give your opinion about any case in the book

User Generated

anqrraf

Writing

Description

i will attach a book and i would like you to write me a one page reflection about any CASE from the book that you would feel comfortable writing about and give your personal opinion about the case.

Unformatted Attachment Preview

Case Studies in Pharmacy Ethics This page intentionally left blank Case Studies in Pharmacy Ethics second edition ROBERT M. VEATCH Professor of Medical Ethics The Kennedy Institute Georgetown University AMY HADDAD Professor of Pharmacy Sciences School of Pharmacy and Health Professions Center for Health Policy and Ethics Creighton University 1 2008 1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright © 2008 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Veatch, Robert M. Case studies in pharmacy ethics / Robert M. Veatch and Amy M. Haddad. – 2nd ed. p. cm. Rev. ed. of: Case studies in pharmacy ethics / Robert M. Veatch, Amy Haddad. 1999. Includes bibliographical references and index. ISBN 978-0-19-530812-9 (pbk.) 1. Pharmaceutical ethics––Case studies. I. Haddad, Amy Marie. II. Veatch, Robert M. Case studies in pharmacy ethics. III. Title. [DNLM: 1. Ethics, Pharmacy. QV 21 .V394c 2007] RS100.5.V43 2008 174.2––dc22 2007014188 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper Robert Veatch dedicates this book to his father, Cecil R. Veatch, R.Ph., 1905–1978 Amy Haddad dedicates this book to her husband, Steve Martin This page intentionally left blank Preface Providing health care increasingly poses ethical choices. Over the past few decades pharmacy has undergone dramatic changes and evolved into a highly patientoriented profession. The changing role of the pharmacist, development of pharmaceutical care as a practice standard, and complex health and drug distribution systems make it almost impossible to avoid ethical issues. The day is gone (if, indeed, it ever existed) when members of the health care team who are not physicians can consider themselves to be doing their jobs adequately simply by following orders. In the seven years since the publication of the first edition of Case Studies in Pharmacy Ethics, important developments and changes have taken place in the practice of pharmacy. The recent addition of a prescription benefit in Medicare has already led to many changes within the profession. Prescription benefit plans have begun to place limits on the choices of patients and providers. Prescriptions intended to be used by patients to commit suicide have become a legal practice in at least one state. The use of drugs for other morally controversial purposes, including abortion, has forced pharmacists to confront more frequently and more systematically conscientious refusal to dispense. Research medicine also has faced new and complex problems, including the first death of a research subject from an attempt to intentionally manipulate the human genetic code. Advances in biomedical ethics also have occurred. The National Bioethics Advisory Commission (1996–2001) and, beginning in 2001, the President’s Council on Bioethics advanced public discussion of bioethics. New editions of major texts and theories have appeared. New court decisions have reshaped public policy. The teaching of ethics in schools of pharmacy has evolved. For all of these reasons, a new edition is needed. viii Preface We have reviewed each case from the first edition, replaced some cases and added others, updated pharmacological, economic, and legal information, and added two new chapters written for this edition. The new Chapter 1 provides our Model for Ethical Problem Solving, a systematic method of dissecting the cases in this volume that will be particularly useful when cases resist less formal analysis. Chapter 13, also entirely new in this edition, acknowledges that the practice of pharmacy is rapidly coming under the influence of formal institutional formularies and drug distribution systems. Hospital and health system formularies are restricting the use of unproven but marginally beneficial and cost-ineffective pharmaceuticals, sometimes forcing pharmacists to cooperate in treatment decisions that are not maximizing the patient’s therapeutic interests. Drug distribution systems involve pharmacists in mail-order pharmacies, drug procurement from foreign sources, and Medicare policies. Pharmacists employed in these new and increasingly dominant systems for dispensing as well as pharmacists who are competing with these systems face new and challenging ethical problems, the focus of cases presented in this chapter. While the other chapter titles remain the same, each case in them has been reviewed. New cases replace those that have become dated. Like all professions, pharmacy imposes ethical standards and obligations on its practitioners. Although pharmacists practice in a variety of settings, such as community pharmacies, hospitals, ambulatory clinics, and home care, there are many problems that all pharmacists share. To begin with, virtually any pharmacist may be asked by a physician, other health care provider, or patient to engage in actions that are not consistent with the pharmacist’s conscience. Unless it is supposed that it is best for pharmacists simply to accommodate any and all requests, instances of legitimate moral conflict are bound to occur between the preferences of pharmacists and those of all the other individuals constituting the practice of health care. Pharmacists may be held accountable for their actions when their professional association has a code, such as the Code of Ethics for Pharmacists of the American Pharmacists Association (APhA). The APhA Code of Ethics calls for certain kinds of conduct. It places the profession (or at least those who are members of the association) on record as viewing the work of its members as people responsible for their actions. The Code of Ethics may conflict, however, with the instruction of the physician, the wishes of the patient, the demands of a third-party payer, or the conscience of an individual caregiver. Codes of various health professions, as we shall see, may actually come into conflict with one another. Every pharmacist, whether aware of it or not, is constantly making ethical choices. Sometimes these choices are dramatic, life-and-death decisions, but often they are more subtle, less-conspicuous choices that are nonetheless important. One way of seeing the implications of these issues and the moral choices inherent in them is to look at the experiences of one’s colleagues, to listen to their stories and the kinds of choices they have had to make in situations like the ones typically faced by pharmacists. This volume is a collection of those situations. It is, we believe, the best way to study the biomedical ethics of the pharmacy profession. Since some teachers of pharmacy ethics may want to use these cases to survey the full range of issues involved in health professional ethics, and given that some courses Preface ix include practitioners and students from other health professions, we have made an effort to include as many topics in health care as possible, including some that pharmacists face only occasionally (such as genetics and birth technologies), and to include examples of pharmacists interacting with representatives of other health professions. Pharmacists constitute a significant force in the health care system. Taken together with the many other members of the health care team who daily face difficult moral situations, the instances wherein pharmacists collectively have involvement in the value-based and ethical dimensions of health care are of such magnitude that the exploration of issues contained in this volume is particularly timely. This collection of cases is based on real situations experienced by practicing pharmacists. Many of the original cases in the first edition were obtained from a national random survey of pharmacists wherein over 400 respondents described ethical problems common to their pharmacy practice.1 Additional cases were solicited from pharmacy alumni and faculty members as well as clinicians locally and nationally. We have modified details to protect anonymity and to provide clarity in presenting the ethical issues, but in each case some pharmacist has had to face the actual problem presented here. We are grateful to all of the pharmacists who helped us by providing cases. The writing of this volume has been a truly collaborative effort. Each of the authors has been involved in every case and commentary. In general, Amy Haddad, who is a professor in the Department of Pharmacy Sciences of the School of Pharmacy and Health Professions of Creighton University, drew on her more than 20 years of teaching ethics in the pharmacy program and clinical interactions with pharmacy colleagues as well as the responses of the pharmacists to the abovementioned survey to prepare first drafts of most of the cases. Robert Veatch, who is a pharmacist and served as a lecturer in pharmacology before pursuing a career in health care ethics, prepared the first draft of much of the introductory material and commentaries, but both participated extensively in all aspects of each chapter and each case. In addition to the pharmacists who helped by providing case material, we also want to acknowledge the assistance of many others who provided insights about the structure of the book, drug information, research or clinical clarification, including Lee Handke, Pharm.D., Vice President of Pharmacy and Wellness, Blue Cross and Blue Shield of Nebraska; Gary Yee, Pharm.D., University of Nebraska College of Pharmacy; Jennifer Upward, Pharm.D., 2005 graduate, Creighton University School of Pharmacy and Health Professions; Amy Wilson, Pharm.D., and Morgan Sperry, Pharm.D., both faculty members of the School of Pharmacy and Health Professions at Creighton University; and the following Doctor of Pharmacy students from Creighton University: Dua Anderson, Nicole Dunn, Thythu Luu, Katie Normile, Amy Schroeder, Jaclyn Waters, and Erika Zender-Weber. Rebecca Crowell and Justin Herrick of the Center for Health Policy and Ethics at Creighton University also were of particular assistance in the organization of the manuscript. Robert Veatch also acknowledges the continuing career-long cooperation of the dedicated professional library staff of the National Reference Center for x Preface Bioethics Literature at the Kennedy Institute of Ethics, Georgetown University. Their commitment to careful, systemic mastery of the bioethics literature makes research in the field a joy. He also thanks Moheba Hanif, Sally Schofield, and Linda Powell at the Kennedy Institute of Ethics as well as all the faculty of the Kennedy Institute, many of whom helped provide documentation and clarity for the cases presented here. In the early stages of this project that resulted in the first edition of this book, Lou Vottero, the former Associate Dean of the Raabe College of Pharmacy at Ohio Northern University, was a full participant. While other responsibilities did not permit him to continue with the writing, we are grateful to him for the role he played in the design of the first edition. While we appreciate the help of all these people, we are, of course, solely responsible for judgments contained in the volume. In the years since the publication of the first edition, our friend and editor, Jeffrey House, has retired. We are pleased to now be working with Peter Ohlin as editor for this second edition. He has made the transition seamless and resolved many publication problems involved in generating this new edition of the pharmacy case collection as well as developing the companion medical ethics volume. At the same time that we have prepared this second edition, we have launched preparation of the manuscript of a companion volume, Case Studies in Medical Ethics. We have adapted the introductory and theoretical material of this volume for a new collection of cases covering more broadly ethical problems in the various health professions. That volume will provide a much-needed update of the original case study volume in what has now become a series of books presenting cases in the health professions, including nursing, dentistry, and allied health, as well as the more general practice of medicine by physicians and other health professionals. Working with physician and bioethicist Dan English, we expect this companion collection of cases to prove useful for courses in medical ethics that involve students of other health professions in addition to pharmacy as well as undergraduate students of medical ethics. Note 1. Haddad, A. M. “Ethical Problems in Pharmacy Practice: A Survey of Difficulty and Incidence.” American Journal of Pharmaceutical Education 55, no. 1 (1991): 1–6. Contents List of Cases xv Introduction: Four Questions of Ethics 3 What Are the Source, Meaning, and Justification of Ethical Claims? 