Ethics
Content
Ethics codes for any pharmacists in Details. With MCQ
September 24, 2013 at 10:28pm
Pharmacist has a professional commitment to the care of their patients. Bioethics is thus central to the understanding of pharmacy practice as a profession. There are a number of ethical principles that are applicable to healthcare professionals. Following ethical principles are identified in the tradition of pharmacy practice which establish ethical duties, obligations, and rights and provide a standard for rationalization of the ethical decisions. • Beneficence – The Duty to Do Good • Non-maleficence – Preventing harm • Autonomy – Right of determination • Veracity – Honesty without deception • Paternalism – Violating autonomy • Confidentiality • Fidelity – Best interest of patient • Justice – Equality with everyone -----------------------------------------------------------------------------
The Principle of Beneficence • The principle of beneficence can be described as “doing well” or working in the best interest of the patient. • The Code of Ethics for members of the Ontario College of Pharmacist states this principle Pharmacists are obliged to act in the best interest of, and advocate for the patient. • Helping patients in achieving the best outcome from their medications; anticipating and helping patients navigate through complicated drug plans; promoting health and wellness in community seminars are all examples of beneficence in action. CASE Smith, a Registered Pharmacist, had a very hectic day due to absence of pharmacy technician and is just about to close the pharmacy. At the same time, Marry brings a narcotic prescription for her son who had an accident and he is in extreme pain. She didn’t take any medicine for her son from this pharmacy before. Smith is alone today and this prescription order may take another 15-20 minutes. ANALYSIS Smith has a number of choices available to him. He can simply tell Marry that order won’t be ready until next day morning or he can work to resolve the issue in a timely manner. Working for the best
outcome of the patient would suggest that Smith should not close pharmacy and dispense medicines in order to help Mary’s son who is in extreme pain. By this action, Smith is keeping the best interest of the patient. ----------------------------------------------------------------------------The Principle of non-maleficence • The principle of Non-maleficence is that of preventing harm. Non-maleficence overlap beneficence but here it prevents harm. • Checking for drug interaction, checking for overdoses, checking for harmful side effects, checking for early or late on refills are the examples of activities that prevent harm to patients. • Medication safety is one of the cornerstone activities of this principle. Pharmacists have an obligation to their patients to see that prescriptions are filled in a safe manner. In the event that an error does occur, the pharmacist can further the principle of Non-maleficence by participating in the analysis of what went wrong and finding ways to ensure that error does not happen again. Sharing the learning from a medication error also supports the principle of preventing harm. CASE Dr. Robert has called the pharmacy to say that the wrong medicine was dispensed to one of his patients. A prescription for a Amiloride 5mg, with the direction to “take three (15mg) tablets per day” was dispensed with Amlodipine 5mg tablet. The patient took the wrong medication for 1 day before the error was detected. Aside from dizziness and headache, the patient suffered no other ill effects. The RPh pulled the original prescription from files and confirmed that Amlodipine was dispensed instead of Amiloride. ANALYSIS The RPh in this case has already taken the first step in preventing further harm by admitting that he dispensed the incorrect medication. Disclosing the error to the patient, following up with the doctor would be reasonable first steps to managing this incident. Upholding the principle of Nonmaleficence would guide the pharmacist to investigate what went wrong and determine if procedures could be put in place that would prevent this and other similar errors from happening in the future. Documentation of their findings is essential and sharing this information with other members of the healthcare team will help to develop an atmosphere of patient safety. ----------------------------------------------------------------------------The Principle of Autonomy • Autonomy is described as the ability to make decision for ourselves: self-determination. A patient can decide to take a medication (or not), to have surgery (or not), or to try alternative treatments.
• Refers to one's moral right to make choices and decisions about one's own course of action, even if it is not in their best interest. Any competent person has the right to make his own decisions about medical treatment and to be given informed consent. • Autonomous decision must be made voluntarily as patient should not be coerced into a decision that they are not comfortable with. Some people may be totally lacking in Autonomy – infants and comatose, are examples. Many people possess some limited capacity to make their own choices. Small children, the mentally retarded, the mentally ill, and the senile all may be able to make limited choices based on their own beliefs and values. • Respecting autonomy of a patient is sometimes difficult, especially when the health professional does not agree with the patient’s decision. For example, a patient may decide to forgo taking medication because of fear of side effects and if the patient has been given all the information to make this decision then the health professional must respect that. • The key is that the patient must be given all the necessary information in order to make an autonomous choice. The best way to achieve this is through patient counselling. The pharmacist can play a key role in facilitating the dialogue with a patient so that the patient receives all the necessary information to make that choice. When counselling is completed effectively, the patient usually sees the benefits of a medication and is much more likely to make well-informed decision about their health care. CASE Mrs. Green has been a loyal patient at her local community pharmacy for the past ten years. Today she presents a prescription for Metronidazole prescribed by Dr.Mark, her family practitioner, to George, a Registered Pharmacist. As Gerogre begins to gather the relevant information Mrs. Green says, “My doctor was really rushed today so he didn’t have time to tell me what this prescription for.” ANALYSIS Mrs. Green has not been given enough information to make an informed, autonomous choice about her health care. George must recognise this deficiency and provide the effective counselling. In this way, Mrs. Green will be able to participate in the choice surrounding her health care and George will be respecting the patient’s autonomy to participate in these decisions. ----------------------------------------------------------------------------The Principle of Veracity • This principle expresses the concept that pharmacist have a duty to act with honesty without deception: telling the truth and being honest. • When working with patient, pharmacist have an obligation to be open and truthful about the information they providing. In so doing, pharmacist can build the trust with patients and patients will come to rely on their pharmacist as a valuable healthcare resource.
