Bioethical Principles and Professional Responsibilities

The profession of pharmacy has the unique characteristic of having both professional and business orientations. There is today, in addition to this unique characteristic, a strong shift in pharmacy towards more involvement in patient‐centred health care, and increased emphasis on the patient's best interests and autonomy, within a framework of what is known as ‘bioethics’

In any pharmacy setting, pharmacists face ethical dilemmas on a daily basis. As the pharmacist’s responsibilities expand, they will soon be faced with dilemmas seen by other healthcare professionals working in clinical settings, leading to higher levels of moral distress. To handle these newer dilemmas and higher levels of distress, pharmacists rely not only on their own moral values but also on ethical rules and principles established by the profession. The pharmacist may face situations in which their own moral values are in conflict with ethical principles established by the profession or in which multiple ethical principles may be applicable, resulting in an ethical dilemma.

These authentic dilemmas faced by pharmacists are complex cognitive and emotional experiences, wherein deeply-held moral and/or ethical values or principles are pitted against one another. A decision must be rendered and no one solution is clearly right or wrong. Thus, the pharmacist must weigh and prioritize numerous moral or ethical options when making a decision. This moral reasoning, upon which life and death decisions in part depend, is a critical component in the moral functioning of pharmacy students and professionals.

Learning to deal with ethical dilemmas starts with understanding the ethical principles established by the pharmacy profession. This understanding of ethical principles requires exposure to ethical dilemmas early in their training, preferably as pharmacy students. To increase moral development, particularly moral reasoning (i.e. the ability to perceive and consider two or more competing moral values or principles in making a moral judgment), during their training, pharmacy schools strive to expose students to ethical dilemmas. Many pharmacy schools include a pharmacy ethics course, often in conjunction with a pharmacy law course, in their curriculum. Outside of these courses, students are also exposed to ethical dilemmas during introductory and advanced pharmacy practice experiences. The goals of this education in ethics are to expand student awareness of ethical dilemmas faced by pharmacists and to develop skills for handling ethical dilemmas.

Bioethical principles

Ethics represent a codified set of standards of behavior adopted by a group of people. For pharmacists this set of ethics is outlined in the American Pharmacists Association’s Code of Ethics. The Pharmacist’s Code of Ethics is based on the primary principles of bioethics: autonomy, beneficence, non-maleficence, and justice, veracity, fidelity, and confidentiality. Although these principles represent the values of the profession, providing a framework and guidance, they are not absolutes and do not give answers as to how to handle the many variables associated with each clinical situation. Instead the ultimate choice lies with the pharmacist. So, how will a pharmacist decide which path to take when faced with an ethical dilemma?

The first principle, autonomy, represents an individual’s right to refuse or choose a course of action. The meaning has evolved to roughly mean “being one’s own person,” including “personal rule of the self while remaining free from both controlling interferences by other and personal limitations”. In healthcare, autonomy is heavily grounded in the patient’s right to consent to or to refuse treatment. In some instances, the patient’s ability to consent is questioned due to their lack of competence. Physical and mental competencies are preconditions for being able to act autonomously, often leaving healthcare providers with the challenge of determining competence.

Although often forgotten, autonomy also encompasses the pharmacist’s rights. This may take the form of the pharmacist choosing to adhere to the law, rather than to “bend” the law to better serve the patient. The pharmacist may also exert autonomy by selecting to put the patient’s rights before the regulations governing pharmacy practice.

Beneficence encourages the pharmacist to act in the best interest of the patient. Not only should the pharmacist not inflict harm, he should prevent and remove harm while promoting good. Beneficence involves performing positive acts, including, but not limited to, mercy, kindness, and charity, rather than the absence of negative acts. In healthcare, beneficence often requires a weighing of risks versus benefits. The third principle, nonmaleficence, is based on the notion of Primum non nocere (“first, do no harm”). In some cases, the distinction between nonmaleficence and beneficence may seem difficult to discern due to the need to balance these two principles. In cases where the patient’s quality of life plays a critical role, such as end of life concerns, weighing nonmaleficence and beneficence takes front stage.

Justice relates to fairness and equality. In healthcare this especially concerns distributive justice when scarcity of and competition for resources exist. When faced with a situation in which health resources are scarce, the healthcare provider must consider who receives treatment. In particular, justice concerns arise in the rationing of healthcare based on ability to pay for care.

Although autonomy, beneficence, nonmaleficence, and justice represent the four primary bioethical principles, veracity, confidentiality, and fidelity are principles essential to the pharmacist-patient relationship. Veracity involves an obligation to tell the patient the truth and not deceive them. This principle relates to the patient’s need for complete information in order to provide informed consent, to the pharmacist’s promise to not mislead, and the need for healthy relationship between pharmacists and patients. In the past few years, the Health Insurance Portability and Accountability Act (HIPAA) (P.L.104-191) has reinforced the importance of confidentiality, requiring healthcare professionals and institutions to further protect patient health information. The final principle, fidelity, from the Latin root “fides” which mean faithfulness, addresses the unspoken covenant between pharmacists and patients and promise keeping.

