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Dilemmas in dispensing, problems in practice? Ethical issues and law in UK community

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PA P E R S

Dilemmas in dispensing, problems in practice?

Ethical issues and law in UK community pharmacy
RJ Cooper*, P Bissell† and J Wingfield*
*Centre for Pharmacy, Health and Society, The University of Nottingham, University Park, Nottingham, NG7 2RD, UK;
†
Section of Public Health, ScHARR, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
Email: paxrjc@nottingham.ac.uk

Abstract
Do UK community pharmacists encounter the high drama dilemmas of the medical ethics literature or
is a ‘morality of the mundane’ more appropriate? This paper presents the findings of a qualitative study
that asked a sample of UK pharmacists to describe their ethical issues and to establish whether these
were ethical dilemmas as understood philosophically or ethical problems of a more legal or emotional
nature. It emerged that although many pharmacists referred to ‘dilemmas’, these were often problems
involving a conflict between an ethical value and a legal or procedural issue and often arose in the
routine minutiae of dispensing prescriptions and selling medicines. Such ethical problems remained of
concern for pharmacists and the commercial environment, corporate pharmacy ownership and
pharmacists’ subordination to doctors, all precipitated ethical problems. Law and ethics appeared to be
understood synonymously but this may reflect a modernity that increasingly brackets out ethical
experiences by encouraging reliance upon law and procedure.

Introduction these changes, pharmacy’s relative neglect in relation to

In contrast to other areas of healthcare, relatively little is
known about ethical issues in pharmacy and what phar-
macists find ethically problematic in their work.1 Previous
empirical pharmacy ethics research has considered ethical
concerns in community pharmacy and identified a range
of issues but many changes to pharmacy practice have
occurred in recent years, as the profession attempts to
counter the threat of de-skilling and routinization that
affect many occupations.2,3 In the UK, for example, a new
National Health Service (NHS) pharmacy contract has
encouraged pharmacists to undertake additional services
such as medicine use reviews and supplementary prescrib-
ing, high profile events such as the Shipman enquiry have
prompted a review of the supply of controlled drugs and
the reporting of health care professionals,4 increasing cor-
porate ownership has led to more pharmacist employees5
and, along with increasing de-regulation of medicines
such as emergency hormonal contraception (EHC), such
changes may lead to further ethical challenges. But despite
Richard Cooper is a practicing UK pharmacist and doctoral research
student with an interest in health care ethics and law, especially in
relation to pharmacy and primary care.
Paul Bissell is a medical sociologist who has worked in the area of
pharmacy practice research for over 10 years. He has a particular interest
in the sociology of the professions and in analysing pharmacy's attempts
at role development within primary health care.
Joy Wingfield promotes the development of education, research and
discourse concerning the application of health care law and ethics to
pharmacy practice. Her previous roles were in professional regulation and
enforcement and in risk management for a national community
pharmacy company.
