Ethics in practice and ethical dilemmas
Introduction
As pharmacists, we are faced and deal with ethical dilemmas every day. Much of the time, we do not recognize them as dilemmas – just a situation that needs to be dealt with.
This chapter will build on the ethical principles described in Chapter 7 and help you ponder on what you need to consider as the best course of action in a given situation.
Towards the end of the chapter, there are some ethical dilemmas that have been faced by pharmacists in practice, together with some of the information you may need to gather to enable you to decide on the best outcome for both you and the patient.
Code of conduct, ethics and performance
The GPhC publishes ‘Standards of conduct, ethics and performance’ that pharmacy professionals must follow. The GPhC is clear in this document that pharmacy professionals are registered pharmacists and pharmacy technicians (see Ch. 5). The standards of conduct has seven principles.
What is an ethical dilemma?
As professionals, every time we make a decision or take an action, we face a potential ethical dilemma. Often the situation is not dramatic and we do not always think in the moment that we have faced a dilemma. It is likely that many situations involving a person(s) has an ethical element and if there is more than one way to deal with the issue, then it is in effect an ethical dilemma.
It is also important to remember that we are pharmacists all day every day. We will sometimes be faced with a decision when we are not working, which because we are pharmacists, will have an ethical element to it, which may not need to be considered by others.
Example of an ethical dilemma
You are attending a party and several people at the party are drunk. You become aware that one of them is planning to drive home. As a non-pharmacist you will choose whether or not you want to get involved in the situation or ignore it.
If the driver is then involved in an accident, unless you were in the car with them, there is unlikely to be any personal consequence of your inaction.
As a pharmacist however, if you chose to ignore the drunken driver you may be in breach of the second principle of the standards of conduct, as you are not protecting the interests of the public and have not done your best to reduce risks to the public – this could mean that you are referred to the GPhC’s FtP committee (see Ch. 5).
A legal issue or an ethical dilemma?
Scenario 1
You are working as a pharmacist and are presented with a prescription for a schedule 2 controlled drug; it is 4 pm on a Saturday afternoon. The prescription is not written correctly – there is no quantity on it. You have tried to get hold of the doctor as you have his mobile phone number but he is not answering. You are very clear that you cannot legally dispense this prescription. When you inform the woman who brought in the prescription, she tells you that it is for her mother who is terminally ill and does not have any of her painkillers left to take that night.
Scenario 2
It is Saturday morning, you are working in a small village pharmacy where the only other shops are the local grocers and the post-office. The village has been cut off by flooding and so your delivery has not arrived and won’t be arriving before Monday. You have a number of drug-user clients who collect daily and you were relying on the delivery to ensure you had enough sugar-free methadone mixture to make up their daily doses. All you have left in the CD cupboard is methadone mixture DTF. You know that in law, the different methadone mixtures are different products legally and so substitution is illegal.
Considerations
Both of these situations have started as legal issues. However, if you leave either scenario at this point and choose not to supply anything for either patient, you are probably not complying with the first principle of the standards of conduct – make patients your first concern.
The law is very straightforward in pharmacy issues – you can either take certain actions under certain circumstances or you cannot. However, as a pharmacist you are also bound by the standards of conduct and so situations that are legally clear become ethical dilemmas when your compliance with the law is in conflict with the standards of conduct.
This is not to say that compliance with the standards of conduct is an excuse for breaking the law; it may, however, be an explanation of why you have made a certain choice in a particular set of circumstances.
Ethical decision-making processes
In many situations, you will make a decision without consciously working through a framework. However, in a more complicated or difficult situation, you may need to follow a structure to help you make the best possible decision. As an individual professional, it is inevitable that your process will be unique to you and will develop and change with time and with increased experience.
Your process should include the following:
Define the problem
What do you believe the problem to be?
Does anybody else involved in the situation have an opinion about the problem?
If these two are different, what else do you need to know to truly identify the problem?
