SUDANESEPHARMACISTASSOCIATIONINQATAR-SPAQ- Scientific Office

10/6/2012 1

A Structured Approach to Confront Ethical Dilemma in Practice

Nadir Kheir PhD FNZCP MPSAsst. Prof, Coordinator of Continuing Professional Pharmacy Development

College of Pharmacy, Qatar University

Disclaimer: PRESENTING AUTHOR HAS NO RELATIONSHIPS TO DISCLOSE

Objectives

• To present, explain, and discuss basic ethical principles and terms

• To illustrate how professional practice and ethical behavior influence and guide the practice of pharmacy

• To introduce a structured approach to deal with ethical dilemmas faced in the daily practice of the pharmacist

A Realistic case

• A young man comes to the pharmacy where you work. He presents a prescription for 8 capsules of an antibiotic (amoxycillin 500 mg capsules), 4 capsules to be taken immediately and 4 at night. You asked the patient what was the antibiotic prescribed for, and he tells you it was for a bout of common cold. Knowing that antibiotics should be prescribed to treat or prevent bacterial infections (and not the common cold which is caused by a virus), you decide to call his doctor and discuss the rational for an antibiotic for a cold, and the doctors tells you that this is a very effective strong dose that will surely clear the cold as per his own experience and asks you to just dispense. He even pointed out that the drug was legally prescribed as antibiotics should.Question: What would you do?

• Follow an ethical decision-making process to rationalize your final action.

Real Cases

1. The Fight!

2. The helpless father

3. The ‘protective’ pharmacist

Health Care and Ethics

• Practicing Pharmacy should involves:

- Dispensing

- Counseling

- Educating

- Monitoring

- Referring

- Providing drug information

- Other roles..

LegalProfessional

Ethical

Personal Values

QU- CPH- NKheir 7

The Case of the Placebo Patient!

• Mrs. H came to the pharmacy and presented a script for her monthly sleeping pills. She is an elderly who had major surgery few years back, and now is well, but she can only sleep after taking her ‘sleeping pills’. The new pharmacist (Mr. J) checks Mrs. H’s history, and found out that she has been on these pills for almost 2 years. Before dispensing, he decided to ask his more experienced boss, Dr. M about this case. Dr. M explained, in private, that Mrs. H was prescribed the benzodiazepine during her illness and after the surgery, but she got addicted. Her doctor contacted him and asked that they start gradually replacing the content inside the capsule with lactose (now she is taking a placebo). She never noticed, and is sleeping happily after her pills. Now the pharmacist (Mr. J) is really concerned. Would he be helping the patient or collaborating in a dishonest act?

6 October 2012

QU- CPH- NKheir 8

Consider:• Is ‘lying’ here ethical?- is it a sort of

beneficence?

• Is ‘lying’ here paternalistic?

• What ethical principle/s were violated n this scenario (or could be violated)?

• Where does veracity fit here?

• Would not lying but ‘withholding the truth’ be a way out?- not labeling the drug, not volunteering information

6 October 2012

• Surface when there are conflicting moral responsibilities

• When there is conflict between moral choices, in which to obey one would result in transgressing another

- Legal vs Personal values

- Legal vs Ethical

- Professional vs Personal Religious

Ethical Dilemmas

• Pharmacists often face ethical dilemmas

• In absence of stated ethical codes, professional standards and expectations, there might not be such dilemmas!

• Ideals, values, guiding principles help the pharmacist identify the ethical issue

• Detailed codes contain Principles & Standards

• Both focus on the duty of pharmacists toward the patient

Ethical Dilemmas in Pharmacy

Ethical Dilemmas

• Do we encounter ethical dilemmas?• Does unethical practices ‘numb’ our judgement

and morality?• Think about:- Selling medicines with no real rational- Dispensing antibiotics without a Rx- Selling psychotropic/controlled drugs without a

Rx- Other dozens of situations..1.

Ethical Dilemmas: examples from overseas..

• The physician prescribes a drug that is not licensed for children under 6 yrs, and insists that the pharmacist dispenses it

• The father of an adolescent girl calls the pharmacist and asks about the names and uses of some of her medicines dispensed from the pharmacy

• A patient demands to have his brand medicine dispensed to her while the MOH instructs dispensing of a generic form of the drug

Ethical Analysis and Decision-Making

• Complex, structured, individualized process

• Involves analysis of each individual unique issue

• Through ethical reasoning, pharmacist need to choose their rational course of action (from many), justify and defend it

• Reflective ethical analysis to resolve ethical conflict will help pharmacy become what the practice of pharmaceutical care proposes: an ethical practice based on an ethical mandate

Veach RM, Haddad A. Case studies in pharmacy ethics. 2nd ed. New York (NY): Oxford University Press Inc; 2008

