ethics and
moral philosophy generally because of my training in what could be described as the
normative Enlightenment traditions in medical ethics. These are reflected in some of
the theoretical positions considered in the first part of chapter two and, specifically, the
centrality of rationality and typified by the influence of utilitarian and deontological
ethical positions, for example. However, it was obvious early in the research that in
undertaking this empirical ethics research that I would need to consider not only the
direct empirical literature but also a meta-ethical concern about the place of empirical
research. This was, in part, an intentional intellectual task that was informed by a
review of the literature but it was also driven by the emergent data and by the need to
account for themes such as the influence of law, for example. But conversely, I believe
that the commentaries on ’late modernity’ offered by writers such as Bauman, Giddens
and Habermas, for example, were an influence upon the research and the further
interpretation and understanding of the data. In recognising the influence of these
accounts of the place of ethics (and law) in society, I do not mean to suggest that they fully explained the data or accounted for my disappointment but simply that they
revealed to me additional insights that were relevant in analysing and interpreting the
data.
A further example of where my reflexive concern for the influence of the theoretical
literature was relevant to the research concerned my decision not to rely upon CMD,
despite its popularity in the empirical ethics literature. My reservations about the often
neglected but fundamental normative assumptions upon which CMD is based - that a
justice-based form of reasoning was the ultimate stage of development according to
Kohlberg - led me to doubt whether this theory could be used solely as a basis for this
research. Of course, I was also concerned that using this approach would not fully
answer the research questions in terms of revealing more situated and subjective
insights but, like Holm (1997), I doubted whether this approach could offer a
comprehensive account of ethical reasoning. But not focusing upon CMD also
influenced how I analysed and contextualised the data and emergent themes and this
was apparent in the case of pharmacists’ legal problems and legalistic self-interest. I
recognise that I have not referred to CMD in explaining the significance and influence
of law for many pharmacists, despite this being a feature of the lower, preconventional
and conventional stages of moral reasoning of CMD, involving egoistic
self-interest and a concern for law. Considering the similarities between this research
and the lower stages of CMD reasoning could perhaps have been explored more but
given the scope of the thesis, I made a decision during the analysis of the interview
data not to engage in what I considered to be a more theoretical line of discussion.
However, I recognise that this could be pursued in further research, perhaps at the level of meta-ethical discussion.
By considering the reflexive concerns identified above and in other parts of this thesis,
I hope that this will provide a transparency to the research and help illuminate stages
of the research such as the framing of the research questions and the analysis of
interviews. In the next section I want to consider some of the implication of the
research for pharmacy practice and then, in the remainder of this chapter, go on to
identify in terms of praxis, a number of more specific changes, followed by the
limitations of the study and opportunities for further research.
7.3 EDUCATION
The findings in this thesis have relevance to several issues in ethics education for
pharmacists. Many undergraduate professional courses now include some form of
ethics instruction (Illingworth 2003, Doyal and Gillon 1998) and the RPSGB, too,
recognises that pharmacy teaching should involve ethics so that ethical problems in
pharmacists’ practice can be dealt with appropriately. In the pharmacy undergraduate
course, for example, one of the pharmacy degree accreditation ‘outcomes’ is for a
pharmacy graduate who:
Is able to recognise ethical dilemmas in healthcare and science, and
understands ways in which these might be managed by healthcare
professionals, whilst taking account of relevant law. (Royal Pharmaceutical
Society 2003)
Furthermore, the Quality Assurance Agency for Higher Education document (2003)
relating to benchmarks in pharmacy education similarly refers to ethics and makes
several references to the need for pharmacy graduates to gain an understanding in
ethical issues and decision-making.
The findings of this thesis may be relevant to the teaching of ethics in pharmacy in a
number of ways. In one respect, it may allow those involved in teaching ethics to be
more aware of the ethical problems that actually occur in practice. This, according to
Holm, might make ethics instruction more effective and he notes that ‘knowledge
about the types of ethical problem that students are to meet in their daily practice is
also important [...]’ (Holm 1997 p.32). This may be achieved by including realistic
scenarios in ethics teaching that have been derived from empirical ethics research,
such as this thesis. This has, in fact, been one of the main aims of previous research
such as Hibbert et al (2000 and Derek Hibbert personal correspondence 2004). The
importance of exposing students to what are thought to be ethical problems that relate
to practice may, however, be potentially problematic. A number of the more recently
qualified pharmacists in this thesis noted that they were provided with scenarios and
asked to make an ethically justified decision about them but what were often recalled
were the emergency supply scenarios or, as Julian noted in chapter four, the paradigm
incorrectly written controlled drug prescription. Perhaps there is a danger of the selffulfilling
prophecy (Merton 1957) in the use of such situations and that, in only being
able to offer student pharmacists a limited number of scenarios, might these therefore
come to dominate and shape how they ‘see’ ethical problems in practice? Hopefully,
this thesis has illustrated not just the range of ethical issues experienced by
pharmacists but, importantly, argued that many are quasi-ethical problems and may not be the most appropriate type to use in undergraduate pharmacy ethics education. But
this thesis has also identified examples of ethical problems that do involve conflict of
rival ethical values or concerns and these may be of relevance to ethics education.
In another respect and perhaps more importantly, however, the findings of this study
might be used to consider whether changes to pharmacy ethics teaching are required.
Although specific educational reforms will be considered later, in the section on
praxis, two general points are relevant here. Firstly, this thesis reflected existing
attempts at teaching ethics, as identified in the comments made by pharmacists about
their undergraduate education. These comments were almost always negative,
unfortunately, and as was indicated, pharmacists either recalled little specific ethics
instruction or noted that what was provided was of limited relevance to practice and
was often legal rather than ethical in nature. Secondly, in addition to these direct
reflections on pharmacists’ ethics education, could it not be argued that the emergent
theme of ethical passivity that characterised many pharmacists in this research might
be, even in part, attributable to how pharmacists were taught as undergraduates?
