Ethics applied to pharmacy practice

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<ul><li><p>10</p><p>Pharmacy W</p><p>orld &amp; ScienceVolum</p><p>e 22 Nr. 1 2000</p><p>Artic</p><p>le</p><p>IntroductionMany of us use the word ethics or the idea ethicswhenever we are in a position to reflect on conflictinginterests of individuals, groups or systems. In private,professional or in public life, choices whether explicit-ly stated or not are to be made at various occasions. </p><p>Todays practice of pharmacy will reveal thesechoices in various fields: A choice for development ofnew medicines in private industry, the limitation ofthe health budget which means a choice between pri-vate and public interests or the choice between theautonomy of the patient and the autonomy of thecare provider.</p><p>The basis from which these choices are made isoften created by traditional elements mixed with emo-tional and practical motives, rather then by a carefulanalysis of moral incentives in todays human behavi-our. Todays society asks for a rational approach toproblems that result from conflicting interests. Moralprinciples which are not based on rationality will leadto conflicts between practitioners and society.</p><p>PHAR 230 pips 257914</p><p>Ethics applied to pharmacy practice R.P.Dess ing</p><p>Pharm World Sci 2000;22(1): 10-16. 2000 Kluwer Academic Publishers. Printed in the Netherlands.</p><p>R.P.Dessing: Apotheek AAN ZEE, Parallelboulevard 214A2202 HT, Noordwijk, The NetherlandsE-mail:rdessing@xs4all.nl</p><p>KeywordsAdverse effectsAutonomyCost controlMedication surveillanceNonmaleficencePharmaceutical carePharmaco economicsPharmacovigilancePharmacyPharmacy professionPhilosophy</p><p>AbstractThis article tries to develop an ethical reasoning that can beapplied to (the practice of) pharmacy. Only general principles,based on accepted values in western society, lead to guidelinesfor ethical behaviour. Such essential values are personalautonomy, democracy and solidarity.The principle ofnonmaleficence can be derived from these. Results of thisanalysis can be applied to health care and pharmacy practice.Subchapters deal with questions such as budget limitationsand the autonomy of the patient versus that of the careprovider. It concludes that protocols are important tools forethical behaviour in every day practice. The ethical problemappears to be the unequal access to the health care system.An analysis of pharmaceutical care in the light of ethics canhelp to formulate the pharmacists responsibilities. Theprinciple of nonmaleficence is strongly connected to thepharmacy profession. Pharmacists should focus more onpossible negative outcomes of pharmacotherapy. Monitoringthe patients medication, identification and prevention ofpossible adverse effects, medication surveillance, propercommunication and information about the use of medicinesare therefore priority items within our profession. A definitionof target groups for pharmaceutical care will facilitate this task.A suggestion for a general code of ethics for pharmacists isproposed and compared with the code of ethics as currentlyaccepted by the International Pharmaceutical Federation (FIP)-council.</p><p>Accepted December 1999</p><p>This article tries to build up a rationality based onprinciples that have been generally respected andaccepted in western society for almost a century. Itseeks to apply it to the practice of pharmacy and torelated fields in healthcare.</p><p>Can we identify universal values?As a first step, it is necessary to analyse the nature oftodays western society its organisation and itsindividuals in terms of belief, values and practicalbehaviour. Moral values and ethics do not seem to bedependent on metaphysical ( = based on any objec-tive external, non physical reality) principles any more[1 2]. People often consider moral principles assomething that rises above culture and tradition.They see it as something objective. As an exampleone could accept the virtues as defined by Aristotle assupra cultural values [3]. But till now it is not pos-sible to prove that this type of supra cultural princi-ples have eternal validity [4].</p><p>The only thing that you could suggest is that ifthere is a set of universal principles, these principleswill manifest themselves in different ways in differentplaces and different times, depending on culture andtradition. One should accept that every cultureexplains and applies these virtues in its own way. Wedont even know exactly how they were understoodin the time and place of their conception. All literaturethat we depend on is secondary and for that reason isinfluenced by cultures that passed information on tofollowing generations.</p><p>A second important example of a philosopher whotried to formulate these eternal values was Kant. Hiscontruction of ethical principles is elegant but his mainuniversal principle that I should always act in such away that my behaviour could be a universal law ofnature, is disputable [5]. An interesting point is thatKant claimed that we are not only bound by this lawbut we can consider ourselves as authors of this law atthe same time. In this way he introduced the conceptof personal autonomy. The idea of people being freehuman beings, free to think and free to act in mattersof morality. Freedom is essential to make choices.