ethical issues may stem from the very the nature of phar-
macy work which, according to Brazier, has meant that:
“…philosophers, social scientists and academic lawyers con-
tinue to demonstrate a worrying tendency to concentrate
almost exclusively on ethical dilemmas of high drama and
low incidence […] The daily round of the pharmacist in hos-
pital or the community simply lacks that drama.” 6 p. xxii
The intention in this paper is to identify and catego-
rize what UK community pharmacists find ethically prob-
lematic in their current work and to present the findings
of an empirical ethics study that asked pharmacists to
describe examples of ethical problems that they had
encountered and how they resolved them. Do pharmacists
encounter the ‘neon issues’7 that dominate the medical
ethics literature and popular press or could pharmacy prac-
tice be more accurately described as a ‘morality of the mun-
dane’?8 In addition, much of the empirical ethics literature
in pharmacy2,3,9 and other health care professions10,11
describes situations in which ethical decisions have to be
made as ethical ‘dilemmas’, but this paper attempts to clar-
ify whether this is an appropriate term for the issues expe-
rienced by pharmacists since, as Jackson notes:
“People commonly describe as ‘dilemmas’ any situations that
face one with a difficult choice [but] let us distinguish two
types of hard choice: those that are dilemmas and those that
are problems.”12 p.35
Whilst ethical dilemmas in the philosophical litera-
ture have been variously defined, defended13 or even
denied14 they usually involve an irresolvable conflict
between two ethical choices – both of which ought to be
done but cannot both be done and so to choose one
option would lead to a moral wrong as one could not also

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CE07.15 1/13/07 10:35 AM Page 2

2 Cooper et al

perform the other option. In contrast, ethical problems Table 1 Summary of sample pharmacists
need not involve such irreconcilable conflicts but are
Pharmacist N=23
therefore often thought of as lesser, practical concerns,
albeit involving hard choices.15 But in recognizing distinct Gender:
ethical ‘problems’ it is possible to accommodate many pos- Male 16
sible psychological or emotional features associated with Female 7
ethical decision-making in practice16 and recognize and
accommodate influences such as self-interest and law,17 Age (years):
20s 6
which are often neglected in the normative literature. 30s 8
Distinguishing between dilemmas and problems may also 40s 5
be important since it would allow for the most appropriate 50s+ 4
contribution from the academics mentioned by Brazier – if
ethical problems rather than dilemmas are identified, then Ethnicity:
perhaps jurisprudential, sociological or psychological anal- Caucasian 19
Asian 3
ysis may be as relevant as philosophical insights. Afro-Caribbean 1

Method
A qualitative approach using semi-structured interview
method was chosen, to allow pharmacists to describe ethi-
cal problems in their own words but also clarify responses
and also stimulate discussion on particular areas of practice,
if necessary. An interview guide was developed that asked
pharmacists to describe and explore ethical issues in their
work and, although not relevant to the present paper, how
they resolved ethical problems and what influenced them.
A key aim was to allow pharmacists to reflect prior to inter-
view on what they considered to be ethical issues in their
work and prompted examples, informed from the existing
literature and on-going analysis of interviews, were avoided
unless pharmacists struggled to recall examples. Questions
relevant to the present paper are included in Box 1.
Twenty-three UK pharmacists were recruited from two
counties in the north of England, UK, from a combination
of contacts of the researcher, opportunistic approaches and
purposive sampling to obtain representation in terms of
age, gender, ethnicity and employment status (Table 1).
The sample size was also determined by theoretical satura-
tion being reached when no further themes emerged from
interviews. Pharmacists were approached by either an ini-
tial telephone call or introductory letter and a follow-up
telephone call was arranged a few weeks later. Of pharma-
cists initially approached, eight did not want to participate
and reasons cited included not being able to recall an eth-
ical problem or being too busy at work. Interviews were
conducted between January 2004 and July 2005 and all but
three pharmacists agreed to interviews being recorded and
these were then fully transcribed. In the non-recorded
interviews, extensive notes were taken and interviews
averaged 50 minutes in duration. Transcribed interviews
were then analysed by a process of constant comparison,
and emergent themes were coded and deviant case analysis
was also undertaken to inform further samples. Analysis
Box 1 Part of interview schedule
1 What do you understand by ethics and ethical problems?
2 Can you recall a specific ethical issue that you were
forced to resolve in your work?
3 What about it made it ethical?
4 What were the values involved?
Employment:
Owner proprietor 5
Employee of:
Small company (<10 pharmacies) 3
Med.company (10–50 pharmacies) 8
Large company (>50 pharmacies) 4
Locum 3
Additional roles:
Superintendent 8
Academia 1
PCT prescribing advice 1
was also informed by framework analysis using an ethical
decision-making model by Jones to gain an understanding
of how community pharmacists identified ethical prob-
lems, use ethical reasoning, establish ethical intent and
finally act upon ethical decisions.18 Relevant ethics
approval was obtained and pseudonyms are used through-
out, to protect anonymity.