Unfortunately, the questions of how effective ethics teaching is and how it could be
measured have been problematic and there appears to be little consensus about how
ethics education could actually be assessed in terms of its success in influencing
practice (Molyneux 2001). Approaches such as measuring ethical knowledge skills
(Sulmasy et al 1997), sensitivity (Mitchell et al 1993), confidence (Molyneux 2001)
and problem solving ability (Savulescu et al 1999) have all been proposed but this may
be an area that requires further research. In spite of this potential difficulty in assessing
the effectiveness of ethics teaching, it is argued that the findings in this thesis and, in particular, the emergent theme of ethical passivity and pharmacists’ synonymous
understanding of law and ethics may reflect problems in how pharmacists come to
understand ethics. In presenting some of the findings of this thesis to academic
pharmacy audiences (Cooper et al 2006), there has been considerable discussion and
interest in how the emergent themes of this thesis may be used to develop or change
how pharmacists are taught in relation to ethics, particularly in terms of how legalism
and isolation could be avoided and these are concerns that I will address more
specifically in terms of praxis later in this chapter.
One further pedagogical issue that emerged was that none of the pharmacists in this
thesis had undertaken any post-graduate ethics education and, given the lack of any
substantive ethics education as undergraduates and especially amongst older
pharmacists, a resultant lacuna in terms of ethical instruction may exist. Hence a
further implication from this thesis is that an assessment of ethical educational needs is
required at a post-graduate as well as undergraduate level. Post-graduate ethical
training has been used with doctors (Molyneux 2001) but although a continuing
education course – Evidence-based practice: dealing with dilemmas – is provided by
the Centre for Pharmacy Postgraduate Education (CPPE), this course does not appear
to be widely available (2006 Dave Dunning, CPPE personal correspondence).
Interestingly, in the course’s description, a number of RPSGB competencies are used
but one that is surprisingly omitted is that of ‘making decisions and solving problems’
(CPPE 2006 p. 27).
7.4 PHARMACY, HEALTHCARE AND SOCIETY
It is also possible to reflect on whether there is something more fundamental involved
in why pharmacists recall little ethical education and why ethics is frequently
understood as law and legalistic self-interest and also why ethical passivity was
identified. It would be naïve to assume that ethical understanding and decision-making
ability could be completely gained by education alone and so it would be inappropriate
to single out education. Perhaps just as relevant may be the more general sociological
claims that, as were described in chapters two and six, individuals in society are being
increasingly regulated for in terms of legislation (Habermas 1987) and codes (Bauman
1993) and that these result in a predictable, secure ‘black and white’ approach to
practice that avoids the need for pharmacists to confront ethical problems and make
ethical decisions. Education is not necessarily exonerated in this alternative view, and
it may be that if such philosophical and sociological accounts of the increasing erosion
of the ethical in individuals’ lives are correct - as not only Bauman and Haberams but
also Giddens (1991) and C. Smith (2002) suggest - then education may perhaps have
some role to play in developing re-moralization or stimulating value awareness (Cribb
and Barber 2000).
Considered in this way, this thesis and the ethical passivity and legalism identified
may be representative of, and support claims that, late modernity – and perhaps
particularly Western liberal culture – is a time of ever eroding ethical relevance. It is
beyond the scope of this thesis to comment more fully upon the attendant sociopolitical
issues that might arise from this - about what Habermas (1987) terms juridification (verrechtilichung) and Giddens (1991) argues requires life politics - but
what this thesis perhaps illustrates in pharmacists’ passivity and legalism is a
microcosm of broader social trends.
It is also hoped that this thesis and the emergent findings may be relevant to healthcare
and in particular to concerns about the relationship between pharmacists and doctors,
for example, and also to whether primary care is sufficiently integrated. Again, these
are not inconsiderable issues that go beyond the scope of this thesis but the emergence
of subordination and isolation as being inimical to an ethical approach to community
pharmacy may be of concern to the most effective delivery of services to patients and
the public. Potential changes to pharmacy practice and healthcare generally are
considered later in this chapter but it is argued that subordination may be relevant to
other paramedical professions and ethical isolation may affect not only pharmacists but
also other primary care practitioners who work alone. In England for example, 6.2% of
general medical practitioners work ‘single handed’ without a medical partner
(Department of Health, 2005) and this research raises the possibility that some
practitioners may be, like pharmacists, ethically isolated ‘islands’, too.
7.5 CODE OF ETHICS
Another implication of this research concerns the code of ethics for pharmacy and, in
particular, the debate as to the relevance of a code (Deans and Dawson 2005) and
whether a change from a rule-based code to a principle-based one is needed (Royal
Pharmaceutical Society 2006b). As noted above, education is not the only way in which ethical values and guidance can potentially be communicated and transmitted
and it is also a function of professional codes of ethics, which have proliferated and
gained popularity in recent years (Veatch 1978, Gorlin 1995). However, in addition to
the normative claim by Bauman that increasing codification is a negative societal
attribute, the findings in this thesis represent a further, empirical claim that may
undermine the relevance and use of a code of ethics for pharmacy. It appeared that the
present pharmacy code of ethics was, rather like ethics education, both unhelpful and
unmemorable for the pharmacists interviewed. As chapter five indicated, little of the
content of the present code could be recalled and few pharmacists identified it as being
of any assistance in ethical decision-making or in guiding their practice. The findings
from this thesis, coupled with similar findings in other studies (Holm 1997, Hibbert et
al 2000, Chaar et al 2005), suggest that codes, in general, may not be an influence for
pharmacists and other health care professions.