</p><p>Essential values in todays western societyToday many people accept that there is no set of uni-versal and transculturally valid moral principles. Thelocal conception of what is a good life, a happy life,a healthy life and what is quality, plays an impor-tant role. The actions and decisions of individualsneed to be examined in terms of values of the societyto which they belong. The consequence is that ethicsshould be observed through windows of time andplace. It means that in ethics people can have differ-ent opinions about what are moral principles. </p><p>The consequence is that you can disagree about aparticular view of ethics and the application to phar-macy profession if you disagree about values that weconsider in our western culture as fundamental.</p><p>Phar vol 22_1 20-03-2000 13:03 Pagina 10</p></li><li><p>Volume 22 N</p><p>r. 1 2000</p><p>Pharmacy W</p><p>orld &amp; Science</p><p>11</p><p>An example of a value which can be considered asbasic is the individuals autonomy. Autonomy can bedefined as the individuals right or freedom to exist, toact, to think and to communicate [6].</p><p>A definition of this principle will give importantmotivation to moral and ethical guidelines. Throughthis perception morality and ethics can be developedin a rational way. It implies that new moral principlescan be introduced, after a careful analysis and athorough debate with participation of the partieswhich are directly involved and with society. Thispoint reveals a connection to the Greek philosophers:Aristotle explained already that ethics meant actingwithin and with society itself. In other words ethicswas connected to politics, to the public life [7]. </p><p>This approach demonstrates also the limitations ofthe autonomy concept. Public life is organisedaccording to democratic rules which should berespected, as they represent a synthesis or equilibriumbetween individual autonomy and man being part ofsociety. The political basis for individual liberty wasformulated by the French thinker Montesquieu.Democracy is not a rigid protocol. A democraticsystem can function at various levels. But in practiceour society is organised as a state and democracyorganised as the system of the parlementary democ-racy. It includes the separation between the legative,executive and judicial powers. Through the commoninterests of all individuals, democracy will result in aform of solidarity. It will not result in the maximumform of solidarity as proposed by Levinas [8], whereonly the OTHER is the leading principle. In thisabstract and strictly philosophical approach, thechoice between personal interest and the interest ofthe other human being will always be in the interestof the OTHER. It would be impossible to make anychoice in personal life(9).To summarise: our reasoning implies that ethics andmorality are a result of a rationality, not of somesupernatural objectivity. Values which are consideredas essential in todays western society are theindividuals autonomy, democracy and solidarity.</p><p>How to interprete these values in healthcarepractice?</p><p>AutonomyIf the individuals autonomy is an important leadingprinciple in todays morality all efforts of society shouldbe mobilised to maintain this quality. Disease is one ofthe conditions that affects or at least threatens autono-my. At this point the connection between our profes-sion and this fundamental ethical principle is revealed.When a person has a health problem, activities ofhealth professionals should be aimed at analysingwhere, how and to what degree the individuals auton-omy is threatened or compromised by this condition.One should careful analyse all elements or fields whichare covered by the forementioned definition:Autonomy means freedom to exist, to think, to actand to communicate. The request of the patient to thehealth care provider will always relate to this principle.But to regard a person who is a patient as an autono-mous human being is more complicated than it seemsat first sight.</p><p>An example: Take for instance the autonomy as</p><p>seen in terms of civil rights. According to law, a per-son has a democratic right to vote until the last sec-ond of his life and almost regardless of his mental orphysical condition. </p><p>But in healthcare, the mental and physical state willdetermine whether a part of the individuals right todecide over herself or himself is (perhaps unintention-ally) taken away and transferred to some professional. Later, I will refer to this in the frame ofinformed consent as a part of this process.</p><p>In practice, a patient with an illness or health prob-lems will ask for help. It means that a patient asks forassistance to inhibit possible worsening factors, tostabilise the personal health condition and if possiblefor a total restoration of autonomy.