The Pharmaceutical Journal Vol 265 No 7111 p308-312
August 26, 2000 Articles

Values and the practice of pharmacy

By S. W. F. Holloway

In this article the author reflects on the continuing debate on the place of values in pharmacy and suggests that greater attention should be paid to what pharmacists actually do and less to what others think they ought to do

In a lecture delivered at King's College London on March 29 this year,¹ Professor Nick Barber argued that the philosophy of pharmaceutical care, as proposed by Hepler and Strand in 1990,² is flawed in several ways. The importance attached to the idea that "pharmaceutical care is provided for the direct benefit of the patient" leads Professor Barber to conclude that "this is a duty-based philosophy". Moreover, pharmaceutical care is preoccupied with avoidance of harm at the expense of other ethical principles like doing good. Since there is no mention of goal-based issues, this philosophy is incomplete; it will not be sufficient for all circumstances. It will not help to deal with such questions as: "If a drug had a low chance of success yet is very expensive, should the NHS pay for it? Or should an antibiotic be given when a throat infection is of unknown cause, but probably viral?" Although Cipolle, Strand and Morley explicitly recognise rights-based morality in their 1998 book on pharmaceutical care,³ there is still no mention of one based on goals. Moreover, they fail to make clear how their philosophy would deal with a patient who wanted to die by euthanasia. The problem with the philosophy of pharmaceutical care seems to be that none of its advocates had heard of Ronald Dworkin's typology of political theories. A greater understanding of philosophy would have led them to use a mixture of moral theories. They should have sacrificed simplicity on the altar of greater adequacy.
Professor Charles Hepler replied to Professor Barber's comments in the correspondence columns of The Pharmaceutical Journal in May.⁴ It seems that Professor Barber had misread and misinterpreted the famous 1990 paper by Hepler and Strand. That paper "clearly states that the ethical basis of pharmaceutical care is covenantal (relationship-based), not duty-based". Moreover, avoiding harm is really much the same as doing good. "Separation of beneficence and non-maleficence is arbitrary, at best." The object of pharmaceutical care is to achieve therapeutic goals, like the cure of disease and the control of symptoms, and even improving the patient's quality of life. So Professor Barber should have realised "that pharmaceutical care goes beyond a preoccupation with avoiding harm". None the less, Professor Hepler had to admit that "pharmaceutical care is not a complete philosophy". A systematic, coherent set of principles would be "a dangerous guide for professional activity". Worse still, it might even bring to an end the philosophical debate.
But no such luck! Professors Barber and Hepler returned to the fray in June.^5,6 Professor Barber was delighted to be corrected by Professor Hepler, but was still puzzled about the pharmacist-patient relationship. "I am not yet clear what it should be," he writes. When a decision has to be made on whether a new drug should be included in a formulary, do you have to think about society as well as the patient? Does the idea of a covenant impose duties on the patient? What if the patient does not play ball? "Which philosophies govern our relationship with these patients?" This is the sort of question the Old Testament prophets kept asking God the Father! In those days, paternalism and caring went together, but, in more secular times, Professor Hepler has to go out of his way to stress that he has no truck with paternalism. Strangely enough, however, his answer to the problem of how to deal with a person who rejects one's care draws upon the imagery and moral of Christ's parable of the prodigal son. Always remain open to the potential of care even if it is rejected; and when care is again requested, renew the relationship.
Before Professor Hepler reaches this compassionate conclusion, he rehearses the hard-edged arguments that derive from philosophical individualism, in which the patient is conceptualised as an autonomous individual, inherently capable of choosing the course of action appropriate to his or her best interests. If such patients refuse to co-operate, the pharmacist could ethically decline to treat them. "Pharmacists do not necessarily have professional relationships with, nor owe a duty of competent care to, every customer." In a professional relationship, a mentally competent patient yields to the professional a measure of the patient's autonomy. "To the extent that a patient neither believes what the professional says nor follows professional advice, there is little hope of real care."