However, it may be argued by supporters of a change to the pharmacy code of ethics
that evidence of the code’s unmemorable and unhelpful nature, such as has emerged
from this and other research, simply reflects a problem with its present form and hence
a change to the code – such as to a principle-based code, for example - is necessary to
make it relevant and beneficial to pharmacy practice. It is argued that the findings of
this thesis do not support even a revised code since many pharmacists in this thesis
struggled to identify and also articulate ethical concepts or values and an overall
ethical illiteracy and inarticulacy appeared to limit many pharmacists’ ability to
discuss ethics issues or reflect upon the decision-making process. Hence, the content of
an ethical code simply may not be understood and subsequently used in practice. The work hands in John Irving’s The Cider House Rules (1993), for example, were unable
to understand the list of rules made for them because of basic illiteracy and for them to
‘read’ the rules would have meant acquiring fundamental skills. The analogy to
pharmacy is that comprehension of a code may be limited by a lack of understanding
of the basic concepts contained within it. A further concern relating to the relevance
and use of a code of ethics that emerges from this thesis is that, especially in the form
of a principle-based code as the RPSGB proposes, pharmacists must be able to balance
and choose from potentially competing principles and this ability was not identified in
this thesis. The RPSGB note that a revised code would include ‘basic ethical principles
which practitioners would apply to their own circumstances in accordance with their
professional judgement’ (Royal Pharmaceutical Society 2005b p. 466). However, this
statement assumes that pharmacists can ‘apply’ the principles correctly and can engage
in the appropriate balancing of rival principles. Even if pharmacists were able to recall
or even understand a principle in a code (which appears not to be the case with the
present code), the findings in this thesis undermine the case that pharmacists may be
able to successfully balance potentially competing principles – as can often occur in
practice – and so apply them appropriately to ethical problems in pharmacy.
So, despite the popularity of codes of ethics for many professions and, increasingly,
organisations (Stevens 1999), they may be undermined by empirical research such as
the findings of this thesis. One frequent claim, however, is to suggest that codes have a
place but alongside other forms of ethical communication (Stevens 1999) or ethical
argumentation (Pellegrino 2001). These claims may be more compatible with the
findings of this thesis, which has identified a dearth of ethical communication that may be related to pharmacists’ isolation and also ethical reasoning. In recognising the
importance of more fundamental issues relating to how ethical values and norms are
communicated in a profession such as pharmacy and to addressing more basic claims
about how professionals like pharmacists come to reason in an ethical way (as opposed
to a legalistic way, for example), it may be possible to find areas of potential change to
pharmacy practice that would avoid the pessimism of, say, Bauman’s post-modernity
and an absolute distrust of codification.
7.6 ADDITIONAL ROLES
One further and significant implication for this thesis concerns the current changes to
practice in UK community pharmacy. Although this research was undertaken at a time
when the new NHS contract for pharmacy in England was being introduced, it was
unfortunately perhaps too early to identify ethical concerns with the enhanced and
extended roles that are proposed for pharmacy. All empirical research and even
longitudinal studies are located within a particular time frame and need to be
understood in terms of this temporality. However, this does not mean that they cannot
have relevance or offer insights into later or proposed issues and it is argued that this
thesis may be relevant to the possible new roles and services for UK community
pharmacists. In one sense, this research threatens possible changes to practice because,
in the proposed roles that might involve supplementary prescribing, medicines use
reviews (MURs) and access to medical records amongst other developments,
pharmacists’ ethical passivity, subordination and legalistic approach may not be conducive to undertaking such tasks. Issues relating to distributive justice,
confidentiality and professional autonomy are immediate ethical concerns that might
arise in the new roles identified but, as this thesis has considered, ethical inattention
and a propensity to identify with legal rather than ethical issues may mean that
pharmacists do not identify or deal with the additional ethical responsibilities of these
new roles.
In another sense, however, it has been argued that the routinization of existing
community pharmacy tasks may be preventing pharmacists from engaging in ethical
issues fully and that, in what might appear to be a contradiction to the above point,
pharmacists should try to undertake less routinized and more ethically challenging
work. But as the previous chapter illustrated, the apparent contradiction in this
statement can be avoided, however, if attention is focused upon more fundamental
concerns in relation to pharmacist’s ethical understanding. If this can be addressed and
ethical passivity avoided, then not only might existing pharmacy tasks be seen to
contain hitherto unseen ethical aspects but also that the additional role for pharmacy
may be dealt with in an ethically sensitive and appropriate way.
7.7 PRAXIS
As noted in the introduction to this thesis, much health service research is directed at
potential policy change and although this thesis did not set out to study changes to
practice, it may be helpful to consider how and where ethically relevant changes could
be made to UK pharmacy practice. In this section I want to argue that, in addition to the concerns already noted about education, codes and new roles, a number of more
specific changes to UK pharmacy should be considered that might be ethically
significant. These build upon the issues already identified such as pharmacists’
education and communication but with a focus upon increasing the amount of
interaction that occurs and promoting ethical debate more effectively.
7.7.1 Integrating undergraduate ethics training
Concerns have already been raised in this chapter about how ethical understanding and
awareness could be developed pedagogically and it was argued that a less legalist
approach was needed to avoid the propensity of pharmacists to see legalistic problems
and solutions in their work. In addition to these concerns about the content of a
pharmacy course is the more general claim, and one that relates to the emergence of
isolation in this thesis, that pharmacy undergraduate training should be more integrated
with other healthcare professions’ training – such as medicine, nursing and dentistry,
for example. By doing so, pharmacy students would have the opportunity to interact
with students of other allied disciplines at an early stage and gain insights into not only
ethical problems that occur in other areas of healthcare but also how these may be
ethically debated and resolved in other disciplines. Increasing interaction specifically
in the area of ethics is by no means a new idea and Hanson (2005), for example, has
argued using American nursing and medical student cohorts as an example, that three
key benefits would result: increased awareness of different healthcare professions’
unique insights into ethical problems, increased collaboration and, significantly given the emergence of subordination in this thesis, a reduction in ‘deference’ and the ‘desire
to avoid making difficult ethical decisions’ amongst nursing cohorts (Hanson 2005,
p.174). In practical terms and of relevance to how this might be achieved in pharmacy,
Hanson notes that barriers to educational integration exist in terms of distinct ethical
textbooks for different healthcare professions that encourages separateness and the
logistical difficulty of trying to organise two curricula that might teach ethics at
different stages of training and with different staff – staff, furthermore, who may not
have specialist ethics or philosophical training. Although the former point may be
challenged by the availability of many general health care ethics textbooks, the latter
point may be significant and was one of the recommendations made by Wingfield,
Wilson and Hall (2006) who argued that, like BMA proposals for medical education,
recruiting a specialist healthcare ethics lecturer (or utilising those in a philosophy
department) could develop and enhance the teaching of ethics.
