In his book Practical Ethics (1979), Peter Singer observes: ‘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’. This has implications for pharmacists, who may be expected to make ethical judgments that not only guide their practice but are also consistent with professional obligations. Ethics in the pharmacy profession has assumed increasing importance given its evolution from a prescription dispensing service to its current standing where pharmacists' duties include being both patient-centred providers of medical and public health advice, and independent prescribers – and managers – of medicines.
For example, Bolt et al (2015) consider ethical aspects in the case of a 21-year-old woman who presented to a pharmacist a dermatologist's prescription for isotretinoin, which has teratogenic potential and is contraindicated in pregnancy, to treat her severe cystic acne. The options available to the pharmacist include dispensing isotretinoin with no further discussion, not dispensing if the patient does not use contraception, and dispensing following consultation with the patient and her dermatologist. When Risvoll et al (2019) investigated pharmacy employees involved in the sale of dietary supplements (DS) to patients with dementia, they concluded: ‘pharmacy employees do not see themselves as primarily responsible for the safe use of DS by persons with dementia. Moreover, they have limited experience with the unsafe use of DS by these persons'.
‘If a pharmacy professional is unwilling to provide a certain service, they should take steps to make sure the person asking for care is at the centre of their decision-making’
The examples quoted could arguably be addressed through adherence to previously established guidelines and protocols. But perhaps a potentially more problematic area for some pharmacists is when their personal moral values and/or religious beliefs prevent them from taking a course of action that their professional guidance would allow. This is acknowledged by the General Pharmaceutical Council (GPC), whose guidance recognises that a pharmacist's beliefs may influence their practice in areas such as contraception (routine or emergency), fertility medicines, hormonal therapies, substance misuse and sexual health (GPC, 2017).
The GPC (2017) notes that the Human Rights Act (1998) incorporates the European Convention on Human Rights into UK law, but while ‘Article 9 protects the right to freedom of thought, conscience and religion. This right is subject to qualiflcation and cannot be used to support an action that disproportionately infringes the rights and freedoms of others.’
At a practical level GPC guidance states: ‘if a pharmacy professional is unwilling to provide a certain service, they should take steps to make sure the person asking for care is at the centre of their decision-making, so they can access the service they need in a timely manner and without hindrance’ (GPC, 2017). But is it acceptable that the beliefs of an individual pharmacist should hinder or prevent them from undertaking their professional duties?
This raises the issue of conscientious objection (CO). Wicclair (2017) advances the argument that chief among the compelling reasons to accommodate health professionals' COs is to allow them to maintain their moral integrity. This in turn provides a ‘moral space’ within which they can practice. By contrast, in considering the example of emergency hormonal contraception (EHC), Deans (2013) argues that a principled categorical refusal by an individual pharmacist to provide EHC is not morally permissible, and that a pharmacist cannot legitimately claim exemption from providing a standard service, even if the service is available elsewhere.
A more strenuous line is adopted by Schuklenk and Smalling (2016), who accept that anyone can hold any number of religious and moral views, but ‘what we are denying is that professionals are entitled to subvert the objectives of the professions they voluntarily joined by prioritising their private beliefs over the professional delivery of services to the public, especially when they are monopoly purveyors of these services'. With their somewhat contentious assertion that medical professionals have no moral claim in a liberal democracy to have their COs accommodated, Schuklenk and Smalling (2016) serve to at least stimulate debate over ethical pharmaceutical practice.
Personal beliefs and values are central to who we are. It seems to me that the extent to which we are prepared to allow such beliefs and values to influence our professional lives demands a degree of introspection, which in itself is a worthwhile undertaking.