• Under this principle, the pharmacist’s primary obligation include respecting the position of trust inherent in the physician-patient, nurse-patient, and other healthcare provider-patient relationships, communicating truthfully and without deception, and maintaining intellectual integrity. • Honesty can sometimes prove to be difficult. How much information has to be disclosed. Does the patient need to know everything? This is where professional judgement plays a role and consultation and collaboration with the pharmacist will be essential CASE Patricia is an elderly, frail patient who is staying in long term care facility and who relies on nurse for assistance with her medication. Patricia’s nurse has presented a prescription to the pharmacist to be filled and she asks that print-out for the medication not be shown to patricia as the side effects often frighten her to the point where she refuses to take her medication. ANALYSIS The pharmacists have an obligation to the patient to be truthful and honest about the medication that has been prescribed. Health professionals have a duty to make sure that patients are adequately informed so they can make autonomous choices about treatment options. But how much information is enough? The pharmacist is in a better position to determine how to present the information during counselling in such a way so as not to alarm the patient. For example, the pharmacist may indeed forgo giving the patient information sheet and discuss the information verbally with Patricia. In this way, the pharmacist can be truthful and honest and yet still address issues that the patient may need to know in the event of a side effect. At the same time, the principle of autonomy will be respected as the patient will be given appropriate information about her medication. -----------------------------------------------------------------------------
The Principle of Paternalism • Paternalism in the context of healthcare is constituted by any action, decision, rule, or policy made by a physician or other healthcare-giver, that dictates what is best for the patient(s) without considering the patient’s own beliefs and value system and when one fails to respect another’s autonomy and act with disregard to the individual rights. (Kills Autonomy) • Due to their having medical expertise that the patient does not possess, physicians and other healthcare providers have an obligation to act beneficently toward the patient in recommending treatments that truly benefit the patient. This expertise, however, does not give the physician or others the right to make decisions for the patient. • Classical Hippocratic ethics in the healthcare professions has been committed to the principle that the health care worker should do whatever is necessary to benefit the patient. This has been understood to include violating the autonomy of the patient. Pharmacist have refused to tell patients the name of the drugs they are taking, fill prescription for placebos, refused to dispense drugs
believed dangerous, and engaged in all manner of violations of the autonomous choices of the patient. CASE Robert Magnuson, Pharm D., is successfully running is independent pharmacy near to the university. He noticed the increase the sales of Gravol (Dimenhydrinate) especially in the adolescent and young adult population. Robert keenly aware that Dimenhydrinate is over the counter medication which is used/abused by adolescents looking for a cheap accessible "highs". Thus Robert decided to do something positive in his pharmacy. He moved all of the Dimenhydrinate products to behind the counter and put up a sign that asked, “Need Gravol, just ask your pharmacist” Robert instructed all of his professional staff to refer all the patients who are looking for Gravol. Mathew Scott, a 24-yar-old guy, was surprised when he saw the sign where the Gravol has been previously shelved in pharmacy. He wanted to purchase Gravol, but he didn’t want to ask for them. He also didn’t want to take the extra time to go to another pharmacy. Mathew asked Robert for a box of Gravol then stated, “I don’t think i should have to ask someone if i can buy Gravol.” “I’m just concerned about your health and the health and well-being of others,” Robert replied and then quickly proceeded to deliver his “lecture” on the potential harms of Gravol overuse. ANALYSIS Robert seems to have grasped the idea all too well that the pharmacist should take seriously the education of the patient about health risks. He has developed a plan whereby the education is, in effect, compulsory. The implication seems to be that Mathew and other potential purchasers of Gravol are not adequately informed about the risks of its overuse and therefore are not really making adequately autonomous choices. It is normally held that, for a choice to be autonomous, the one making it must have enough information to compare alternative courses and know about the risks and benefits. Robert’s plan of making all adolescent and adult customers to ask for Gravol and making their purchase contingent on hearing the lecture on potential harms of overuse of Gravol is a mild form of paternalism. ----------------------------------------------------------------------------The Principle of Confidentiality • Confidentiality in healthcare is essential for healthcare providers to achieve effective treatment and provide the best possible outcomes for a patient. Patient may not be willing to disclose sensitive personal information if they feel that their information is not protected. • Essentially, patients demand and expect that their personal health information will be respected and only used for treatment purposes. Any use or disclosure outside the workplace would be considered a violation of this principle.
