The Pharmaceutical Journal Vol 264 No 7095 p692
May 6, 2000 Letters

Pharmaceutical care

Relationship-based, not duty-based

From Professor C. D. Hepler, PhD

SIR, - According to an extract of his lecture on March 29 to King's College London, Professor Nick Barber believes that pharmaceutical care is a "duty-based philosophy of practice" (PJ, April 15, p603). He also asserts that pharmaceutical care is preoccupied with avoidance of harm (non-maleficence) at the expense of other ethical principles, in particular, creation of good (beneficence). This, he says, keeps pharmaceutical care from being a complete philosophy. He states that he developed his impressions from reading the 1990 paper by Linda Strand and myself.¹
I believe it is necessary to reply to Professor Barber's comments. I am aware that some  practical-minded people may feel impatient with "philosophical musings" (PJ, April 22, p609); however, values actually inform, or should inform, every part of a professional practice. The question is not whether moral philosophy is important in professional life but, rather, how clearly professionals recognise fundamental values and how well they can connect their actions to those values.
Therefore, with all respect to Professor Barber, five points must be made to restore some measure of intellectual balance. First, although many highly respected ethical systems are duty-based, our 1990 paper on pharmaceutical care clearly states that the ethical basis of pharmaceutical care is covenantal (relationship-based), not duty-based.  The significance of this is, in part, that pharmacists do not necessarily have professional relationships with, nor owe a duty of competent caring to, every customer. They do owe competent care to those with whom they have a professional relationship. The 1990 paper offered  many supporting references to earlier work, including  the work of William F. May, which could clarify these points.
Second, non-maleficence can be - actually should be - seen as a part of the idea of beneficence. The usual formulation of the principle of beneficence is: first, do no harm; second, prevent harm; third, remove harm; fourth, create good. Actually creating good, distinct from removing harm, is often beyond the power of health professionals, but that would not invalidate the ideal. For example, attempts to remove the harm of disease may cause further harm. The existence of preventable adverse outcomes of medicines use offer hundreds of pertinent examples. Separation of beneficence and non-maleficence is arbitrary, at best.
Third, as the extract itself states, the objective of phar-maceutical care is to achieve therapeutic goals. These are enumerated in the 1990 paper as including the cure of disease and control of symptoms. The very definition of pharmaceutical care refers to the purpose of improving a patient's quality of life. These points should make it abundantly clear that pharmaceutical care goes beyond a preoccupation with avoiding harm.
Fourth, the 1990 paper had a broad and practical scope. It did not focus on the questions to which Professor Barber has sought answers. Other publications have explored the philosophical implications of pharmaceutical care in a bit more detail.²
Finally, I readily admit that pharmaceutical care is not a complete philosophy. Frankly, many "complete" philosophies resort to dogma, which is recognised as a dangerous guide for professional activity. On the contrary, pharmaceutical care could, with lots more scholarship from many people, become a valuable part of a philosophy of practice.  The paper on the basic values of pharmacy, mentioned by Professor Barber at the end of his presentation, and to which he has significantly contributed, will be a most welcome step in that direction.

Charles D. Hepler
Distinguished Professor, College of Pharmacy, University of Florida, Gainesville, Florida, United States

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