According to Singer (1979:2), ‘… an ethical judgment that is no good in practice must suffer from a theoretical defect as well, for the whole point of ethical judgments is to guide practice.’ With the well-publicised and ongoing challenges in the NHS, the public understands that many health professionals – including those in the pharmacy profession – suffer from stress-related conditions. So in this context, to what extent can pharmacists be expected to make sound ethical judgments?
Kalvemark et al (2004) note that ‘stress due to ethical dilemmas is usually referred to as ‘‘moral distress’’’, and they ask, ‘Does the hospital/pharmacy provide support to the professionals troubled by ethical dilemmas? Are there any support structures and resources to increase moral competence at the workplace?’ It’s a good question, and almost 2 decades after Kalvemark et al (2004) observed that ethical dilemmas tend to be topics typically discussed during coffee breaks and similar occasions, it seems unlikely that such a time span has seen any significant evolution in how health professionals reflect on ethical matters.
It is self-evident that a pharmacist in a hospital setting considers themselves as a healthcare provider; but does the same apply to community pharmacists, some of whom might regard themselves primarily as retailers? An interesting perspective was provided by Cooper et al (2007) whose analysis raised the consideration that the pharmacy environment might influence a pharmacist’s ethical reasoning. Although they cite one study which found ‘that problems occurred more often in the community setting than in other areas of pharmacy practice’, another study suggested that the community pharmacy environment was detrimental to moral reasoning. Yet Cooper et al (2007) concede that their review unearthed a complex picture of ethical influence.
They acknowledge that pharmacists must often have to deal with ‘patient representatives and encounter confidentiality issues; regulations relating to emergency supplies and controlled drugs lead to conflicts between benefiting the patient and complying with legal requirements; [and] supplying syringes to addicts to prevent health risks must be balanced by a concern about theft from the pharmacy …’
In 2019, according to the General Pharmaceutical Council (2019), only 15% of pharmacists in England (including London) were independent prescribers. If, as can be reasonably expected, more clinical work will be undertaken by pharmacists, prescribing skills will become an integral part of pharmacists’ training to enable them to independently prescribe after registration.
It follows, therefore, that one could anticipate further ethical challenges to arise, such as one posed recently by Xiang et al (2023) who argue that physicians and patients – and one can also envisage a prescribing pharmacist facing this dilemma – often give undue weight to risks related to antibiotic allergy, resulting in second-line therapy being used too often, when, if antibiotic allergy risks were properly evaluated, first-line therapy might confer a better balance of benefits and harms.
While noting that some 10% of hospitalised patients in high-income countries report penicillin allergies, Xiang et al (2023) also indicate that approximately 5% of these will have a ‘true’ allergy after testing, meaning that fewer than 1% of people will mount a confirmed allergic reaction to penicillin antibiotics, with around 0.001% to 0.0005% having anaphylaxis. Patients who are allergic to penicillin are often given second-line, rather than first-line antibiotics, with second-line drugs ‘typically associated with individual harms including lower cure rates and more non-allergy adverse drug reactions as well as public health harms including greater healthcare costs and increased prevalence of resistant bacteria’ (Xiang et al, 2023).
A busy pharmacist considering this prescribing dilemma, perhaps in the small hours of the morning, might seek refuge in the precautionary principle allied to the undertaking to ‘first do no harm’. Xiang et al (2023), however, contend that patients cannot be wholly insulated from risk ‘since a wide range of beneficial clinical activities (from surgery to drug prescription) involve risk to patients. Avoiding risk altogether would involve foregoing almost every benefit of modern medicine. In many cases, this would result in greater expected harms (in terms of lost benefits) to patients.’
It is one thing to discuss such dilemmas in the relaxed environment of a ‘watercooler chat’, but quite another to ask – and to answer – an ethical question in a high-pressure situation. Perhaps prospective pharmacist prescribers’ professional development should include a greater focus on ethics, whose whole point, as Singer (1979) explains, ‘is to guide practice.’