Professor Hepler tempers the logic of this philosophy with a knowledge of the realities of practice. Others may be less merciful. These are the words of Kim Bessell, (president of the Pharmaceutical Society of Australia [South Australia branch]): "As Janne Graham (Consumer Health Forum) would say, if you provide adequate directions on the pack label, give them the CPI [comprehensive patient information] and then the consumer throws all the info away, takes an overdose and dies, well that is the right of the consumer! They can accept or reject whatever we advise or provide; that is their decision. If we withhold information because we think the consumer may become scared, not use the medication or may not understand the info, then we are playing God. Remember that it is a pharmacist's duty of care to ensure the ‘safe and effective use of medication'. If a pharmacist provides the info and counselling for that duty of care and the consumer decides to do something else, well that's their decision, the pharmacist has fulfilled all his/her responsibilities."⁷
Kim Bessell's statement draws attention to some of the less benevolent implications of ethical principles. "Respect for the autonomy of the individual" turns the patient into a consumer and allows the pharmacist to relinquish all responsibility for the death from an overdose. Yet the autonomous individual is nothing more than a metaphysical myth - an invention of philosophers in the 17th century. The professional-patient relationship is a relationship; the professional and the patient are interdependent, in fact and in theory. Interdependencies necessarily constrain people to a greater or lesser extent. There can be no relationship without reciprocity. Pharmacists who treat their customers as autonomous individuals deny the very possibility of a therapeutic relationship. Professor Hepler's imaginary covenant is another moral fiction, but one in which interdependency is highlighted. There is, however, no actual covenant between patient and professional. The danger is that, if we allow philosophers and lawyers to over-rule doctors and pharmacists, the patient will end up being obliged to sign a legally binding contract before any therapy can begin.
Instead of starting from abstract principles and moral fictions, it might be better to begin with a more modest but more realistic understanding of the patient founded on empirical research. Professor Alison Blenkinsopp has led a team of researchers working with patients suffering from hypertension, asthma and depression.⁸ Their work has highlighted differences in perspectives between patients and health professionals on the subject of medicines and medicine taking. Patients were found to have quite different understandings and information needs than those anticipated by health professionals. Far from treating patients as knowledgeable, sovereign individuals, the pharmacist would do well to listen to their concerns, appreciate their difficulties and provide them with individually tailored information. The patient is not an isolated individual, but is bound into relationships with families and friends; their attitudes and understandings may initially carry greater weight than those of the health professional. The patient's freedom of choice is expanded by the intervention of the pharmacist: his or her scientific expertise is made available to the patient.
If all this is true, the pharmacist who approaches his relationships with patients with his mind unencumbered with preconstituted, ahistorical, philosophical constructs is more likely to carry out his duties effectively than someone who has undergone a rigorous training in value literacy. The issue is a matter not of open versus closed minds, but of the validity of the theories, perspectives, concepts and ideas that we use to make sense of ourselves and of our relationships with other people and other things. The more congruent with reality our concepts are, the better will be our understanding. The search for facts should precede the application of values. Science is a superior form of knowledge than philosophy. It produces solutions instead of interminable discussions.
The distinction between what is and what ought to be is fundamental to this discussion. Professor Hepler eludes this issue when he writes: "Values actually inform, or should inform, every part of a professional practice." Whether values, and which values, permeate professional practice is a matter of fact which can, in principle, be discovered by empirical investigation. The statement that values should inform practice is an expression of Professor Hepler's own values. It is open to debate, but not to further confirmation.