Case Over the past year, Andrew Turner, owner of pharmacy, has enjoyed the friendship of Pamela Hicks, a medical service representative for a large pharmaceutical firm. Andrew and Pamela are frequent golfing partners and served together on committees of their local pharmaceutical association. Today, Pamela drops in for a cup of coffee and mentioned that she has been trying to introduce a new prescription speciality to area physician without much success. Although her company provides her with sales figure on the new drug, she would like to identify prescribing patterns of the physicians in her area, and thus be able to target her marketing efforts. “Can i flip through your new scripts, Andrew?” Pamela asks casually. Analysis Andrew is in an awkward position of having access to personal health information and feeling a pressure from a friend to disclose this information. Andrew must quickly recognize that disclosure of this information would violet the principle of confidentiality. Andrew has an obligation to let Pamela know that all the prescription which contains personal health information of all his clients cannot be shown unless all clients agree to it. Andrew must refuse to show all scripts to Pamela and preserve the confidentiality of all scripts and related health information. ----------------------------------------------------------------------------The Principle of Fidelity • Fidelity refers to the concept of keeping promise or a commitment. The principle of fidelity requires that healthcare provider (i.e., doctor, pharmacist, nurse) be faithful to their patients and provide services that are in the patient’s best interest. In other words: Fidelity is the right of a patient to have health professional provide services that promote patient interest rather than their own. • Example of infidelity are: recommending vitamins that patients don’t need, failing to confront a doctor with an inappropriate prescription due to fear that the doctor will direct his/her patients elsewhere. ----------------------------------------------------------------------------The Principle of Justice • A general principle of justice requires that we act in ways that treat people equitably and fairly. Actions that discriminate against individuals or a class of people arbitrarily or without a justifiable basis would violate this basic principle. • The principle of equality requires that all benefits and burdens be distributed equally. The advantage to this conception of justice is that everyone is entitled to an equal share of resources;
however the principle becomes problematic when not everyone is perceived as equally deserving of an equal share -----------------------------------------------------------------------------
PRACTICE QUESTIONS
1. The right to self-determination and freedom from the control of others is called: a. Beneficence b. Justice c. Fidelity d. Autonomy e. Veracity 2. The physician referred a patient to a psychiatrist due to the physician‟s concerns about the patient‟s level of depression. The psychiatrist suggested a trial of antidepressant medication despite the patient‟s vehement refusal to take any prescription medication due to religious beliefs. The psychiatrist ignored: a. Beneficence b. Justice c. Autonomy d. Fidelity e. Veracity 3. A pharmacist recognizes that the patient has shown up for his refills of medications with his stomach growling so bad that it is louder than the clock in the counseling area. The pharmacist discovers that the patient is living on a limited income, has several children to feed, and often goes several days without eating. As a result, the pharmacist obtains a list of local food pantries provide assistance to this patient. This would be an example of: a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence e. All of above 4. To act so that no harm is done to a patient would be define as: I. Nonmaleficence II. Beneficence
III. Autonomy a. I only b. III only c. I and II only d. II and III only e. I, II, and III 5. A pharmacist who is also asthma educator who visits an impoverished area of the Canada each month to provide asthma education would be exercising which ethical principle? a. Nonmaleficence b. Autonomy c. Beneficence d. Justice e. A and C 6. A pharmacist has been providing mental health counseling service to the patient for over one year. The patient has developed an eating disorder. The pharmacist is not competent to provide counseling service addressing this significant concern. As a result, the pharmacist decides the best course of action is to refer the patient to a service provider who has specialized training in addressing the patient‟s eating disorder. The pharmacist has followed the ethical principle of: a. Autonomy b. Nonmaleficence c. Fidelity d. Veracity e. Justice 7. The pharmacist has worked with several challenging patient throughout the day and he is scheduled to meet his pharmacy manager at the end of the day for submit all reports of that day. During the discussion the pharmacist tells the difficulties he gone through throughout the day. The pharmacy manager is aware of the confidential nature of the information the pharmacist is sharing. However, the pharmacy manager shares one of the cases with her spouse, who works in the front store. Which ethical principle has been violated: a. Autonomy b. Veracity c. Confidentiality d. Justice e. None of the above