Results
The pharmacists interviewed identified what could often
be categorized as ethical problems rather than dilemmas in
their work, and these were often related to routine, low
drama aspects of their work in the areas of dispensing pre-
scription medicines and selling over the counter (OTC)
medicines. There was considerable variation in pharma-
cists’ ability to identify and describe ethical issues and
whilst some could readily recollect ethical concerns and
describe them in terms of their relevant ethical values,
many pharmacists struggled to either identify an ethical
problem or subsequently describe it. This related to the
first stage of Jones’ decision-making model and it appeared
that many pharmacists were ethical inattentive.19 The
influence of legal and procedural aspects of pharmacy
practice for pharmacists was significant for many pharma-
cists and, although the examples that follow indicate the
range of ethical issues identified in the study, pharmacists
often referred to legalistic concerns.
Ethical problems relating to dispensing
prescription medicines
The dispensing process in community pharmacy appeared
to be the aspect of practice that generated most ethical

Clinical Ethics 2007 Volume 2 Number 1

CE07.15 1/13/07 10:35 AM Page 3
Dilemmas in dispensing, problems in practice?
concerns and also the most commonly cited example of
ethical problem, involving controlled drug prescriptions.
Around 650 million prescriptions are dispensed annually
in the UK,20 the majority of these from community phar-
macies and although many pharmacists found dispensing
prescriptions a ‘monotonous’, ‘tedious’ or ‘boring’ almost
Sisyphean task, it nevertheless generated a number of dis-
tinct ethical problems for pharmacists.
Controlled drugs
By far the most common ethical concern for pharmacists
involved situations where a controlled drug was needed by
a patient on a prescription, but for various reasons, it
would be illegal to supply it. Variations included prescrip-
tions that were not written correctly or were unverifiable,
faxed alterations to existing prescriptions, or in several
cases, doctors’ unlawful telephone requests that pharma-
cists supply a controlled drug pending a later prescription.
As Shahid noted:
“A classic one is palliative care: a cancer patient on, say,
morphine and loads of controlled drugs. Scripts incorrectly
written, no date, not signed. You know it’s a definite patient,
you know they’ve been coming in regularly and in that case
it’s a dying patient and they’re going to be in pain...in pain
over the weekend period just for you not supplying some-
thing just because a doctor, from his mistakes, has forgotten
to put something down. From the Misuse of Drugs Act and
the MEP [pharmacy medicines, ethics and practice guide],
we can’t really give it without it being illegal [...] We’re sup-
posed to be pharmacists looking out for patients and to turn
someone away who needs palliative care, that’s going to be
pain over the weekend just because there’s not a date there.”
This example did not relate to a specific situation and
this generalized construction of an ethical problem, also
identified by Braunack-Mayer,7 was commonly used by
pharmacists. What made such situations problematic were
often the competing claims of complying with the law or
doing what was best for the patient and preventing suffer-
ing. Providing medication for the terminally ill was often
cited as being especially problematic but such situations
were also complicated by requiring urgent decisions to be
made, often at times when other forms of assistance could
not be sought, such as weekends and evenings, and fre-
quently involved pressure to supply from both prescribers
and patient’s representatives. Pharmacists’ legal concerns
have been previously identified2,3 and the present study
confirms their prevalence. However, whilst previous stud-
ies and also the pharmacists in the present study often
referred to such situations as ‘dilemmas’, these often did
not involve conflicts of competing or irreconcilable ethi-
cal values. Rather, they concerned whether a single ethical
value, often the welfare or best interests of the patient,
could be accommodated in a strict, and for many pharma-
cists influential, legal and procedural framework and using
the term ethical problem may be a more appropriate
description.