4 1. Distinguish Between Evaluative Statements and Statements Presenting Nonevaluative Facts 4 2. Distinguish Between Moral and Nonmoral Evaluations 5 3. Determine Who Ought to Decide 7 What Kinds of Acts Are Right? 9 Consequentialism 9 Deontological or “Duty-Based” Ethics 10 Other Issues of Normative Ethics 12 How Do Rules Apply to Specific Situations? 13 What Ought to Be Done in Specific Cases? 15 Notes 17 PART I Ethics and Values in Pharmacy Chapter 1: A Model for Ethical Problem Solving The Five-Step Model 21 Application of the Model 22 1. Respond to the Sense That Something Is Wrong 2. Gather Information 24 3. Identify the Ethical Problem/Moral Diagnosis 21 23 25 xii Contents 4. Seek a Resolution 26 5. Work with Others to Choose a Course of Action Notes 28 Chapter 2: Values in Health and Illness Identifying Value Judgments in Pharmacy Separating Ethical and Other Evaluations 27 29 30 35 Chapter 3: What Is the Source of Moral Judgments? 41 Grounding Ethics in the Professional Code 42 Grounding Ethics in the Physician’s Orders 46 Grounding Ethics in Hospital Policy 49 Grounding Ethics in the Patient’s Values 51 Grounding Ethics in Religious or Philosophical Perspectives Notes 54 52 PART II Ethical Principles in Pharmacy Ethics Chapter 4: Benefiting the Patient and Others: The Duty to Do Good and Avoid Harm 57 Benefiting the Patient 58 Health in Conflict with Other Goods 58 Relating Benefits and Harms 61 Benefits of Rules and Benefits in Specific Cases 63 Benefiting Society and Individuals Who Are Not Patients Benefits to Society 65 Benefits to Specific Nonpatients 68 Benefits to the Profession 69 Benefits to the Pharmacist and the Pharmacist’s Family Notes 72 65 Chapter 5: Justice: The Allocation of Health Resources Justice Among Patients 74 Justice Between Patients and Others Justice in Public Policy 79 Justice and Other Ethical Principles Notes 85 Chapter 6: Autonomy 73 77 83 86 Determining Whether a Patient Is Autonomous External Constraints on Autonomy 93 Overriding the Choices of Autonomous Persons Notes 100 89 95 Chapter 7: Veracity: Dealing Honestly with Patients The Condition of Doubt Lying in Order to Benefit 71 104 106 102 Contents xiii Protecting the Patient by Lying 106 Protecting the Welfare of Others 108 Special Cases of Truth Telling 111 Patients Who Don’t Want to Be Told 111 Family Members Who Insist That the Patient Not Be Told The Right of Access to Medical Records 114 Notes 116 113 Chapter 8: Fidelity: Promise-Keeping and Confidentiality 118 The Ethics of Promises: Explicit and Implicit 119 The Limits on the Promise of Confidentiality 122 Breaking Confidence to Benefit the Patient 123 Breaking Confidence to Benefit Others 126 Incompetent, Impaired, and Dishonest Colleagues 128 Notes 133 Chapter 9: Avoidance of Killing 134 Active Killing Versus Letting One Die 137 Withholding Versus Withdrawing Treatment Direct Versus Indirect Killing 144 Justifiable Omissions 148 Voluntary and Involuntary Killing 150 Killing as Punishment 152 Notes 155 142 Part III Special Problem Areas Chapter 10: Abortion, Sterilization, and Contraception 159 Abortion 159 Abortion for Medical Problems of the Fetus 161 Abortion Following Sexual Assault 164 Abortion to Save the Life of the Pregnant Woman 167 Abortion and the Mentally Incapacitated Woman 169 Abortion for Socioeconomic Reasons 171 Sterilization 172 Contraception 174 Notes 179 Chapter 11: Genetics, Birth, and the Biological Revolution Genetic Counseling 183 Genetic Screening 187 In Vitro Fertilization 189 Surrogate Motherhood 192 Genetic Engineering 194 Notes 196 181 xiv Contents Chapter 12: Mental Health and Behavior Control 199 The Concept of Mental Health 200 Mental Illness and Autonomous Behavior 203 Mental Illness and Third-Party Interests 207 Other Behavior-Controlling Therapies 209 Notes 213 Chapter 13: Formularies and Drug Distribution Systems 215 Formularies 216 Eliminating Unproven Therapies 217 Eliminating Proven but Marginally Beneficial Therapies 220 Eliminating Proven but Cost-Ineffective Therapies 222 Appeals to Override Formularies 224 Physician Behavior with Drug Company Influence 226 Drug Distribution Systems 229 Mail-Order Pharmacies 229 Drugs from Canada 231 Notes 234 Chapter 14: Experimentation on Human Subjects 236 Calculating Risks and Benefits 239 Privacy and Confidentiality 242 Equity in Research 245 Conflicts of Interest in Research 248 Informed Consent in Research 250 Notes 253 Chapter 15: Consent and the Right to Refuse Treatment The Elements of a Consent 256 The Standards for Consent 259 Comprehension and Voluntariness Notes 272 Chapter 16: Death and Dying 263 274 The Definition of Death 275 Competent and Formerly Competent Patients Never-Competent Patients 281 Limits Based on Interests of Others 285 Notes 289 Appendix 293 The Hippocratic Oath 293 Code of Ethics for Pharmacists Index 297 294 278 255 Cases Case 1-1: Reporting a Possibly Lethal Error: Who Needs to Know? Case 2-1: Over-the-Counter Diet Pills Case 2-2: Managing Dental Pain Case 2-3: Use of Generic Drugs 22 30 33 34 Case 2-4: Nonprescription Access to Legend Drugs Case 2-5: What Should Be Behind the Counter? 36 39 Case 3-1: What Is “In the Best Interest of the Patient”? 43 Case 3-2: Professional and Public Views on Closing a Pharmacy Case 3-3: Whether to Dispense a Potentially Lethal Drug Case 3-4: Respecting the Wishes of the Terminally Ill 44 46 47 Case 3-5: A Medication Error on the Oncology Unit: Who Has the Final Word? 49 Case 3-6: Is the Patient Always Right? 51 Case 3-7: Oral Contraceptives: The Pharmacist’s Refusal to Dispense 52 xv xvi Cases Case 4-1: A Matter of Priorities: A Patient Who Chooses to Reduce Antihypertensive Medication 59 Case 4-2: Aesthetics Versus Health 59 Case 4-3: The Benefits and Harms of High-Risk Chemotherapy 62 Case 4-4: When the Exception Breaks the Rule: Charitable Use of Outdated Drugs 64 Case 4-5: The Benefit of Cost Savings in a Health Maintenance Organization 66 Case 4-6: The Interests of the Patient Versus His Family: Burdens on the Caregiver 68 Case 4-7: For the Welfare of the Profession: Should Pharmacists Strike? 69 Case 4-8: Choosing Between Patients and Pharmacist’s Family 71 Case 5-1: The Hypochondriac and the Patient in Crisis: Whose Needs Take Priority? 74 Case 5-2: The Obligations of Pharmaceutical Manufacturers 76 Case 5-3: The Distraught Husband: Balancing the Needs of Patients and Others 77 Case 5-4: Compromising the Welfare of Others: The Patient Cheating Medicaid 78 Case 5-5: Maximizing Benefits in a Health Maintenance Organization 79 Case 5-6: Erectile Dysfunction Therapy: Who Should Pay? Case 5-7: Justice Versus Fidelity 80 84 Case 6-1: The Partially Competent Patient 90 Case 6-2: Borderline Incompetence: HIV and Natural Remedies 91 Case 6-3: Can Prisoners Consent? External Factors That Infringe on Autonomy 93 Case 6-4: Compulsory Education About STDs 96 Case 6-5: Overriding Patient Autonomy: Hiding the Side Effects of Chemotherapy 97 Case 6-6: Overriding Patient Autonomy (to Save a Life) 99 Cases xvii Case 7-1: The Duty to Disclose Doubtful Information Case 7-2: Placebos for Addiction Withdrawal 104 106 Case 7-3: Reporting a Colleague’s Innocent Mistake 108 Case 7-4: Revealing Alcoholism on a Job Application 109 Case 7-5: Refusing to Learn the Risks of Chemotherapy Case 7-6: When the Family Asks Not to Tell Case 7-7: The Right to Health Records 111 113 115 Case 8-1: Keeping a Promise to a Medical Colleague 120 Case 8-2: The Adolescent on the Pill: Maintaining Confidentiality When the Patient May Be Harmed 123 Case 8-3: The Policeman with Bipolar Disorder: When Others May Be Harmed 126 Case 8-4: Careless Parenteral Preparation: Marginally Competent Colleagues 128 Case 8-5: The Impaired Colleague: The Colleague in an Emotional Crisis 130 Case 8-6: Dishonest Colleagues: Intentionally Shorting Tablet Counts 131 Case 9-1: Prescriptions for Suicide: Forming a Policy for Pharmacy Case 9-2: Deciding Whether to Fill a Lethal Prescription 137 138 Case 9-3: The ALS Patient: Does Voluntary Choice Justify Terminal Sedation? 141 Case 9-4: Withdrawing an Antibiotic: Is It Active Killing? Case 9-5: Unintended but Foreseen Killing with Morphine 143 146 Case 9-6: Can an Antibiotic Be an Extraordinary Means of Saving Life? 148 Case 9-7: Assisted Suicide and Chronic Depression Case 9-8: Participation in Capital Punishment Case 10-1: Abortion for Teratogenic Indications 150 153 161 Case 10-2: Postcoital Contraception of Abortion: Moral Choices Following a Rape 164 xviii Cases Case 10-3: Abortion to Save a Pregnant Woman’s Life 167 Case 10-4: Abortion for the Mentally Incapacitated Patient Case 10-5: Abortion for Socioeconomic Reasons 170 171 Case 10-6: Sterilization of an Economically Deprived Woman 173 Case 10-7: Biased Counseling: Teaching About Birth Control 175 Case 10-8: Transdermal Contraceptive Patches 177 Case 11-1: Genetic Counseling: Explaining Ambiguous Results Case 11-2: Disclosure of Unanticipated Findings 183 186 Case 11-3: Genetic Screening to Reduce Tay-Sachs Disease 187 Case 11-4: In Vitro Fertilization: Assessing a New Technology Case 11-5: Embryo Biopsy 189 191 Case 11-6: Surrogate Motherhood: Medical Miracle or Exploitation of Women? 192 Case 11-7: Genetic Engineering 195 Case 12-1: Mentally Ill or Just a Troublemaker? The Concept of Mental Illness 201 Case 12-2: The Case of the Hostile Bag Lady: Mental Illness and Autonomous Behavior 204 Case 12-3: A Compulsion to Kill: The Mentally Ill and Third-Party Interests 207 Case 12-4: A Shocking Ambivalence: ECT Without Consent Case 12-5: Treating Pedophiles with Aversive Therapy 209 211 Case 13-1: Avastin for Breast Cancer: Eliminating Unproven, Expensive Therapies 217 Case 13-2: Antibiotic for a Child’s Otitis Media 221 Case 13-3: Marginal Benefit from an Additional Antiemetic Agent 223 Case 13-4: Overriding Formularies: Therapeutic Equivalents That Cause Different Side Effects 225 Case 13-5: Conflict of Interest on a P & T Committee 227 Case 13-6: Counseling Patients Using Mail-Order Pharmacies 230 Cases xix Case 13-7: Drugs from Canada for Montgomery County, Maryland, Employees 231 Case 13-8: Pharmacy Promotion of a Medicare Part D Plan 233 Case 14-1: An Experiment of Last Resort: Calculating Risks and Benefits 239 Case 14-2: Data Mining a Pharmacy Benefit Plan’s Prescription Records 243 Case 14-3: Recruiting Subjects from the Clinic for Indigents Case 14-4: Profiting from Enrolling Subjects in Research 246 249 Case 14-5: Consent for Randomized Assignment of ACE Inhibitors 251 Case 15-1: Therapeutic Privilege: The Case of the Placebo Narcotic 256 Case 15-2: Explaining Phenytoin Side Effects: The Problem of Adequate Disclosure 260 Case 15-3: Consenting to the Risks of an Antipsychotic: Capacity to Consent 263 Case 15-4: Chemical Castration or Prison: Is There Really a Choice? Case 15-5: Consent for Incompetents 266 268 Case 16-1: His Brain Is Gone, but Is He Dead? 276 Case 16-2: Who Decides What Counts as “Comfort Care”? 279 Case 16-3: May a Residential Facility Director Refuse Life Support for a Resident? 