8. Mark is 27-year-old man who has a chronic back pain related to an old back injury. His pain is becoming difficult to treat, refractory to the usual analgesic. But his doctor hesitant to start narcotic because of risk of addiction. So he decides to prescribe Niacin for its placebo benefits. Which ethical principle has been violated by doctor? a. Nonmaleficence b. Beneficence c. Paternalism d. Autonomy e. None of the above 9. Mark is 27-year-old man who has a chronic back pain related to an old back injury. His pain is becoming difficult to treat, refractory to the usual analgesic. But his doctor hesitant to start narcotic because of risk of addiction. So he decides to prescribe Niacin for its placebo benefits. Which ethical principle has been followed by doctor? a. Nonmaleficence b. Beneficence c. Paternalism d. Autonomy e. None of the above 10. A 12 year old child has undergone several treatment regimes for cancer over a period of years none of which have been successful. New treatments might offer some benefit but are considered unlikely to lead to a complete cure. Research trials indicate that the benefit can be between a few months to a year of life. After much discussion the parents withhold their consent when the new treatment is suggested by the clinical specialists at the hospital. The parents are concerned that the potential side effects outweigh the possible extension of the child‟s life. They believe their child has already suffered enough over the years of treatment. If the physician goes ahead and gives the new treatment, what ethical principle will have been violated the most? a. Nonmaleficence b. Beneficence c. Autonomy d. Paternalism e. Justice 11. A 12 year old child has undergone several treatment regimes for cancer over a period of years none of which have been successful. The parents have heard of a new treatment which clinical trials suggest might prolong life of some cancer patients by between a few months and a year. As a result they have requested that this treatment be given to their child. However, the specialist clinicians at the hospital do not believe there would be any significant
benefit for the child and do not give the new treatment, what ethical principle will have been followed by physician? I. Beneficence II. Justice III. Paternalism a. I only b. III only c. I and II only d. II and III only 12. Mary is a RPh and working in a busy pharmacy in downtown. Alice, a patient present to the pharmacy to purchase Plan B (an OTC emergency contraceptive). Mary is a catholic and believes emergency contraception is abortion and amounts to the killing of innocent human life. This was happened once before and another pharmacist was able to help the patient. But today she is the only pharmacist working and she refused to dispense Plan B to Alice. Which ethical principle she violets? a. Beneficence b. Nonmaleficence c. Justice d. Autonomy e. Veracity Case: Question 13 -14: Ms.Edward is starting on a new medication for schizophrenia. The drug has a number of side effects, some of which are serious. She asks you several questions about the purpose of the medication and possible side effects. When you ask her what the physician told her about the medication, she reports that he said, “This is a multivitamin. I have got a lot of patients on this multivitamin and they are doing fine.” It is obvious that her doctor does not want to tell her about the side effects of drug because if he does, Ms.Edward will not take it. So you dispensed the medication as Multivitamin. 13.Both the physician and pharmacist seek for which ethics: a. Beneficence b. Justice c. Veracity d. Paternalism e. Autonomy 14. Both the physician and pharmacist violets which ethics:
a. Autonomy – Justice b. Veracity – Beneficence c. Veracity – Autonomy d. Nonmaleficence – Fidelity e. None of the above Case: Question 15-16: Alec bently, a 17 year old patient was diagnosed with epilepsy and prescribed phenytoin 6 months ago. Cathy, a RPh, understand that he is embarrassed by his diseases and he is not convinced the doctor is right about the diagnosis. He thinks he does not need the drug. Cathy tried to educate him on the med and the importance of taking it properly but it has not worked – he still omits doses frequently. He also continuous to drive, and was recently in a non-injury accident. His father sometimes picks up his med, but does not seem to have knowledge his son‟s disease or his non-compliance. 15. Today Cathy doesn‟t want to counsel Alec about his med and compliance. Which ethical principle she mostly violets: a. Autonomy b. Beneficence c. Nonmaleficence d. Veracity e. Justice 16. If Cathy disclose to the father that Alec is not taking the medication, which ethical principle mostly she violets: a. Veracity b. Autonomy c. Beneficence d. Nonmaleficence e. Confidentiality 17. Which principle includes the notion of self-determination and noninterference with decisions? a. Beneficence b. Nonmaleficence c. Justice d. Fidelity e. Autonomy
18. When counseling a patient, you believe that you should spend time with patients who have adequate education to appreciate your instruction. Which ethical principle would you most clearly violating? a. Autonomy b. Justice c. Nonmaleficence d. Beneficence e. None of the above 19. A regular client approaches you this morning with a beaming smile … you recognize Liz, distinctly remembering her agonizing journey through breast cancer diagnosis and subsequent therapy. You also remember her eye for detail and the well researched questions she always seemed to pose. Liz is, after all, a high school teacher. Today, Liz has a bundle of papers in hand and requests a particular complementary product. The product has only recently been released on the Canadian market and you are unfamiliar with its contents or mechanism of action. You are also wary of complementary preparations for serious conditions, because they are not subject to clinical trials or stringent regulatory conditions of sale. Skimming through the printed articles you find little research based clinical evidence to support the claim that the product helps prevent breast cancer related metastases or recurrence at the primary site.
