Topic #3 : Ethical PrinciplesLecture :4

Dr. Mohammad AlmermeshLecturer

Pharmacology and Clinical Pharmacy Department

Overveiw

• One way to approach ethical decision-making in pharmacy is to examine principles that describe general characteristics of actions that tend to make them morally right.

• Principles are considered to be fundamental truths or laws that we employ as a basis for reasoning, or in deciding what action to take.

• Pharmacists have a professional commitment to the care of their patients.• Pharmacists may meet head-on ethical conflict in their practices. • Ethical dilemmas occur in pharmacy practice when two principles conflict

and signal that a pharmacist may be unable to act fully on responsibilities and duties.

Pharmacy Ethics Principles

Benefiting the Patient and Others

Autonomy

Veracity

Fidelity

Avoidance of

Killing

Justice

Benefiting the Patient

• Important moral principle is that the pharmacist should act so as to benefit the patient

• Simple principle turns out to raise serious problems of interpretations

• Many ethical systems take as their goal producing good results for people

Example

A case 4-1

• The couple is poor and hypertensive and want to split the tablets due financial problems

• What is your decision? Is half of the medication worse

than not taking any at all (doctor response)

it could lower BP from critical to tolerable (one opinion)

Less expensive medication If the two patients have

different degrees of severity HPN/ might not be proper

Is it a complex case? Would you consider comfort

vs. health of your patients?

Relating Benefits and Harms Patient with chronic myelogenous leukemia (CML)This type of leukemia is less responsive to chemotherapy. The patient respond to an oral short course of busulfan and hyroxyurea after diagnosis. His WBCs were greatly reduced. The patient has asked the clinical pharmacist about his treatment options as suggested by the doctor and ask him to help. The options are:• Start interferon alpha • Think about a stem cell transplant/ maybe cured? Or lives

latent phase for years • High dose chemo with stem cell transplant

Case 4-3 page 62

The clinical pharmacist's possible suggestions:1. The possibility of infection and other

complications are very high, the patient could die from HSCT

2. Best option is to watch and wait and give interferon/ but progress to acute leukemia, there is no much help to the patient

3. He might counsel him to choose that option that maximizes the benefit for him/ but still in dilemma

4. The clinical pharmacist is not sure where to begin due to the same case died from transplant

Commentary• Is there a moral reason to prefer one option to another?• Risk-benefit outsights/ there is one option is morally reason to

choose /there is no moral reason to choose the risky• Is to compare the ratios of benefits and harms and choose one

that has the greatest ratio of benefit to harm.

Benefits of Rules and Benefits in Specific Cases

• There is another difficulty the pharmacist might face in figuring out what will benefit the patient; people are two groups

Who calculate consequences with reference to the specific case considered in isolation; they look only at the effects of alternative actions in specific case

Others are equally focused on consequences but they are interested in the potential consequences of alternative rules = rule utilitarian (choose the rule that is as good as or better than any alternative)

An example;

……..How these two approaches to calculating consequences impact on a pharmacist’s moral choice

Case 4-4 page 64

a Russian doctor works in the US asked the director of pharmacy at the local hospital to donate any expired or soon-to-expire products to his project, he convinced him by saying that any medications even those that are not fully potent could be used.

• Does the hospital policy allows this?• What about the FDA?• He decide to give him the soon-to-expire

medications

Commentary

Justice• One of the problems raised by the last principle was the

conflict between the welfare of the patient and the welfare of other parties.

• Pharmacists often find themselves in situations in which the interests of their patients are in conflict. The pharmacist must choose between patients or between a patient and those who are not patients.

• Whether to provide medications for those who cannot pay the full costs and shift the costs onto those who can is one example.

Justice, Cont…

• The Hippocratic mandate to serve the interests of the patient (in the singular) does not help.

• It seems ethically perfect, simply to count up the total amounts of good and harm and choose the course that maximizes total social outcome regardless of the impact on the individuals affected.

• That could lead, for instance, to refusing to provide services to those who are not useful to society or to those who can benefit only modestly from the pharmacist’s services.

Justice, Cont…

• The problems of allocating scarce resources arise in pharmacy in planning health care system formularies and in the operation of drug-distribution systems.

• justice is concerned with how the goods and harms are distributed.

• Justice is concerned with the equity or fairness of the patterns of the benefits and harms

Distribution of Good and Harm

• There are many schools of thought: • Just distribution:• Might focus on the effort of the various parties

(Maximize efficiency called for the principle of beneficence and nonmaleficence (nonharming))

• Equitable distribution:• Look at the needs of the parties (distributing resources

equitably- called for by the principle of justice

Justice Among Patients

• Some pharmacists accept the traditional Hippocratic ethic that limits the focus of the pharmacist’s ethical responsibility to the welfare of the patient.

• But, They may face a direct conflict between the interests of different patients.

Justice Among Patients, Cont….

• Commentary:

1. First, consider what Dr. Citron would do if he were acting only on the basis of the more social version of an ethic of beneficence and nonmaleficence, if his only goal was to do as much good as possible considering the sum of the effects.

2. Now consider what else Dr. Citron might take into account other than the sum of the benefits and harms.

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Justice Among Patients, Cont….

3. There are other factors to consider here:• What should Dr. Citron make of the fact that Ms.

Jorgensen had been waiting longer?• Does the idea of first come/first served apply here, and

if so, why?• What should Dr. Citron make of the fact that he has

previously given Ms. Jorgensen a great deal of his time?

• Does Ms. Riley have a claim to equal time?4. Finally, what should Dr. Citron make of the fact that he

had promised Ms. Jorgensen that he would see her at a certain time? Does that promise give her a special priority?

Justice Between Patients and Others

• A pharmacist must choose between the patient and others.

• In purely Hippocratic ethics, the patient is the only interest that is morally relevant.

• Neither other patients nor those who are not patients count morally.

• Sometimes this is hard to do

Justice Between Patients and Others, Cont….

• Commentory:• Ms. Walsh, and especially her children, seem to be in

special need.• Assuming Celestine Morano considers both Ms. Walsh and

the children to be her patients, she might also assume she has a special duty to benefit them.

• From a purely Hippocratic perspective of having the pharmacist do what will benefit the patient, a case can be made for ignoring the broader social dimensions.

./References/%5bRobert_M._Veatch__Amy_Haddad%5d_Case_Studies_in_Pha(BookZZ.org).pdf Pg 78

Justice Between Patients and Others, Cont….

• From the perspective of justice:• First, it is not really clear whether Ms. Walsh and her children

are really worse off than the others who are being injured by her behavior.• Is she taking Medicaid funds that would go to persons in even

greater need? If so, then justice would require that Celestine Morano focus her attention on the others.• what should be made of the fact that Ms. Walsh is engaging in a

behavior that is cheating the system, a behavior that is illegal as well as unethical?• Is the goal to benefit the patient, to help the person who is

worse off, or to make sure that cheating the system is prevented so that Medicaid resources can be stretched as far as they can?

Justice in Public Policy

• The pharmacist facing policy decisions does not have a specific patient or patients in mind whose interests can be served.

• If a specific patient’s case is debated, it is as an example of a more general policy question in which the interests of a group are at stake.

Other possible conflicts

• Justice in Public Policy• Justice and Other Ethical Principles