Moral dilemmas of community pharmacists: a narrative study
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Background Pharmacists are increasingly involved in patient care. This new role in a complex healthcare system with demanding patients may lead to moral dilemmas. There has been little research into pharmacy ethics, and existing data are limited by their retrospective nature and small sample sizes. A thematic overview of the moral dilemmas experienced by community pharmacists is still missing. Objective To make a thematic overview of moral dilemmas experienced in daily pharmacy practice. Setting Dutch community pharmacy. Methods Dutch community pharmacists wrote a narrative about a moral dilemma they had experienced in clinical practice. The narratives were analysed using qualitative content analysis to identify underlying themes. Main outcome measure Themes of moral dilemmas. Results Twenty-two themes were identified in 128 narratives. These moral dilemmas arose predominantly during pharmacists’ contact with patients and other health professionals. The relationship between the pharmacist, patient and other health professionals was complicated by other parties, such as legal representatives, health insurance companies, and regulators. Conclusion The moral dilemmas experienced by community pharmacists are more diverse than previously reported. The main dilemmas arose in their professional contacts, frequently when their professional autonomy was challenged by the behaviour of patients and other health professionals.
KeywordsCommunity pharmacists Moral dilemmas Netherlands Pharmacy ethics
Impact on practice
The moral dilemmas for pharmacists are diverse, but underlying is often a troubled relationship with physicians and/or patients that hampers the pharmacist to deliver appropriate pharmaceutical care.
Reflection on moral dilemmas may help community pharmacists to strengthen their professional autonomy.
Investing in good professional relationships with other health professionals and in a therapeutic relationship with patients may benefit recognition of pharmacists’ expertise.
Worldwide, the primary focus of pharmacists is shifting from products to patients [1, 2, 3, 4, 5, 6, 7]. This patient-centred approach means that pharmacists have to identify patients’ concerns and needs, and collaborate closely with other health professionals in order to ensure effective and safe use of medicines . Lastly, pharmacists are responsible for helping patients to achieve definite health outcomes.
Nowadays, health professionals such as pharmacists are faced with ever more regulations, financial pressure, and increased competition. At the same time, the demand for health services is growing as a result of population ageing, more chronic illnesses, and increased healthcare consumerism [9, 10]. Economic and legal constraints and demanding patients challenge health professionals’ autonomy to act in the best interests of society and the individual patient [9, 11, 12, 13, 14, 15, 16, 17, 18, 19]. In this complex setting, pharmacists are frequently confronted with moral dilemmas [20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30] arising from conflicting personal, professional, institutional or societal values of the different parties involved [28, 31, 32, 33].
There have been few international studies of the moral dilemmas experienced by community pharmacists, and existing studies vary widely in aim, method and presentation of results [24, 25, 26, 27, 29, 30, 40]. In most existing studies, pharmacists were presented with scenarios of moral dilemmas and their moral reasoning was assessed. Pharmacists found it difficult to recall moral dilemmas and most studies interviewed a limited number of pharmacists [20, 21, 22, 23, 30, 41]. Hence the themes of moral dilemmas experienced in clinical practice may still be incomplete.
Aim of the study
We aimed to make a thematic overview of moral dilemmas community pharmacists actually experienced in clinical practice.
The Medical Ethics Review Committee of the University Medical Centre Leiden concluded that the Dutch Medical Research Involving Human Subjects Act (WMO) was not applicable. All participants consented that their narratives could be used for the purpose of the study. Data that could give clues about the origin of dilemmas (e.g. names of patients, cities, pharmacies, pharmacists or physicians) were removed.
Study design and setting
Pharmacists wrote a narrative of a moral dilemma they had experienced in clinical practice, as an assignment during either pre- or postgraduate training. The pharmacists were asked to write this narrative immediately after they had experienced the dilemma. A stratified random sample of these narratives was taken. All pharmacists had been taught how to recognise moral dilemmas. This study followed scientific standards for reporting qualitative research (SRQR; see “Appendix”) [42, 43].