Liz is convinced this is the treatment she wishes to take from now on … a „natural‟ product. Liz is now in remission and has decided she need not be on the oestrogen-receptor antagonist any longer. The doctor‟s orders were to remain on Tamoxifen for a good while – her case was a particularly aggressive type of breast cancer and all treatment options were utilized last year to establish remission; her doctors told her it was a very fragile situation, but Liz was not prepared to suffer any medication side effects any longer. What are the two contradicting ethics you will face in dealing this case? a. Veracity – Justice b. Beneficence – Nonmaleficence c. Nonmaleficence – Autonomy d. Veracity – Nonmaleficence e. None of the above
September 24, 2013 at 10:28pm
Pharmacist has a professional commitment to the care of their patients. Bioethics is thus central to the understanding of pharmacy practice as a profession. There are a number of ethical principles that are applicable to healthcare professionals. Following ethical principles are identified in the tradition of pharmacy practice which establish ethical duties, obligations, and rights and provide a standard for rationalization of the ethical decisions. • Beneficence – The Duty to Do Good • Non-maleficence – Preventing harm • Autonomy – Right of determination • Veracity – Honesty without deception • Paternalism – Violating autonomy • Confidentiality • Fidelity – Best interest of patient • Justice – Equality with everyone -----------------------------------------------------------------------------
The Principle of Beneficence • The principle of beneficence can be described as “doing well” or working in the best interest of the patient. • The Code of Ethics for members of the Ontario College of Pharmacist states this principle Pharmacists are obliged to act in the best interest of, and advocate for the patient. • Helping patients in achieving the best outcome from their medications; anticipating and helping patients navigate through complicated drug plans; promoting health and wellness in community seminars are all examples of beneficence in action. CASE Smith, a Registered Pharmacist, had a very hectic day due to absence of pharmacy technician and is just about to close the pharmacy. At the same time, Marry brings a narcotic prescription for her son who had an accident and he is in extreme pain. She didn’t take any medicine for her son from this pharmacy before. Smith is alone today and this prescription order may take another 15-20 minutes. ANALYSIS Smith has a number of choices available to him. He can simply tell Marry that order won’t be ready until next day morning or he can work to resolve the issue in a timely manner. Working for the best
outcome of the patient would suggest that Smith should not close pharmacy and dispense medicines in order to help Mary’s son who is in extreme pain. By this action, Smith is keeping the best interest of the patient. ----------------------------------------------------------------------------The Principle of non-maleficence • The principle of Non-maleficence is that of preventing harm. Non-maleficence overlap beneficence but here it prevents harm. • Checking for drug interaction, checking for overdoses, checking for harmful side effects, checking for early or late on refills are the examples of activities that prevent harm to patients. • Medication safety is one of the cornerstone activities of this principle. Pharmacists have an obligation to their patients to see that prescriptions are filled in a safe manner. In the event that an error does occur, the pharmacist can further the principle of Non-maleficence by participating in the analysis of what went wrong and finding ways to ensure that error does not happen again. Sharing the learning from a medication error also supports the principle of preventing harm. CASE Dr. Robert has called the pharmacy to say that the wrong medicine was dispensed to one of his patients. A prescription for a Amiloride 5mg, with the direction to “take three (15mg) tablets per day” was dispensed with Amlodipine 5mg tablet. The patient took the wrong medication for 1 day before the error was detected. Aside from dizziness and headache, the patient suffered no other ill effects. The RPh pulled the original prescription from files and confirmed that Amlodipine was dispensed instead of Amiloride. ANALYSIS The RPh in this case has already taken the first step in preventing further harm by admitting that he dispensed the incorrect medication. Disclosing the error to the patient, following up with the doctor would be reasonable first steps to managing this incident. Upholding the principle of Nonmaleficence would guide the pharmacist to investigate what went wrong and determine if procedures could be put in place that would prevent this and other similar errors from happening in the future. Documentation of their findings is essential and sharing this information with other members of the healthcare team will help to develop an atmosphere of patient safety. ----------------------------------------------------------------------------The Principle of Autonomy • Autonomy is described as the ability to make decision for ourselves: self-determination. A patient can decide to take a medication (or not), to have surgery (or not), or to try alternative treatments.
• Refers to one's moral right to make choices and decisions about one's own course of action, even if it is not in their best interest. Any competent person has the right to make his own decisions about medical treatment and to be given informed consent. • Autonomous decision must be made voluntarily as patient should not be coerced into a decision that they are not comfortable with. Some people may be totally lacking in Autonomy – infants and comatose, are examples. Many people possess some limited capacity to make their own choices. Small children, the mentally retarded, the mentally ill, and the senile all may be able to make limited choices based on their own beliefs and values. • Respecting autonomy of a patient is sometimes difficult, especially when the health professional does not agree with the patient’s decision. For example, a patient may decide to forgo taking medication because of fear of side effects and if the patient has been given all the information to make this decision then the health professional must respect that. • The key is that the patient must be given all the necessary information in order to make an autonomous choice. The best way to achieve this is through patient counselling. The pharmacist can play a key role in facilitating the dialogue with a patient so that the patient receives all the necessary information to make that choice. When counselling is completed effectively, the patient usually sees the benefits of a medication and is much more likely to make well-informed decision about their health care. CASE Mrs. Green has been a loyal patient at her local community pharmacy for the past ten years. Today she presents a prescription for Metronidazole prescribed by Dr.Mark, her family practitioner, to George, a Registered Pharmacist. As Gerogre begins to gather the relevant information Mrs. Green says, “My doctor was really rushed today so he didn’t have time to tell me what this prescription for.” ANALYSIS Mrs. Green has not been given enough information to make an informed, autonomous choice about her health care. George must recognise this deficiency and provide the effective counselling. In this way, Mrs. Green will be able to participate in the choice surrounding her health care and George will be respecting the patient’s autonomy to participate in these decisions. ----------------------------------------------------------------------------The Principle of Veracity • This principle expresses the concept that pharmacist have a duty to act with honesty without deception: telling the truth and being honest. • When working with patient, pharmacist have an obligation to be open and truthful about the information they providing. In so doing, pharmacist can build the trust with patients and patients will come to rely on their pharmacist as a valuable healthcare resource.