Integrative approaches to healthcare education have become more accepted and these
have increasingly challenged a tradition of education along ‘discrete occupational
lines’ (Elston 2004). An important aspect of this integrative approach is that it may be
significant in the professional socialisation process and may even help develop a
healthcare culture that recognises the interdependency of different professions such as
pharmacy, medicine and nursing and may inculcate a greater desire for interaction and
communication. Whilst this is argued to be ethically beneficial to pharmacy students,
practicing pharmacists would not gain but there may be other changes that could be
ethically relevant and these are now considered.
7.7.2 Increasing professional interaction and communication
Linked to the concern about isolation and an associated anomie and lack of
communication identified in the previous chapter, how can pharmacy practice be
changed to facilitate more interaction and communication? One possibility would be to
change the work arrangements within pharmacies and, specifically, encourage more
than one pharmacist to work at a pharmacy at one time, as is currently the norm.
Although perhaps at odds with the current debate about supervision and developments
such as remote supervision (Bellingham 2004), having pharmacists working together
rather than in separate pharmacies may allow for greater debate and assistance -
clinically, professionally and ethically. This would help allay the concerns of many
pharmacists in this research that they were alone in their work and ethical decisions
and had no one to discuss ethical issues with.
Although it was recognised that pharmacists who had alrerady qualified would not
benefit from integration of undergraduate ethics training, changes could be made to
post-graduate education and specifically ethics. In addition to promoting a specific
continuing education ethics course, as already noted in this chapter, developing
continuing education ethics programmes that were suitable not just for pharmacists but
also doctors, nurses, social care workers and others working in primary care may allow
for increased communication and perhaps the benefits that Hanson (2005) noted. The
ability to gain insights into the ethical perspectives of other healthcare professionals
and how they try to resolve ethical problems could be valuable for pharmacists’ decision-making. In addition, it could offer insights into complex issues such as
medical subordination by allowing dominant medical professionals to see how ethical
problems result from hierarchical healthcare arrangements.
One further opportunity for postgraduate ethics training exists in the form of taught
courses in healthcare ethics offered by several universities. Perhaps more could be
done to make pharmacists aware of such courses by advertising in publications such as
The Pharmaceutical Journal or in pharmacy departments or through employers and for
such courses to be accredited for continuing professional development.
7.7.3 Raising the profile of ethics in the pharmacy literature
A final form of praxis, and once that is related to the point made above about
advertising, is that more should be done to increase pharmacists’ understanding of
ethics and encourage debate and thought through the available literature. Although
publication such as The Pharmaceutical Journal and Chemist and Druggist have
previously included occasional articles on ethical ‘dilemmas’ (Royal Pharmaceutical
Society 2001), more should be done to provide a regular feature, focusing upon ethical
debate and even normative philosophical approaches. The Pharmaceutical Journal
does provide an occasional ‘Law and Ethics Bulletin’ but this often focus’s upon
practical and legal or procedural aspects of pharmacy practice rather than ethical issues
or broader ethical concepts and theory. An allied concern is that pharmacy lacks a
dedicated ethics journal (in contrast to medicine and nursing, for example) and this is
an area of change that could be ethically relevant. Although it may be argued that practicing pharmacists would not have routine access to academic journals, creating a
literature forum such as a pharmacy ethics journal would provide the catalyst for not
only more pharmacy ethics research but also the ability of such research to inform
practice in relation to ethical concerns.
conclusions and consider the implications of this research for not only pharmacists and
pharmacy practice but also healthcare and society more generally. I will identify
possible limitations to the thesis, indicate areas of further research and provide further
reflexive insights into the research.
It is hoped that this thesis has provided unique and important insights into the nature of
ethical issues in UK community pharmacy and that these offer a significant
contribution to the pharmacy literature. The main conclusions of this thesis are that
community pharmacists encounter a range of ethical problems in their work but that
these often involve the routine, legal or procedural minutiae of community pharmacy
practice. As such, it may be more appropriate to consider these as quasi-ethical
problems rather than dilemmas since they often involved an ethical value and a legal,
procedural or financial issue rather than rival ethical values or normative conflicts. The
centrality of law for many pharmacists in this study was striking and law appeared not
only to be synonymous with ethics for many but it also defined and decided many
problems identified in pharmacists’ practice. The concept of ethically passivity
emerged as an appropriate description of pharmacists who were ethically inattentive,
concerned with self-interest and who did not engage in ethical action. However,
aspects of the community pharmacy environment, such as pharmacists’ isolation from peers, professionals and public, subordination to doctors and routinized work,
appeared to precipitate ethical problems and contribute to ethical passivity.
Before considering a number of specific conclusions, limitations and ethically relevant
potential changes to pharmacy practice from this thesis, I want to first of all reflect
upon the overall research process and consider several additional insights that will
offer a transparent and reflexive account of this research.
7.2 REFLEXIVITY
This thesis has involved an attempt to be reflexive about the research process and in
chapter one, for example, I indicated how my own experiences of community
pharmacy practice influenced the research and research questions and, in chapter three,
how decisions, changes and revisions to the research process occurred. In this section,
however, I want to focus upon a number of additional experiences from the research
and reflect upon how these reflexive concerns had relevance to the overall research
process, too.
In particular, I want to address the issues of my own development during the research
and also how the findings from this thesis could be located within my own
understanding of ethics and pharmacy practice. As noted in chapter one, I do not
subscribe to the notion of value neutrality in the research process and believe that it is
important to recognise how my own educational and professional background and
assumptions about ethics and the construction of knowledge have shaped and,
significantly, been shaped by this research.