Reflect on values, conflicts of interest and if this is an ethical dilemma
You need to identify the values involved in the situation so that you can check whether your own innate values may influence your thought process
Does anyone involved in the process, including yourself, have a conflict of interest with anyone else in the process or with any elements of the process and what is the conflict?
If values, ethics and beliefs are not involved in the situation it is unlikely to be an ethical dilemma.
Is making ethical decisions always a comfortable process?
Some ethical decisions are easier to make than others and some decisions will be easier for one pharmacist than another, because pharmacists are all individuals with different underlying beliefs and different life experiences.
Hopefully, you will choose a particular answer to a dilemma which you feel is the best option for your patient, even if this means the patient may be following a course of action that you would not be prepared to follow yourself.
An example of this is contraception and sexual activity outside of marriage. Your beliefs may mean that you believe that sexual activity should be confined to marriage and that you only believe in natural methods of contraception. As a pharmacist, you will be asked to advise about other methods of contraception and often, you will find out that the patient asking for advice is unmarried. Even if you have chosen not to supply contraceptives, the best option for the patient is that, in a non-judgemental way, you refer them to someone else who is able to help them, even if you feel that what they want is wrong.
Is there always a right answer?
In more complicated dilemmas, there is rarely a ‘right’ answer; your responsibility is to obtain enough information about the situation to enable you to decide, possibly with the patient, what is the best answer in that particular set of circumstances. If, after gathering the information, there is only one option available, then you are not facing a dilemma.
Can you justify what you have chosen to do?
If you have followed a robust decision-making process, then it should be very straightforward to explain your reasons for the outcome you have chosen. As a professional, you should always be prepared to justify and explain your decisions.
You may, on occasion, need to make these explanations some time after the decision was made. This may mean that you choose to make some notes about a particular situation at the time, so that you can remember your thought processes at a later date.
If you are making notes about an incident, you should only record factual information. You must also ensure that the notes are stored in a way that ensures patient confidentiality is maintained and access to them is restricted.
What is the difference between inaction and no action?
If you have followed your process, gathered your information and considered your options, you may on some occasions choose to take no action. You may decide this because it was one of your options and after considering all the other options, you decide that no action is your best choice and that you can justify this decision.
Inaction is different and rarely justifiable. Inaction is where you consciously choose not to engage in an ethical decision-making process. This may happen for one of the following reasons:
Can you ask someone else’s opinion?
Yes, is the simple answer. It is often useful as a professional to talk through complicated issues with a colleague. You have to be careful to make sure that you are not breaching other codes of practice, such as confidentiality, however, when discussing a situation. For example, another pharmacist does not need to know the patient’s name as part of the discussion unless they were also involved in that patient’s care.
As a professional, you should also consider what you would do if you discussed a scenario with several colleagues, all of whom pick the same outcome but this outcome is very different to the one you had chosen. You should then reflect on why your choices are different to a group of your peers and whether you have considered all the information fully.
Can someone else make the decision for you?
Again there is a very simple answer to this – No. As a professional you are required under your code of conduct to take responsibility for your working practice. You cannot justify your actions by saying that you took them because someone else had done the same thing or someone else gave you a solution to a dilemma and you chose to follow it, without considering whether it was the right thing to do. This would also include following something you had read in a journal or book, without question. You have to be able to justify your own actions and thought processes for a specific situation.
Can someone else force you to make a decision?
If you have read the earlier parts of this chapter, you will know that the answer to this question is a resounding No. However, you need to be aware that on occasions, people try to put pressure on you to make certain decisions.
Patients
Occasionally, patients will try to influence you. Some people can be very manipulative and have an agenda that may not initially be clear to you. Some people will provide you with misleading or untrue information to help them achieve what they want. You will need to develop questioning techniques to ensure you get the most accurate information available (see Ch. 17).
Line managers
If you are an employee, you will have a line manager who will have their own set of values and beliefs. Sometimes your line manager will not be a pharmacist and have limited understanding of your ethical responsibilities. You may, therefore, feel at times that you are being pressurized to take a specific course of action that you do not agree with.