The meaning of ethics and law
Pharmacists were asked during interviews what they
understood by ethics and an ethical issue and their answers
frequently involved the use of legal examples or defini-
tions. Ethics and law appeared to be synonymous terms or
3
even syncategorematic in the linguistic sense, with ethics
being incapable of understanding or explication except
with reference to law or procedures. Sharon, a recently
qualified pharmacist, explained that:
“Ethics means to me, whether you should, if a patient comes
with a prescription like a CD prescription and it’s not writ-
ten correctly, whether you should dispense it or not dispense
it, really. But also, you’ve got to look at the law side of it but
also you’ve got to look at the patient’s best interests so it’s
really about…as long as you can argue your case and the rea-
sons why you’ve done it – dispensed the prescription on not,
then fair enough and that’s what I think. So you can stand
up in a court of law […]”
Many pharmacists extended not only their definition
of ethics, but also how they decided such situations to a
legal interpretation, as in the above example. A fear of
legal or disciplinary action in relation to ethical issues was
apparent for many and, as Deans similarly noted,21 this
legally defensive attitude may be detrimental to ethical
decision-making. Pharmacists’ undergraduate education
may be relevant to this legalistic approach and most phar-
macists remembered being taught law but little ethics or,
for older pharmacists, no ethics whatsoever. Although law
and ethics appeared synonymous for many, some distin-
guished the concepts and simple chromatic metaphors
were employed to differentiate ethics and law. Ethics was
described as a ‘grey area’, ‘entering the grey area’ or ‘getting a
bit grey’ whilst law was referred to by some in terms of
‘black and white’ rules and regulations. ‘Grey’ appeared to
indicate a situation that was more indeterminate than the
clearly defined legal or procedural rules that were associ-
ated with pharmacy work.
The minutiae of practice
Many of the ethical problems that pharmacists described
related to very specific aspects of their practice, especially
of a legal or procedural nature. Several pharmacists identi-
fied issues with emergency supplies of medicines to
patients and specific situations involved requests by repre-
sentatives of the patient rather than the patient them-
selves to have a medicine provided, or where pharmacists
believed a patient expected a supply to be made. These
examples were identified spontaneously by pharmacists
and, like problems involving controlled drugs, required
pharmacists to make a decision that involved balancing a
value such as the welfare of a patient with a legal or proce-
dural concern. The increasing use of medicine compliance
aids – which pharmacists make up and which allow
patients to control their medicine doses more effectively –
appeared to cause several problems. Examples included
whether patients should initially be provided with such
compliance aids, with concerns about the use of deception
in relation to their storage in patients’ homes, to whether
patients should be charged for such services, whether con-
trolled drugs should be used in them, and several pharma-
cists mentioned receiving requests to re-dispense hospital
issued medicines into compliance aids. The emergence of
such ethical problems for pharmacists suggests that they
are not high drama, ‘neon’ issues, but relate to the minu-
tiae of pharmacy practice and to specific aspects of proce-
dures and rules.
Clinical Ethics 2007 Volume 2 Number 1
CE07.15 1/13/07 10:35 AM Page 4
4 Cooper et al
Challenging prescribers
Occasionally, ethical issues in dispensing arose that did
not involve legal and procedural concerns, including
whether pharmacists should challenge doctors’ prescribing
when a clinical problem or error had been identified.
Matthew, for example, described a recurrent ethical prob-
lems involving a drug interaction from a local doctor's pre-
scribing:
“Is this interaction serious? Is it not? Is it ethical to let it go?
Is it clinically wrong? And there you enter the minefield and
that’s one of the big problems and one of my scenarios is an
interaction and how far do you go with it. Do you take it to
one patient? Do you take it to the whole practice? […] But
one interaction kept coming up from the same doctor and I
rang up [and the general practitioner doctor said] ‘Oh yes,
I’m aware of it. It’s not a problem. Tell the patient to continue’
but if that’s the GP’s action to one, and knowing the GP
that would be the action to all of them, and then you’re into
that dilemma […]”
In such examples, the welfare and best interests of the
patient conflicted not with a legal concern, but with the
autonomy of health care professionals and the welfare of
the patient. Pharmacists’ subordination to doctors
appeared to be evident in such ethical problems9 and, as
Turner argues,22 although professions such as pharmacy
have been afforded some status within the medical hierar-
chy, this has come at the expense of relatively restricted
professional autonomy in relation to medicine.
Furthermore, although other pharmacists recounted ethi-
cal problems where they had successfully challenged a doc-
tor’s error, even these more positive examples may reflect
pharmacists’ enduring subordination since these are,
according to Dingwall,23 ‘atrocity stories’ and are symp-
tomatic of subordinate healthcare professionals’ attempts
to redress status inequalities.