Developing the first point about how the findings of this research could be
accommodated in my own experiences, a reflexive concern emerges - and one that
may be apparent to a reader comparing, say, chapter one with chapter four of this
thesis, for example – that my own ethical concerns as a practicing pharmacist did not
appear to be reflected in those of the cohort pharmacists interviewed. It may be
questioned, therefore, whether I was surprised or even disappointed in finding
legalistic and procedural ethical problems amongst many of the cohort pharmacists, for
example, or in often identifying only basic forms of ethical argumentation and
justification. To return to the analogy with Conrad’s Heart of Darkness briefly
(although I will make further comparisons at the end of this thesis), was there a
concern similar to that experienced by Marlowe, when he realises that his search for
Kurtz revealed something less than he had expected? He admitted that:
There was a sense of extreme disappointment, as though I had found out I had
been striving after something altogether without a substance. (Conrad 1902
p.67)
For Marlowe, this disappointment arose because of the disparity between what had
been reported about Kurtz and what he actually saw. To some extent, this perception
mirrors my own concerns and surprise and this may have arisen because my review of
the empirical pharmacy ethics research literature had revealed studies that had not
asked questions such as: how do pharmacists understand ethics issues, and were there
different approaches to resolving such issues in their work? What the published
literature did not indicate, for example, was whether pharmacists were forthcoming or
not in their responses and their ability to talk about ethical concerns. Hence, an initial sense of disappointment did arise in relation to some of the interviews in this research
since several were very difficult to conduct in terms of eliciting the participating
pharmacist’s experiences of ethical concerns in their work and to having them reflect
upon how they dealt with problems. Although this will be considered later in terms of
study limitations, I did consider using not just prompting about possible areas of
ethical concern but actual hypothetical vignettes. Looking back at this decision in the
research process, despite the difficulty of some interviews, I believed it was important
to continue to ask what did pharmacists understand by, and experience as ethical issues
in their work, and that this was justified since it revealed hitherto unidentified issues
such a legalistic conception of ethics and self-interest.
In the earlier interviews, my sense of disappointment with an interview was perhaps
more noticeable but I attributed this to anxiety about my research skills, manifest in a
number of concerns: since my research background prior to this had been quantitative,
laboratory-based pharmacy studies, I was worried that my skills at qualitative
techniques such as semi-structured interviewing might have led to interviews being
difficult; I also recall feeling an impatience and that I wanted obvious themes to
emerge following interviews, which in hindsight I think resulted from an anxiety about
the analytical stage of the research since this, again, was not a research approach I had
previously used. Looking back over the research process, these anxieties were
probably misplaced and occurred as a result of my initial inexperience: later interviews
did not necessarily lead to increased responses from interviewees, despite my
becoming more confident and experienced at interviewing as the research progressed,
for example, and, as the next reflexive concern hopefully indicates, understanding how the theoretical literature was of value in interpreting and analysing the interview data
was an important stage in the process for me.
In addition to my developing skills in qualitative techniques during the research
process, a further reflexive concern involved my increased theoretical understanding of
the ethics literature. In particular, I want to consider how this knowledge informed but
was also informed by, the research and data over the course of the three years of this
research. I was conscious at the early stages of the research (before beginning
recruitment and interviewing) of holding onto a more rigid understanding of ethics and
moral philosophy generally because of my training in what could be described as the
normative Enlightenment traditions in medical ethics. These are reflected in some of
the theoretical positions considered in the first part of chapter two and, specifically, the
centrality of rationality and typified by the influence of utilitarian and deontological
ethical positions, for example. However, it was obvious early in the research that in
undertaking this empirical ethics research that I would need to consider not only the
direct empirical literature but also a meta-ethical concern about the place of empirical
research. This was, in part, an intentional intellectual task that was informed by a
review of the literature but it was also driven by the emergent data and by the need to
account for themes such as the influence of law, for example. But conversely, I believe
that the commentaries on ’late modernity’ offered by writers such as Bauman, Giddens
and Habermas, for example, were an influence upon the research and the further
interpretation and understanding of the data. In recognising the influence of these
accounts of the place of ethics (and law) in society, I do not mean to suggest that they fully explained the data or accounted for my disappointment but simply that they
revealed to me additional insights that were relevant in analysing and interpreting the
data.
A further example of where my reflexive concern for the influence of the theoretical
literature was relevant to the research concerned my decision not to rely upon CMD,
despite its popularity in the empirical ethics literature. My reservations about the often
neglected but fundamental normative assumptions upon which CMD is based - that a
justice-based form of reasoning was the ultimate stage of development according to
Kohlberg - led me to doubt whether this theory could be used solely as a basis for this
research. Of course, I was also concerned that using this approach would not fully
answer the research questions in terms of revealing more situated and subjective
insights but, like Holm (1997), I doubted whether this approach could offer a
comprehensive account of ethical reasoning. But not focusing upon CMD also
influenced how I analysed and contextualised the data and emergent themes and this
was apparent in the case of pharmacists’ legal problems and legalistic self-interest. I
recognise that I have not referred to CMD in explaining the significance and influence
of law for many pharmacists, despite this being a feature of the lower, preconventional
and conventional stages of moral reasoning of CMD, involving egoistic
self-interest and a concern for law. Considering the similarities between this research
and the lower stages of CMD reasoning could perhaps have been explored more but
given the scope of the thesis, I made a decision during the analysis of the interview
data not to engage in what I considered to be a more theoretical line of discussion.
However, I recognise that this could be pursued in further research, perhaps at the level of meta-ethical discussion.
By considering the reflexive concerns identified above and in other parts of this thesis,
I hope that this will provide a transparency to the research and help illuminate stages
of the research such as the framing of the research questions and the analysis of
interviews. In the next section I want to consider some of the implication of the
research for pharmacy practice and then, in the remainder of this chapter, go on to
identify in terms of praxis, a number of more specific changes, followed by the
limitations of the study and opportunities for further research.
7.3 EDUCATION
The findings in this thesis have relevance to several issues in ethics education for
pharmacists. Many undergraduate professional courses now include some form of
ethics instruction (Illingworth 2003, Doyal and Gillon 1998) and the RPSGB, too,
recognises that pharmacy teaching should involve ethics so that ethical problems in
pharmacists’ practice can be dealt with appropriately. In the pharmacy undergraduate
course, for example, one of the pharmacy degree accreditation ‘outcomes’ is for a
pharmacy graduate who:
Is able to recognise ethical dilemmas in healthcare and science, and
understands ways in which these might be managed by healthcare
professionals, whilst taking account of relevant law. (Royal Pharmaceutical
Society 2003)
Furthermore, the Quality Assurance Agency for Higher Education document (2003)
relating to benchmarks in pharmacy education similarly refers to ethics and makes
several references to the need for pharmacy graduates to gain an understanding in
ethical issues and decision-making.
