traditional functions of pharmacy
-compounding and dispensing
-pre-date the pharmacy profession itself
basic human values
compassion, dignity, justice and truth
humanistic disciplines
philosophy, religion
success of interventions with patients
-interpersonal value-based relationships
-technical competence
potential outcomes
-sell a product based upon clinical judgement
-recommend medical intervention
-suggest a lifestyle change
-offer comfort and reassurance
influencing factors
-patient's socioeconomic status
-pressures for cost-containment
-acceptance of pharmaceutical care
-personal value systems
conflicts in values
-between pharmacists and patients
-between pharmacists and colleagues
-between pharmacists and other medical professionals
ethical decisions
-help determine the right course of action when a conflict exists
-may occur when values differ between individuals having shared goals or decisions
-questions:
Am I allowing personal values (political, religious, social) to interfere with professional re
social interventions
-mandatory continued professional education
-periodic re-licensure procedures
consumerism movement
-full disclosure of product and service information
-high standards of product safety
-fair and equitable health-care costs
patient expectations
-if a drug can produce a beneficial effect, it should be used without reservation; direct-to-consumer advertising
-the "miracle drug" effect; no margin for therapeutic failure or compromise; unrealistic patients expectations
-legal issues: even minor side
consumer sophistication
-medically sophisticated patients seek to use their knowledge to take control of their disease management and therapy
-is this a problem?
Patients expect to be included in decisions
Alternative medicines
How reliable is the patient's knowledge level?
How
traditional boundaries of practice
-compounded or prepared drugs for dispensing
-limited information to patients
-product oriented information to physicians
-technical competence: state boards have measured entry-level competence since the 1800s; limited to competency involving commanding
pharmacy's patient-centered focus
-benefits: improved patient care, more rational drug therapy, higher rates of compliance
-complications: expanded personal contacts with patients increase pharmacists exposure to moral and ethical dilemmas
decision-making techniques
-emotional reactions
-reliance upon experience or instinct
-ethical reasoning: a complex, learned process that involves sorting through ethical principles, virtues and values, rules and codes to reach a decision; may represent the most laudable form of pr
highly-valued interpersonal relationships
-decisions tend to enhance relationships
-pharmacists may provide therapy by breaking rules or losing reimbursement
importance of non-personal values
-ex. rules, efficiency, third-party policies
-pharmacists may refuse to continue maintenance therapy for indigent patients due to program constraints
competing values
-decisions may be based upon whim or instinct, patient idiosyncrasies or appearance
-result: inconsistent professional behavior
individual value systems guide professional decisions
consistent professional behavior is based in part on an examination and reaffirmation of personal values used when working through ethical conflicts
social contract
-two mutually exclusive groups in society recognize expectations of each other and conduct their affairs according to those expectations
-pharmacy as a profession came to exist because of society's needs; there is a mutual dependence between the two group
social contract theory
norm of justice provides an adequate framework of universal rules of the moral dimensions of professional practice
ethics of care
-emphasizes ethical actions based upon an understanding of specific situations
-focus is upon moral skills (kindness, sensitivity, attentiveness, tact, patience and reliability)
justice ethics
-relations between individuals are reduced to a consideration of only those universal rights possessed by all persons
-rules are applied without regard to the situation
consequentialism
-concerned only with the outcomes or consequences of actions
-an action is right or wrong based upon the benefit or harm the patient and other concerned individuals might derive from the action
-lying to a patient would not only be permissible but may be
nonconsequentialism
-based upon actions themselves without regard to their consequences
-actions are either right or wrong regardless of the outcome
-lying to a patient is wrong by definition, whether or not the concerned individuals might benefit from the deception
-less pa
beneficence
-principle that guides practitioners actions and behaviors toward beneficial patient outcomes
-ex. providing critically needed drugs to patients in emergency situations without regard to legal consequences
-taking an action
non-maleficence
-principle that guides practitioners to avoid actions and behaviors the tight bring harm to their patients
-ex. refusing to fill a prescription because of concern for patient safety or well-being
-involves avoiding an action
justice
-strategies or acts that ensure fair allocation of goods and services
ex. Attempting to treat patients equally, without regard to their circumstances, their likelihood of benefiting from a particular therapy, or their ability to pay
