Several years ago, a hospital pharmacist came out of the IV admixture room to consult with the other pharmacist on duty. They both looked at a paper order. On the left side was the physician order, “1500 mg morphine sulfate in 50 cc normal saline.” On the Progress Note on the right side of the sheet it said, “Have discussed with family. Will ease patient out.”
A patient brings in a prescription for an abortifacent drug.
You have one dose of a special medication and both your patients on it need it today. One is a productive member of society and the other is on welfare. Or one is a man and the other is a woman. Or one is an adult and the other is a child.
A man comes into a pharmacy. His drug abuse is well known, as the multiple needle marks on his arm testify. He wants to buy insulin syringes and needles; his profile shows no diagnosis or other medications that indicate the need for such a purchase.
What are you going to do in these situations? Fill the fatal cocktail? Who gets the medication? Dispense an abortifacent drug? Sell or deny the syringes?
This blog has addressed professional judgment and conscience clauses in the past. And these do have a bearing on the above situations. However, the major part of the decision-making in these cases is not going to fall on these, but land right in the lap of morals and ethics.
And these situations are coming, if they have not already arrived, at a pharmacy near you.
Moral and ethical issues are becoming a larger part of practice. And as the profession of pharmacy continues to expand and evolve, the numbers of these will increase. New issues emanating from morals and ethics that we cannot imagine now will join those we are currently familiar with.
Morals and ethics are developed over time by the influences we have in our environment. Parents, teachers, friends, spiritual leaders, all act and talk in ways that help us decide what morals we embrace, what ethics we follow. They may evolve or change over time as these influences wax and wane, as old influences depart and new ones enter our environment. As we enter adulthood, most of us have a core set of values.
What is a moral issue? It is a decision to provide or not provide some service to a patient, the decision not having a professional basis but one that arouses intense moral or ethical ( I am including religious when using the words “moral and ethical”) feelings. “Can I provide this service when it’s strongly offends my personal beliefs?” When these feelings collide with professional service, the pharmacist is undergoing a moral dilemma. “How can I provide a fatal cocktail for a patient when doing so offends my belief that all life is sacred and death should be left to God, not man?”
While commentators have addressed this in many print, live, and online forums, the bottom line is that there is no easy answer to the moral dilemma. Denying the patient is not an appropriate act when the sought after result is the pharmacist’s personal satisfaction. The patient comes first. Yet, how does the pharmacist fulfill her professional duty in an appropriate manner when that duty regularly, or rarely, calls upon the pharmacist to compromise or abandon long held beliefs?
Let’s look at the patient seeking clinically assisted end of life (I, for one, do not consider it suicide). This is legal in five states. Twenty-two others are considering legislation on the issue, and more will do so in the coming years. Are you ready to face this? A well-informed patient making a lucid decision to end horrific pain (and the full expectation that her life will end soon anyway) versus taking part in an affirmative step to ending a life. I recognize that for some, this is an easy decision, but recent polls show that it is a moral dilemma for approximately half the pharmacists in practice today.
The way end of life laws are written, pharmacists can rest assured the patient is making an informed decision. Hence, there is no legal issue. As well, most states provide a shield against liability if anything goes awry during the administration of the fatal drugs. (Most end of life laws also have opt-out provisions for health care professionals who do not want to participate, but this blog is for those who do seek to resolve dilemmas) This leaves the issue of participation solely in the moral arena.
How do pharmacists–and others–resolve a moral dilemma? Understanding that the following will not fully remove doubts and concerns, I suggest this as criteria:
1. Seek to view the situation as objectively as possible, outside the scope of morals
2. Make your priority standard “the best interest of the patient”
3. Review the latest literature on this issue for any concepts/thoughts that may ease the dilemma
4. Get the opinions/thoughts of peers on both sides of the dilemma
Keep in mind that following your morals over a patient’s wishes/decision may have circumstances. I have seen more than one pharmacist lose a job, be sued, and/or be punished by a Board of Pharmacy for deciding a patient’s therapy based on the pharmacist’s ethics. I regularly encounter pharmacists who defiantly announce they will not surrender their morals and ethics to the profession or patients. Remember the pharmacists who did this in the past ended up in court and lost. Holding on to morals produces self-worth and satisfaction, but does not pay the mortgage, car, the kids’ braces, etc. The battle between professional service and personal beliefs needs to be resolved, to the best of your ability, before the moral dilemma appears. Doing so will not provide you with a 100% solution; it may help prepare you for the lack of satisfaction if you provide the service or the repercussions if you do not.
I have heard it said: “If you cannot provide the service, you do not belong in pharmacy.” I do not agree. Pharmacists are compassionate and caring people. We did not get this way by a lack of morals, but with a set of deeply ingrained set of strong beliefs. Thus, however we may feel, at some point we are ALL going to face a moral dilemma.
Thus, the question becomes: how will we respond?