Ethical Issues in Pharmacy: A Biblical Perspective
Dr. Poirier is Professor of Clinical Pharmacy at Duquesne University and Director of Clinical Pharmacy Services at St. Francis Medical Center in Pittsburgh, Pennsylvania. She received her pharmacy degree from the Albany College of Pharmacy in Albany, New York, and her Doctor of Pharmacy Degree from the University of Michigan. She is a member of Allegheny ('enter Alliance Church in Pittsburgh.
Pharmacy as a profession has evolved to a model of "pharmaceutical care." This is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patients quality of life.1 Three major functions are involved: (1) identifying potential and actual drug-related problems, (2) resolving actual drug-related problems, and (3) preventing potential drug-related problems. The mission of pharmacy practice is no longer just to dispense the right drug upon the authorization by a physician prescriber but to render pharmaceutical care.2 As the profession has evolved toward a more responsible role for outcomes of patient drug therapy, there are an increasing number of ethical issues faced by pharmacists.
The goal of this article is to present an overview of major ethical issues in pharmacy. This will be followed by a biblical perspective on these issues.
Five ethical principles are commonly encountered in pharmacy. These include autonomy, veracity, confidentiality, nonmaleficence, and justice. The ethical principle of autonomy versus interference with the physician-patient relationship is an issue. Pharmacists are commonly in a position in which there is a conflict between patient's rights for informed consent and self-governance and the potential negative consequences to the patient of full disclosure of information regarding adverse effects of medications. For example, a physician may not desire that a patient be informed of the side effects from chemotherapy because of traditional paternalistic attitude that this information may harm the patient by his or her refusal to take a drug with certain side effects.
A second issue is veracity or truth telling versus social responsibility. This occurs when pharmacists are called to provide drug information to be used for questionable purposes. For example, a person may call for information before a pre-employment physical, i.e., school bus driver, on the length of time marijuana remains detectable in the urine.
A third issue is confidentiality versus veracity. This occurs when a pharmacist is asked to identify drugs found in the possession of children or to reveal that a daughter is on birth control pills.
A fourth issue is nonmaleficence or "to do no harm." Pharmacists may be asked to dispense drugs used as abortifacients such as diethylstilbestrol, the "morning after pill." Can a pharmacist conscientiously object to dispense these medications?
A fifth ethical issue that is becoming a major dilemma in the 1990's is justice. Pharmacists are being asked to ration the use of certain high cost drugs in an era of cost containment and limited resources. The question is how do we morally justify the use of new expensive biotechnologic ("biotech") drugs. An example would be an elderly person on Medicare with a clinical condition in which a high cost biotech drug may be indicated, but whose care is already a net revenue loss.
The final ethical dilemma is faced by pharmacists as a member of a Pharmacy and Therapeutics Committee. This committee is involved with making decisions on what drugs to include on a formulary and to set guidelines on what drugs are used in a hospital setting. Pharmacists have an active role in this clinical decision-making process. A potential conflict of interest could arise when a decision on a status of a drug must be made when there is personal vested interest, e.g., owning stocks, research support, speaker's bureau, in the company who manufactures that drug.
As Christians we are guided by the Scriptures which are our ultimate authority on what is right and wrong. The authority of God takes priority over any other authority. Thus there are times when other authorities must be disobeyed if there is a conflict with the Word of God. (Acts 5:29 -"We must obey God rather than men.") Christianity is also very person-oriented. Thus there is a focus on treating patients as persons.
The first ethical principle mentioned was autonomy. Frame believes that the word "autonomy" is contrary to the Word of God.3 Autonomy implies lawlessness which is in contrast to man's responsibility to God. He prefers that any competent person has the right to make his own decisions about medical treatment and to be given informed consent. (Eph. 4:25 - "Each of you must put off falsehood and speak truthfully to his neighbor;" Exodus 20:16 -"You shall not give false testimony against your neighbor.") Competence according to the Bible is conformity to God's will.3 If a person is incompetent then family and church family have the responsibility to determine the proper treatment for an incompetent person. The health care worker also has personal responsibility to refuse treatment or to give information that contradicts one s conscience or if one believes that this is in the patient's best interest.