• Under this principle, the pharmacist’s primary obligation include respecting the position of trust inherent in the physician-patient, nurse-patient, and other healthcare provider-patient relationships, communicating truthfully and without deception, and maintaining intellectual integrity. • Honesty can sometimes prove to be difficult. How much information has to be disclosed. Does the patient need to know everything? This is where professional judgement plays a role and consultation and collaboration with the pharmacist will be essential CASE Patricia is an elderly, frail patient who is staying in long term care facility and who relies on nurse for assistance with her medication. Patricia’s nurse has presented a prescription to the pharmacist to be filled and she asks that print-out for the medication not be shown to patricia as the side effects often frighten her to the point where she refuses to take her medication. ANALYSIS The pharmacists have an obligation to the patient to be truthful and honest about the medication that has been prescribed. Health professionals have a duty to make sure that patients are adequately informed so they can make autonomous choices about treatment options. But how much information is enough? The pharmacist is in a better position to determine how to present the information during counselling in such a way so as not to alarm the patient. For example, the pharmacist may indeed forgo giving the patient information sheet and discuss the information verbally with Patricia. In this way, the pharmacist can be truthful and honest and yet still address issues that the patient may need to know in the event of a side effect. At the same time, the principle of autonomy will be respected as the patient will be given appropriate information about her medication. -----------------------------------------------------------------------------
The Principle of Paternalism • Paternalism in the context of healthcare is constituted by any action, decision, rule, or policy made by a physician or other healthcare-giver, that dictates what is best for the patient(s) without considering the patient’s own beliefs and value system and when one fails to respect another’s autonomy and act with disregard to the individual rights. (Kills Autonomy) • Due to their having medical expertise that the patient does not possess, physicians and other healthcare providers have an obligation to act beneficently toward the patient in recommending treatments that truly benefit the patient. This expertise, however, does not give the physician or others the right to make decisions for the patient. • Classical Hippocratic ethics in the healthcare professions has been committed to the principle that the health care worker should do whatever is necessary to benefit the patient. This has been understood to include violating the autonomy of the patient. Pharmacist have refused to tell patients the name of the drugs they are taking, fill prescription for placebos, refused to dispense drugs
believed dangerous, and engaged in all manner of violations of the autonomous choices of the patient. CASE Robert Magnuson, Pharm D., is successfully running is independent pharmacy near to the university. He noticed the increase the sales of Gravol (Dimenhydrinate) especially in the adolescent and young adult population. Robert keenly aware that Dimenhydrinate is over the counter medication which is used/abused by adolescents looking for a cheap accessible "highs". Thus Robert decided to do something positive in his pharmacy. He moved all of the Dimenhydrinate products to behind the counter and put up a sign that asked, “Need Gravol, just ask your pharmacist” Robert instructed all of his professional staff to refer all the patients who are looking for Gravol. Mathew Scott, a 24-yar-old guy, was surprised when he saw the sign where the Gravol has been previously shelved in pharmacy. He wanted to purchase Gravol, but he didn’t want to ask for them. He also didn’t want to take the extra time to go to another pharmacy. Mathew asked Robert for a box of Gravol then stated, “I don’t think i should have to ask someone if i can buy Gravol.” “I’m just concerned about your health and the health and well-being of others,” Robert replied and then quickly proceeded to deliver his “lecture” on the potential harms of Gravol overuse. ANALYSIS Robert seems to have grasped the idea all too well that the pharmacist should take seriously the education of the patient about health risks. He has developed a plan whereby the education is, in effect, compulsory. The implication seems to be that Mathew and other potential purchasers of Gravol are not adequately informed about the risks of its overuse and therefore are not really making adequately autonomous choices. It is normally held that, for a choice to be autonomous, the one making it must have enough information to compare alternative courses and know about the risks and benefits. Robert’s plan of making all adolescent and adult customers to ask for Gravol and making their purchase contingent on hearing the lecture on potential harms of overuse of Gravol is a mild form of paternalism. ----------------------------------------------------------------------------The Principle of Confidentiality • Confidentiality in healthcare is essential for healthcare providers to achieve effective treatment and provide the best possible outcomes for a patient. Patient may not be willing to disclose sensitive personal information if they feel that their information is not protected. • Essentially, patients demand and expect that their personal health information will be respected and only used for treatment purposes. Any use or disclosure outside the workplace would be considered a violation of this principle.