Definition of moral dilemmas
On the basis of the various definitions in the literature [25, 29, 35, 40, 44, 45], a ‘moral dilemma’ was defined as: a situation in which there is a choice between at least two courses of action, neither of which is obviously morally preferable. Narratives were checked against this working definition by both the first author (MK) and a member of an expert panel consisting of eleven senior pharmacists active in the special interest group on pharmacy ethics of the Royal Dutch Pharmacists Association. All panellists had been trained in a half-day ethics course to identify moral dilemmas. If consensus was not reached, a third pharmacist from the research group (WG, MB or AF) was consulted. Narratives that did not comply with our working definition were excluded.
Inductive content analysis of narratives to identify themes of moral dilemmas was facilitated with ATLAS.ti (version 7.5.17) . Consensus on final themes and main categories was reached in two rounds, during independent validation by the research group and during a consensus meeting with both the expert panel and research group.
Themes of moral dilemmas experienced by community pharmacists in clinical practice (N = 128)
Category 1: The pharmacist–patient relationship
n = 59
• Drug abuse or addiction
• Drug misuse
• Deviating treatment preference
• Claiming and/or aggressive behaviour
• Medication understanding
• Patient’s privacy
• Sharing relevant patient data with health professionals
• Public health policy and third-party payer regulations
Category 2: The pharmacist-colleague relationship
n = 35
• Disruptive behaviour of a physiciana
• Disruptive behaviour of a colleague
• Pharmacist and physician have a different opinion about appropriate pharmacotherapy
• A troubled relationship with the physician
• Deviating from a prescription with the physiciana absent
• Missing relevant patient data with the physiciana absent
• Loyalty conflicts
• Physician’sa self-prescribing
Category 3: Various relationships or involved parties
n = 34
• Reimbursement for a pharmaceutical product or pharmaceutical care
• Risk of harm to children
• Risk to the unborn child
• End-of-life pharmaceutical care
• Dispensing without a prescription
• Quality defects
Category 1: The pharmacist–patient relationship
Drug abuse or addiction
PHARM-276: This patient is heavily addicted to an opiate and regularly asks for, and gets, a refill too early. “He always has excuses like ‘I carried a heavy load yesterday’ or ‘I lost my medication during holidays’. However, he does experience pain and needs an analgesic. If he needs the opiate because he has really lost it, he should get it. But how long should I contribute to his opiate addiction.”
PHARM-1082: The pharmacist is aware that a student has been collecting methylphenidate only twice a year (coinciding with exams in January and June). The prescriber is the patient’s father. “Should I cooperate, give priority to the patient’s autonomy and dispense this medicine when I doubt whether the drug is actually indicated for a ‘chronic’ illness? Or do I need to address this presumed off-label use?”
Deviating treatment preference
PHARM-1235: A mother requested paracetamol for her 1-year-old baby who had a high fever for a week. “I tried to convince her to consult her GP as her baby might have a dangerous infection. She didn’t agree. Her attitude frustrated me. I want to do what is best for the baby, but at the same time have to respect the mother’s decision.”
Claiming and/or aggressive behaviour
PHARM-1062: A patient asked the pharmacist for a prescription of oxazepam that had been faxed 2 months ago. The electronic patient record, however, suggested that the prescription had already been dispensed. The patient became furious and insisted that he had never received the drug and needed it urgently. “I felt attacked, but also had my doubts because of his convincing manner of speaking. Did we make a mistake? Should I dispense once again without a prescription?”
PHARM-314: An elderly Spanish speaking patient did not understand the pharmacist who explained the need for gastroprotection during NSAID use. She kept repeating that she was in pain and only needed the NSAID. This situation did not change even with a translator. “I wanted to assist and advise her correctly but poor communication made that impossible. I had my doubts about dispensing the NSAID without gastroprotection because of the possible health risks.”