autonomy
-strategies or acts that respect the self-determination of other persons
ex. Avoiding interference with patient's right to make their own decisions; Not influencing decisions by withholding or shading drug information that might result in the patient's no
fidelity
-strategies or acts that stress faithfulness, honesty, and promise-keeping
-ex, maintaining clinical information in strict confidence; being truthful with patients and keeping promises
virtue
-defined in terms of valued character traits (faithfulness, fortitude, tenderness, compassion)
-society's reaction: people tend to forgive or overlook occasional lapses of people considered to be virtuous; people are less forgiving of those who are non-vi
filial piety
-be good to one's parents
Take care of them
Engage in good conduct outside the home so as to bring a good name to one's parents and ancestors
Perform job duties well
Don't be rebellious
Display courtesy
Ensure male heirs
Display sorrow for parent's sickne
practice implications
-virtues are held by individuals and reflect individual beliefs
-people have different virtues and assign different levels of importance to the same virtue
-ex. Pharmacists who value justice will offer services to everyone, without regard to appearance o
altruism
-concern for the welfare of others
-attidues: commitment, compassion, generosity
-behavior: gives full attention to patients, assets other health-care personnel, sensitive to social issues
equality
-having the same rights, privileges, or status
-attitudes: fairness, self-esteem, tolerance
-behavior: provides services based upon needs, relates to others without discriminating, provides leadership in improving access to health care
esthetics
-qualities of objects, events, and persons that provide satisfaction
-attitudes: appreciation, creativity, sensitivity
-behavior: creates supportive patient-care environments
freedom
-capacity to exercise choice
-attitudes: openness, self-direction, self-discipline
-behavior: respects each individual's autonomy
human dignity
-inherent worth and uniqueness of an individual
-attitudes: empathy, kindess, trust
-behavior: respects the right of privacy, maintains confidentiality
justice
-upholding moral and legal principles
-attitudes: integrity and morality
-behavior: acts as a health-care advocate, allocates resources fairly, reports incompetent, unethical, and illegal practices
truth
-faithfulness to fact or reality
-attitudes: accountability, honesty, rationality
-behvior: documents the actions accurately, protects the public from misinformation about pharmacy
fair dealing and equity
-pharmacists are traditionally fair and equitable in professional and business relationships
-held to a higher standard than many other professions
patient-centered services
-code of ethics require pharmacists to promote the good of every patient
-dilemmas occur in balancing business requirements with patient needs and values
faithfulness
-the pharmacist-patient relationship is a "covenant"
-patients are treated in a private and confidential manner
natural rights
inherent to the human condition (right to life, freedom, die)
bestowed rights
granted by others (right to a living wage, right to privacy, right to health care)
legal rights
-established through regulations, legislation or courts
-enforced by sanctions (fines or imprisonment)
moral rights
established through commonly held religious beliefs or cultural tenets
duties
-every right has an associated obligation that another party will behave in a certain manner
-examples:
The "right of health care to the indigent" requires practitioners to provide that care in an equitable manner
Duty to be faithful to your patients
Duty
steps in ethical decision-making
1. identify the problem
2. consider alternative courses of action
3. select one alternative
4. consider objections to the selected alternative
identifying the problem
1. identify technical facts
2. identify moral parameters
3. identify legal constraints
4. identify relevant human values
identify technical facts
who is involved?
-direct: patient, pharmacist, physician
-indirect: pharmacist's employer, patient's family, other physicians
Personal moral standards involved
-assess within the context of the situation
identify moral parameters
-identify and distinguish moral dilemmas and ethical issues associated with the problem
ex. Using oral contraceptives as a "loss leader" by selling them below cost and making up the difference by charging higher professional fees for maintenance meds
prob
identify legal constraints
-laws and regulations may restrict your decisions
-ex. discussing a patient's prescription records with a third party
identify relevant human values
-aids pharmacists in framing the ethical problem
-personal values determine whether the ethical problem is perceived as a problem
-may suggest alternatives for resolution
-ex. Angry father wanting confidential information about an adolescent daughter's me
alternative courses of action
-mutually exclusive alternatives
-identify relevant ethical principles for each alternative
-recognize ethical assumptions for each alternative
-determine additional emerging ethical products
identify relevant ethical principles for each alternative
-often, competing principles are revealed
ex.