The findings of this thesis may be relevant to the teaching of ethics in pharmacy in a
number of ways. In one respect, it may allow those involved in teaching ethics to be
more aware of the ethical problems that actually occur in practice. This, according to
Holm, might make ethics instruction more effective and he notes that ‘knowledge
about the types of ethical problem that students are to meet in their daily practice is
also important [...]’ (Holm 1997 p.32). This may be achieved by including realistic
scenarios in ethics teaching that have been derived from empirical ethics research,
such as this thesis. This has, in fact, been one of the main aims of previous research
such as Hibbert et al (2000 and Derek Hibbert personal correspondence 2004). The
importance of exposing students to what are thought to be ethical problems that relate
to practice may, however, be potentially problematic. A number of the more recently
qualified pharmacists in this thesis noted that they were provided with scenarios and
asked to make an ethically justified decision about them but what were often recalled
were the emergency supply scenarios or, as Julian noted in chapter four, the paradigm
incorrectly written controlled drug prescription. Perhaps there is a danger of the selffulfilling
prophecy (Merton 1957) in the use of such situations and that, in only being
able to offer student pharmacists a limited number of scenarios, might these therefore
come to dominate and shape how they ‘see’ ethical problems in practice? Hopefully,
this thesis has illustrated not just the range of ethical issues experienced by
pharmacists but, importantly, argued that many are quasi-ethical problems and may not be the most appropriate type to use in undergraduate pharmacy ethics education. But
this thesis has also identified examples of ethical problems that do involve conflict of
rival ethical values or concerns and these may be of relevance to ethics education.
In another respect and perhaps more importantly, however, the findings of this study
might be used to consider whether changes to pharmacy ethics teaching are required.
Although specific educational reforms will be considered later, in the section on
praxis, two general points are relevant here. Firstly, this thesis reflected existing
attempts at teaching ethics, as identified in the comments made by pharmacists about
their undergraduate education. These comments were almost always negative,
unfortunately, and as was indicated, pharmacists either recalled little specific ethics
instruction or noted that what was provided was of limited relevance to practice and
was often legal rather than ethical in nature. Secondly, in addition to these direct
reflections on pharmacists’ ethics education, could it not be argued that the emergent
theme of ethical passivity that characterised many pharmacists in this research might
be, even in part, attributable to how pharmacists were taught as undergraduates?
Unfortunately, the questions of how effective ethics teaching is and how it could be
measured have been problematic and there appears to be little consensus about how
ethics education could actually be assessed in terms of its success in influencing
practice (Molyneux 2001). Approaches such as measuring ethical knowledge skills
(Sulmasy et al 1997), sensitivity (Mitchell et al 1993), confidence (Molyneux 2001)
and problem solving ability (Savulescu et al 1999) have all been proposed but this may
be an area that requires further research. In spite of this potential difficulty in assessing
the effectiveness of ethics teaching, it is argued that the findings in this thesis and, in particular, the emergent theme of ethical passivity and pharmacists’ synonymous
understanding of law and ethics may reflect problems in how pharmacists come to
understand ethics. In presenting some of the findings of this thesis to academic
pharmacy audiences (Cooper et al 2006), there has been considerable discussion and
interest in how the emergent themes of this thesis may be used to develop or change
how pharmacists are taught in relation to ethics, particularly in terms of how legalism
and isolation could be avoided and these are concerns that I will address more
specifically in terms of praxis later in this chapter.
One further pedagogical issue that emerged was that none of the pharmacists in this
thesis had undertaken any post-graduate ethics education and, given the lack of any
substantive ethics education as undergraduates and especially amongst older
pharmacists, a resultant lacuna in terms of ethical instruction may exist. Hence a
further implication from this thesis is that an assessment of ethical educational needs is
required at a post-graduate as well as undergraduate level. Post-graduate ethical
training has been used with doctors (Molyneux 2001) but although a continuing
education course – Evidence-based practice: dealing with dilemmas – is provided by
the Centre for Pharmacy Postgraduate Education (CPPE), this course does not appear
to be widely available (2006 Dave Dunning, CPPE personal correspondence).
Interestingly, in the course’s description, a number of RPSGB competencies are used
but one that is surprisingly omitted is that of ‘making decisions and solving problems’
(CPPE 2006 p. 27).
7.4 PHARMACY, HEALTHCARE AND SOCIETY
It is also possible to reflect on whether there is something more fundamental involved
in why pharmacists recall little ethical education and why ethics is frequently
understood as law and legalistic self-interest and also why ethical passivity was
identified. It would be naïve to assume that ethical understanding and decision-making
ability could be completely gained by education alone and so it would be inappropriate
to single out education. Perhaps just as relevant may be the more general sociological
claims that, as were described in chapters two and six, individuals in society are being
increasingly regulated for in terms of legislation (Habermas 1987) and codes (Bauman
1993) and that these result in a predictable, secure ‘black and white’ approach to
practice that avoids the need for pharmacists to confront ethical problems and make
ethical decisions. Education is not necessarily exonerated in this alternative view, and
it may be that if such philosophical and sociological accounts of the increasing erosion
of the ethical in individuals’ lives are correct - as not only Bauman and Haberams but
also Giddens (1991) and C. Smith (2002) suggest - then education may perhaps have
some role to play in developing re-moralization or stimulating value awareness (Cribb
and Barber 2000).
Considered in this way, this thesis and the ethical passivity and legalism identified
may be representative of, and support claims that, late modernity – and perhaps
particularly Western liberal culture – is a time of ever eroding ethical relevance. It is
beyond the scope of this thesis to comment more fully upon the attendant sociopolitical
issues that might arise from this - about what Habermas (1987) terms juridification (verrechtilichung) and Giddens (1991) argues requires life politics - but
what this thesis perhaps illustrates in pharmacists’ passivity and legalism is a
microcosm of broader social trends.