• Gather all relevant information

• Identify the real problem

• Analyze and weigh options

• Choose the best solution (risk-

benefit)

• Be ready to justify the chosen course

of action

• Evaluate

Ethical Analysis and Decision-Making

6 October 2012 QU- CPH- NKheir 15

A Framework for Decision-Making in Pharmacy Practice

• Process that help pharmacists make ethics-related decisions

• Steps based on objectivity and critical thinking

• 4-step problem-solving process:

1. Identify the problem

2. Consider alternative courses of action

3. Select one action

4. Consider objections to the selected course of action

6 October 2012 QU- CPH- NKheir 16

1. Identify the problem

• Clearly identify the real problem through 4 steps:1. Identify technical facts: who is involved? How would a decision affect

each party?

2. Identify moral dilemmas: analyze conflicting ethical issues, rights, values, and virtues involved and could be violated or supported. Identify your own personal bias, morality, religious beliefs which can cloud your decision

3. Identify legal constraints: does regulations support possible course of action? Balance between law and morality. Not every dilemma can be sorted out by law

4. Identify relevant human values: most important step; knowledge of human values involved and acting accordingly may result in better judgement and much more defensible ethical decision, consider: what extent do personal beliefs bias actions?

Veach RM, Haddad A. Case studies in pharmacy ethics. 2nd ed. New York (NY): Oxford University Press Inc; 2008

6 October 2012 QU- CPH- NKheir 17

2. Develop Alternative Courses of Action

• List ALL possible course of actions• Avoid ruling-out by instinct• An action chosen from many represents an

informed decision, not a rushed conclusion• This step involves:1. Identifying relevant ethical principles for

each alternative2. Recognizing ethical assumptions for each

alternative3. Determining additional ethical problems

Veach RM, Haddad A. Case studies in pharmacy ethics. 2nd ed. New York (NY): Oxford University Press Inc; 2008

6 October 2012 QU- CPH- NKheir 18

Contd: Develop Alternative Courses of Action

1. Identifying relevant ethical principles for each alternative:

All ethical issues attached with each alternative

This will reveal competing ethical values and

Solutions

2. Recognizing ethical assumptions for each alternative:

Ethical principles we base the alternative action upon

3. Determining additional ethical problems:

Consider OTHER possible ethical issues emerging from the course of action

Veach RM, Haddad A. Case studies in pharmacy ethics. 2nd ed. New York (NY): Oxford University Press Inc; 2008

6 October 2012 QU- CPH- NKheir 19

3. Select the One Alternative Course of Action

• Now, from all the possible choices, select one course of action

1. Justify the selection: ask yourself: why did I choose this action? Consider ethical principles involved: virtues maintained, rights protected

2. Defend your selection upon ethical ground:

When faced by competing moral values, be ready to explain why you have chosen one of them (must has moral foundation that overweighs the other option)

Veach RM, Haddad A. Case studies in pharmacy ethics. 2nd ed. New York (NY): Oxford University Press Inc; 2008

6 October 2012 QU- CPH- NKheir 20

4. Consider Objections to the Selected Action

• Anticipate objections on what action you have taken

• Decisions based on ethical values always get challenged through objections related to:

1. Factual errors: being detailed and fact-oriented will eliminate this possibility

2. Faulty reasoning: must have relevant AND sufficiently convincing (consider using standards, codes of ethics, religious beliefs (!))

3. Conflicting values: others may have different value systems and can justify, articulate, and defend them

Veach RM, Haddad A. Case studies in pharmacy ethics. 2nd ed. New York (NY): Oxford University Press Inc; 2008

Cases involving General Ethical problems

The Case..again• A young man comes to the pharmacy where you work. He presents

a prescription for 8 capsules of an antibiotic (amoxycillin 500 mg capsules), 4 capsules to be taken immediately and 4 at night. You asked the patient what was the antibiotic prescribed for, and he tells you it was for a bout of common cold. Knowing that antibiotics should be prescribed to treat or prevent bacterial infections (and not the common cold which is caused by a virus), you decide to call his doctor and discuss the rational for an antibiotic for a cold, and the doctors tells you that this is a very effective strong dose that will surely clear the cold as per his own experience and asks you to just dispense. He even pointed out that the drug was legally prescribed as antibiotics should.Question: What would you do?

• Follow an ethical decision-making process to rationalize your final action.