In the first situation regarding revealing information about a drug to a patient, if full disclosure of information about adverse effects of medication is determined not to harm the patient, it is our responsibility to give the patient the information even though this may be contrary to the wishes of the physician. I would attempt to discuss the issue with the physician and inform him that it is my responsibility to inform the patient about the adverse effects of the chemotherapy. I would share with the physician that the patients knowledge about adverse effects of the medications will not harm the patient and that patients do better when given the truth.3
The second principle is veracity. Again, we are commanded by Scripture to be truthful to one another. (Eph. 4:25, Exod. 20:16) However, the Scripture does not require us to tell the whole truth unless this omission is deceitful. There are situations in which nondisclosure is appropriate. Irrelevant or unhelpful information does not have to be given. Scripture also warrants nondisclosure, even deceit, to save life. (Exodus 1:15-22)
In the second situation when a person asks for drug information which will be used for questionable purposes, there are two approaches which are scripturally consistent. One approach is to inform the caller that this information will not be given because its intended use is contrary to the Word of God when there are risks to other lives involved. The second approach (the example of the marijuana question) is that of partial disclosure where the caller would be informed that the length of time the drug remains in the urine is highly variable and there is no way to deceive the system. It is imperative that pharmacists have the necessary background information in order to make a scripturally consistent decision.
The third issue is confidentiality. According to Scripture, confidentiality is not absolute. There are times when we must tell what we hear. (I Cor. 14:26; Eph. 4:29 - "Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs, that it may benefit those who listen.") We can keep confidences only as far as our conscience permits. However, we are also instructed not to gossip. (Prov. 10:19 - "When words are many, sin is not absent, but he who holds his tongue is wise;" Eccl. 10:14 - "And the fool multiplies his words;" Prov. 11:13 -"A gossip betrays a confidence but a trustworthy man keeps a secret.")
In the third situation, revealing to parents that a child is on drugs or on birth control pills is reaffirmed by Scriptural principles. Parents have the responsibility to help their children to protect them from harmful behaviors such as promiscuity. We probably should also inform our patients that we will be following biblical principles of confidentiality. If they do not agree to allow us to do this, they should seek services elsewhere.
The fourth issue is nonmaleficence. The Scriptures forbid physical harm of the innocent. (Exod. 22:12-24) Thus any means to induce an abortion is morally wrong. We are commanded to disobey lower authorities when they conflict with higher ones. (Acts 5:29; Exod. 1:15-22) In the situation given, the pharmacist can conscientiously refuse to dispense the "morning after pill." The other guiding scriptures revolve around the motives. Scripture demands pure motives. (Deut 6:5 -"Love the Lord your God with all your strength;" Mart. 5:8 - "Blessed are the pure in heart, for they will see God.") It requires faith and love and condemns selfishness. When evaluating the act of abortion, it is obvious that this is not only the killing of a person but is also an act of selfishness.
The fifth principle is justice. The main criterion according to the scriptures in determining how to distribute medical care is need. The parable of the Good Samaritan illustrates this beautifully. (Luke 10:25-37) When scarce resources are involved, the priorities should be such that the help given is maximized. Thus factors such as geography, ability to contribute to the healing of others, and the prospect for success would be considerations. Factors such as age, ability to pay, social worth or part of the "group" should not be determinants of who gets care. All lives are precious in God's sight since each is made in the image of God. However, the scriptures do not command that physical life be prolonged as an absolute priority. (Phil 1:20-26)
Distribution of care should not be based on ability to pay. Human life is more important than economic prosperity. Neglect of the poor is a sin. (Exod. 22:25; Deut. 15:7-11; Prov. 19:17) The Scripture commands us to be willing to share financial resources. (Acts 2:45 - "... selling their possessions and goods, they gave to anyone as he had need;" Also, 2 Cor. 8, Gal. 2:10, and Eph. 4:28.) However, the Scripture does not ask that we go bankrupt because of unreimbursed charity. A system of priorities should be used to determine who gets care.
In the situation give, the decision as to whether to use a high cost biotech drug should not be determined by the person's age or ability to pay. The determinant would be the likelihood that the drug's benefit would outweigh the risks involved.
The sixth ethical dilemma posed was a potential conflict of interest. Scripture guides us to act honestly and to base our decisions on the benefits to our patients and the avoidance of harm. We are guided not to act selfishly and for our own personal gains. Thus, a formulary decision would be based on the objective scientific evidence of risks and benefits, and the availability of less costly but equally safe and effective alternatives. Basing a decision on one's personal vested interests such as stock ownership would be contrary to biblical principles.
1. Hepler, C., & Strand, L., Opportunities and responsibilities in pharmaceutical care, Am. 1. Hosp. Pharm., Vol. 47, 1990, pp. 533-543.
2. Commission to Implement Change in Pharmaceutical Education. Background Paper I, Nov. 1991.
3. Frame, J., Medical Ethics: Principles, Persons, and Problems, Presbyterian and Reformed Publishing Co., Phillipsburg, New Jersey, 1988.
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