</p><p>All solutions will have a central theme: A properassessment of the factors which threaten personalautonomy and which are therefore the subject ofinteraction between patient and health care profes-sional. This will include a closer look at techniqueswhich are required to get proper access not only tothe body but also to the mind of the patient in orderto verify that both parties understand each otherproperly in respect of the personal health-topic [10]. </p><p>Democracy and solidarityIs it immoral to discuss cost in health care [11]. Is itunethical behaviour to refuse a treatment to a specificpatient for financial reasons? </p><p>First, healthcare as a common good is strongly connected to democracy. The result is that the statethrough democratic procedures plays a vital role inorganising the availability and activities in the health-care field. At the other side, there is a huge innovating,privately organised health care industry. The publichealth budget is per definition insufficient to meet allpossible requests for support.</p><p>And within the various sections in health care thereis competition as well. Take for instance pharmaco-therapy: today it is clear that the costs of drug treat-ment are in competition with the costs of other fieldsof care: care for the elderly, care for the mentally ill,drug addicts etc. </p><p>This all reveals fundamental and controversial inter-ests. And it implies that ethical questions are at stake.As we pointed out before, the individuals autonomyis one of the leading principles and an important cor-nerstone for ethical behaviour. But at the same timewe know that a compromise between this autonomyand general interests is necessary to avoid a climate ofanarchy. </p><p>In daily life, these types of compromises are real-ised on many levels. To compromise in this respect isin fact an important result of our upbringing. On alarger scale, in society, we know that total autonomywithout a controlling system would result in thestrongest individuals making the rules. A societywould emerge where a large part of the populationwould be condemned to poverty and dependence. Asociety where many health provisions would not beaccessible for a significant part of the population.Such a picture is recognisable to some minoritygroups in various megacities in the (western) world.These limitations for individual behaviour and thepolitical consequences where already recognised bythe american philosopher Richard Rorty in his bookContingency, Irony and Solidarity (1989) [12]. </p><p>Phar vol 22_1 20-03-2000 13:03 Pagina 11</p></li><li><p>Rorty explains that a certain level of solidarity guar-antees a society that is stable enough to secure indi-vidual safety and prosperity. In fact, the public agree-ment about this is translated in a democratic politicalsystem which forces by majority vote every citizen tocomply with this system. The result is a constant anddynamic tension between what Rorty calls the privateand the public domain.</p><p>The practice of pharmacy</p><p>Clinical researchThe main purpose of clinical pharmacology researchis to investigate whether a specific treatment withmedicines has an effect in terms of benefit versus risk[13]. Outcomes from a particular trial show positiveeffects on the patients condition. Or they indicate noeffect or a worsening of the patients health. In the ter-minology of ethics it is an assesment of the effects ofthe drug on the patients autonomy. This approachbecomes really complicated when we study theeffects of medicines which should prevent diseases.The so called number needed to treat (NNT, whichmeans the number of persons that must be treated toprevent one defined incident in a certain period or tohave one succesful treatment) should be ideally 1. Formany (preventive) therapies the NNT is much higher,up to a few hundred to be treated for many years.Apart from the financial aspects, it means that oneperson will benefit from this stategy but simultane-ously many persons will gain nothing, but will be medicalised for a long time, while others definitelyexperience adverse effects. These effects are neverfully quantified (or published?) and balanced againstthe one fatal accident. Is this a matter of ethics,where to avoid death is the leading principle?</p><p>This balancing is a culturally dependent process. Adifferent society could have different moralstandards with respect to this process. The standardsfor such an evaluation are developed by professionalswho hopefully present the results as clear choices tothe public. At this level there should be a thorough,creative and imaginative discussion. The conclusionsshould be accepted on a democratic-political level. Sofar it seems to be a clear pathway. But then we impli-citly assume that every individual will have personalvalues which comply with this system. The question isif we accept the result of a group decision if it touchesour personal life. </p><p>A specific clinical study may seem sound and logi-cal but ethical issues are always concealed in this pro-cess. The ethical aspects become more clear later,when practitioners must apply this knowledge on alarger scale in daily life. It brings forward the relationbetween knowledge, research, innovation an...</p></li></ul>