Patient’s privacy/sharing relevant patient data
PHARM-252: A woman treated for a bipolar disorder told her pharmacist that she wanted to discontinue mirtazapine. She explicitly asked the pharmacist not to notify her psychiatrist. “I explained to her that I couldn’t provide proper pharmaceutical counselling because I didn’t have relevant background information.” Although the pharmacist wanted to respect her autonomy, he also felt he should notify the psychiatrist.
Public health policy and third-party payer regulations
PHARM-84: A patient, objected strongly to generic salbutamol. “After persistently trying to explain the drug reimbursement policy to him, I convinced him to try the generic for at least 14 days. A few hours later, he reported numerous complaints. Later the patient came with a prescription for the branded aerosol and a statement from his physician declaring the necessity of him having the original drug. Somehow, I felt the patient had never really tried the generic.” The pharmacist had doubts about whether he should start the conversation with the patient again or fill the prescription.
Category 2: The pharmacist–colleague relationship
Disruptive behaviour of a physician/a troubled relationship with the physician
PHARM-54: A cardiologist deviated from the guideline for combining antiplatelet drugs. When the pharmacist requested clarification, the cardiologist’s replied: “Do you mind if I continue with my patients now?” The pharmacist could not properly inform the patient about his doubts about the therapy. “I had strong doubts about the safety of this combination. Informing the patient about the risks, however, might worry the patient and undermine his confidence in the cardiologist.”
Disruptive behaviour of a colleague
Pharmacists reported disruptive behaviour of colleagues, such as gossip, lying or suspected fraud. Both neglecting and addressing such behaviour could influence the work climate in the pharmacy.
PHARM-1084: A pharmacy is reimbursed for every patient who receives instructions about a new inhaler. The senior pharmacist asked a junior pharmacist to send a list of all patients who had received a new inhaler with instructions to the insurance company for reimbursement. The junior pharmacist was reluctant to do this, struggling with going against his senior colleague’s request as well as his responsibility to society. “I was uncertain whether the instructions had always been given. Technicians didn’t always document this and patients sometimes refused the instructions or had already received them elsewhere.”
Pharmacist and physician have a different opinion about appropriate pharmacotherapy
PHARM-22: The pharmacist had suggestions about alternative therapy options for a patient with serious pain complaints. However, the physician said that he had tried everything and that nothing more could be done and did not want to change the medication. “In the end, it is the physician who prescribes. I wanted to help the patient but suggesting these options directly to the patient also did not feel appropriate.”
Deviating from a prescription or missing relevant data with the physician absent
PHARM-350: A dentist prescribed amoxicillin. The pharmacist knew that the patient had previously had an allergic reaction on amoxicillin. The dentist could not be reached, but the patient urgently needed medication. “What if the dentist does not agree with the alternative antibiotic clindamycin?
PHARM-115: A physician asked the pharmacist to urgently prepare a midazolam infusion to start palliative sedation for a patient registered at a neighbouring pharmacy. The physician explained that the pharmacist of that pharmacy was not able to prepare the infusion that day. “In my opinion not dispensing wasn’t an option because of the condition of the patient. On the other hand, I didn’t want to overrule the decision of my colleague-pharmacist who is the responsible professional for this patient.”
PHARM-1176: A physician prescribed midazolam for himself. “Dispensing felt problematic because sleep medication might have negative effects on the physician’s daily functioning. Moreover, the pharmacist did not want to become the accomplice of an addicted physician. However, not dispensing could damage the professional relationship and future collaboration.
Category 3: Various relationships or involved parties
The previous categories of dilemmas involved patients or health professionals. In the following themes other ‘stakeholders’ were involved, such as health insurance companies and manufacturers. We also included dilemmas with (unborn) children and adolescents in this category, as pharmacists in these situations have a complex responsibility towards these unborn children, minors and their parent(s) or legal representatives.
