ETHICAL DECISION MAKING

PROBLEMS IN PHARMACY PRACTICE

• Simple:
Drug- food interaction: eg. tetracycline and dairy products.
Side effect of a drug eg. constipation due to iron therapy.
Non- adherence: in old people due to polypharmacy.
• Complex:
Ethical problems
 DEFINITIONS
• Problem: “something that is difficult to deal with: something that is a source of
trouble, worry, etc.”
• Decision: “a choice that you make about something (a problem) after thinking
about it: the result of deciding.”
• therefore, decision making and problem solving are processes around which
difficult choices are made.
• Ethical problem in pharmacy: is the conflict between moral obligations or
principals that can put in danger the pharmacological treatment that is best for
the patient
• Ethical decision-making: refers to the process of evaluating and choosing among
alternatives in a manner consistent with ethical principles. In making ethical
decisions, it is necessary to perceive and eliminate unethical options and select the
best ethical alternative.
• Decision-making and problem-solving skills are an essential job responsibility for
pharmacists.
• For eg,
1- Would you always deny a patient access to pain-killing
controlled drugs because her prescription is not legally valid?
2- Would you always tell the police about suspected abuse
of drugs by young teenager?
Conflicts can arise:

• between the guidelines and best patient care,

• or between differing ethical goals
• such as telling the truth or respecting the patient’s wishes.
 5 STEPS IN DECISION MAKING PROCESS

• 1.Respond to the “sense” or feeling that something is wrong.

• 2. Gather information/make an assessment.
• 3. Identify the ethical problem/consider a moral diagnosis.
• 4. Seek a resolution.
• 5. Work with others to determine a course of action.
 A LETHAL ERROR, WHO NEEDS TO KNOW???
• Patient A in the RCU with pulmonary embolism after a fractured femur during a
fall in the nursing home,
• Patient B in the next room with liver cirrhosis due to alcohol abuse and had
ruptured esophageal varices.

•A B
• Later, patient B died, the physician went to the unit and was shocked to see in the
trash the IV fluid with the label of heparin (not octeriotide) which was
administered to patient B , he went to patient A to see that he is receiving
octeriotide.
• What will be the decision of the pharmacist (responsible for the mistake)

• Tell the intensivist (who was treating both patients) who can’t withstand mistakes?
Reason: To avoid such mistakes in the future and to adjust treatment of patient A
• Don’t tell him??
Reason: since the patient died?
• Step 1: the wrong drug is given to patients (both A, B).
• Step 2: medical history, diagnosis, prognosis,
Even if the treatment was effective in managing the bleeding, it would not
resolve the underlying problem of cirrhosis.
• Step 3: the principles in conflict in this case are non maleficence and
honesty.
• Step 4:
(1) Fully share information about the error with all those involved;
(2) Tell the intensivist about the error and other internal entities in the hospital but
not inform patient’s family
(3) Keep the knowledge to herself and not tell anyone and try to correct the error.
(4) Wait to tell the intensivist about the error with patient A medication until she can
determine if it is having any side effects.
• Step 5:
• A better decision can be reached if the people who are involved have the
opportunity to openly discuss their perceptions, values, and concerns.
 EG.2
• A 30 years old female was diagnosed to have Hodgkin lymphoma,
ABVD chemotherapy and radiation were prescribed, during
conversation, she stated that she refuses any treatment that causes loss
of hair and she asked the physician to prescribe drugs that don’t
cause hair loss, during filling her prescription, the pharmacist asked
this patient if her doctor told her about these drug side effects and
found out that the doctor told her about hematological and GIT side
effects only.
• At this time a pharmacist realized an ethical problem
• Beneficence ( treat the disease with ABVD) ,
• Autonomy ( avoid alopecia)
 DISCUSSION ( REFLECTION AND REASONS OF THE ACTION
CHOSEN )
• BENEFICENCE (the doctor idea): the patient confidence with pharmacist and physician will be lost
at the time side effects occur ( hair loss) and may lead to patient non compliance and refusal to
continue with any medication
• AUTONOMY: the patient may refuse taking ABVD and subject herself to disease mortality ( not
best choice, this mean autonomy conflict with non maleficence )
• best ethical decision: beneficence ( choosing ABVD) but on the same side we need to discuss this
with the patient and tell him about disease consequence which may be fatal, additionally we can
tell the patient that hair loss will be temporary during ABVD courses and hair will regrow again,
if the patient accept this would be the best choice .
 FACTORS THAT AFFECT DECISION MAKING PROCESS
INCLUDE
• The presence of legal facts or any law in such a case.
• The professional knowledge and competence.
• Ethics and moral behavior.
 PERSPECTIVES (APPROACHES) FOR MAKING
DECISIONS

• Economic
• Ethical
• Clinical: patients and overall wellbeing
• Managerial
 A PROBLEM IN A COMMUNITY PHARMACY

• The pharmacist receives a call from one of the store’s technicians that the latter is
sick and cannot make her shift.
• This absence will leave the pharmacist with only one technician for the remainder
of the day to complete the normal workflow. The manager of the busy store
informs the pharmacist that, being shorthanded, they may need to cut corners to
get all of the work done.
 SOLUTIONS
• Complete the normal workflow with the staff present, focusing efforts on activities
with the greatest potential income, and without using resources to pay for an
overtime technician. (Economic)
• Closing the pharmacy early is another option if staffing is insufficient to provide
care that is up to the minimal standards of the clinician (ethical).
• Call in another technician or pharmacist to work overtime at any cost (Clinical).
• The pharmacist may decide to focus all resources on filling prescriptions and give
low priority to counseling activities that may require more time and attention from
the staff. (Managerial)
 A PROBLEM IN IN-PATIENT SETTING

• If a physician wants to use a medication for a patient, but when the request is
submitted to the pharmacy and therapeutics committee, it is deemed too costly
and thus not available for use.
 SOLUTION
• The members of the committee maximize the cost-effectiveness of medication
procurement and use, while optimizing resource allocation and efficiency.
• If all physicians had the authority to prescribe and dispense their medication of
choice for each patient, this approach may be moral, but would be of
detrimental cost to the organization and a poor business decision. These contrasts
reinforce the need to have an understanding of the different decision
approaches, their use in practice, and the importance of professional discretion.
 FEATURES OF A GOOD DECISION
1- systematic structure: involving a system, a method, or a plan.
Eg. Pharmacist can apply judgement and experience within a systematic framework
of questions and options to achieve a resolution
2- rational reasoning: eg. Abuser came to the pharmacy asking for a CNS drug
Decision A:
A pharmacist refuses to give a drug for an abuser with patients
Reason: harmful to patient and society
Decision B:
A pharmacist agree to give the drug.
Reason: since that patient is so violent and may cause danger to me or other people
• 3- value-based reasoning: decision-making based on suppression of emotional response
and reliance on logic alone.
• Eg. Patient refuse to take injection of iron because it is painful, but injection is better for
him than oral iron.
• 4-recored decision:
• Pharmacist should record their decisions, he may need to depend on them in the future.
• THANK YOU FOR LISTENING