A student’s ResponseStep

Identify the Problem ◦Technical facts: wrong practice of using antibiotics to treat common cold, the dr, pharmacist , physician are involved and maybe the hospital and pharmacy management. Any decision taken my affect me , my position at the pharmacy , profit , reputation of the Dr.◦Legal issues: the Dr. is prohibited from irrational unsafe prescribing. Although technically the drug is legally prescribed, the Dr. overlooked the legal clauses that warn against violating the pt's safety◦Ethical issue & human values: Dispensing the drug as prescribed will be a direct violation to the concepts of beneficence and non-malificence,. If we dispense without telling the patient, we're violating veracity. So above all, we're not being patient-centered. The patient-physician relationship might be affected if we tell the patient, and the pharmacist-physician professional relationship might be affected as well

Alternative Courses of Action:

Dispense the drug, Don't dispense and tell the patient, Don't dispense and tell the boss, Talk to the physician again, Report the physician to the medical director, Ask the patient to see another physician and obtain another prescription, Do not dispense the drug and ask another pharmacist to do so,Quit job..

Choose the Course of Action

Contd: Objections to the chosen course of action, justification and defense:

• The patient has the right to receive the best health care, and being a patient centered pharmacist, I shall put this above any personal consideration

• I know the action I chose might harm the patient-physician relationship, but I tried to avoid this by talking to the physician first and he did not response

• I cannot placet harming the patient as an option to avoid altering his relationship with the physician

• I shall also follow my moral, ethical, and professional responsibility towards the patients: being honest with the patient, doing good to them, and avoiding harm

• It's the patient's decision afterwards to either follow my suggestion and see another physician, or just take the drug as prescribed (patient's autonomy)

Cases with Ethical Dilemmas

The Top 10 Ethical dilemmas faced by Physicians (Provided by Dina ELTayeb)

1. Accepting or refusing gifts from pharmaceutical companies.2. Prescribing/dispensing a placebo to a patient who insists for a

treatment. 3. Life sustaining therapy.4. Under treat patient pain to prevent him/her from becoming an

addict.5. Cover up mistakes whether it would or wouldn't harm the patient.6. Hide information about an illness.7. Assist suicide in some situation.8. Report colleague if he's on drugs, ill or non competent.9. Refer patient to a doctor that is not best qualified only because he

is a friend etc.10. Discuss patient information in social places where their privacy is

not protected

Dilemma 1• Mrs. SH (58 years old client) comes to the pharmacy

where you work. Se presents a prescription for Atorvastatin 10 mg to be taken once at night. You start discussing with her and find out that he is newly diagnosed with hyperlipidemia. You decided to assess her risk factors and noticed that her lipid profile and LDL level places her on the category of those who should be on TLC for 3 months before resorting to medication.

• Question: What would you do?

Follow an ethical decision-making process to rationalize your final action

Dilemma 2

• While waiting for full registration to start your full time job with HMC, you took a part-time job in this community pharmacy which gave you the opportunity to meet patients and use your many professional skills to help them. Today, a patient came in and asked for a herbal product that he heard from many people proved very effective in male baldness (his hair is thinning). You made a quick search and found no reliable data supporting these claims. You were convinced that this product is basically useless, but costs a good sum of money.

Follow a structured ethical-Decision process to arrive at an action in this case scenario

Dilemma 3

• You, a pharmacist, had started working in this primary health clinic’s pharmacy. You have noticed several prescriptions written by Dr. Warda, who has excellent relationship with her patients (actually: fans), which do not seem to follow best practice or are evidence-based (salbutamol inhalers for cough, antibiotics for flu, etc)

• You are concerned. Your pharmacy manager asked you to just dispense Dr. Warda’s scripts, as she is ultimately responsible.

• You decided to talk to Dr. Warda, which you did, politely.

• She says that she knows what she is doing

Follow a structured ethical-Decision process to arrive at an action in this case scenario

Dilemma 4

A month’s supply of medicine is the maximum that is allowed, based on the hospital’s rule

A patient comes to the pharmacist, asking for 12 tablets of Warfarin 5 mg as he lost his tablet bottle and his appointment is after 12 days

He has been on the drug for weeks “to prevent clots in my legs”, he says

This is a demonstration of how law could conflict with ethicsWhat would you do? How would you decide? How would a pharmacist working in a primary health care clinic resolve this dilemma? Will most pharmacists consider it a dilemma?

Dilemma 5 (provided by Dina EL Tayeb)

• A 25 year old male was admitted because of alcohol intoxication and drug abuse

• He doesn't want his parents to know but the parents are very worried about their son and want to know what happened

• What should the doctors tell them, and what shouldn't they?

Complex issues involving global ethics, culture, norms and rights

6 October 2012 QU- CPH- NKheir 32

Go through the process:

1. Identify the real problem: technical, legal, own values

2. Develop alternative actions with their ethical issues attached (with, against, emerging)

3. Select ONE action: defend it, justify it

4. Respond to objections about it