What are values? How are they to be identified? The obvious place to turn for guidance must surely be "Developing pharmacy values: stimulating the debate", a discussion paper produced by the Royal Pharmaceutical Society's core values working group and published by the practice research division of the Society.⁹ Dr Alan Cribb and Professor Nick Barber carried out the research and prepared the first draft for the working group. The pamphlet, attractively produced on smooth and shiny paper, has the appearance of a glossy holiday brochure: the discussion paper is clearly intended to have wide circulation. Values, the authors state on p17 of the document, echoing Professor Hepler, are pervasive. "Values do not only define the framework of what matters in pharmacy, by determining the goals and the relationships inherent in the profession, they also make up its warp and woof. . . . The philosophy and practice of pharmacy are not separate. All of the many day-to-day judgments and actions of pharmacists embody values. . . . Values are at the ‘core' of pharmacy." This passage seems to be a statement of fact; a statement of what "is" rather than of what "ought to be". If this is the case, then the question of what the core values of pharmacy are can be answered, and can only be answered, by empirical research. This view of values as objective social facts which determine the aims, relationships and actions of pharmacists is also evidenced in the lecture on "Science, values and the future of pharmacy", delivered by Professor Barber in March and referred to at the start of this article.¹ In it, he confidently asserts that "values are the motives for action". In the typescript of his lecture, he writes: "It is values that drive technology development, and it is values that determine how we set policy and decide on how we measure and interpret the effects of technology." This perspective envisages values as drives or forces acting upon individuals and groups and compelling them to act in certain predetermined ways. The autonomous individual has vanished, and in his place we find an automaton controlled by ubiquitous values. Individual desires have been replaced by collective obligation.
Alas! Things are not so simple. The search to discover the meaning of the term "values" is not yet over. The authors of the Society's discussion paper⁹ use the term "values" in other and quite contrary ways, without signalling the difference. When they ask, "what exactly are the values on which pharmacy is based?", they reply in terms of what goals pharmacists ought to be working towards, and what valuable qualities of conduct and character ought they to manifest in the way they work. Thus values become aspirations or ideals to be realised in the future, and not the motives and forces which explain the present. Instead of empirical facts that might be discovered by psychologists and sociologists, we have subjective expressions of preference. To clarify this point, consider the example of the medical profession. In 1995–96 the British Medical Association made a little list of its core values. In alphabetical order, it ran thus: advocacy, caring, commitment, compassion, competence, integrity, responsibility, and spirit of inquiry.⁹ Does anyone believe that these values determine the goals and the relationships that actually exist within the medical profession? Do these values explain the behaviour of doctors? Was the BMA seeking to describe reality or taking part in a public relations exercise? If a serious attempt were made to specify what the core values of the medical profession actually were, would not some reference have to be made to the pursuit of monetary rewards and ambition for promotion and honours? If reality is compounded with ideals, understanding evaporates. "Developing pharmacy values: stimulating the debate" does not help us to grasp the meaning of values. The expectation aroused by the title, that the latent image of pharmacy values is about to be made manifest, is not fulfilled.
Professor Barber, in his recent lecture, comments on the division between "is" and "ought". "I think," he says, "it describes well the core of pharmacy practice research. We study the facts of what people do - what practice is, and we go on to make recommendations of what practice is good-what pharmacists ought to do." At the start of his lecture, Professor Barber seems to endorse the view that there is a fundamental split between facts and values and, in the pharmacy values discussion paper, the word "values" is used "to refer to all those aspects of pharmacy that are not purely factual or technical."⁹ Yet Professor Barber also believes that "scientific investigation can provide facts that lead to value statements about the profession" and "research into the real processes will be used as a basis for deciding which values are the right ones to apply". Knowledge of the facts will be used to determine the values. This could be taken to mean that whatever is, is right. But we can be confident that Professor Barber does not hold such a view. He wants to change the profession of pharmacy. What he seems to be saying is that practice research identifies, or can be used to identify, good practice. Practice research would, therefore, demonstrate that good practice was possible and would indicate the conditions necessary for its accomplishment. This assumes, however, that we already know what constitutes good practice and that there is a consensus within the profession on this point. It is just possible that Professor Barber is saying that what he thinks is good practice should be taken on board by the whole profession.
