From Mr A. Cribb, and Professor N. Barber, MRPharmS
SIR,-When we wrote "Developing pharmacy values, stimulating the debate", we deliberately chose to open out debate rather than close it down, and we are delighted that Sydney Holloway has obliged us (PJ, August 26, p308). What is more, we enjoyed some of his teasing comments, which we are happy to take in the spirit of academic knockabout.
With regard to content it was encouraging to see how much he agreed with us - we appear to agree, for example, on the following: that induction into the existing day-to-day good practice of pharmacists, overseen by standards, regulations and guidelines is the foundation of professional ethics; that - for instance - pharmacists should be attentive and responsive to their patients; that the values held by pharmacists can and should be investigated by empirical research; that any statement about the values of the profession should be based upon the values held by pharmacists; that the "four principles" of medical ethics, or any other abstract statement of principles, have their limitations; that there are also limitations to the usefulness of lists of core values; that open-ended debate is not a good model for practice; that ethics change over time. All these beliefs shaped the "values" document. Where we differ is in our view of the implications of these beliefs, and in particular on what should be done. Holloway's account focuses on the framework of rules - which he labels mandatory, preferential and permissive rules, following Dahrendorf.
Through these rules, he argues, the Royal Pharmaceutical Society "has the authority to ensure that the values which should permeate pharmaceutical practice actually do so". We agree that rules and guidelines are a key part of any solution, but cannot agree that they are sufficient on their own.
Professional behaviour cannot be completely defined by rules. There will always be a need for individual and collective professional judgments on what is right, as society advances, and as technology advances, and as pharmacists find themselves in changing or unique circumstances. More fundamentally we would ask, "Is the setting, wording or implementation of the rules or the ‘values which should permeate pharmaceutical practice' never open to discussion or debate?" If they are then that is all we call for in the document. If not, then we are at a loss as to where exactly they come from, and why pharmacists should treat them with the necessary respect.
Perhaps in the end any disagreement here is over style and scope rather than substance. As Holloway acknowledges, our document was designed to be exploratory. This was our brief. The whole point was to "hedge bets" on matters of substance. We are, therefore, grateful that he sees it as a "minor masterpiece" is this respect! But we acknowledge that this open-endedness will be frustrating to some readers. For example, we deliberately chose to work with a very loose conception of "values" so as to signal a very broad domain of concerns for potential discussion and debate. By contrast, Holloway is clearly working with his own narrower (and often pejorative) conception of values. There may also be differences in the scope of our concerns. Holloway concentrates his account on standards of professional practice. In many respects we agree with what he says about this. However, we are equally interested in the wider context within which the standards, policies, and priorities of health care are determined, and in asking for suggestions about how pharmacists might play the optimum part in these processes.
Pharmacy needs to move forward on all these fronts if it is to progress.
Alan Cribb
Centre for Public Policy Research, King's College London
Nick Barber
Professor of the Practice of Pharmacy, School of Pharmacy, London