From Mr J. C. Gould, MRPharmS
SIR,-I agree with Nick Barber (PJ, April 15, p603) that pharmaceutical care "is a duty-based philosophy of practice".
This can be illustrated at the most fundamental level in that all decisions community pharmacists make at the praxis are necessarily referred (or ought be) through codes of deontological morality. I refer specifically to the "categorical imperatives" capsulised in our Code of Ethics and the various pertinent dispensations of the law in, say, the Medicines Act 1968 or the Misuse of Drugs Act 1971.
While many colleagues may regard the "philosophical musings" thus far expressed on this topic to be part of what is a generally vapourous, circumlocutory debate, ethics, it should be noted, is, in many respects, a very precise science. Language, in particular, a concern for the exact meanings of words and how they are juxtaposed, is of paramount importance. To conflate, in even the slightest manner, what is meant by, say, the word "good" (or beneficent) with what is meant by the word "right" (or true) can instantly invalidate a line of argument in moral philosophy.
For example, Professor Hepler's contention (PJ, May 6, p692) that "values actually inform, or should inform, every part of professional practice" is a contradiction in terms. "Values", being arbitrary, discretionary intellectual constructs, have no place in discussions of "duty-based" morality. They (values) pertain to the realm of teleology - a branch of ethics which concentrates on how the scientific principle of "cause and effect" can be employed to direct means to ends in the pursuit of universal happiness or, say, the greater "good", etc. The pragmatist, utilitarian systems of morality developed by philosophers like John Stuart Mill, Jeremey Bentham and Herbert Spencer are teleologies as opposed to much of Emanuel Kant's work, which is, for example, concerned with duty-based morality or deontology. The point is that "values" should inform nothing. No duty is owed in respect of any value.
Ethical dilemmas can and do arise at the pharmaceutical care praxis. The most interesting and difficult are those that involve conflict between pertinent deontologies. Consider the following example.
An inspector on a routine visit notes the following entry in a pharmacy's private prescription register:
Emergency supply
Customer: a foreign national not registered with a British GP
Customer's GP: a foreign national, not registered in Britain
Date: XX/XX/2000
Place: an airport pharmacy in Britain
Time: any Sunday, 6.35am
Medicine dispensed: tabs glibenclamide 5mg, ii od, 20 (twenty) tablets dispensed
The pharmacist making this supply supplements the entry with the following addendum:
"Customer diabetic in need of glibenclamide tablets 5mg. Has lost current supply in preparations for journey and begining to experience what are the symptoms of hypoglycaemia. Twenty tablets dispensed to cover return journey to foreign rural districts where customer advises that his medication may be difficult/impossible to obtain. Dispensed in this quantity and despite not having a British registered GP because of potential harm to customer were supply in sufficient quantity refused."
The inspector detecting this entry has no option but to prosecute the pharmacist for criminal breaches of the Medicines Act 1968. To turn a (teleological) "blind eye" to the transgressions would be wrong - an abnegation of the moral duty he or she has to uphold the law of the land.
The pharmacist, in his or her defence, argues that the customer had a flight to catch within 45 minutes of discovering that he had lost his tablets and would have taken that flight with or without his tablets and contrary to any warnings given about the danger of so doing. Supply had therefore been granted in respect of the moral imperative capsulised in Principle One of his or her Code of Ethics: "A pharmacist's prime concern must be for the welfare of the patient and other members of the public."
Here then, is an ethical dilemma in which two legitimate deontologies are drawn into direct conflict at the pharmaceutical care praxis. The "values" held by the inspector and the pharmacist are irrelevant. Doing the right thing - acting in accordance with one's duty - generates a Catch 22 situation.
This scenario is one of scores that come to mind, and not merely to do with the provisions for emergency supply. The broader point I would make is that while pharmacy has moved into a New Age, the laws that govern its practice are over 30 years out-dated and increasingly likely to generate ethical questions that cannot be dismissed as mere "philosophical musings".
John Gould
Bishop's Stortford, Hertfordshire
Mrs Susan Sharpe (director of professional standards, Royal Pharmaceutical Society) comments: While I do not wish to challenge the central thesis of this letter, that dilemmas can arise where what the law requires is incompatible with the needs of a patient, it is wrong to state that the inspector has no option but to prosecute the pharmacist. Decisions whether to prosecute (taken by the Council, not by individual inspectors) will take into account all the circumstances leading to commission of an offence.
In nine years that I have held this position no case such as that described has led to a prosecution.
A pharmacist must give very careful consideration in such cases to the legal requirements.