One of the principal findings of the discussion paper "Developing pharmacy values: stimulating the debate" is that there is a need for pharmacists to become more literate about, and engaged with, value issues. "This will require a cultural change for the profession," the paper concludes.⁹ A recently published research paper on the ethical awareness of community pharmacists seems to suggest otherwise.¹⁰ Derek Hibbert, Judith Rees and Ian Smith argue that ethical dilemmas are a recurrent feature of community pharmacy, that pharmacists are aware of ethical issues and have the practical skills to deal with moral uncertainty. The researchers claim that the examples of ethical dilemmas revealed in their interviews "could be classified and interpreted to demonstrate a knowledge of the basic ethical concepts and the wider legal, occupational, organisational and personal value sets which encompass ethics in the work place". Although different pharmacists respond to the same ethical dilemma in different ways, "this situation is acceptable since ethical dilemmas often have more than one right answer, but it is essential that each pharmacist should be able to justify and defend his or her decisions on a moral basis". Perhaps, therefore, some training in value literacy would be helpful.
Hibbert, Rees and Smith deserve credit for setting out to discover, by empirical research, the extent to which community pharmacists encounter and resolve ethical dilemmas in their daily work. But their investigation is contaminated by the fact that the concept of "ethical dilemma" was imposed upon the participants from the outset. We can never know whether the pharmacists in the study would have themselves conceptualised these matters as "ethical dilemmas". The fact that few of the pharmacists interviewed claimed to consult the Royal Pharmaceutical Society's Code of Ethics to resolve day-to-day issues or indeed to know the code in any detail suggests that the ethical dimension of the remembered encounters was not uppermost in the pharmacists' minds. A much more serious objection to this study relates to the interpretation imposed upon the data. The authors claim to have found "evidence that pharmacists demonstrated a direct or implied knowledge of the normative principles which underpin professional responsibilities and obligations. These principles are autonomy, beneficence, non-maleficence and justice."
A pharmacist's statement that patients have got a right to know about the side effects of medicines, is taken to demonstrate that he "had an awareness, and appreciation, of the concept of patient autonomy even if the term was not expressed explicitly". The authors continue: "The implication here was that the patient had ‘rights' (the capacity for free action and rational choice) and that the pharmacist was respecting these ‘rights', in other words, patient autonomy." The authors have no justification for imposing this interpretation on what the pharmacist said. It could be said, with equal authority, that the pharmacist recognises that the patient's choice and freedom of action is so restricted that without his active intervention the patient will be completely dependent on the decision of the prescriber. What minimal freedom the patient has in respect of his medication is created for him by the action of the pharmacist. In another example, the authors assert that a pharmacist had taken the ethical principle of beneficence into account in dealing with a customer and they conclude that "the principle of beneficence overrides that of autonomy in the ethical decision-making of this pharmacist". Yet no evidence is presented that the pharmacist referred to either principle in the interview. If Professor Barber has difficulty in identifying the ethical foundations of Hepler and Strand, how are Hibbert, Rees and Smith able so confidently to unearth the principles hidden in these interviews? There can be little point in interviewing people unless you intend to treat what they say seriously on its own terms. Hibbert, Rees and Smith imply that they know better than the pharmacists themselves what is really being said. If the pharmacists had conceptualised their actions in the language of formalised normative principles, would they have acted in the way they did? What is the relationship between how people define the situation and how they act within it? How fortunate one would be to have one's examination papers marked by Hibbert, Rees and Smith: after writing banal drivel, one would presumably be credited with a deep knowledge of abstract and theoretical ideas.
Hibbert, Rees and Smith appear to believe that the principles of autonomy, beneficence, non-maleficence and justice do, in reality, form the substructure of professional responsibilities and obligations. They imply that beneath the surface of everyday behaviour, there lies a bedrock of ethical principles which can be discovered by scientific methods of inquiry and formulated as abstract universal statements; these underlying principles are the fundamental causes of ethical behaviour. This is an upside-down way of looking at the world.