281 Case 16-4: Parents Who Refuse Life Support for Their Baby 282 Case 16-5: Futile Treatment: Diagnostic Surgery on a Man Who Appears to Be Dying 286 This page intentionally left blank Case Studies in Pharmacy Ethics This page intentionally left blank Introduction Four Questions of Ethics Biomedical ethics as a field presents a fundamental problem. As a branch of applied ethics, biomedical ethics becomes interesting and relevant only when it abandons the ephemeral realm of theory and abstract speculation and gets down to practical questions raised by real, everyday problems of health and illness. Much of biomedical ethics, especially as practiced within the health professions, is indeed oriented to the practical questions of what should be done in a particular case. Pharmacists, like all health professionals, are, thus, case oriented. Yet if those who must resolve the ever-increasing ethical dilemmas in health care—including not just pharmacists, but patients, physicians, hospital administrators, public policy–makers—treat every case as something entirely novel, they will lose perhaps the best way of reaching a solution, that is, by understanding the general principles of ethics and facing each new situation from a systematic ethical stance. This is a volume of case studies in pharmacy ethics. It begins by recognizing the fact that one cannot do any ethics, especially health care ethics, in the abstract. It is only in real-life, flesh-and-blood situations that fundamental ethical questions are raised. This volume also acknowledges that a general framework is needed from which to resolve the dilemmas of practicing one’s profession. The chapters and the issues discussed within chapters are therefore arranged in order to work systematically through the questions of ethics. Since the main purpose of this book is to provide a collection of case studies from which to build a more comprehensive scheme for health care ethics, the first few pages are addressed to the more theoretical issues. The object is to construct a framework of the basic questions that must be answered in any complete and systematic bioethical system. 3 4 Case Studies in Pharmacy Ethics We suggest that four fundamental questions must be answered in order for someone to take a complete and systematic ethical position. Each question has several plausible answers that have emerged over 2,000 years of Western thought. For normal, day-to-day decisions made by the pharmacist, it is not necessary to consider each of these questions. In fact, to do so would paralyze the decision-maker. Most decisions are quite ordinary—such as deciding the proper dosing schedule, the most efficacious combination of drugs for a particular disease state, or counseling a patient on drug side effects—and do not always demand full ethical analysis. Other decisions, as in the case of emergency intervention, are not ordinary at all. Still, in both ordinary and emergency situations it is only possible to act without becoming immobilized by ethical or other value because some general rules or guidelines have emerged from previous experience and reflection. If ethical conflict is serious enough, it will be necessary to deal, at least implicitly, with all four of the fundamental questions of ethics. What Are the Source, Meaning, and Justification of Ethical Claims? At the most general level, which ethicists call the level of metaethics, the first question is: what are the source, meaning, and justification of ethical claims? What is it about a judgment that makes it an ethical judgment? It may not at first be obvious what counts as an ethical problem for a pharmacist. Pharmacists easily recognize the moral crisis in deciding whether to turn away a patient who cannot afford the prescribed medication, force antipsychotic drugs on an unwilling patient, or dispense the “morning-after pill” for what to the pharmacist seem like trivial reasons or in deciding whether to dispense a lethal medication to help a terminally ill patient in pain end his or her life. These situations clearly involve ethical problems. Yet it is not immediately evident why we call these problems ethical while other choices faced more commonly in the routine practice of pharmacy are not. To make ethical problems obvious, several steps should be followed: 1. Distinguish Between Evaluative Statements and Statements Presenting Nonevaluative Facts Ethics involves making evaluations; therefore, it is a normative enterprise. Moving from the judgment that we can do something to the one that we ought to do something involves incorporating a set of norms—of judgments of value, rights, duties, and responsibilities. Thus, in order to be ethically responsible in pharmacy, it is important to develop the ability to recognize evaluations or value judgments as they are made. Steps in Identifying Ethical Judgments 1. Distinguish between evaluative statements and statements presenting nonevaluative facts. 2. Distinguish between moral and nonmoral evaluations. 3. Determine who ought to decide. Introduction 5 Pharmacists may believe that normally their professional practice does not involve any evaluations. Value judgments are sometimes hard to recognize, especially when they are not controversial. To develop the ability to identify an evaluation, try the following: Select an experience that at first seems not to involve any particular value judgments such as providing counseling to a patient with a new prescription. Then begin to describe what occurred, keeping watch for evaluative words. Every time a word expressing value is encountered, note it. Among the words to watch out for are such verbs as want, desire, prefer, should, or ought. These evaluations may also be expressed as nouns, such as benefit, harm, duty, responsibility, right, or obligation, or in related adjectival forms, such as good and bad, right and wrong, responsible, fitting, and the like. Terms Signaling Normative Evaluations Verbs Nouns Adjectives Want Benefit Good Desire Harm Bad Prefer Duty Right Should Responsibility Wrong Feel Obliged Obligation Fitting Ought Right Responsible Sometimes evaluations are made in terms that are not literal, direct expressions of opinion but nonetheless clearly function as value judgments. The Code of Ethics for Pharmacists of the American Pharmacists Association (APhA), for example, states that a pharmacist “respects the autonomy and dignity of each patient.”1 By this statement, the APhA could be describing the way all pharmacists actually behave. Obviously, however, this is not what the statement describes. Rather it is saying that the pharmacist ought to respect the autonomy and dignity of each patient and that the good pharmacist does so. 2. Distinguish Between Moral and Nonmoral Evaluations This process of distinguishing between moral and nonmoral evaluations can be much harder because often the difference cannot be discerned from the language itself. If one says that the pharmacist did a good job providing information about drug therapy, the statement could express many kinds of evaluations. It could mean the pharmacist did a good job legally, that the pharmacist fulfilled the law. It could also mean the pharmacist did a good job psychologically, that the job was done in a way that produced a good psychological impact on the patient. It could mean the pharmacist did a good job technically, that every relevant piece of information was conveyed accurately. Or it could mean the pharmacist did a good job ethically, that the pharmacist did what was morally required. Conceivably, doing a good job 6 Case Studies in Pharmacy Ethics legally or technically could still leave open the question of whether the pharmacist fulfilled every ethical obligation. For example, the pharmacist could fulfill all the laws of the jurisdiction and state all the information in a technically accurate fashion but still fail to convey what the patient needed to know in order to make a substantially autonomous choice about whether to use the medication. Sometimes value judgments in health care simply express nonmoral evaluations. Saying that the patient ate well does not express a moral evaluation of the way the patient consumed his or her food. Saying that another day of hospitalization will be good for the patient means only that the patient will be helped physically or psychologically, not morally. Even these apparently nonmoral judgments about benefits and harms, however, may quickly lead one into the sphere of ethics. When the patient’s judgment of what will be beneficial, for example, differs from the health professional’s judgment, ethical dilemmas may emerge. A health professional who is committed morally to doing what will benefit the patient will choose one course while the one who is committed to preserving patient autonomy may reluctantly choose the other. Ethical or moral evaluations are judgments of what is good or bad, right or wrong, having certain characteristics that separate them from nonmoral evaluations, such as aesthetic judgments, personal preferences, beliefs, or matters of taste. The difference between moral and nonmoral evaluations lies in the grounds on or the reasons for which they are being made.2 Moral evaluations possess certain characteristics. They are evaluations of human actions, practices, or character traits rather than of inanimate objects, such as paintings or architectural structures. Not all evaluations of human actions are moral evaluations, however. We may say that a hospital pharmacist is a good administrator or a good clinician without making a moral evaluation. To be considered moral, an evaluation must have additional characteristics. Three characteristics are often mentioned as the distinctive features of moral evaluations. First, the evaluations must be ultimate. They must have a certain preemptive quality, meaning that other values or human ends cannot, as a rule, override them.3 Second, they must possess universality. Moral evaluations are thought of as reflecting a standpoint that applies to everyone. They are evaluations that everyone in principle ought to be able to make and understand (even if some in fact do not do so).4 Finally, many add a third, more material, condition: that moral evaluations must treat the good of everyone alike. They must be general in the sense that they avoid giving a special place to one’s own welfare. They must have an “other-regarding” focus or, at least, consider one’s own welfare no more important than that of another.5 Characteristics of Moral Evaluations 1. The evaluations must be ultimate or beyond any further appeal. 2. The evaluations must possess universality. All persons ought to agree (even if they do not). 3. The evaluations must treat the good of everyone alike. One’s own welfare should get no special consideration. Introduction 7 Moral judgments possessing these characteristics can sometimes conflict with one another. Conflicts over whether the health care provider ought to care for a patient in the way thought to be most beneficial or most respecting of the patient’s autonomy (even though harm may result) can involve conflicts between moral characteristics. Or the caregiver may be faced with the choice between preserving the patient’s welfare or that of someone else. He or she may have to choose whether to keep a promise of confidentiality or provide needed assistance for a patient even though a confidence would have to be broken. The caregiver may have to decide whether to protect the interests of colleagues or the institution, whether to serve future patients by striking for better conditions or serve present patients by refusing to strike. These are moral conflicts faced by health care professionals. Chapter 2 presents a series of cases in which both moral and nonmoral evaluations are made in what appear to be quite ordinary health care situations faced by pharmacists. The main task is to discern the value dimensions and to separate them from physiological, psychological, and other facts. 