Financial concerns
Most pharmacists noted that that they worked in an inher-
ently profit-driven environment and several referred to
issues such as remuneration and profit in relation to dis-
pensing prescriptions. Situations arose due to customer
requests for a particular brand or where the unavailability
of a cheaper medicine meant the pharmacist had to decide
whether to provide a more expensive alternative. These
often involved potential financial losses for a pharmacy, or
threats to repeat custom but occasional references were
made to less instrumental concerns involving economic
justice. One pharmacist found charging a patient a weekly
fee for dispensing a compliance aid in accordance with her
company’s policy ethically problematic. Of concern for
another pharmacist was whether claims should be made
for dispensed but uncollected medicines and this was one
of the few occasions where a pharmacist considered the
implications of medicine cost in broader terms, as a claim
against the finite resources of the NHS in the UK.
Ethical concerns relating to medicine sales
The second main area of ethical problem involved the sale
of medicines within community pharmacies. Several ethi-
cal concerns emerged in relation to this aspect of commu-
nity pharmacy work but these often followed prompts. The
inherently commercial and increasingly consumerist
Clinical Ethics 2007 Volume 2 Number 1
nature of medicine sales24 caused ethical concern and some
pharmacists spoke of customer’s demands for medicines
and employee pharmacists cited company pressure to gen-
erate sales. Some pharmacists felt that customers had
become increasingly empowered and expected to be sup-
plied medicines despite pharmacists’ concerns about their
inappropriateness and possible harm. The increasing own-
ership of pharmacies by larger organizations meant that
more and more pharmacists were employees and company
policies and procedures, especially for the sale and promo-
tion of medicines, precipitated ethical problems. The use
of ‘three for two’ offers on medicines, following the
removal of re-sale price maintenance in the UK, was a
cause of ethical concern for some employees and they felt
that they could not prevent such sales or their marketing,
despite reservations about their clinical appropriateness.
The policy of link selling also appeared to be ethically
problematic, involving not only ethical concerns about
the welfare of patients potentially receiving inappropriate
medicines, but also the autonomy of the patient and
whether they should have such promotional activities
imposed upon them, as Amadika noted:
“So, you know, you always feel pressure and when [company
line managers] do come, they’re just watching you to see if
you are link selling, as they call it […] I think if I was a cus-
tomer I wouldn’t like it so I don’t like giving it, no. No, I
wouldn’t do it and you see that’s pressure – I’m succumbing
to pressure, aren’t I?”
The business environment was argued by Chaar et al3
to have considerable influence upon ethical decisions and
resulted in pharmacists prioritizing profit and commercial
gain over customer welfare and proprietor pharmacists may
be more likely again to do so.25 Several pharmacists, all
owners of pharmacies, did reflect upon occasions relating
to the sale of medicines which may have been ethically
problematic and where, in fact, they acted unethically.
Situations were described in which OTC sales might be
influenced by commercial factors such as the amount of
stock they were holding, the expiry dates of particular
medicines, or the profitability of products that are not
thought suitable for sale in pharmacies, such as confec-
tionery.
Emergency hormonal contraception
Increasing deregulation of former prescription medicines
in the UK is intended to increase access to medicines,
reduce NHS costs and utilize pharmacists rather than doc-
tors but the recent availability of EHC from pharmacies
appeared to result in ethical concern for some pharmacists.
In contrast to many of the examples identified in this
study, EHC caused ethical concern not in relation to legal
concerns but to more high profile concerns about abortion
and the value of life and to the consequences of unwanted
babies. A minority of the pharmacists interviewed
emphatically opposed EHC sales and recalled that the
decision to deregulate EHC had led to considerable ethical
concern and anxiety for them since they believed it to be a
form of abortion and involved the taking of a life. Other
pharmacists argued that although EHC involved the loss
of a life, the main ethical concern involved balancing this
with the consequences of an unwanted pregnancy for both
child and parent and this was most evident in economi-
CE07.15 1/13/07 10:35 AM Page 5
Dilemmas in dispensing, problems in practice?
