4.6 CONCLUSIONS
The intention in this chapter has been to consider what are ethical problems for
community pharmacists and to frame such problems in terms of pharmacists’
understanding of ethics and the particularities of community practice. It has been
argued that the pharmacists interviewed in this thesis often identified problems that
were highly contextual in nature – relating to unique aspects of community pharmacy
such as dispensing prescriptions and the minutiae of practice. Many of the issues
identified in this chapter correspond to the ‘ethical dilemmas’ that have been described
previously in the empirical pharmacy ethics literature. But a number of additional and
significant ethical concerns have emerged such as whistle-blowing, EHC supplies,
compliance aids, OTC medicine sales and employees’ company policy. It would
appear that pharmacists do not experience the high profile, ‘neon light’ issues that
frequent the bioethics literature and engage philosophers and lawyers. Perhaps Caplan
and Kane’s somewhat disparaging term, a ‘morality of the mundane’ is a more fitting
term for community pharmacists’ ethical concerns (Caplan and Kane 1990). The
phrase was originally applied to ethical issues that arose in American nursing homes
but Caplan and Kane made it clear that such apparently mundane and ethically
unexceptional environments were, in fact, no less worthy of ethical enquiry and
discussion:
But ethics concerns not only questions of life and death but how one ought to
live and interact with others on a daily basis. The ethics of the ordinary is just
as much a part of health care ethics as the ethics of the extraordinary. (Caplan
and Kane 1990 p.38)
The same may be said of community pharmacy in that pharmacists appear to be
preoccupied by concerns about acting legally when other ethical values may be at
stake and they identify ethical problems in apparently routine tasks such as filling compliance aids or transferring medicines. Yet these remain ethical problems for
pharmacists and despite not appearing to reflect what is often the subject of the
normative applied ethics literature, they are of concern in community pharmacists’
everyday work.
It has also been argued that these routine problems should be so described rather than
referring to them as dilemmas. Although the pharmacists interviewed (and indeed
previous empirical pharmacy ethics studies) often referred to examples of ethical
concerns as dilemmas, it is perhaps more appropriate to term such quasi-ethical issues
as mere problems to distinguish them from the truly irresolvable ethical value conflicts
discussed in philosophy. Again, the intention is not to demote such ethical concerns
but to hopefully distinguish and not diminish the importance of ethical problems for
pharmacists and, as noted in the introduction, one of the aims of the present empirical
research is to identify ethical issues that philosophers, social scientists and lawyers can
comment on or assist with. This more apposite definition of ethical, quasi-ethical or
even practical issues is intended to contextualise and appropriately categorise such
problems.
But what else may be said of the issues identified in this chapter? It is apparent that as
examples of micro-social phenomena, the various ethical problems raised relate to
patients or customers of community pharmacies but that, commonly, pharmacists
appear to deal with representatives or intermediaries. For example, in the initial
examples of controlled drug prescriptions, emergency supplies and compliance aids,
pharmacists often mentioned dealing with a patient’s relative or carer and this appears to distance the pharmacist not only from the patient, as the object of the ethical
problem, but also the consequences of their actions. Moreover, in the case of medicine
sales, whilst patients often presented at pharmacies, delegation occurred and assistants
made most sales as in the example of the pharmacist who was unsure of whether to
intervene in an assistant’s medicine recommendation and sale. Medicine sales also
appear to be discrete transactions that were transitory in nature and, as one pharmacist
mentioned, patients were sufficiently empowered and mobile to take their custom to
other pharmacies if their requests were not granted. It is in this context that one word
in this chapter is conspicuous by its absence and that is relationships. In other studies
(Holm 1997, Uden et al 1992), the relationship between health care practitioner and
patient is identified and argued to be significant. However, differences are identified
between health care practitioners and nurses favour the development of a relationship
with a patient in relation to ethical concerns. As Holm describes the meaning of
relationship amongst his sample:
Nurses speak more eloquently about this subject than doctors, not only when
they recount their own ethical problems but also when they respond to the
cases that were presented during the interview. The simplest explanation for the
difference is that it is a function of their working conditions, as it is both easier
and more necessary for nurses to establish relationships with patients. This
explanation is somewhat supported by the findings that within the group of
doctors interviewed, general practitioners and psychiatrists speak more about
the importance of relationships with patients. (Holm 1997 p. 101)
As the above quotation alludes to, some environments such as hospital medical
practice may be more inimical to developing relationships and this may be true of
community pharmacy. The use of proxies and lack of proximity of pharmacists to patients, and the discrete and transitory nature of medicine sales to customers may
limit pharmacists’ ability to develop relationships and result in the ethical environment
often described in this chapter’s examples. A sense of isolation appeared to prevail in
relation to community pharmacists’ ethical concerns and this theme will be more fully
explored in chapter six.
This chapter has attempted to illustrate what are ethical problems for community
pharmacists and to consider this thematically in relation to a typology of issues that are
characterised by their practical quasi-ethical nature, their legal and procedural origins
and their concern with routine tasks within community pharmacy. In the next chapter,
the question not of what are ethical problems but how they are then resolved is
considered, to build a more complete picture of ethical issues and understanding
amongst pharmacists. The examples provided in this chapter are referred to again in
relation to a framework of decision-making stages and to develop, as will be shown, a
more complete picture of pharmacists as predominantly ethically passive in their
approach to ethical concerns in their work. However, some of the issues developed in
this chapter such as a legalistic approach to ethical understanding and practice, the
routine nature of many pharmacy tasks, subordination and isolation are returned to in
chapters six in discussing in more detail why pharmacists understand ethics as they do,
why they encounter particular ethical problems and, as the next chapter will show, why
they try to resolve ethical problems as they do.
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