The situations and decisions faced by healthcare are rarely black and white. More often than not, these decisions are shrouded in ethical and moral complexities that not only affect the decisions made at the time, but also influence future decisions through learning processes, reflection, and contextual development. Even in times when the choices don’t seem complicated, everyday circumstances can make it harder to follow than expected.
For example, it is clearly ethical to provide the highest level of care to every patient. But what does ‘highest level of care’ actually mean? Even if the pharmacy staff are efficient and adept at dealing with patients’ problems, wouldn’t the ‘highest quality of care’ dictate that you spend quite a long time (several minutes, even up to an hour or so) with that patient? can spend? Can you be absolutely convinced that every patient who leaves the pharmacy with a prescription understands it? everythingthey need to know and that they will abide by it? The reality is that this is quite difficult to achieve as we have to provide at least some level of quality care to every patient we encounter, despite ethically having to spend time with some patients we don’t really have.
It’s not often that the work of pharmacists is reviewed in a peer-reviewed epilepsy journal. Researcher Ramzi Shawahna, PhD, examined the ethical, legal and professional considerations in everyday healthcare practice by multiple practitioners, including pharmacists.1 He devised a case study of a patient, 32 years old, married without children, who obtained a prescription for valproic acid to top up. The patient had been diagnosed with juvenile myoclonic epilepsy at age 14 and was seizure free until he started a new job with a high stress level and increased travel. He missed doses and had had 3 breakthrough generalized tonic-clinical seizures in the previous month. He traveled to the pharmacy with his car. When discussing driving, the patient indicated that he also uses the car for commuting and does not want to be dependent on alternative transport.
Shawahna used a reflective tool to facilitate deliberations and promote responsible decision-making when professionals face dilemmas in everyday practice. This included several questions such as identifying the ethical issue in the case, the possible course of action, the information to be collected, who the different stakeholders are, how strong the arguments are in the case and how the desired course of action can be carried out. The pharmacists and students who participated answered these questions and their arguments were compared against various ethical principles, such as fairness, trust, efficiency, respect for patient autonomy, legal accountability, benevolence and health maximization. The main weight was that the pharmacist could advise the patient about the dangers or risks of driving while experiencing breakthrough seizures, inform him not to drive during this period and make a decision together with the patient to inform the state authorities set. Voluntary reporting to the authorities was also considered.
High-level ethical decision-making takes into account various ethical components and all stakeholders, such as the patient’s family, the patient’s obligations, employers, friends, law enforcement, and others. Unfortunately, some pharmacists may not discuss driving with the patient at all. The choice to go further and offer knowledge to governments can be seen as a shared, voluntary or mandatory obligation. These are gray areas.
It is best to involve the patient in the joint decision-making process as much as possible, and this includes other cases as well, such as when the patient engages in other contraindicated behaviors or even contraindicated therapeutic modalities. Ethical decision-making is not an innate quality; but rather it is something that we can continuously improve upon.
Additional information about Ethical decision making can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.
Shawahna R. Facilitating ethical, legal and professional considerations to resolve dilemmas in everyday health care: a case of driver with breakthrough seizures. Epilepsy and behavior. DOI: 10.1016.i.yebeh.2019.106703
About the author
Shane P. Desselle, RPh, PhD, FAPhA, is a professor of social and behavioral pharmacy at Touro University California College of Pharmacy.