cally disadvantaged areas. Ethical concerns prevented sales
for other pharmacists due to the perceived risks of
increased promiscuity or being insufficiently skilled in
counselling about EHC and sexual health. Even referring a
customer to another pharmacy was problematic for
Christopher, whose firmly held moral and religious convic-
tions meant that providing any form of assistance in
obtaining supplies was ethically problematic:
“[…] if we have an objection to it, we need not provide con-
traception but we must tell the patient where else they can
go to get it. Now even that, telling someone else where to go
to get the morning after pill which, to me, is a means of ter-
minating life, is almost as bad as doing it yourself. So there’s
a conflict immediately because I’m having to tell someone
where to go to get this thing that I am particularly, strongly
against.”
However, Chris, like several others who found EHC
sales ethically problematic, found no ethical problem with
dispensing EHC on prescription, arguing that in such
cases, the prescribing doctor was taking the responsibility
for the supply and this appeared to involve yet another
example of pharmacists’ subordination. Most pharmacists,
however, were in favour of selling EHC sales and, although
tolerant and supportive of their peer's decisions not to sup-
ply, did raise ethical concerns about the consequences of
non-supplying for customers and the inconsistency of dis-
pensing but not selling EHC.
Overall, ethical problems involving medicine sales
were raised far less often and less spontaneously than dis-
pensing problems, reflecting perhaps the relative amount of
time pharmacists spent engaged in the respective activities.
Ethical problems common to health care
Although there has been discussion about identifying
common values across health care and the possibility of a
shared ethical code,26 many of the ethical examples identi-
fied so far have involved specific, and often legal or proce-
dural, aspects of community pharmacy. However, although
not commonly identified, several ethical problems
emerged that concerned more general ethical issues within
healthcare such as whistle-blowing, confidentiality and
withholding treatment.7,10
Several pharmacists described situations in which
treatment qua medication might have to be refused. This
was often as a result of patients’ behaviour in, for example,
stealing stock or as Helen explains in her example:
“We have one very aggressive epileptic gentleman we do a
[compliance aid] for and he’ll be very aggressive to the staff.
I’ve got to the point where he’s nearly had me in tears and I
wanted to say ‘Right, you’re not coming here anymore’ but
there’s no-one else who’ll have him. So that’s my ethical
dilemma, every time the staff say ‘we can’t deal with him’ –
the staff won’t, they hide […] and it’s not his fault, he’s got
problems and I understand that but that is one of my big
issues […]”
Unlike many of the examples raised by pharmacists,
this appeared to involve a conflict between rival ethical
concerns – of avoiding harm to the patient but also the
staff and pharmacist.
Within bioethics, concern about treatment refusal and
patients’ decisions not to accept medical treatment are fre-
quent and high profile but the community pharmacy set-
5
ting appeared not to result in such dramatic ethical con-
cerns for pharmacists and only one example was provided
that related to a patient’s request not to be made to con-
sume a full dose of supervised medication for drug depen-
dency but where, once again, the pharmacist appeared to
be more concerned about their own legal liability rather
than the welfare of the patient.
Few of this study’s pharmacists cited confidentiality as
an ethical problem in their work, despite being prompted
about this general area of potential ethical concern.
Several, however, noted that dealing with patients’ repre-
sentatives caused ethical problems – where relatives were
collecting patients’ medicines or asking questions about
them. For one pharmacist, this involved an ethical con-
cern about whether to inform a mother about her daugh-
ter’s contraceptive medicine, when the mother presented
with a prescription for her daughter and several pharma-
cists described confidentiality issues relating to whether
the police could request access to patient data.
Whistle-blowing
Although whistle blowing was not spontaneous identified
as an example, many pharmacists recalled ethical problems
when asked whether that had felt the need to report the
conduct of others. Many examples were provided includ-
ing the conduct of doctors, receptionists, nurses and other
pharmacists and locums but the most common situation
involved a doctor suspected of self-prescribing medicines
of abuse, typified by Dan’s situation:
“[…] there was an incident with a GP self-prescribing con-
trolled drugs. This was pre-Shipman and I did have a con-
cern about the private prescriptions that he was issuing for
himself […] I do think he had a genuine case and he had a
spinal injury and had titrated up to quite a high dose of
diamorphine and possibly there maybe was a level of depen-
dency [but] it was something that came along with the
branch, that this particular GP always got this prescription
and the first time, ‘okay’, the second time ‘yea, okay’ and the
third time, I started to worry […]”
Several pharmacists linked such concerns to the
Shipman affair and hinted at the difficulty of reporting the
inappropriate use of medicines by doctors, especially since
the doctors were often well respected, local GPs.