Reimbursement for a pharmaceutical product/care activity or additional service
PHARM-278: A nursing home requested multidose drug dispensing systems for every patient. This would include anticoagulant medication, the dosing of which often has to be adjusted. The pharmacy did not have the capacity to change the multidose drug dispensing systems manually each week. “I realise the importance of this request, but it would almost take an extra technician without getting any reimbursement.”
Risk of harm to (unborn) children
PHARM-1202: “A psychiatrist told me he did not want to tell a pregnant woman with a major depressive disorder about the teratogenic risks of paroxetine because he was afraid that she would not take the drug. The psychiatrist considered that the mother not taking paroxetine would potentially be riskier for the unborn child than the small teratogenic risk. I struggled with appropriate counselling.”
End-of-life pharmaceutical care
These dilemmas concern euthanasia or palliative sedation. Dutch Pharmacists’ and Physicians’ Associations have a joint guideline on providing euthanasia . Sometimes physicians did not adhere to the guideline recommendations; e.g. a physician requested euthanasia drugs without timely communication with the pharmacist. Pharmacists were then reluctant to cooperate. However not dispensing felt wrong because the patient was suffering.
PHARM-57: This pharmacist did not dispense drugs for euthanasia because of religious objections. Surrounding physicians knew about this. A physician from another area, unaware of the objections, requested these drugs too late in the day to find another pharmacist. “Should I remain faithful to my personal values but then trouble both the patient and physician, or should I dispense the drugs this one time?”
Dispensing without a prescription
PHARM-71: The middle-aged son of an elderly patient visited the pharmacy just before closing time. He showed a picture on his mobile phone of an oxycodone prescription for his father who had just been discharged from hospital. He said his father suffered from severe pain and he could not get the real prescription in time before the pharmacy closed. “The prescription does not comply with the law but this patient could suffer unnecessarily if I don’t dispense.”
PHARM-309: A patient visited the pharmacy with three golimumab injections worth €3500 which had been outside the refrigerator for about 1 day. “The manufacturer told me they expected no quality issues but could not give any guarantee.” The pharmacist doubted whether the patient would be harmed by using the injections, and felt that, given their cost, discarding the injections was not socially responsible.
This study presents moral dilemmas experienced by community pharmacists in clinical practice. The underlying themes address the challenges pharmacists face while providing care in a complex setting with economic and legal constraints, demanding patients and limited professional autonomy. Analysis showed that most moral dilemmas concerned the relationship between pharmacists, patients and physicians. This is not surprising considering that pharmacists are responsible for helping patients achieve positive health outcomes, and this responsibility requires that they work with patients and other health professionals .
As far as we know, no previous study used narratives to understand the moral dilemmas that pharmacists experience in clinical practice [26, 29, 40]. Writing a narrative shortly after a dilemma occurred avoids recall problems and enables pharmacists to reflect directly on their feelings. Previous studies generally interviewed pharmacists and asked them to recall dilemmas that occurred in the past [29, 40]. This may be the reason why, in those studies, pharmacists mainly recalled dilemmas with a high legal impact. For example, pharmacists expressed fear of breaking the law when a patient asked for a controlled drug without a (valid) prescription [26, 29, 40]. When legal issues occurred in this study, pharmacists were more concerned about the patient’s well-being and the mutual trust in the treatment relationship than about breaking the law.
Pharmacists experienced dilemmas during their professional contacts because the behaviour of patients and physicians made it difficult for them to act autonomously, according to their professional core values . Since the days of Hippocrates, health professionals’ core value is not to harm patients and to act in their best interest. However, conflicts may arise when more than one health professional aims to act according to that value. The degree of professional autonomy of an individual health professional depends on the extent to which other health professionals grant that autonomy . Regular collaboration between pharmacists and other health professionals may promote mutual trust and respect for each other’s knowledge and expertise [52, 53, 54].