It is also hoped that this thesis and the emergent findings may be relevant to healthcare
and in particular to concerns about the relationship between pharmacists and doctors,
for example, and also to whether primary care is sufficiently integrated. Again, these
are not inconsiderable issues that go beyond the scope of this thesis but the emergence
of subordination and isolation as being inimical to an ethical approach to community
pharmacy may be of concern to the most effective delivery of services to patients and
the public. Potential changes to pharmacy practice and healthcare generally are
considered later in this chapter but it is argued that subordination may be relevant to
other paramedical professions and ethical isolation may affect not only pharmacists but
also other primary care practitioners who work alone. In England for example, 6.2% of
general medical practitioners work ‘single handed’ without a medical partner
(Department of Health, 2005) and this research raises the possibility that some
practitioners may be, like pharmacists, ethically isolated ‘islands’, too.
7.5 CODE OF ETHICS
Another implication of this research concerns the code of ethics for pharmacy and, in
particular, the debate as to the relevance of a code (Deans and Dawson 2005) and
whether a change from a rule-based code to a principle-based one is needed (Royal
Pharmaceutical Society 2006b). As noted above, education is not the only way in which ethical values and guidance can potentially be communicated and transmitted
and it is also a function of professional codes of ethics, which have proliferated and
gained popularity in recent years (Veatch 1978, Gorlin 1995). However, in addition to
the normative claim by Bauman that increasing codification is a negative societal
attribute, the findings in this thesis represent a further, empirical claim that may
undermine the relevance and use of a code of ethics for pharmacy. It appeared that the
present pharmacy code of ethics was, rather like ethics education, both unhelpful and
unmemorable for the pharmacists interviewed. As chapter five indicated, little of the
content of the present code could be recalled and few pharmacists identified it as being
of any assistance in ethical decision-making or in guiding their practice. The findings
from this thesis, coupled with similar findings in other studies (Holm 1997, Hibbert et
al 2000, Chaar et al 2005), suggest that codes, in general, may not be an influence for
pharmacists and other health care professions.
However, it may be argued by supporters of a change to the pharmacy code of ethics
that evidence of the code’s unmemorable and unhelpful nature, such as has emerged
from this and other research, simply reflects a problem with its present form and hence
a change to the code – such as to a principle-based code, for example - is necessary to
make it relevant and beneficial to pharmacy practice. It is argued that the findings of
this thesis do not support even a revised code since many pharmacists in this thesis
struggled to identify and also articulate ethical concepts or values and an overall
ethical illiteracy and inarticulacy appeared to limit many pharmacists’ ability to
discuss ethics issues or reflect upon the decision-making process. Hence, the content of
an ethical code simply may not be understood and subsequently used in practice. The work hands in John Irving’s The Cider House Rules (1993), for example, were unable
to understand the list of rules made for them because of basic illiteracy and for them to
‘read’ the rules would have meant acquiring fundamental skills. The analogy to
pharmacy is that comprehension of a code may be limited by a lack of understanding
of the basic concepts contained within it. A further concern relating to the relevance
and use of a code of ethics that emerges from this thesis is that, especially in the form
of a principle-based code as the RPSGB proposes, pharmacists must be able to balance
and choose from potentially competing principles and this ability was not identified in
this thesis. The RPSGB note that a revised code would include ‘basic ethical principles
which practitioners would apply to their own circumstances in accordance with their
professional judgement’ (Royal Pharmaceutical Society 2005b p. 466). However, this
statement assumes that pharmacists can ‘apply’ the principles correctly and can engage
in the appropriate balancing of rival principles. Even if pharmacists were able to recall
or even understand a principle in a code (which appears not to be the case with the
present code), the findings in this thesis undermine the case that pharmacists may be
able to successfully balance potentially competing principles – as can often occur in
practice – and so apply them appropriately to ethical problems in pharmacy.
So, despite the popularity of codes of ethics for many professions and, increasingly,
organisations (Stevens 1999), they may be undermined by empirical research such as
the findings of this thesis. One frequent claim, however, is to suggest that codes have a
place but alongside other forms of ethical communication (Stevens 1999) or ethical
argumentation (Pellegrino 2001). These claims may be more compatible with the
findings of this thesis, which has identified a dearth of ethical communication that may be related to pharmacists’ isolation and also ethical reasoning. In recognising the
importance of more fundamental issues relating to how ethical values and norms are
communicated in a profession such as pharmacy and to addressing more basic claims
about how professionals like pharmacists come to reason in an ethical way (as opposed
to a legalistic way, for example), it may be possible to find areas of potential change to
pharmacy practice that would avoid the pessimism of, say, Bauman’s post-modernity
and an absolute distrust of codification.
7.6 ADDITIONAL ROLES
One further and significant implication for this thesis concerns the current changes to
practice in UK community pharmacy. Although this research was undertaken at a time
when the new NHS contract for pharmacy in England was being introduced, it was
unfortunately perhaps too early to identify ethical concerns with the enhanced and
extended roles that are proposed for pharmacy. All empirical research and even
longitudinal studies are located within a particular time frame and need to be
understood in terms of this temporality. However, this does not mean that they cannot
have relevance or offer insights into later or proposed issues and it is argued that this
thesis may be relevant to the possible new roles and services for UK community
pharmacists. In one sense, this research threatens possible changes to practice because,
in the proposed roles that might involve supplementary prescribing, medicines use
reviews (MURs) and access to medical records amongst other developments,
pharmacists’ ethical passivity, subordination and legalistic approach may not be conducive to undertaking such tasks. Issues relating to distributive justice,
confidentiality and professional autonomy are immediate ethical concerns that might
arise in the new roles identified but, as this thesis has considered, ethical inattention
and a propensity to identify with legal rather than ethical issues may mean that
pharmacists do not identify or deal with the additional ethical responsibilities of these
new roles.