Case Over the past year, Andrew Turner, owner of pharmacy, has enjoyed the friendship of Pamela Hicks, a medical service representative for a large pharmaceutical firm. Andrew and Pamela are frequent golfing partners and served together on committees of their local pharmaceutical association. Today, Pamela drops in for a cup of coffee and mentioned that she has been trying to introduce a new prescription speciality to area physician without much success. Although her company provides her with sales figure on the new drug, she would like to identify prescribing patterns of the physicians in her area, and thus be able to target her marketing efforts. “Can i flip through your new scripts, Andrew?” Pamela asks casually. Analysis Andrew is in an awkward position of having access to personal health information and feeling a pressure from a friend to disclose this information. Andrew must quickly recognize that disclosure of this information would violet the principle of confidentiality. Andrew has an obligation to let Pamela know that all the prescription which contains personal health information of all his clients cannot be shown unless all clients agree to it. Andrew must refuse to show all scripts to Pamela and preserve the confidentiality of all scripts and related health information. ----------------------------------------------------------------------------The Principle of Fidelity • Fidelity refers to the concept of keeping promise or a commitment. The principle of fidelity requires that healthcare provider (i.e., doctor, pharmacist, nurse) be faithful to their patients and provide services that are in the patient’s best interest. In other words: Fidelity is the right of a patient to have health professional provide services that promote patient interest rather than their own. • Example of infidelity are: recommending vitamins that patients don’t need, failing to confront a doctor with an inappropriate prescription due to fear that the doctor will direct his/her patients elsewhere. ----------------------------------------------------------------------------The Principle of Justice • A general principle of justice requires that we act in ways that treat people equitably and fairly. Actions that discriminate against individuals or a class of people arbitrarily or without a justifiable basis would violate this basic principle. • The principle of equality requires that all benefits and burdens be distributed equally. The advantage to this conception of justice is that everyone is entitled to an equal share of resources;
however the principle becomes problematic when not everyone is perceived as equally deserving of an equal share -----------------------------------------------------------------------------
PRACTICE QUESTIONS
1. The right to self-determination and freedom from the control of others is called: a. Beneficence b. Justice c. Fidelity d. Autonomy e. Veracity 2. The physician referred a patient to a psychiatrist due to the physician‟s concerns about the patient‟s level of depression. The psychiatrist suggested a trial of antidepressant medication despite the patient‟s vehement refusal to take any prescription medication due to religious beliefs. The psychiatrist ignored: a. Beneficence b. Justice c. Autonomy d. Fidelity e. Veracity 3. A pharmacist recognizes that the patient has shown up for his refills of medications with his stomach growling so bad that it is louder than the clock in the counseling area. The pharmacist discovers that the patient is living on a limited income, has several children to feed, and often goes several days without eating. As a result, the pharmacist obtains a list of local food pantries provide assistance to this patient. This would be an example of: a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence e. All of above 4. To act so that no harm is done to a patient would be define as: I. Nonmaleficence II. Beneficence
III. Autonomy a. I only b. III only c. I and II only d. II and III only e. I, II, and III 5. A pharmacist who is also asthma educator who visits an impoverished area of the Canada each month to provide asthma education would be exercising which ethical principle? a. Nonmaleficence b. Autonomy c. Beneficence d. Justice e. A and C 6. A pharmacist has been providing mental health counseling service to the patient for over one year. The patient has developed an eating disorder. The pharmacist is not competent to provide counseling service addressing this significant concern. As a result, the pharmacist decides the best course of action is to refer the patient to a service provider who has specialized training in addressing the patient‟s eating disorder. The pharmacist has followed the ethical principle of: a. Autonomy b. Nonmaleficence c. Fidelity d. Veracity e. Justice 7. The pharmacist has worked with several challenging patient throughout the day and he is scheduled to meet his pharmacy manager at the end of the day for submit all reports of that day. During the discussion the pharmacist tells the difficulties he gone through throughout the day. The pharmacy manager is aware of the confidential nature of the information the pharmacist is sharing. However, the pharmacy manager shares one of the cases with her spouse, who works in the front store. Which ethical principle has been violated: a. Autonomy b. Veracity c. Confidentiality d. Justice e. None of the above