Hibbert, Rees and Smith may be justified in saying that a pharmacist's statement exemplifies an ethical principle, but it does not follow that the pharmacist's behaviour was caused by the principle. Individuals, when asked, invariably provide reasons for doing whatever they do. The pharmacists in this study, when invited to recall recent examples of ethical dilemmas in their practice, had no difficulty in categorising segments of their behaviour in this way. But can we then take their statements and reinterpret them to get at underlying values? Only if we admit that the process of symbolic reinterpretation has no empirical controls and consequently may differ fundamentally from one researcher to another. Moreover, the relationship between statements of motives, reasons and purposes, on the one hand, and actual behaviour, on the other, remains unanalysed.
Hibbert, Rees and Smith seem to believe that autonomy, beneficence, non-maleficence and justice do in reality underpin the professional responsibilites and obligations of pharmacists. But these principles have only existed as a set for less than a decade. Each principle has a venerable ancestry from quite separate families of discourse. Far from living happily together, the first and the last have difficulty in co-existing; they have been torn like bleeding chunks from incompatible bodies of organic thought. They were crudely stitched together by Beauchamp and Childress¹¹ to take their place in the long series of attempts to establish a code of medical ethics.
Far from constituting a bedrock of unchanging moral imperatives, medical ethics change with the times. The perception of what is "ethical" has changed greatly in the past. At different periods and in different groups, practices like infanticide and abortion and a doctor's refusal to take hopeless cases presented no problems: at other times they encountered the severest moral censure. Hippocratic ethics are now seen as an expression of the loftiest moral ideals, but were originally designed to protect one group of physicians against competition from another. A system of ethics that appeared to benefit the patient at the expense of the doctor was devised to give a competitive edge to the practitioners who espoused it. Before the introduction of licensing and diplomas, the moral goodness of health practitioners was inseparable from their technical competence. The ethics of bedside conduct were justified as a way of making the doctor a more effective healer; they boosted the mutual confidence of patient and practitioner.¹²
A Muslim, a Hindu, a Calvinist, a Catholic, a Marxist, and a Humanist all refrain from stealing: but each gives a different explanation of his conduct, and each explanation can be linked to a set of values fundamentally different from the rest. Similarly, any action, no matter how atrocious, can be justified in terms of the verbal formulas in which values are couched. The most appalling single act in the history of mankind, the dropping of an atomic bomb on Nagasaki, has been morally justified by philosophers in the United States of America. The genocide and ethnic cleansing of the native Indian population, intrinsic to the creation of the American nation, was carried out in the name of Christian civilisation.The appearance of new and the disappearance of old values and their constant readjustment within the hierarchy of values become incomprehensible under the assumption of the sovereignty of real, underlying values. The most important questions that can be asked of any set of values are: Whose values are these? Whose interests do they serve? What consequences will follow from the adoption of these values? Who will benefit? Who will suffer? Philosophy can be used to obscure these issues, to mystify reality. Debates about values are reflections of power struggles between different groups, and they are decided, not by rational argument, but by the balance of power between the contending groups. The victors are given medals; the defeated are arraigned before war tribunals.
One of the ethical principles, which Hibbert, Rees, and Smith see underpinning professional responsibilities and obligations, is "justice". In the first book of Plato's ‘Republic', Socrates and Thrasymachus discuss the meaning of "justice". Thrasymachus claims that justice "means nothing but . . . the interest of the stronger party. . . . in every case the laws are made by the ruling party in its own interest. . . . By making these laws they define as ‘right' for their subjects whatever is for their own interest, and they call anyone who breaks them a ‘wrongdoer' and punish him accordingly. . . . in all states alike ‘right' has the same meaning, namely what is for the interest of the party established in power, and that is the strongest." Socrates attempts to refute this view by saying that, if Thrasymachus's notion of justice were correct, people would be divided, hate one another, and engage in conflict. For Socrates, "justice" is the state in which everybody does what he is supposed to do, a state of perfect harmony, without conflict and without change.¹³
This brief incursion into the history of philosophy makes clear that the concept of justice has always been a contested issue, not some unchanging essence. Fortunately, neither Socrates nor his many followers have had the power to enforce their notion of what justice is on the rest of us. Societies throughout history have been filled with conflict, striving, deceit and cunning. Far from being predictors of behaviour, values are themselves the product of the constant interplay of interests, changing conditions, dominance, force, fraud, ignorance, and knowledge. Thrasymachus alerts us to the need to stick to the facts of the case and to be suspicious of appeals to abstract principles and moral imperatives.