3. Determine Who Ought to Decide A closely related problem that depends on the question of the source, meaning, and justification of ethical claims is: who ought to decide? This is the focus of Chapter 3. Having learned to recognize the difference between the factual and evaluative dimensions of a case in health care ethics, one will constantly encounter the problem of who ought to decide or where the locus of decision-making ought to rest. The answer will depend, of course, on deciding from where morals come. Chapter 3 presents cases considering a range of sources of moral authority, from professional organizations, health care institutions, patients, families, physicians, and administrators to professional committees and the general public. The choice among these decision-makers depends, at least in part, on what it is that ethical terms mean, or more generally, what it is that makes right acts right. Several answers to this question have been offered. One answer recognizes that different societies seem to reach different conclusions about whether a given act is right or wrong. From this perspective, to say that an act is morally right means nothing more than that it is in accord with the values of the group to which the speaker belongs or simply that it is approved by the speaker’s group. This position, called social relativism, explains rightness or wrongness on the basis of whether the act fits within the social customs, mores, and folkways of the group. One problem with this view is that it seems to make sense to say that sometimes an act is morally wrong even though it is approved by the speaker’s group. That would be impossible if moral judgments were based simply on the values of the speaker’s group. A second answer to the question of what makes right acts right attempts to correct this problem. According to this position, to say that an act is right means that it is approved by the speaker. This position, called personal relativism, reduces ethical meaning to personal preference. Of course, according to this position, behavior thought to be immoral by some is approved by others. Some say that the reason this can happen is that moral judgments are merely expressions of the speaker’s preference. 8 Case Studies in Pharmacy Ethics Such differences in judgment, however, may have another explanation other than that ethical terms refer to the speaker’s own preferences. Those disagreeing might simply not be working with the same facts. To claim that two people are in moral disagreement simply because the same act is seen as right by one person or group and wrong by another requires proof that both see the facts in the same way. Differences of circumstances, perspective, or belief about the facts could easily account for many moral differences. In contrast with social and personal relativism, there is a third group of answers to the question of what makes right acts right. These positions, collectively called universalism or sometimes absolutism, hold that, in principle, acts that are called morally right or wrong are right or wrong independent of social or personal views. Certainly some choices merely involve personal taste: flavors of ice cream or hair lengths vary from time to time, place to place, and person to person. But these are matters of preference, not morality. Other evaluations appeal beyond the standards of social and personal taste to a more universal, an ultimate frame of reference. When these are concerned with acts or character traits—as opposed to, say, paintings or music—they are thought of as moral evaluations. However, the nature of the universal standard is often disputed. For the theologically oriented, it may be a single divine standard as we see in the monotheistic religions. According to this view, calling it right to disconnect a respirator that is keeping a terminally ill, comatose patient alive is to say that God would approve of the act or that it is in accord with God’s will. This position is sometimes called theological absolutism or theological universalism. Still another view among universalists takes empirical observation as the model. The standard in this case is nature or external reality. The problem of knowing whether an act is right or wrong is then the problem of knowing what is in nature. Empirical absolutism, as the view is sometimes called, sees the problem of knowing right and wrong as analogous to knowing scientific facts.6 While astronomers try to discern the real nature of the universe of stars and chemists the real nature of atoms as ordered in nature, ethics, according to this view, is an effort to discern rightness and wrongness as ordered in nature. The position sometimes takes the form of a natural law position. As with the physicist’s law of gravity, moral laws are thought to be rooted in nature. Natural law positions may be secular or may have a theological foundation, such as in the ethics of Thomas Aquinas and traditional Catholic moral theology. Still another form of universalism or absolutism rejects both the theological and the empirical models. It supposes that right and wrong are not empirically knowable, but are nonnatural properties known only by intuition. Thus, the position is sometimes called intuitionism or nonnaturalism.7 Although for the intuitionist or nonnaturalist, right and wrong are not empirically knowable, they are still universal. All persons should in principle have the same intuitions about a particular act, provided they are intuiting properly. Still others, sometimes called rationalists, hold that reason can determine what is ethically required.8 There are other answers to the question of what makes right acts right. One view—in various forms called noncognitivism, emotivism, or prescriptivism— Introduction 9 which ascended to popularity during the mid–twentieth century, perceived ethical utterances as evincing feelings about a particular act.9 A full exploration of the answers to the question of the source, meaning, and justification of ethical claims—this most abstract of ethical questions—is not possible here.10 Ultimately, however, if an ethical dispute growing out of a case is serious enough and cannot be resolved at any other level, this question must be faced. If one says that it is wrong to dispense abortifacients and another says that it is right to do so in the same circumstances, some way must be found of adjudicating the dispute between the two views. If the dispute is a moral one, the act cannot be both right and wrong at the same time. One must ask what it is that makes right acts right, how conflicts can be resolved, what the final authority is for morality, and whose judgment about what is right should prevail. What Kinds of Acts Are Right? A second fundamental question of ethics moves beyond determining what makes right acts right to ask: What kinds of acts are right? This is the realm of normative ethics. The main question at this level is whether there are any general principles or norms describing the characteristics that make actions right or wrong. Consequentialism Two major schools of thought dominate Western thought regarding general ethical principles. One position looks at the consequences of acts; the other, at what is taken to be inherently right or wrong. The first position claims that acts are right to the extent that they produce good consequences and wrong to the extent that they produce bad consequences. The two principles of consequentialist ethics are referred to as beneficence (the idea that actions are right insofar as they produce benefits) and nonmaleficence (the idea that actions are wrong insofar as they produce bad consequences). The key evaluative terms for this position, known in various forms as utilitarianism or consequentialism, are good and bad. The focus is on the consequences or ends of action. This is the position of John Stuart Mill and Jeremy Bentham as well as of Epicurus, Thomas Aquinas, and capitalist economics. Aquinas, for example, argued that the first principle of the natural law is that “good is to be done and promoted and evil is to be avoided.”11 Since Aquinas stands at the center of the Roman Catholic natural law tradition, he illustrates that natural law thinking (which is one answer to the first question of what makes right acts right) is not incompatible with consequentialism. The two positions are answers to two different questions. While natural law thinkers are not always consequentialists, they can be. Classical utilitarianism determines what kinds of acts are right by figuring the net of good consequences minus bad ones for each person affected and then adding up to find the total net good.12 The certainty and duration of the benefits and harms are taken into account. This form of consequentialism is indifferent to who obtains the benefits and harms. Thus, if the total net benefits of providing expensive drug 10 Case Studies in Pharmacy Ethics therapy for a relatively healthy but powerful figure are thought to be greater than those of providing the same to a sicker Medicare recipient, the healthy and powerful ought to be given the care without further ethical debate. Traditional pharmacy ethics, like physician and nursing ethics, is oriented to benefiting patients. This tradition combines the utilitarian answer to the question of what kinds of acts are right with a particular answer to the question of to whom moral duty is owed. Loyalty is to the patient, and the goal is toward what will produce the most benefit and avoid the most harm to the patient. The ethics of the pharmacy profession has traditionally held that the pharmacist’s primary commitment is to the patient’s care and safety. Some interpret this as giving first priority to protecting the patient from harm rather than to benefiting the patient. Like the principle of physician ethics, primum non nocere or “first of all do no harm,” this view gives special weight to avoiding harm over and above the weight given to goods that can be produced. Among some health professionals the principle of doing no harm is often interpreted conservatively. When a potentially risky intervention is contemplated, harm may be avoided by refusing to intervene. That way no harm is done (although the health care provider thereby avoids doing any good that the intervention could have brought). This form of consequentialism, which gives priority to avoiding harm, needs to be distinguished from classical utilitarianism, which counts goods and harms equally in calculating the net benefit of an action. Problems arise from tension between classical utilitarianism (which counts benefits to all in society equally) and traditional, or Hippocratic, health care ethics. Hippocratic ethics, referring to the ethics of the Oath named after the father of Western medicine, focuses on the individual patient and sometimes gives special weight to avoiding harms through the prescriptive duty of advocacy. These issues are raised in the cases presented in Chapter 4. Deontological or “Duty-Based” Ethics Over against these positions that are oriented to consequences, the other major group of answers to the question of what kinds of acts are right asserts that rightness and wrongness are inherent in the act itself, independent of the consequences. These positions, collectively known as formalism or deontologism, hold that right- and wrong-making characteristics may be independent of consequences, that morality is a matter of duty rather than of merely evaluating consequences. Hence this approach can be called “duty-based” ethics. Kant stated the position most starkly.13 It is based on ethical principles that express these duties, the duty to respect autonomy or to avoid killing being possible examples. Chapter 5 takes up problems of health care delivery and in doing so poses probably the most significant challenge to the consequentialist ethic. Today some of the most challenging ethical problems in health care arise in cases in which pharmacists have so many demands placed on them that they cannot do everything they would like for their patients. One approach is to simply determine which course of action will do the most good overall. That, however, could mean leaving some patients Introduction 11 virtually without care. It seems unfair or unjust (even if it turns out to be efficient in maximizing the total good done). One principle that is sometimes thought to restrain the production of overall good is the principle of justice. Taken in the sense of fairness in distributing goods and harms, justice is held by many to be an ethical right-making characteristic even if the consequences are not the best. The problem is whether it is morally preferable to have a higher net total of benefits in society even if unevenly distributed or to have a somewhat lower total good but to have that good more equally distributed. This issue will be the focus of the cases in Chapter 4. Utilitarians may acknowledge that the distribution of the good is relevant but only because the net benefits tend to be greater when benefits are distributed more evenly. The benefits may be larger because of decreasing marginal utility—that is, because the more benefits one possesses, the less valuable each marginal additional benefit is. They claim