Pharmacists’ autonomy may also be challenged because pharmacists are often the last link in a multidisciplinary care chain, e.g. in end-of-life pharmaceutical care issues. In that position pharmacists’ expertise comes into play too late or is not recognised [55, 56]. Pharmacists in these situations described that their expertise was disregarded and that they were expected to dispense only. These moral dilemmas demonstrate that pharmacists need more training to convince physicians of their expertise.
The professional autonomy of pharmacists may also be restricted by patients or parties such as insurance companies or the health inspectorate. Patients may also consider physicians to have more authority than pharmacists. This can sometimes lead to claiming and/or aggressive behaviour of patients. This behaviour undermines the trust relationship between the pharmacist and the patient. This resembles healthcare consumerism, which is reported to challenge the ability of health professionals to optimally fulfil patients’ and societal needs [9, 10, 11, 12, 13, 14]. Dilemmas under the theme public health policy and third-party payer regulations showed that health insurance companies can also undermine pharmacists’ autonomous professional decision-making and actions. Insurance companies oblige pharmacists to replace expensive branded drugs with cheaper generics. Although pharmacists do not object to dispensing cheaper medicines whenever possible, this responsibility also disturbed their relationship with patients who strongly objected to generics. This finding confirms a worldwide trend that economically motivated health policies challenge the professional autonomy of all health professionals [12, 13, 14, 17, 18]. Health policy makers should realise that weakening health professionals’ autonomy, for example due to reimbursement policies, may negatively affect patients’ trust in health care .
This study has some limitations. Firstly, the moral dilemmas were reported by ‘early career’ pharmacists. These pharmacists may be more committed to patients’ well-being, because of more advanced training on the patient perspective than earlier generations of pharmacists. Moreover, the training provided might have influenced their sensitivity for moral dilemmas . The themes underlying the moral dilemmas were not less numerous than those in previous studies involving more experienced pharmacists. Exceptions to this are primary business dilemmas. The underreporting of these types of dilemmas might be explained by the fact that the early career pharmacists in our study generally do not own a pharmacy. A second limitation is that saturation of themes was not formally assessed. We did, however, have no clues on additional themes from the excluded narratives. Moreover, screening of an additional stratified random sample of 50 narratives by two authors (MK and MB) neither gave clues on missed themes. Therefore, we are of the opinion that the most important themes for the Dutch context are identified. This does, however, not imply that every individual pharmacist will identify these dilemmas. Furthermore, our results are not completely generalizable to countries with different health systems and a different position of the community pharmacist in health care. Lastly, the written narratives contained much richer information than reported in our brief summaries; some narratives were excluded because they were unclear. As we were primarily interested in the themes, we did not analyse the feelings of pharmacists in depth.
Implications for practice
This study suggests that a short training enables pharmacists to write narratives on moral dilemmas they experience in clinical practice. Reflecting on these dilemmas may help pharmacists to increase their professionalism. Hence, we suggest to integrate such ethical training in experiential learning within both pre- and postgraduate education. This will raise pharmacists’ awareness on moral conflicts and will support the profession’s transition to delivering pharmaceutical care.
Pharmacists experience a number of moral dilemmas in clinical practice. The narrative method enables pharmacists to reflect directly on their feelings at the time these dilemmas occur. Most dilemmas involve the pharmacists’ professional relationships and often arise when the professional autonomy of pharmacists is challenged by patients’ and other health professionals’ behaviour.
We express our gratitude to all the participating pharmacists who shared their moral reflections with us. Also, we want to thank the pharmacists who participated in the expert panel.
We received unrestricted grants from the Royal Dutch Pharmacists Association (KNMP) and from the foundation ‘Stichting Management voor Apothekers en voor de Gezondheidszorg’ (MAG).
Conflicts of interest
All authors declare that they have no conflict of interests that are directly relevant to the content of this study. Further, all authors are aware of this submission and agree with it.
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