Although studies are available to evaluate how pharmacists and pharmacy students handle ethical dilemmas, no studies are available which compare pharmacy students versus pharmacists in their selection of bioethical principles to deal with ethical dilemmas. Available studies only look at pharmacist application of bioethical principles but reported that pharmacists relied most heavily on respect for medicines and doing what was in the patient’s best interest when dealing with ethical dilemmas. In the study by Hibbert and colleagues, community pharmacists report routinely dealing with ethical dilemmas including situations pertaining to autonomy of the patient and pharmacy personnel, beneficence, and nonmaleficence. When faced with a dilemma which required choosing between ethical principles and legal requirements, the pharmacists opted to comply with the Code of Ethics, rather than staying within the law. These results differ from those found by Lowenthal. Although he also noted a high degree of concern for the patient and the patient’s rights, he found that this concern for the patient was maintained regardless of the economic or legal conflicts.

Ethics in Pharmacy

Pharmacists are an essential part of the healthcare multidisciplinary team. They help to ensure that medicines are used in the safest and most effective manner. However, the profession, particularly community pharmacy, sits at the intersection between health and retail, as the profits are gained from making sales of medications. This introduces a number of ethical complications and a strong need for guidelines to base decisions on that are centered on moral obligations and virtues.

Ethical Principles

The code of conduct to guide decision-making for pharmacist and maintain ethical integrity varies according to the country and professional body that creates the guidelines. However, the ethical principles are similar and can be separated into five main categories: the responsibility for the consumer, the community, the profession, the business and the wider healthcare team.

The ethical responsibilities of a pharmacist that relate to the consumer include:

• To recognize the consumer’s health and wellbeing as their first priority, and utilize knowledge and provide compassionate care in an appropriate and professional manner.
• To respect the consumer’s autonomy and rights and assist them in making informed decisions about their health. This should include respecting the dignity, privacy, confidentiality, individuality and choice of the consumer.

The ethical responsibilities of a pharmacist that relate to the community include:

• To maintain the reputation and trust that the public has placed on the profession and refrain from abusing this trust and respect.
• To acknowledge their place in the wider community, including their professional role and responsibilities to control and supply pharmaceutical goods for optimal health outcomes.

The ethical responsibilities of a pharmacist that relate to the profession include:

• To commit to the development and enhancement of the profession by becoming involved in activities such as training staff, teaching, being a preceptor or mentor for students, interns or colleagues, participating in initiatives to develop the profession and demonstrate positive leadership.
• To keep up-to-date with knowledge of pharmacy practice with lifelong learning and self-development to maintain professional competence and personal health to continue practicing.
• To practice only when their professional independence, judgment and integrity remains upheld, and manage situations with a conflict of interest appropriately.

The ethical responsibilities of a pharmacist that relate to business practices include:

• To conduct the business practices of pharmacy in an ethical and professional manner with the consumer’s best interest in mind and due respect to colleagues and the reputation of the profession.

The ethical responsibilities of a pharmacist that relate to other health professionals include:

• To work in cooperation and collaboration with other healthcare professionals to achieve the optimal health outcomes for consumers.

Ethics in Pharmacy Practice

It is important that pharmacists always uphold their professional integrity and endeavor to provide the best service to their patients. This includes staying up-to-date with new knowledge that could affect their decision and using the trust held by the pharmacy profession for positive outcomes to promote the health of the general public whenever possible.

The ethical guidelines should underpin every action that a pharmacist takes throughout their workday, in such a way that ethical decision-making becomes a second nature to the pharmacist and optimal decisions are made on a consistent basis.

CONCLUSION

Ethics in the area of pharmaceuticals which concern the pharmacist as a person and the pharmaceutical company as a corporate body is experiencing evolution, where pharmacy practice is different today than it was previously. Pharmaceutical innovation and technology advancement has shaped the pharmaceutical industry and pharmacists themselves and the need of solid strong ethics to be embedded into the pharmacist as an individual which will then form the organization of pharmaceutical with high ethical values. Ethics and pharmacy at large must be sensitive and responsive to an unavoidably changing environment.

REFERENCES :

1. Book: Professional ethics in pharmacy: the Australian experience, Volume13, Issue3 September 2005 Pages 195-204
2. https://onlinelibrary.wiley.com/doi/epdf/10.1211/ijpp.13.3.0005
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4100952/
4. Social Science & Medicine, Volume 98, December 2013, Pages 319-329
5. https://www.news-medical.net/health/Ethics-in-Pharmacy.aspx
6. https://www.researchgate.net/publication/221927642_Ethics_in_Pharmaceutical_Issues