that the only reason to distribute goods, such as health care, more evenly is to maximize the total good. However, the formalist who holds that justice is a right-making characteristic independent of utility does not require an item-by-item calculation of benefits and harms before concluding that the unequal distribution of goods is prima facie wrong, that is, wrong with regard to fairness. Another major challenge to consequentialism comes from the principle of autonomy. Classical utilitarianism demands noninterference with the autonomy of others in society only when this produces greater net benefits. By contrast, Kantian formalism leads to the moral demand that persons and their beliefs be respected even if doing so will not produce the most good. Conflicts between the health care provider’s nonconsequentialist duties to respect the autonomy or selfdetermination of individual patients and the provider’s consequentialist duties to produce benefit are discussed in Chapter 6. Another ethical principle that many formalists hold to be independent of consequences is that of veracity or truth telling. As with the other principles, utilitarians argue that truth telling is an operational principle designed to guarantee maximum benefit. When truth telling does more harm than good, according to the utilitarians, there is no obligation to tell the truth. To them, telling the dying patient of his condition can be cruel and therefore wrong. In contrast, to one who holds that truth telling is a right-making ethical principle in itself, the problem of what the dying patient would be told is much more complex. Telling a lie is wrong in itself even if telling the lie does more good than telling the truth. This problem of what the patient should be told is the subject of Chapter 7. Another principle that formalists may believe to be right-making independent of consequences is fidelity, especially the keeping of promises. Those who include the principle of fidelity in their normative ethics hold that people owe to others certain acts based on commitments they have made. Keeping these commitments is morally obligatory even if the consequences would be better if they were not kept. Kant and others have held that breaking a promise is wrong independent of the consequences. The utilitarian points out that breaking a promise often has bad consequences. For them, we usually should keep our promises, but only because of the bad consequences if we do not. The formalist, although granting this danger, 12 Case Studies in Pharmacy Ethics argues that there is something more intrinsically wrong in breaking a promise and that to know this one need not even go on to look at the consequences. The formalist might, with the utilitarian, grant that to look at consequences may reveal even more reasons to oppose promise-breaking, but this is not necessary to know that promise-breaking is prima facie wrong. The provider-patient relationship can be viewed essentially as one involving promises or contracts or, to use a term with fewer legalistic implications, covenants. The relationship is founded on implied and sometimes explicit promises. One of these promises is that information disclosed in the provider-patient relationship is confidential, that it will not be disclosed by the health care provider without the patient’s permission. The duty of confidentiality in ethics is really a specification of the principle of promise-keeping in ethics in general. In Chapter 8, cases present the various problems growing out of the ethical principle of fidelity. The cases of Chapter 9 introduce a final principle that can be included in a general ethical system: the avoidance of killing. All societies have some kind of prohibition on killing. The Buddhists make it one of their five basic precepts. Those in the Judeo-Christian tradition recognize it as one of the Ten Commandments. The moral foundation of the prohibition on killing is not always clear, however. For some people, who base their ethic on doing good and avoiding evil, prohibiting killing is simply a rule summarizing the obvious conclusion that it usually harms people to kill them. If that is the full foundation of the prohibition on killing, then killing is just an example of a way that one can do harm. This presents a problem, however. Many people believe they are aware of special cases where killing someone may actually do good, on balance. It will stop a greater evil that the one killed would otherwise have committed, or it will, in health care, possibly relieve a terminally ill patient of otherwise intractable pain. Is killing a human being always morally a characteristic of actions that tends to make them wrong, or is it wrong only when more harm than good results from the killing? For those who hold that killing is always a wrong-making characteristic, avoiding killing takes on a life as an independent principle, much like veracity or autonomy or fidelity. The pharmacist is increasingly being asked to dispense prescriptions that could be used to terminate life. This practice is legal in Oregon as well as the Netherlands, and may arise outside the law in other jurisdictions. The cases of Chapter 9 explore these questions. Other Issues of Normative Ethics In health care ethics over the past 30 years, the major issue in normative ethics has been the debate over what are the principles of morally right action. The two consequenceoriented principles of benefiting the patient (beneficence) and protecting the patient from harm (nonmaleficence) have been contrasted with the duty-based principles, such as justice, respecting autonomy, avoiding killing, veracity, and fidelity. Sometimes ethical controversy involves other issues, however. Here it is important to get the terminology straight. Ethicists contrast principles, virtues, and values. When they speak precisely, these terms refer to different aspects of normative ethics. Introduction 13 Principles, as we have seen, are general criteria that make human actions morally right or wrong. They refer to the actions (or groups of actions) rather than to the character of the actors. Hence, a pharmacist with a despicable character could, theoretically, fulfill all the moral principles. He or she might do so even though it was done for selfish reasons or bad motives. Sometimes ethical evaluations address the character of the actor rather than the nature of the behavior. When we assess the character of an actor, we use the terms virtue and vice. In our everyday interactions with others, we make the distinction between character and actions. For example, when a generally unpleasant colleague does something nice, our reaction could easily be one of suspicion regarding this seemingly out-of-character action. Virtues are praiseworthy traits of character, and vices are blameworthy ones. Among the virtues often arising in health care ethics are compassion, humaneness, and caring. A pharmacist might fulfill the principle of veracity without showing any of these virtues (or violate the principle of veracity while being compassionate, humane, or caring). Principles refer to the actions; virtues, to the disposition or character of the actor. In this volume we will focus primarily on principles of right action, though sometimes we may want to assess the character of the pharmacist as well. For normative ethics that are concerned about consequences, there is still another dimension of normative ethics. If producing good consequences or avoiding harmful ones is seen as important in ethics, then we need to ask what outcomes count as good or bad consequences. We will use the term value to refer to a good outcome and intrinsic value to refer to whatever counts as an outcome that is good in itself. Money is valued by most people but usually because it enables us to buy things we consider valuable. Money and similar goods can be thought of as instrumentally valuable. Those things that are good in themselves are intrinsically valuable. One branch of normative ethics is devoted to “value theory,” that is, the theory of what is intrinsically valuable. Among the goods often seen as intrinsically valuable are knowledge, aesthetic beauty, and health. Health is, of course, particularly important to pharmacists and other health care professionals. We will use the word principle to refer to general characteristics of actions that make them morally right (independent of the character of the actor) and virtue to refer to persistent dispositions or traits of people that are considered praiseworthy (independent of whether the behavior of those people always conforms to ethical principles). We will reserve the word value to refer to those things that are considered good or beneficial. How Do Rules Apply to Specific Situations? A third question that also is important in providing a full ethical evaluation of a pharmacist’s conduct stems from the fact that each case raising an ethical problem is at least in some ways situationally unique. The ethical principles of beneficence (producing benefit), justice, autonomy, veracity, fidelity, and avoidance of killing are extremely broad. They constitute a small set of criteria that make up the most general right-making characteristics of actions or practices. The question is: how do the general principles apply to specific situations? 14 Case Studies in Pharmacy Ethics As a bridge to the specific case, an intermediate, more specific set of rules is often used. These intermediate rules probably cause more problems in ethics than any other component of ethical theory. At the same time, they probably are more helpful than anything else as guides to day-to-day ethical behavior. The problems arise in part because of a misunderstanding of the nature and function of these rules. Rules may have two functions. They may simply serve as guidelines summarizing conclusions we tend to reach in moral problems of a certain kind. When rules have the function of simply summarizing experiences from similar situations of the past, they are called guiding rules or summary rules. In contrast, rules may function to specify behavior that is required independent of individual judgment about a specific situation. The rules against abortion of a viable fetus or against killing a dying patient are examples of rules that are often directly linked to right-making characteristics. Sometimes this kind of rule is called a rule of practice. The rule specifies a practice that, in turn, is justified by the general principles. For example, a rule of the practice of pharmacy has been that the pharmacist should not cooperate in the active, intentional killing of patients by dispensing pharmaceuticals that are intended to end a patient’s life. Even if the patient is terminally ill and suffering, intentional killing has been considered to be ethically unacceptable. According to this rules-of-practice view, it is unacceptable to overturn a general practice simply because the outcome in a particular case would be better. The conflict between those who believe that the rules themselves should be the defining factor and those who consider the situation itself to be the most critical determinant of moral rightness led to a major ethical controversy in the mid–twentieth century. It is sometimes called the rules-situation debate.14 At one extreme is the rigorist who insists that rules should never be violated. At the other is the antinomian (literally “against rules”) who claims that rules never apply because every situation is unique. Probably both positions taken to the extreme lead to absurdity. Rigorists are immobilized when two of their rules conflict. Antinomians are immobilized when they treat a situation as so brand new that no moral help can be gained from past experience. Between these two extremes are two more complex but more plausible views. A situationalist is one who considers every situation as unique and will not legalistically apply rules but is willing to be guided by the moral rules. Those rules are seen as summarizing past experience in similar situations, as guidelines, but not as rules to be followed blindly. A second intermediate position is closer to the rigorist end of the spectrum. Those endorsing what is called the “rules-of-practice” view take moral rules very seriously. They hold that normally