It will never be justifiable to follow a course of action unless you believe professionally it is the correct thing to do. You will, therefore, have to be prepared to explain your decision and stand firm about the correctness of it. Even if you feel that you are jeopardizing your job, this will not be an acceptable reason for not complying with the standards of conduct. You would need to be prepared to take further action to protect yourself and consider your position in terms of employment law and your employer’s whistle-blowing policy.
Dilemmas to consider
For each of the dilemmas that follow, think about the following:
Do you need any more information?
What could you do next? This should be a series of options and you need to consider if there is a ‘best’ option.
After the scenarios below, are some thoughts about each, but remember in practice you will have to make your own decision, so there is no ‘best’ option chosen here for you.
Dilemma 1
A customer visits a community pharmacy and asks to buy a bottle of Phenergan elixir®. As part of the conversation, the following information is obtained:
The customer is the mother of a 10-month-old child
The customer wishes to buy the Phenergan® as the child keeps waking up in the night and disturbing her mother’s sleep
During the discussion, the customer becomes quite agitated and verbally demands you sell her Phenergan® as she’s entitled to decide the right course of action for her child.
Dilemma 2
You realize, over a period of weeks, that when one of your pharmacy technicians returns from her lunch each day, you can smell alcohol on her breath. It does not seem to be affecting her work. When, one day, you ask her if she could take a later lunch break she shouts at you and says that you are not being fair and that she needs to go for her lunch at her normal time.
Dilemma 1 comments
Some of the information you may need:
Is the drug suitable for the condition?
Is the drug appropriate for this age of child?
Is the product licensed for this condition in this age of child?
Is the mother’s reason for wanting the product in the best interests of the child?
Why is the mother becoming agitated?
Is the mother correct in her statement that she is entitled to decide what is right for her child?
Some options to consider (remember that none of these may be appropriate depending on the extra information you obtain)
Sell the product – she is the child’s mother
Don’t sell the product, it is not appropriate
Tell her that the product is out of stock, it is easier than having an argument
Think of different alternatives to help both mother and child
Phone social services, the mother clearly wants to sedate her child inappropriately
Explain why the product is not appropriate and try to come up with another solution
If you decide not to supply her, contact the pharmacy across the road as you can see this is where the mother is now going, to let the pharmacist know about what has happened
Dilemma 2 comments
Some of the information you may need:
Why is it so important to her to go for her lunch at her normal time?
What does she do at lunchtime?
Is she the type of person to shout at you?
What would you do normally if a member of your team shouted at you?
Is she drinking alcohol every lunchtime?
Why do you feel her work is not affected – is this factually accurate?
Does she have problems outside work that you are not aware of?
Some options to consider (remember that none of these may be appropriate depending on the extra information you obtain)
Do nothing, she is obviously just having a bad day
Talk to her to find out why she shouted and try to get her to open up about whether she is drinking alcohol in the middle of the working day and if she is drinking regularly or to excess
Gossip with everyone else you both work with to see if they also think she is an alcoholic
Dismiss her, she must be dangerous and you do not want to miss a dispensing error she makes
Talk to her and explain to her that you are concerned about her, but that she cannot work in the dispensary if you think she is under the influence of alcohol
Dilemma 3 comments
Some of the information you may need:
Could the medicines be for anything else?
Are you certain the prescription is for your sister-in-law and not your niece who has the same name and still lives at home?
Some options to consider (remember that none of these may be appropriate depending on the extra information you obtain)
Do nothing, you only have the information because you are a pharmacist
Ask your brother if his wife is better, as you noticed she’d had a prescription for antibiotics
Tell other members of your family that your sister-in-law is having an affair
Talk to your sister-in-law and try to explain why you think your brother needs to know about the infection
Key Points
Dealing with ethical dilemmas is part of the everyday role of being a professional
You must comply with the standards of conduct and use it to steer your decision-making processes and actions
Different people will have different ways of dealing with situations
It is important to be able to justify your decisions and actions
There is unlikely to be one correct course of action to follow as a result of an ethical dilemma