8. Mark is 27-year-old man who has a chronic back pain related to an old back injury. His pain is becoming difficult to treat, refractory to the usual analgesic. But his doctor hesitant to start narcotic because of risk of addiction. So he decides to prescribe Niacin for its placebo benefits. Which ethical principle has been violated by doctor? a. Nonmaleficence b. Beneficence c. Paternalism d. Autonomy e. None of the above 9. Mark is 27-year-old man who has a chronic back pain related to an old back injury. His pain is becoming difficult to treat, refractory to the usual analgesic. But his doctor hesitant to start narcotic because of risk of addiction. So he decides to prescribe Niacin for its placebo benefits. Which ethical principle has been followed by doctor? a. Nonmaleficence b. Beneficence c. Paternalism d. Autonomy e. None of the above 10. A 12 year old child has undergone several treatment regimes for cancer over a period of years none of which have been successful. New treatments might offer some benefit but are considered unlikely to lead to a complete cure. Research trials indicate that the benefit can be between a few months to a year of life. After much discussion the parents withhold their consent when the new treatment is suggested by the clinical specialists at the hospital. The parents are concerned that the potential side effects outweigh the possible extension of the child‟s life. They believe their child has already suffered enough over the years of treatment. If the physician goes ahead and gives the new treatment, what ethical principle will have been violated the most? a. Nonmaleficence b. Beneficence c. Autonomy d. Paternalism e. Justice 11. A 12 year old child has undergone several treatment regimes for cancer over a period of years none of which have been successful. The parents have heard of a new treatment which clinical trials suggest might prolong life of some cancer patients by between a few months and a year. As a result they have requested that this treatment be given to their child. However, the specialist clinicians at the hospital do not believe there would be any significant
benefit for the child and do not give the new treatment, what ethical principle will have been followed by physician? I. Beneficence II. Justice III. Paternalism a. I only b. III only c. I and II only d. II and III only 12. Mary is a RPh and working in a busy pharmacy in downtown. Alice, a patient present to the pharmacy to purchase Plan B (an OTC emergency contraceptive). Mary is a catholic and believes emergency contraception is abortion and amounts to the killing of innocent human life. This was happened once before and another pharmacist was able to help the patient. But today she is the only pharmacist working and she refused to dispense Plan B to Alice. Which ethical principle she violets? a. Beneficence b. Nonmaleficence c. Justice d. Autonomy e. Veracity Case: Question 13 -14: Ms.Edward is starting on a new medication for schizophrenia. The drug has a number of side effects, some of which are serious. She asks you several questions about the purpose of the medication and possible side effects. When you ask her what the physician told her about the medication, she reports that he said, “This is a multivitamin. I have got a lot of patients on this multivitamin and they are doing fine.” It is obvious that her doctor does not want to tell her about the side effects of drug because if he does, Ms.Edward will not take it. So you dispensed the medication as Multivitamin. 13.Both the physician and pharmacist seek for which ethics: a. Beneficence b. Justice c. Veracity d. Paternalism e. Autonomy 14. Both the physician and pharmacist violets which ethics:
a. Autonomy – Justice b. Veracity – Beneficence c. Veracity – Autonomy d. Nonmaleficence – Fidelity e. None of the above Case: Question 15-16: Alec bently, a 17 year old patient was diagnosed with epilepsy and prescribed phenytoin 6 months ago. Cathy, a RPh, understand that he is embarrassed by his diseases and he is not convinced the doctor is right about the diagnosis. He thinks he does not need the drug. Cathy tried to educate him on the med and the importance of taking it properly but it has not worked – he still omits doses frequently. He also continuous to drive, and was recently in a non-injury accident. His father sometimes picks up his med, but does not seem to have knowledge his son‟s disease or his non-compliance. 15. Today Cathy doesn‟t want to counsel Alec about his med and compliance. Which ethical principle she mostly violets: a. Autonomy b. Beneficence c. Nonmaleficence d. Veracity e. Justice 16. If Cathy disclose to the father that Alec is not taking the medication, which ethical principle mostly she violets: a. Veracity b. Autonomy c. Beneficence d. Nonmaleficence e. Confidentiality 17. Which principle includes the notion of self-determination and noninterference with decisions? a. Beneficence b. Nonmaleficence c. Justice d. Fidelity e. Autonomy
18. When counseling a patient, you believe that you should spend time with patients who have adequate education to appreciate your instruction. Which ethical principle would you most clearly violating? a. Autonomy b. Justice c. Nonmaleficence d. Beneficence e. None of the above 19. A regular client approaches you this morning with a beaming smile … you recognize Liz, distinctly remembering her agonizing journey through breast cancer diagnosis and subsequent therapy. You also remember her eye for detail and the well researched questions she always seemed to pose. Liz is, after all, a high school teacher. Today, Liz has a bundle of papers in hand and requests a particular complementary product. The product has only recently been released on the Canadian market and you are unfamiliar with its contents or mechanism of action. You are also wary of complementary preparations for serious conditions, because they are not subject to clinical trials or stringent regulatory conditions of sale. Skimming through the printed articles you find little research based clinical evidence to support the claim that the product helps prevent breast cancer related metastases or recurrence at the primary site.
Liz is convinced this is the treatment she wishes to take from now on … a „natural‟ product. Liz is now in remission and has decided she need not be on the oestrogen-receptor antagonist any longer. The doctor‟s orders were to remain on Tamoxifen for a good while – her case was a particularly aggressive type of breast cancer and all treatment options were utilized last year to establish remission; her doctors told her it was a very fragile situation, but Liz was not prepared to suffer any medication side effects any longer. What are the two contradicting ethics you will face in dealing this case? a. Veracity – Justice b. Beneficence – Nonmaleficence c. Nonmaleficence – Autonomy d. Veracity – Nonmaleficence e. None of the above