the rules should just be applied rather than each case evaluated from scratch. Nevertheless, holders of the “rulesof-practice” position are willing in special situations to reassess the rules to see if the rules should be reformulated to reflect more accurately the requirements of the moral principles. Sometimes an analogy to the game of baseball is cited by defenders of the rules-of-practice position. On the one hand, they claim that, in baseball, the rules cannot be changed in the middle of the game—that it is inappropriate to propose in the late innings that it should take four strikes to make the batter out. On the other hand, also in baseball, there are special moments when those in charge might get together to reassess the rules, for example, at the annual meetings of the baseball team owners. So, likewise, defenders of the rules-of-practice view claim that Introduction 15 at special moments in history moral rules may be reevaluated in order to formulate a more accurate specification of the general principles. Society has reassessed certain practices in pharmacy such that the moral rules have changed. Fifty years ago, pharmacists were not supposed to tell patients the name of the drugs they were taking because of concern that patients would misunderstand and suffer psychological harm. For example, taking a pharmaceutical that had many uses might lead a patient mistakenly to believe that he or she had some condition other than the one for which the drug was dispensed. Over the years the rule against disclosing the name of a drug has changed. The rules-of-practice view accepts these changes in the rules—perhaps expressed in a change in the code of ethics of the pharmaceutical association while it does not accept the notion that the pharmacist should decide in the individual case whether the rule applies. The situationalist is more willing to reassess the rules on a case-by-case basis. This difference over how seriously rules should be taken cuts across the answers to the question of what kinds of action are right. One can be a utilitarian, who assesses the consequences case by case, or a rule-utilitarian, someone who believes in the rules-of-practice view, holding that rules should govern individual moral choices but that the rules should be chosen based on their expected consequences. Likewise, someone who is a deontologist, who believes there are certain inherent right-making characteristics of actions independent of the consequences, can either apply the general principles (such as autonomy or veracity) directly to individual situations or use them to generate a set of rules, which are then applied to individual cases. The former would be an act-deontologist; the latter, a rule-deontologist. The rules-situation debate does not lend itself to special cases grouped together. The problem arises continually throughout the cases in this volume. The final question we address is what ought to be done in specific cases. This question requires special chapters with cases selected to examine the problems raised. What Ought to Be Done in Specific Cases? After the determination of the source and meaning of ethical judgments, what kinds of actions are right, and how rules apply to specific situations, there are still a large number of specific situations that make up the bulk of problems in pharmacy ethics. The question remains, what ought to be done in a specific case or kind of case? Pharmacists and other health care professionals, being particularly oriented to case problems, are given to organizing ethical problems around specific kinds of cases. The first two parts of this volume emphasize the overarching problems of how to relate facts to values, of who ought to decide, of respecting autonomy, veracity, fidelity, of avoiding killing, and of delivering health care in a just manner. These are among the larger questions of biomedical ethics. Part three shifts to cases involving specific problem areas. Cases in Chapter 10 raise the problems of abortion, sterilization, and conception control. Chapter 11 moves to the related problems of genetic counseling and engineering and of intervention in the prenatal period. The next chapters take up in turn the problems of mental health and the control of human behavior; formularies and drug-distribution systems; human experimentation; consent and the right to refuse medical treatment; and finally, death and dying. 16 Case Studies in Pharmacy Ethics The answer to the question of what ought to be done in a specific case requires the integration of the answers to all of the other questions if a thorough analysis and justification is to be given. The first line of moral defense will probably be a set of moral rules and rights thought to apply to the case. In abortion, the right to control one’s body and the right of the health care professional to practice his or her profession are pitted against the right to life. In human experimentation, the rules of informed consent pertain. Among the dying, rules concerning euthanasia conflict with the right to pursue happiness, and the right to refuse medical treatment conflicts with the rule that the health care provider ought to do everything possible to preserve life. In many cases in which the tension between conflicting rules cannot be resolved, the analysis escalates from an issue of moral rules and rights to the higher, more abstract level of ethical principle. It must be determined, for example, whether informed consent is designed to maximize benefits to the experimental subject or to facilitate the subject’s freedom of self-determination. It must also be explored whether harm to the patient justifies withholding information from the patient or whether the formalist truth-telling principle justifies disclosure. The Levels of Ethical Analysis Metaethics: The Source, Meaning, and Justification of Ethical Claims ↕ Normative Ethics: Principles, Virtues, and Values ↕ Rules and Rights ↕ Specific Cases Solving the problem of what ought to be done in a specific case also requires a great deal of information beyond what is moral. It requires considerable empirical data. Value-relevant biological and psychological facts have developed around many case problems in biomedical ethics. The predictive capacity of a flat electroencephalogram may be important for the definition of death. The legal facts are relevant for the refusal of treatment. Basic religious and philosophical beliefs of the patient may be critical for resolving some cases in health care ethics. It is impossible to present all of the relevant facts such as medical, genetic, legal, cultural practices, and psychological that are necessary for a complete analysis of any case, but it is possible to present the major facts required for understanding. Readers will have to supplement these facts for a fuller understanding of the cases, just as they will have to supplement their reading in ethical theory for a fuller understanding of the basic questions of ethics. Introduction 17 Notes 1. American Pharmaceutical Association. “Code of Ethics for Pharmacists.” Washington, DC: American Pharmaceutical Association, 1995. This code was adopted October 27, 1994, and published the following year. The organization changed its name to the American Pharmacists Association in 2003 but retains this code of ethics. 2. Frankena, William. Ethics. Second Edition. Englewood Cliffs, NJ: Prentice-Hall, 1973, p. 62. 3. Beauchamp, Tom L., and James F. Childress, Editors. Principles of Biomedical Ethics. Third Edition. New York: Oxford University Press, 1989, p. 18. 4. Fried, Charles. Right and Wrong. Cambridge, MA: Harvard University Press, 1978, p. 12. 5. Beauchamp and Childress, Principles of Biomedical Ethics, Third Edition, pp. 20– 21; Also see Rawls, John. A Theory of Justice. Cambridge, MA: Harvard University Press, 1971, pp. 131–136; and Baier, Kurt. The Moral View. New York: Random House, 1965, pp. 106–109. 6. Firth, Roderick. “Ethical Absolutism and the Ideal Observer Theory.” Philosophy and Phenomonological Research 12 (1952): 317–345; Broad, C. D. “Some Reflections on Moral-Sense Theories in Ethics.” Proceedings, the Aristotelian Society (1944–1945): 131–166. 7. Ross, W. D. The Right and the Good. Oxford: Oxford University Press, 1939. 8. Kant, Immanuel. Groundwork of the Metaphysic of Morals. H. J. Paton, Translator. New York: Harper and Row, 1964. 9. Ayer, A. J. Language, Truth, and Logic. London: Victor Gollancz Ltd., 1948; Stevenson, C. L. Ethics and Language. New Haven, CT: Yale University Press, 1944; Hare, R. M. The Language of Morals. Oxford: Clarendon, 1952. 10. For basic surveys of ethical theory see Frankena, Ethics, and Warnock, G. J. Contemporary Moral Philosophy. New York: St. Martin’s, 1967. For more detailed introductions see Brandt, Richard B. Ethical Theory: The Problems of Normative and Critical Ethics. Englewood Cliffs, NJ: Prentice-Hall, 1959; Beauchamp, Tom L. Philosophical Ethics: An Introduction to Moral Philosophy. New York: McGraw-Hill Book Co., 1982; Feldman, Fred. Introductory Ethics. Englewood Cliffs, NJ: Prentice-Hall, 1978; and Taylor, Paul W. Principles of Ethics: An Introduction. Encino, CA: Dickenson Publishing Co., 1975. For works containing classical sources see Brandt, Richard B. Value and Obligation: Systematic Readings in Ethics. New York: Harcourt, Brace, & World, 1961; and Melden, A. I., Editor. Ethical Theories: A Book of Readings. Second Edition. Englewood Cliffs, NJ: Prentice-Hall, 1967. 11. Thomas Aquinas. Summa theologica I–II, A. 94, Art. 2. Fathers of the English Dominican Province, Editors. London: R & T Washbourne Ltd., 1915. 12. Bentham, Jeremy. “An Introduction to the Principles of Morals and Legislation.” In Melden, Ethical Theories, pp. 367–390. 13. Kant, Groundwork of the Metaphysic of Morals. 14. Rawls, John. “Two Concepts of Rules.” Philosophical Review 44 (1955): 3–32; Fletcher, Joseph. Situation Ethics: The New Morality. Philadelphia: Westminster, 1966; Ramsey, Paul. Deeds and Rules in Christian Ethics. New York: Charles Scribner’s Sons, 1967; and Bayles, Michael D., Editor. Contemporary Utilitarianism. Garden City, NY: Doubleday, 1968. This page intentionally left blank Part I Ethics and Values in Pharmacy This page intentionally left blank 1 A Model for Ethical Problem Solving After the determination of the source and meaning of ethical judgments, what kinds of actions are right, and how rules apply to specific situations—the topics of the introduction to this volume—the question remains of what ought to be done in a specific case or situation. Pharmacists and other health professionals often go through the process of determining the correct action in a specific case unconsciously. Furthermore, if asked, they would be hard pressed to articulate just what steps they went through to arrive at a sound and justifiable decision. There are many normative models for resolving ethical problems in the health science literature,1 but all require critical thinking and should result in a choice that is morally justifiable. Decision-making, whether in ethics or any other area of life, is often thought of entirely in terms of its anatomy or structure and the relationships among the structures. To appreciate the complexity of ethical decision-making, one must also understand the functions of the parts of the decision-making process. The majority of the volume addresses the “function” of how general ethical principles apply to ethical problems in pharmacy. Here, a framework is offered that includes the principles and a step-wise process to systematically resolve ethical problems in particular cases. The Five-Step Model The five steps listed below provide the structure for the decision-making process, and they are linear, that is, they should be carried out in the order presented: 1. Respond to the “sense” or feeling that something is wrong. 2. Gather information/make an assessment. 21 22 Ethics and Values in Pharmacy 3. Identify the ethical problem/consider a moral diagnosis. 4. Seek a resolution. 