Pharmacists facing ethical dilemmas have shown weaknesses in principled reasoning and disclosure. The chapter describes research on Portuguese community pharmacists' moral reasoning and narrative ethics. A cross-sectional survey comprising vignettes with practice ethical dilemmas, their possible justifications, and an open box for textual accounts was used as the research tool. More than 270 pharmacists replied, primarily young (<35 years old) female practitioners, and 75% were involved in direct contact with patients. At least 50% of the sample showed compliance with the expected ethical-based decisions, except for the non-maleficence principle (10.9%); although receiving the highest proportion of the corresponding justification (30.3%), no open accounts or narratives were registered. The present findings suggest ethical passivity associated with decision making in practice and a potential conflict between the clinical and the business roles. Explicit ethical norms for practice guidance and additional moral reasoning and narrative training are suggested.
TopIntroduction
Pharmacists are health professionals who provide patient care services designed to safeguard individuals’ well-being (Assembleia da República, 2015; Wiedenmayer et al., 2006). Pharmacists contribute to the rational use of these and other health technologies through the procurement, dispensing and management of medicines, activities which include the information needed for health promotion and disease prevention (Who Consultive Group on the Role of the Pharmacist, 1997).
Community pharmacists are widely accessible to the general population, playing a relevant role in public health and primary care, as confirmed during the Covid-19 pandemic (Cadogan & Hughes, 2021). While serving their communities, pharmacists should deliver optimal patient care, complying with the pharmacists’ code of conduct (Assembleia da República, 2015) and ethical principles shared by all healthcare practitioners (Varkey, 2021).
In Portugal, the professions’ code of conduct is inscribed in the regulatory body’s legal statutes, Ordem dos Farmacêuticos (OF) (i.e., the Portuguese Pharmaceutical Society). The Society is responsible for issuing the license to practice, internal regulations, and guidelines, including the deontological code applicable to pharmacists’ duties. The statutes of the Pharmaceutical Society invoke the profession’s ethical standards, including the assumption that any pharmaceutical activity has the ultimate goal of caring for all patients (1st Article) (Assembleia da República, 2015).
Like any other healthcare practitioner, community pharmacists should be acquainted with the higher ethical principles of non-maleficence, beneficence, autonomy, justice, and confidentiality (Summers, 2009). The five principles are briefly described herein (Varkey, 2021; Schlesselman, 2014):
Beneficence. It refers to the obligation to act for the patient’s benefit, i.e., to defend their rights and actively promote their welfare. A beneficent decision can only be accurate if the same decision is made regardless of who makes it.
Non-Maleficence. It can be described as the obligation to ‘not harm.’ Providers must ask themselves whether their actions may harm the patient by omission or commission. Harm by omission means withholding or not performing any activity that could avoid damage, while harm by the commission is doing something that resulted in harm, e.g., delivering medication in the wrong dose or to the wrong patient. Professionals should endorse the moral rules of avoiding causing any burden or depriving the patient of benefits by weighing the advantages against the disadvantages of all interventions.
Autonomy. It describes recognizing individuals’ power to make rational and moral choices and being allowed to exercise their capacity for self-determination or self-ruling. It requires that patients are told the truth about their condition and informed about the risks and benefits of a treatment to make informed decisions. Patients are permitted to refuse treatment even if the best and most reliable information indicates that treatment would be beneficial unless their action may harm another individual’s or community’s well-being.
Justice. It comprises fair, equitable, and appropriate actions for all people. In this study, this principle refers to comparative justice, i.e., how healthcare is delivered at the individual level, looking at the different treatment of patients based on age, disability, gender, race, ethnicity, and religion. The distributive justice of healthcare resources throughout society, i.e., equal access according to needs, efforts, contributions, and free-market exchanges, was not addressed.
Confidentiality. It refers to the obligation of not disclosing personal information given by a patient to another party without the patient’s authorization, independently from the mean or recipient. Exceptions include, among others, legal reporting of situations that may cause significant harm to another (e.g., infectious diseases, notification of genetic risks).