In another sense, however, it has been argued that the routinization of existing
community pharmacy tasks may be preventing pharmacists from engaging in ethical
issues fully and that, in what might appear to be a contradiction to the above point,
pharmacists should try to undertake less routinized and more ethically challenging
work. But as the previous chapter illustrated, the apparent contradiction in this
statement can be avoided, however, if attention is focused upon more fundamental
concerns in relation to pharmacist’s ethical understanding. If this can be addressed and
ethical passivity avoided, then not only might existing pharmacy tasks be seen to
contain hitherto unseen ethical aspects but also that the additional role for pharmacy
may be dealt with in an ethically sensitive and appropriate way.
7.7 PRAXIS
As noted in the introduction to this thesis, much health service research is directed at
potential policy change and although this thesis did not set out to study changes to
practice, it may be helpful to consider how and where ethically relevant changes could
be made to UK pharmacy practice. In this section I want to argue that, in addition to the concerns already noted about education, codes and new roles, a number of more
specific changes to UK pharmacy should be considered that might be ethically
significant. These build upon the issues already identified such as pharmacists’
education and communication but with a focus upon increasing the amount of
interaction that occurs and promoting ethical debate more effectively.
7.7.1 Integrating undergraduate ethics training
Concerns have already been raised in this chapter about how ethical understanding and
awareness could be developed pedagogically and it was argued that a less legalist
approach was needed to avoid the propensity of pharmacists to see legalistic problems
and solutions in their work. In addition to these concerns about the content of a
pharmacy course is the more general claim, and one that relates to the emergence of
isolation in this thesis, that pharmacy undergraduate training should be more integrated
with other healthcare professions’ training – such as medicine, nursing and dentistry,
for example. By doing so, pharmacy students would have the opportunity to interact
with students of other allied disciplines at an early stage and gain insights into not only
ethical problems that occur in other areas of healthcare but also how these may be
ethically debated and resolved in other disciplines. Increasing interaction specifically
in the area of ethics is by no means a new idea and Hanson (2005), for example, has
argued using American nursing and medical student cohorts as an example, that three
key benefits would result: increased awareness of different healthcare professions’
unique insights into ethical problems, increased collaboration and, significantly given the emergence of subordination in this thesis, a reduction in ‘deference’ and the ‘desire
to avoid making difficult ethical decisions’ amongst nursing cohorts (Hanson 2005,
p.174). In practical terms and of relevance to how this might be achieved in pharmacy,
Hanson notes that barriers to educational integration exist in terms of distinct ethical
textbooks for different healthcare professions that encourages separateness and the
logistical difficulty of trying to organise two curricula that might teach ethics at
different stages of training and with different staff – staff, furthermore, who may not
have specialist ethics or philosophical training. Although the former point may be
challenged by the availability of many general health care ethics textbooks, the latter
point may be significant and was one of the recommendations made by Wingfield,
Wilson and Hall (2006) who argued that, like BMA proposals for medical education,
recruiting a specialist healthcare ethics lecturer (or utilising those in a philosophy
department) could develop and enhance the teaching of ethics.
Integrative approaches to healthcare education have become more accepted and these
have increasingly challenged a tradition of education along ‘discrete occupational
lines’ (Elston 2004). An important aspect of this integrative approach is that it may be
significant in the professional socialisation process and may even help develop a
healthcare culture that recognises the interdependency of different professions such as
pharmacy, medicine and nursing and may inculcate a greater desire for interaction and
communication. Whilst this is argued to be ethically beneficial to pharmacy students,
practicing pharmacists would not gain but there may be other changes that could be
ethically relevant and these are now considered.
7.7.2 Increasing professional interaction and communication
Linked to the concern about isolation and an associated anomie and lack of
communication identified in the previous chapter, how can pharmacy practice be
changed to facilitate more interaction and communication? One possibility would be to
change the work arrangements within pharmacies and, specifically, encourage more
than one pharmacist to work at a pharmacy at one time, as is currently the norm.
Although perhaps at odds with the current debate about supervision and developments
such as remote supervision (Bellingham 2004), having pharmacists working together
rather than in separate pharmacies may allow for greater debate and assistance -
clinically, professionally and ethically. This would help allay the concerns of many
pharmacists in this research that they were alone in their work and ethical decisions
and had no one to discuss ethical issues with.
Although it was recognised that pharmacists who had alrerady qualified would not
benefit from integration of undergraduate ethics training, changes could be made to
post-graduate education and specifically ethics. In addition to promoting a specific
continuing education ethics course, as already noted in this chapter, developing
continuing education ethics programmes that were suitable not just for pharmacists but
also doctors, nurses, social care workers and others working in primary care may allow
for increased communication and perhaps the benefits that Hanson (2005) noted. The
ability to gain insights into the ethical perspectives of other healthcare professionals
and how they try to resolve ethical problems could be valuable for pharmacists’ decision-making. In addition, it could offer insights into complex issues such as
medical subordination by allowing dominant medical professionals to see how ethical
problems result from hierarchical healthcare arrangements.
One further opportunity for postgraduate ethics training exists in the form of taught
courses in healthcare ethics offered by several universities. Perhaps more could be
done to make pharmacists aware of such courses by advertising in publications such as
The Pharmaceutical Journal or in pharmacy departments or through employers and for
such courses to be accredited for continuing professional development.
7.7.3 Raising the profile of ethics in the pharmacy literature
A final form of praxis, and once that is related to the point made above about
advertising, is that more should be done to increase pharmacists’ understanding of
ethics and encourage debate and thought through the available literature. Although
publication such as The Pharmaceutical Journal and Chemist and Druggist have
previously included occasional articles on ethical ‘dilemmas’ (Royal Pharmaceutical
Society 2001), more should be done to provide a regular feature, focusing upon ethical
debate and even normative philosophical approaches. The Pharmaceutical Journal
does provide an occasional ‘Law and Ethics Bulletin’ but this often focus’s upon
practical and legal or procedural aspects of pharmacy practice rather than ethical issues
or broader ethical concepts and theory. An allied concern is that pharmacy lacks a
dedicated ethics journal (in contrast to medicine and nursing, for example) and this is
an area of change that could be ethically relevant. Although it may be argued that practicing pharmacists would not have routine access to academic journals, creating a
literature forum such as a pharmacy ethics journal would provide the catalyst for not
only more pharmacy ethics research but also the ability of such research to inform
practice in relation to ethical concerns.
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