-If the pharmacist supplies the information to the father, he is not respecting the autonomy of the daughter
-If the pharmacist evades the request and refers the father to the physician, he ignores the values
selecting an alternative
-you should be able to justify your selection and defend it upon ethical grounds
-principles, virtues, rights or theories
-process of reasoning used to reach the decision
-why the other possibilities were discarded
-if competing principles are involved, y
considering objections
-factual errors: minimize by paying attention to details
-faculty reasoning: the selected alternative should meet the criteria of relevancy and sufficiency; reasons should be relevant to the situation and sufficiently convincing
-conflicting values: often
fiduciary aspects
-based upon trust and confidence
-patients trust their health professionals
-patients cannot easily judge competency
-society licenses pharmacists to practice; pharmacists often have less direct patient contact than other health professionals
voluntary aspects
patients request services from pharmacists
covenantal aspects
-relationship begins with patient request
-commitments by pharmacists
-maintain technical skills
-safeguard patients
-observe personal rights of patients
-treat patients with dignity
functional complexity
-a slow evolution has occurred from distributive functions alone to expanded clinical functions
-development of pharmaceutical care: benefits vs. expectations; lack of patient information in community settings
dimensional complexity
-physician-pharmacist-patient triad
-customers, consumers, patrons, or patients
-economic model: focus upon relationships that can affect income, learn the needs of your patients, physicians as "source of business"; maintain good will
-value-based model:
veracity
-the duty to tell the truth and not to lie or deceive others
-the truth, the whole truth and nothing but the truth
-only part of the truth (placebo therapy)
-just the portion of the truth that the patient should understand
ideals
-conduct which is morally optional, but meritorious or praiseworthy
-treating patients equally, without regard for appearance, socioeconomic level, or personal demeanor
-being understanding or considerate to difficult patients
virtues
-based upon valued character traits
-consensus changes over time and between generations
-appropriate communication to different aged patients
double paradigm in pharmacy practice
-tradition role: technial defined by safe, accurate dispensing; questions referred to physicians
-clinical paradigm: practice role in which pharmacists solve patient-related therapy problems in consultation with other health care providers
patient counseling standards
-introduced possibility of increased accountability for professional negligence
-expanded potential for professional malpractice suits and higher liability insurance premiums
-increased awareness upon autonomy and self-determination of patients
-importanc
professional practice standard
-a community of professionals will ultimately develop the needed standard of practice
-practicing pharmacists acting in the best interest of their patients determine the appropriate information disclosure standard
-problems: no generally accepted customar
reasonable person standard
-relies upon a consideration of the kind and amount of information reasonable patients would want to known; risks alternatives, consequences of therapy
-shifts the determination of the extent of information disclosure from the pharmacists to the patient
-
subjective disclosure standard
-requires health professionals to disclose whatever information is related to the counseling of a particular patient
-patients must be given info that they desire or need to know as long as there is a reasonable connection between these desires, the need
euthanasia
-the mercy killing of the hopelessly ill, injured, or incapacitated
-complex debate:
Ensure patient's constitutional rights are protected
Society's interest in preserving life
Allow or prevent suicide
Preserve integrity of the medical profession
Right to
active euthanasia
-intentional commission of an act resulting in death; giving a patient a lethal drug
-suicide when patients do this themselves
-when patients cannot do it for themselves and another person does the act; assisting person can be subject to prosecution depen
passive euthanasia
-when lifesaving treatment is withdrawn/withheld; patient dies a natural death
-generally accepted as legal, but based upon facts of individual cases
voluntary euthanasia
-patient with incurable illness makes the decision to die
-must be legally competent adult
-must be given information on possible ramifications and alternatives available
involuntary euthanasia
-decisions to terminate the life of an incurable person is made by someone other than the person
-mentally incompetent
-unconsenting competent
Patient Self-Determination Act (1990)
Health care organizations have the responsibility to explain to patients, staff, and families that patients have legal rights to direct their medical and nursing care as it corresponds to existing state law
traditional definition of death
Cessation of respiration, heartbeat, and certain indications of central nervous system activity, such as respiration and pulsation
advance directives
-patients have the right to make decisions about their healthcare: agreeing to proposed treatments, chosen among offered treatments, or refusing treatment
-allow the patient to state in advance the kinds of medical care that are acceptable or unacceptable
living will
-legal document describing treatments the patient wants or does not want if incapacitated
-provides legally valid instructions, protects the patient's rights, protects the providers who honor them
-considerations:
Signed/dated by 2 witnesses (not relative
power of attorney
-legal device permitting one individual (the "principal") to give another person (the "attorney-in-fact") the authority to act on his or her behalf
-other person may handle banking, real estate, incur expenses, pay bills and hand legal affairs for a speci
durable power of attorney
-principal may specify that the POA survive disability or incompetency
-may grant authority for health care decisions
-patient does not have to be in imminent danger of death (required in living wills)
-principal is not required to specify desired medical
surrogate decision making
-agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision
-designated by the patient before losing their decision-making ability
-rights are limited to specific instructions in the document
-agent's decisions ta
guardianship
-court declares a person incompetent and appoints a guardian
-guardian assumes responsibility for financial affairs, living arrangements and medical care
health care proxy
-health care agent is appointed to make treatment decisions in the event the principal becomes incompetent to make decisions
-may be designated by the patient or authorized by state statute
-agent must be made aware of patient's wishes
DNR orders
-given by physician; indicate that in the event of cardiac or respiratory arrest "no" resuscitative measures should be used to revive the patient
-generally made when "heroic" rescue measures are no longer in the patient's best interest
-made at the reque