Ethical Hot Spots: Nine Case Studies for Pharmacists

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Community pharmacists face legal and ethical issues every day. So common are they, pharmacists often don't think of them in those terms. They are just practice decisions that must be made--and made quickly. But given more time to reflect, would they make a different judgment? Would it be an ethical one, conforming to the profession's accepted standards of conduct? Or are practicing pharmacists facing situations where the standards are unclear or still evolving?

The editors of Drug Topics created nine hypothetical case studies that raised ethical questions that might occur in a community pharmacy on any given day. We then stated how the fictional pharmacist handled each situation, and asked a panel of pharmacists to agree or disagree, based on their personal beliefs and experiences.

Then, to get a different perspective, we presented the same cases to Bruce D. Weinstein, Ph.D., who teaches pharmacy ethics at West Virginia University School of Pharmacy. "The pharmacists surveyed were asked whether they would do the same thing as the pharmacist in each case study did," said Weinstein, associate director of WVUs Center for Health Ethics & Law.

"An answer to the question, 'What would you do?' tells us many things," continued Weinstein. "We learn about the psychological makeup of the respondent: what he or she desires, fears, likes or dislikes. What we don't necessarily learn is how the respondent thinks from a moral point of view. To learn that, we need to ask a different question: 'What should you do?'

"The answer to this question is grounded in ethical rules and principles. 'What should you do is an ethical question. 'What would you do?' is not."

Weinstein said that his focus in the commentaries following each case study was to consider whether what the pharmacists said they would do is what they should do. He said that he applied the following systematic procedure for making ethical or moral decisions, terms he used synonymously, in patient care:

1. Identify the ethical questions raised by the situation.

2. Gather the medical, social, and all other clinically relevant facts of the case.

3. Identify all of the values that play a role and decide which values are in conflict.

4. Propose possible solutions to resolve the conflict. That is, answer the question, "What could you do?"

5. Choose the better solutions for this particular case, justify them, and respond to possible criticisms. That is, answer the question, "What should you do, and why?"

This is a statistical tie. The most agreement with the decision came from the Midwest (61% versus 3), while disagreement was strongest in the West (66% versus 34%). Chain pharmacists disagreed 55% versus 45%. Independents, which includes owners and staff R.Ph.s, agreed by a 53% to 47% margin.

"I practice in a small rural town," a Kentucky independent reported. "The same situation was presented to me. I also decided to do nothing." An independent in Minnesota observed: "Rural towns are hard to change. Do the counseling in the store, or when asked to." A Missouri independent said, "Condom use is not only a health matter but also a serious moral issue for many. To have a respected health professional condone, in effect, the use of a condom presupposes that the only responsible method of behavior in sexuality is to limit the spread of the disease." Added a Texas independent, 9 don't believe in advocating condoms, which morally is OK'ing premarital sex. Abstinence is the only message to preach to our children."

From an Oklahoma store owner who said she lives in a conservative, small town, not immune to HIV: "The saddest thing about all of this is people continue to deny that it exists in our town. You would rather teenagers not have sex, but you have to be realistic and know that teenagers do, and they need to know about condoms." A chain R.Ph. said, If you go out of business, what else can you do? …