5. Work with others to determine a course of action. The steps in the model outline a process, a way of making judgments about what should be done in a particular situation. Additional steps could be added, and much elaboration could be included within each step. But the basic framework is sufficient to focus moral judgments and simple enough to recall and apply in actual clinical practice. Application of the Model The five-step structure will be applied to Case 1-1 to illustrate the process of decision-making. CASE 1-1 Reporting a Possibly Lethal Error: Who Needs to Know? Roger Lucas, 70 years old, was admitted to the medical intensive care unit from the surgical floor of the hospital with what appeared to be a pulmonary embolism. Mr. Lucas had fractured his femur in a fall at the nursing home where he is a patient and was awaiting surgery the next morning when he developed dyspnea, tachypnea, and tachycardia. At almost the same moment that Mr. Lucas arrived in the ICU, another patient, Ronald London, was admitted in the next room under equally emergent conditions. Mr. London was 60 years old and had a history of liver cirrhosis from alcohol abuse. Mr. London had ruptured esophageal varices. Helen Fowler, Pharm.D., was the pharmacy supervisor for the evening shift for the six intensive care units in the hospital. She and two other pharmacists worked frantically to fill all the orders for intravenous drugs and parenteral solutions that came from the intensive care units. Later, after the rush had subsided, Dr. Fowler decided to conduct rounds and learned that Mr. London had died. The code team was still picking up their equipment when Dr. Fowler got to the unit. “That’s a shame,” Dr. Fowler said to the nurse who was straightening up the room and conducting postmortem care so that Mr. London’s family could spend some time with him before his body was sent to the morgue. Then Dr. Fowler noticed the label on the IV bag in the trash, the one that had held the IV the nurse had just removed from Mr. London’s arm. Dr. Fowler was shocked to see that the empty IV bag included heparin, not the octreotide he should have received. A hemorrhaging patient should never receive heparin. Without saying anything to the nurse, Dr. Fowler stepped next door to see what solution was hanging in Mr. Lucas’s room. Much to her dismay, Mr. Lucas was receiving octreotide when he should have been receiving heparin. And, the two names had been switched on the labels. In the rush and confusion surrounding the admissions and the critical nature of both patients, the IVs were inappropriately labeled. Apparently no one checked the bags for the name of the drug before hanging them since in each case the patient’s name and room number were correct. A Model for Ethical Problem Solving 23 CASE 1-1 Continued. Dr. Fowler knew that the risk of mortality is high with patients who have ruptured esophageal varices, so the mix-up with the heparin may not have had anything to do with Mr. London’s death, but she knew that such a patient should not receive heparin. Dr. Fowler believed the next step should be to stop the octreotide IV and notify the pharmacy to send up the right drug for Mr. Lucas. She thought she had to tell Dr. Janice Mann, the intensivist who was treating both patients, but dreaded doing so because Dr. Mann did not tolerate mistakes. But, Dr. Mann needed to know so that she could adjust Mr. Lucas’s treatment. Then there was the issue of Mr. London’s family. Dr. Fowler wasn’t as sure that they needed to be told about the error. Commentary This case is complex but reveals potential ethical concerns. As the pharmacist involved in the case, Dr. Fowler will need to decide what she needs to do and why. The five-step model can help Dr. Fowler work toward a justifiable resolution. 1. Respond to the Sense That Something Is Wrong The first step in the ethical decision-making process is to respond to the intuitive sense that something is wrong in a given situation. Unlike obvious signs and symptoms, such as a rise in partial thromboplastin time or a drop in hemoglobin level, there are no objective signs that one is involved in an ethical problem. It is obvious that urgent care areas, such as the emergency department and intensive care units, can be fraught with stress and emotion. Do these emotional signs indicate that an ethical problem is in progress? The answer, as is often the case in ethics, is yes and no. Just because people are emotionally upset with each other or under a lot of stress does not necessarily mean that an ethical problem is involved. However, heightened emotional sensitivity—along with “. . . stress and tension intrapersonally or interpersonally; and ineffective communication patterns such as avoidance, nagging, or silence” 2—is often a warning sign that one is involved in an ethical problem. In Mr. London’s case, Dr. Fowler happened to notice the discarded IV bag that led to her discovery of a drug error that may or may not have contributed to Mr. London’s death. Dr. Fowler also experiences a sense of dread when she thinks about reporting the error to the intensivist in charge of both patients. She can certainly expect some type of negative reaction from Dr. Mann based on past interpersonal interactions. She may also feel guilty about the error that has occurred. She expresses “dismay” when she sees the wrong drug being administered in Mr. Lucas’ room. These negative emotions are indications that an ethical problem is present. This first step in the decision-making process merely requires one to respond to the feeling that something is wrong. One should then move on to the next step. 24 Ethics and Values in Pharmacy 2. Gather Information There is an old saw in ethics: “Good ethics begins with good facts.” Clearly, to make an informed decision, one must have the facts. To organize the numerous facts in the situation in which Dr. Fowler is involved, one can classify them into clinical and situational information. Clinical information deals with the relevant clinical data in the case in question. The following types of clinical questions are relevant when reviewing a case: What is the medical status of the patient or patients involved in the situation? Medical history? Diagnosis? Prognosis? What drugs are involved, and what are their actions, side effects, etc.? What is the patient’s probable life expectancy and general condition if treatment is given? What is the patient’s probable life expectancy and general condition if treatment is not given? In Mr. London’s case, the clinical information appeared to be unambiguous. His illness was acute and life-threatening. If not treated immediately with appropriate drug therapy and other life-saving measures, Mr. London would certainly die from hemorrhage and shock. Even if the treatment was effective in managing the bleeding, it would not resolve the underlying problem of cirrhosis. Additionally, the chance that treatment would be effective was small given the underlying condition. The administration of heparin to a patient who is already hemorrhaging would increase the risk of bleeding, but it may not have hastened Mr. London’s death. As much as possible, it is important to clarify the relevant clinical information in the case before moving on to a more in-depth analysis of the moral relevance of these facts. Situational information includes data regarding the values and perspectives of the principals involved; their authority; verbal and nonverbal communication, including language barriers; cultural and religious factors; setting and time constraints; and the relationships of those immediately involved in the case. In other words, even if the clinical “facts” of a case remain constant, changes in the situational or contextual factors, such as the values of a key principal in the case, could change the ethical focus or intensify the ethical conflict. Of all the situational data mentioned, the most important is the identification and understanding of the value judgments involved in a case. An extensive discussion of value judgments is in Chapter 2. The main players in this case are the two patients, any family involved, Dr. Fowler, Dr. Mann, the pharmacist(s) who prepared the drugs, and members of the nursing staff responsible for hanging the IV medications. All the individuals involved in the case possess values about many things, including values about health, honesty, professional competence, and loyalty, to name a few. We know specifically that Dr. Mann “. . . did not tolerate mistakes.” What does this mean in practical terms? Do individuals who make mistakes lose their jobs? The case also includes a situational factor that impinges on the case—urgency and time constraints. Two emergencies occurred almost simultaneously. If the two admissions to the intensive care unit had been spaced further apart, it is possible that the error would not have happened. We know that responsibility for the error-free care of Mr. London and Mr. Lucas rested with various members of the health care team. Each member’s responsibilities are distinct yet overlap. As part of the information-gathering step it is important to sort out the A Model for Ethical Problem Solving 25 various responsibilities, not for placing blame but for identifying moral accountability. For example, Dr. Fowler may not be the one who mislabeled the IV bags, but as evening supervisor she has overarching responsibility for all medications that leave the pharmacy. Second, she is the one who discovered the error. Knowledge of the error carries its own responsibility. These are only some of the facts affecting ethical decision-making in this case. Once all the facts are outlined, they can be examined to see whether the situation has the characteristics of an ethical problem. 3. Identify the Ethical Problem/Moral Diagnosis As has been noted in the introduction, ethics deals with a wide range of imperatives and obligations regarding human dignity and conduct. The distinct characteristics of moral evaluation, also mentioned in the introduction, apply to this third step of the fivestep model, that is, they must be ultimate, possess universality, and treat the good of everyone alike. Ethical principles are relevant sources of ethical guidance and can serve as guidelines to identify the types of ethical problems involved in a case. The values, rights, duties, or principles that are in conflict should be identified. The ethical principles most often involved in complex cases, such as Dr. Fowler’s situation, are (1) patient and health professional autonomy, (2) beneficence and nonmaleficence, and (3) justice. In this volume, veracity, fidelity, and avoidance of killing are treated as possible principles as well. Separate chapters presented in Part II develop each of these principles. At a minimum the principles in conflict in this case are nonmaleficence and veracity. Clearly an error has occurred. In the case of Mr. London, the degree of harm caused by the error is still in question. Even an autopsy might not be able to determine whether the error contributed to his death. All we know for certain is that the error deprived him of drug therapy that could have provided benefit. The error may have caused harm to Mr. Lucas as well. He too was deprived, at least for a while, of a treatment that could have helped him. Thus, harms have occurred that, at this point, are unknown to key players in the case. Nonmaleficence suggests that Dr. Fowler has a duty to protect the pharmacist involved from having to endure the unjustified wrath of Dr. Mann but also to prevent further harm to Mr. Lucas by making sure he begins to receive the right drug. Nonmaleficence would also suggest a duty to initiate procedures to make sure this kind of error does not occur again. Also at stake is the principle of veracity, the moral notion that one is obligated to speak truthfully, especially when one’s role in the situation makes it ethically impossible to keep silent. As far as we know to this point, only Dr. Fowler knows about the error. As soon as she calls attention to the error by stopping the octreotide IV and ordering the correct medication from the pharmacy, others will become aware of the error too. She believes she is obligated to tell the truth to Dr. Mann so that she can adjust Mr. Lucas’s treatment. But there are others involved in the case who have a claim on knowing the truth, the other members of the health care team, such as the nurses and pharmacists, as well as Mr. London’s family. Dr. Fowler seems to feel quite certain that she has a duty to