Let us return to consider pharmacy as it is actually practised in Britain today. Hibbert, Rees and Smith are surely right in their conclusion that pharmacists, using their common sense, already have the practical skills to deal with whatever ethical issues they encounter in their daily practice. But this is not because they have some innate moral gyrocompass, or because they have undergone courses in value literacy, but because they are subject to various forms of regulation. There is here an important distinction between values (including ethical principles) and specific rules of conduct. These standards are not the result of values, although the existence of values is often inferred from the operation of standards. Standards are enforced by sanctions and buttressed by rewards. They represent the cutting edge of social control. Values are the vague, slippery ideologies, rationalisations, and generalisations people use to justify their observance or non-observance of rules. Values are the limitless sophistries of thought that gush from the mouths, computers and pens of politicians, journalists, priests, philosophers, academics, scientists and other special pleaders.
This distinction between rules and values is not an empty intellectual exercise. It is crucial to empirical investigation of pharmacy practice. The pharmacist's role cannot be understood without reference to the rules which govern his or her professional relationships. These rules represent the present state of power relations controlling the pharmacist's behaviour. The rules both constrain and empower. They can best be understood by examining the mechanisms by which the role of pharmacist is regulated.
A valuable classification of social rules was proposed by Professor Ralf Dahrendorf in 1958.¹³ He distinguished three kinds of role expectations: "must" or "mandatory" expectations; "shall" or "preferential" expectations; and "can" or "permissive" expectations.The labels he has used indicate the relative strengths of the sanctions for each type of rule. "Must" or "mandatory" expectations are reinforced by legal or quasi-legal sanctions, and refer to the rules and standards that must be complied with to avoid prosecution in the law courts or being brought before the Statutory Committee. "Shall" or "preferential" expectations refer to the basic minimum requirements of professional role performance. These are the requirements that pharmacists must meet to avoid being sacked, losing out on promotion, becoming bankrupt, or being labelled by others as idle, irresponsible, or incompetent. The sanctions attached to "shall" or "preferential" expectations were until recently mainly economic and social. Within recent decades even basic professional role performance has become increasingly subject to legal and quasi-legal regulation. "Can" or "permissive" expectations refer to ways of performing occupational roles, over and above minimum requirements, which gain social approval for the individual.
Dahrendorf's classification is both dated and rudimentary but, by focussing on rules and sanctions, it brings an air of reality into the discussion of values and professional practice. What pharmacists think they ought to do is more likely to be determined by what they must do than the other way round. An investigation of the structure of sanctions and rewards will provide a better understanding of actual behaviour than the analysis of verbal rationalisations.
The concept of "pharmacist" is a functional concept. Throughout the world, "pharmacist" is defined in terms of the function that a pharmacist is characteristically expected to fulfill. It follows that the concept of a pharmacist cannot be defined independently of that of a good pharmacist; the criterion of somebody being a pharmacist and the criterion of somebody being a good pharmacist are not independent of each other. And both sets of criteria are factual. On the basis of facts alone, we can determine whether a person is a good pharmacist or not. From such factual premises as "Each year she spends part of her annual vacation attending the British Pharmaceutical Conference", "She has recently set aside part of her pharmacy as a site for confidential consultations," and "She has substantially increased the number of prescriptions dispensed at her pharmacy during the last year", the value-laden conclusion validly follows that "She is a good community pharmacist". Similarly, from the premise "He is a hospital pharmacist", the conclusion may be validly inferred that he ought to do whatever a hospital pharmacist ought to do.
