From Professor N. Barber, MRPharmS
SIR,-I was delighted to find Professor Hepler responding to an extract from my lecture, "Science, values and the future of pharmacy" (PJ, May 6, p692). As part of that lecture, to illustrate a point, I explained a theory of philosophy and then applied it to pharmaceutical care and concordance. It was this extract that was published by the PJ.
It is clear from Professor Hepler's letter that he recognises this. However, it does mean that he has had to comment on a limited presentation of my arguments. I will address his points in the order they are presented in his letter.
First, I admit I diminished the importance of pharmaceutical care being relationship based. My writing has been on the philosophy of clinical pharmacy, and I would argue that some of its activities, such as decision making on whether a new drug is accepted in a formulary, are beyond the 1:1, professional:patient relationship in which pharmaceutical care seems to have been formulated. These decisions are framed within a relationship with society which, while related (and probably covenantal), is subtly different. There is a need for a philosophy to govern these activities.
Second, a covenantal relationship imposes duties on the patient - what if they do not accept them? Which philosophies govern our relationship with these patients?
I stand by my description of the original pharmaceutical care paper of Hepler and Strand as duty based when analysed from the perspective of ethical principles. The rationale at the start of the paper is all about avoiding harm and creating good. The definition of pharmaceutical care describes duty-based principles at the start and only describes the relationship three-quarters of the way through. However, thinking and debate have progressed in the past decade and other papers by Professor Hepler have made the relationship base clearer.
It is a lot easier to criticise philosophies than to create them. A reader may ask how I define the pharmacist-patient relationship, and I am afraid I only have a rather limp answer - I am not yet clear what it should be. I do have some defence for this position. I have previously related the philosophy of clinical pharmacy to a principle-based description of good prescribing. Although I have made some description of virtue ethics in an earlier paper,1 and briefly touched on the relationship with patients,2 these are not adequate.
For the past few years, I have been part of a multidisciplinary team studying doctor-patient communication about prescribing. I would rather wait until I have conducted more analysis of these findings before reflecting on their significance for pharmacy.
The second and third points are about avoiding harm and doing good. I suspect these come from Professor Hepler having had to deal with an extract from a lecture; we have no differences here - we are trying to do good, and avoiding harm can be considered part of that.
The fourth point is that the philosophical implications of pharmaceutical care are explored elsewhere - I had read the paper referenced and still feel there is a failure adequately to deal with the goal-based ethical issues.
The final point recognises the limitations of pharmaceutical care and calls for greater debate. I welcome this. There is a need to bring together relationship-based and principle-based ethics. Professor Hepler and I have come at the same issue from different angles, both of which are valid. Our goals, and those of others, are to bring them together, perhaps with other theories, in a coherent philosophy. Let us work towards this through more philosophical debate.
Nick Barber
Professor of the Practice of Pharmacy, Centre for Practice and Policy, School of Pharmacy, University of London, London WC1N 1AX
| 1. Barber N, O'Neill R. Suggestions for a new code of ethics. Pharm J 1999;262: 923-5. |
| 2. Cribb A, Barber N. Developing pharmacy values: stimulating the debate. London: Royal Pharmaceutical Society, 2000. |
Professor Barber sent a copy of this letter to Professor CHARLES Hepler, who responds as follows: In his letter, Professor Nick Barber continues our discussion about the philosophical basis of pharmaceutical care. He notes that a covenantal relationship imposes duties on the patient, and asks how a professional would respond if the patient did not accept those duties. Later, he confirms his earlier opinion that pharmacuetical care is "duty-based".
This is an interesting issue, and his question goes to the heart of the subject.
In a professional covenant a mentally competent client or patient voluntarily yields to a professional a measure of the patient's autonomy, ie, authority over his own beliefs and actions, and expects professionally competent care in return. The idea of "yielding" authority is related to the ideas of informed consent and to patient concordance. For his or her part, the professional offers competent care, ie, the professional agrees to harness his knowledge and judgment to serve the interests of the patient and expects co-operation in return. Incidentally, this exchange is seen as occurring among parties who both bring something of value to the relationship: each needs what the other has.
So, the answer to Professor Barber's question is: to the extent that a patient neither believes what the professional says nor follows professional advice, there is little hope of real care.
There is no exchange of value because the patient's behaviour does not help the professional and the professional's skill is worthless to the patient. The professional may none the less try to act on the patient's behalf, but the professional's actual ability to do so would be quite limited, and his ethical obligations would be unlike those in a covenant. For example, a duty to serve patient interest is absurd if a patient will not disclose those interests.
This is not merely a philosophical fine point - a professional usually can improve a patient's quality of life much more with close co-operation from the patient (or patient representative) than without.
In some ways, this is quite hard-edged. In the ethics of covenant, there might be more circumstances in which a professional could ethically decline to continue with patients who voluntarily withhold their side of the covenant. (People who cannot co-operate in their care are outside this discussion, and duty per se may play a much larger role in their care.)
The short answer to the question of what philosophy governs us when patients refuse their side of the covenant is found in the dictionary, under "care". The longer answer is that a covenant for care honours both the principles of beneficence and of respect for persons. One can offer care to someone who does not wish to be cared for, ie, by continuing to offer information and advice about what to do. However, to the extent these offers are rejected, care is impossible except in an abstract and potential sense. In the real world, this would not normally go on forever, but it would mean that when a "prodigal patient" once again requested care, an ethical response would be first to establish or renew the relationship.
Caring for one who does not want to be cared for may evoke images of paternalism, but that is not what I mean. By definition, one cannot force a covenant on another, but one can remain open to a relationship.
To pursue further the distinction between duty-based ethics and covenantal ethics would require more careful definitions than we have been using. I am not sure the distinction matters much as long as we agree that professionals do not have an equal set of duties to everyone.
As far as I am aware, duty-based ethics are unconditional, eg, a duty to tell the truth. Some professional duties may exist outside individual relationships. However, duties to care seem to pre-suppose a professional relationship with an individual.
Professor Barber and I agree about the value to our profession and our patients of a wider discussion of professional ethics. I concur with him that we have approached the same issues from different angles, both of which are valid.