Pharmacists did also comment upon their pharmacist peers
and ethical issues arose in terms of what standard of prac-
tice should be expected.
Discussion
Overall, pharmacists in this study did not identify many of
the high profile, ‘neon issues’ that frequent the bioethics
literature. Although this paper has attempted to illustrate
the range and diversity of ethical issues and included con-
cerns about professional autonomy, abortion and whistle-
blowing, community pharmacists often reported problems
of a more mundane nature. The ethical problems that
emerged often concerned the routinized tasks in commu-
nity practice and were often overtly legal or procedural in
nature, yet, importantly, these remain ethical problems for
pharmacists and led to concern, uncertainty or anxiety in
community pharmacists’ everyday work. Pharmacists’ ethi-
cal concerns may well be a ‘morality of the mundane’ but
the high drama issues that frequent the medical ethics lit-
Clinical Ethics 2006 Volume 1 Number 1
CE07.15 1/13/07 10:35 AM Page 6
6 Cooper et al
erature may offer a distorted account of the ethical issues
that occur in various aspects of health care7 and as Caplan
notes:
“[...] ethics concerns not only questions of life and death but
how one ought to live and interact with others on a daily
basis. The ethics of the ordinary is just as much a part of
health care ethics as the ethics of the extraordinary.”8 p.38
But as this paper has shown, the prevalence of a legal
basis for many of pharmacists’ ethical issues, including the
paradigm illegal controlled drug prescription, means that
recognizing ethics problems as well as dilemmas may offer
a more complete and rich account of the issues encoun-
tered in community pharmacy in the UK. Pharmacists’
subsumption of ethics into law, however, does not imply
that law is any less important or necessary or that the two
cannot complement each other. What is of concern, how-
ever, is that, despite the range of ethical problems that
have been described, pharmacists’ legalist account of prob-
lems may obscure or ignore relevant ethical concerns in
their work. Pharmacists’ propensity to identify problems of
a legalistic nature may, however, be symptomatic of more
general social trends in late modernity. Habermas, for
example, identifies the influence of ever more complex
and multifarious laws and regulations is as being a conse-
quence of increasing state involvement in individuals’ per-
sonal and ethical activities.28 This colonization of the
lifeworld is inimical to individuals’ ability to make ethical
decisions and may inhibit the communication of values
and ethical debate. For Bauman,29 also, modernity is
threatened by a universalistic set of laws and ethical codes
that serve to disengage individuals from having to make
ethical decisions that are inherently difficult. Increasing
reliance upon formal laws and codification comes at the
expense of not recognizing the responsibility that individ-
uals have for each other. Considered in this way, the phar-
macists in this study may be no different from other
societal members in being increasingly regulated by, and
ultimately reliant upon, legal and procedural systems.
Further research is needed to consider how pharma-
cists’ legalistic conception of practice qua ethical issues
arises not only in the context of the moral malaise of
modernity identified by Habermas or Bauman, but also
pedagogically, in terms of how pharmacists are educated in
relation to law and especially ethics. Additional research
may also be needed to assess how new developments will
affect community pharmacists’ ethical problems and, in
particular, how increasing ownership of pharmacies by
larger organizations may precipitate ethical issues and
whether pharmacists’ new roles might lead to additional
ethical concerns.
CE-07-0014 Taylor Author queries
References 1 and 18 are the same. Please remove the duplicate and re-order references.
Please give author initials for reference 24.
Please give full citation for reference 25.
References 27 and 32 are the same. Please remove the duplicate and re-order references.
Clinical Ethics 2006 Volume 1 Number 1
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