In Great Britain, the concept of "pharmacist" is legally and institutionally defined. All pharmacists are members of the Royal Pharmaceutical Society of Great Britain and are registered pharmaceutical chemists. The Royal Pharmaceutical Society, acting within the framework of national law, is, therefore, the body authorised to define the duties and responsibilities of the pharmacist in Britain. The Society, under the constraints of the legal system, is the final arbiter of which values should inform the professional practice of pharmacy; the Society has the authority to ensure that the values which should permeate pharmaceutical practice actually do so. In the past the Code of Ethics has eschewed the declaration of abstract principles to concentrate on detailed and specific guidance for the ethical practice of pharmacy. Such details reassure the public of the practical seriousness of the Society's regulation of its members. Appeals to abstract moral imperatives arouse suspicion and are felt to be ineffective and diversionary.
The process of revising the Code of Ethics is of great importance, and, in a democratically constituted professional association, all members should become involved. The definition of what constitutes good professional practice is a matter for discussion and decision by the members of the Society. It is not something that can be determined by philosophers, and it is certainly not something that has already been determined by philosophy. There is no set of core values enshrined in philosophy waiting to be applied to pharmacy. The Code of Ethics is important, not as a statement of values, but as the basis of professional discipline, the framework for the application of sanctions. The consultation document issued by the Society last year¹⁴ combines a brief gloss on ethics and accountability with substantial sections on standards of professional performance and specifications of service provision. These are the important sections; here is found the public framework against which breaches of professional conduct will be judged. These are the sections the public will consult to determine how well the Royal Pharmaceutical Society is carrying out its essential regulatory function.
In the light of these considerations, the discussion paper, "Developing pharmacy values: stimulating the debate", must be pronounced a disappointing failure. It creates two unfortunate impressions: first, that pharmacists have to be value-literate before they can contribute effectively to current debates in pharmacy (including the revision of the Code of Ethics); second, that such debates will continue indefinitely and get nowhere.
Value literacy includes: (i) "an awareness of, interest in, and capability in identifying, discussing and ‘handling' value and ethical issues in pharmacy", (ii) "a facility for the ‘languages' of values," (iii) "reflective awareness of value and ethical contexts and issues", (iv) "ethical sensitivity, judgment and mediation skills" and (v) "some acceptance of uncertainty and indeterminacy".⁹
"It is important for pharmacists to be literate about values and ethics", say the authors of the discussion paper, "both in order to be able to reflect on, and account for, their own practice, and to be able to participate in broader debates about pharmacy practice, medicines policy, health care and society." They believe that "professional ethics, professional performance more generally, and the role of the pharmacy profession in society will all be strengthened by the development of greater value literacy amongst members of the profession".⁹
Having acquired value-literacy, pharmacists will be able to participate in an unending debate on pharmacy values. Hemant Patel, the chairman of the core values working party, observes that "this paper offers no solutions", and adds for good measure, "the journey is more important than the destination". The authors themselves agree; their paper "is designed to promote discussion and debate rather than to offer definitive solutions". They reiterate that there is no clear or agreed way to settle value-conflicts; ethical dilemmas do not yield simple "correct" answers; pharmacists have to embrace uncertainty, disagreement and argument. The process of searching for pharmacy's values is likely to be of more benefit than the outcome.
"Developing pharmacy values: stimulating the debate" is a minor masterpiece in the art of hedging one's bets. Hemant Patel admits that he and other members of the working group struggled at times to make sensible comments on the paper's various drafts. It is not difficult to empathise with them. At least one serious and careful reader reached the end of the paper without discovering at any stage what the authors meant by the crucial word "values". That reader, not being entirely self-effacing, was left wondering whether he or the authors suffered from value-illiteracy.

Sydney Holloway is a former senior lecturer in the faculty of social sciences at the University of Leicester. He is the author of 'Royal Pharmaceutical Society of Great Britain 1941-1991', which was published to celebrate the Society's 150th anniversary

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