inform Dr. Mann but isn’t as clear about her obligation to Mr. London’s family. One could propose arguments for either telling or withholding the truth from the family. The harm to 26 Ethics and Values in Pharmacy Mr. London has already occurred and is irreversible. The principle of nonmaleficence, or of doing no harm, could lead Dr. Fowler to be concerned about causing unnecessary psychological stress on his family. Traditionally, the Hippocratic ethic permits, or even requires, health professionals to remain silent whenever information would be needlessly disturbing to patients or families. On the other hand, the family could benefit from knowing what happened. They could pursue legal action that would benefit them financially and may help them gain closure over the incident. Beneficence involves balancing the burdens and the benefits of an action, an analysis that can be extremely difficult. The ethical principle of fidelity requires that people act out of loyalty to those with whom they stand in a special relationship, such as between health provider and patient. The requirements of fidelity when a provider interacts with family members are more complex, but a case could be made that, in this situation, Dr. Fowler owes it to Mr. London’s family to let them know truthfully what happened. At this point, exploring various courses of action requires both determining which principles are involved and what their implications are. At that point, we can move to the fourth step in solving the problem at hand. 4. Seek a Resolution Proposing more than one course of action and examining the ethical justification of various actions is, indeed, the working phase of decision-making. Many people try to avoid this step and, at the same time, to reduce the stress of the situation by settling for the first option that comes to mind or for what initially appears to be the safe choice. Several courses of action are open to Dr. Fowler: (1) She could fully share information about the error with all those involved; (2) she could tell Dr. Mann about the error and other internal entities in the hospital but not inform Mr. London’s family or Mr. Lucas’s family; (3) she could keep the knowledge to herself and not tell anyone and try to correct the error without being caught or just let the wrong drug continue to infuse into Mr. Lucas; or (4) she could wait to tell Dr. Mann about the error with Mr. Lucas’s medication until she can determine if it is having any side effects. These actions actually fall into the categories of telling, not telling, or waiting to tell, the last being a version of not telling. Because the error affected two patients, the range of possible actions doubles. To determine which options are morally justifiable, one must project the probable consequences of each action and the underlying intention of the action as well as whether there are moral duties that prevail independent of the consequences. This process involves the application of the ethical principles presented earlier and the ethical theories described below. By following this process, one can reject some options immediately because they would result in harm or would conflict with another basic ethical principle. Choosing the first option would be in compliance with deontological (or dutybased) ethical theories, which assert that the rightness of an act can be judged insofar as it fulfills some principle of duty, in this case particularly the duty of veracity. This option would be compatible with the respect, dignity, and equality that all human A Model for Ethical Problem Solving 27 beings deserve. Telling the physician fulfills the principle of veracity vis-à-vis the physician but leaves open what that principle requires with regard to the family. The dutybased principles of veracity and fidelity require showing respect for others, especially when some special relation exists. Not telling the family members does not respect the dignity of the family members. The third option of withholding the truth about the error and not doing anything else would be hard to justify from the perspective of these duty-based principles. Furthermore, not telling and trying to correct the error without telling anyone about it is fraught with problems, not the least of which is the great possibility of getting caught in the act of a cover-up. The credibility of not only Dr. Fowler but of the entire pharmacy would be at stake should that happen. The fourth option delays the truth but holds open the possibility that it will be disclosed at a later time. This option seems to be based on the assumption that disclosure is warranted only if the consequences require it. This brings us to consideration of the consequence-oriented principles—beneficence and nonmaleficence. Two major versions of consequence-oriented ethics were presented in the introduction: utilitarianism and Hippocratic ethics. Hippocratic ethics would focus on the principles of beneficence and nonmaleficence, but only insofar as the action has an impact on the patient. Mr. London is dead; he cannot be affected one way or the other. Mr. Lucas, conversely, is very likely to be affected. At least he needs to begin immediately receiving the right medication, but that may not require disclosure of the error. Then, too, disclosure may be distressing to him. A good case can be made that the error should be kept between Dr. Fowler and those who need to know in order to correct it. Utilitarianism differs from Hippocratic ethics by not focusing on the principles of beneficence and nonmaleficence but on which consequences are relevant. Utilitarianism holds that the option that would bring about the greatest good for the greatest number should be chosen. If telling the truth would likely produce more benefits for all the affected parties than any other alternative, then it would be good and right. If not, it would be bad and wrong. To decide whether the various options are right or wrong one would have to consider the effects of each on everyone concerned. Utilitarianism would consider the effects not only on the two patients, Mr. Lucas and Mr. London, but also on the pharmacist who apparently made the error and the nurses who failed to check the medications and catch the error. It would consider the families involved. Most critically, it would consider the effects on future patients who might benefit if the error is reported and procedures are put in place to make sure it does not happen again. We have at this point identified several possible courses of action and the implications of various ethical principles for each of those courses. 5. Work with Others to Choose a Course of Action No one makes decisions alone in a health care setting. The same is true for ethical decisions. A better decision can be reached if the people who are legitimately involved have the opportunity to openly discuss their perceptions, values, and concerns. In a complex case such as this, Dr. Fowler should call on the input of colleagues in pharmacy, the physician, and the nursing staff. By discussing concerns together, they can reach a more comprehensive decision that is ethically justifiable. 28 Ethics and Values in Pharmacy It is apparent that the duty-based principles, such as autonomy, veracity, and fidelity, push very hard toward requiring disclosure of the error—at least to Dr. Mann and other hospital authorities and probably to the patients’ families as well. On the other hand, the Hippocratic form of a consequence-based ethic provides the most plausible basis for supporting nondisclosure. Mr. London cannot be helped by the disclosure, and Mr. Lucas probably can be helped as much without it. A more social form of a consequence-based ethic, such as utilitarianism, leaves us in an ambiguous spot. Harms can come—to the families who will be placed in distress and certainly to the pharmacist who made the error. Significant benefits from disclosure also can be expected, perhaps to Mr. Lucas but definitely to future patients. It is possible that the family members might gain benefits as well. Notes 1. Purtilo, Ruth. Ethical Dimensions in the Health Professions. Third Edition. Philadelphia: W. B. Saunders, 2005; Fletcher, John C., Editor. Fletcher’s Introduction to Clinical Ethics. Second Edition. Frederick, MD: University Publishing Group, 2005; Haddad, A., and M. Kapp. Ethical and Legal Problems in Home Health Care. Norwalk, CT: Appleton and Lange, 2001; Rule, James T., and Robert M. Veatch. Ethical Questions in Dentistry. Second Edition. Chicago: Quintessence Books, 2004. 2. Salladay, Susan, and Amy Haddad. “Point-Counterpoint Technique in Assessing Hidden Agendas.” Dimensions of Critical Care Nursing 5, no. 4 (1986): 238–243. 2 Values in Health and Illness It might appear that ethical and other value problems arise infrequently for the pharmacist. Although the physician is increasingly seen as confronting such issues—in decisions about abortion, euthanasia, test-tube baby cases, and genetics, for example—the pharmacist’s day may, to the layperson, seem less filled with such controversial issues. In fact, there are pharmaceutical dimensions to almost all of the dramatic ethical problems in health care. Abortion can involve decisions about the use of abortifacient agents; euthanasia, about the use of barbiturates and narcotic analgesics to hasten death; pharmaceutical agents are used in producing superovulation that precedes in vitro fertilizations; and genetic engineering includes many pharmaceutical applications in drug manufacturing and decisions about alternative therapies. Thus almost every dramatic and controversial issue in health care ethics can pose problems directly related to pharmacy. Nevertheless, many of the day-to-day ethical dilemmas faced by the pharmacist arise not in the context of these dramatic, ethically exotic cases, but in much more normal, routine pharmacy practice. Every prescription raises issues about informed consent, assessment of risks and benefits, and the ethics of determining a fair price. Many patients will be faced with difficult choices about the wisdom of using drugs their physicians have prescribed. Other patients will turn directly to the pharmacist for medical advice, raising questions not only about the ethics of informing patients, but also about the moral limits on the pharmacist’s role as health care practitioner. Before turning to specific topics, such as the ethics of informed consent, pricing, and the dispensing of morally controversial medications, some preliminary work must be done. Having developed a five-step model for analyzing ethical cases, 29 30 Ethics and Values in Pharmacy we now need to examine the ethical and other value judgments in pharmacy decisions (the focus of this chapter) and the problem of where moral judgments are grounded (the topic of the next chapter). Identifying Value Judgments in Pharmacy Normative judgments (or evaluative judgments) occur constantly in all health care decisions. It is impossible to get to a clinical conclusion—to prescribe a drug, use an over-the-counter medication, substitute a generic, check the accuracy of a dosage with the physician, include a medication in a formulary, or report a suspected drug abuser—without making a normative judgment. Whenever someone decides to act (or refrain from acting), some evaluation has taken place. A decision is made that a particular course is the right one. It is better than available alternatives. It is what one ought to do. One key to learning to recognize that evaluative judgments have taken place is to watch for value terms. Words like right, better, and ought all signal a process of evaluation. It is the nature of a clinical science like pharmacy that these evaluations take place constantly. Case 2-1 does not raise a dramatic or grave ethical issue. It may not raise any ethical issue at all. It does involve a number of evaluations, however. In deciding how the pharmacist should respond to the patient/customer in this case, one has to be able to identify what value judgments are being made. In readin...
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

...


Anonymous
I was stuck on this subject and a friend recommended Studypool. I'm so glad I checked it out!

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Related Tags