Vanessa Pigrum explores some ethical questions raised in an overworked and under-funded healthcare system
Australians trust pharmacists. One study ranked them the third-most trusted professionals in the country. Not just within health, but across all sectors. It is essential that this trust is not misplaced, since pharmacists are often the first port of call for people seeking help with their health. This frontline community care plays a crucial role in preventing illness, and helps to reduce the strain on the nation’s health system by keeping patients out of GP waiting rooms and hospital emergency departments.
As the costs of medical care rise, pharmacies and pharmacists are expected to play an ever-increasing role in patient care. Beyond filling scripts and selling band aids, pharmacists provide treatment advice and referrals, issue absence from work certificates, deliver vaccinations and, in some cases, prescribe medication.
Navigating the free market while delivering a public good
While ethical dilemmas are present across the health sector, pharmacists face particular challenges, since they operate both as part of the publicly-funded healthcare system and within retail businesses seeking to turn a profit. Despite the delineation between the front and back of the shop, each affects the other. As philosopher Michael Sandel says, markets leave a mark. For example, the trust gained through the delivery of healthcare services influences consumers’ consideration of other products, which may include supplements of little or no therapeutic value. Is that right? Even if the supplements do no harm, a low-income customer may be wasting scarce resources on a useless product.
Pharmacists grapple with this conundrum daily. Do they run a commercial enterprise or a healthcare service? Are the people that enter their doors customers or patients? It feels safe to assume the answer is both.
There’s no shortage of codes of practice or professional guidelines to refer to. But these are either unspecific (if admirable) aspirations or clear-cut regulatory requirements. It’s easy to agree with the Pharmaceutical Society of Australia’s ethical code, built around the values of care, competency and integrity. Just as there’s no question about Pharmacy Board of Australia’s requirements around informed consent when working with patients. But what if there is no specific rule to follow and overarching principles are too general to provide guidance?
Do the most good you can do
Take the annual flu shot. How should its delivery be prioritised? There are many ways of thinking about this. A libertarian who puts personal freedom above all else might say that vaccination is a matter of individual choice and personal responsibility and not something health authorities need be concerned about. The free market view would be to serve the first through the door at whatever price they’re willing to pay. The philosophy of utilitarianism, demands our actions produce the greatest good for the greatest number. This might suggest flu shots should simply be provided to as many people as possible. But since resources are limited, this would fail the test of fairness. Young healthy people for whom the flu is dangerous but not life threatening may get the vaccine ahead of the frail and elderly for whom it could be deadly. The health system’s response to these competing ethical approaches is a scheme that provides free flu vaccinations for those considered most vulnerable and at risk.
What is the good we are seeking?
Such outcomes are the result of reasoned debate. No one set of actions is going to apply in every circumstance and pharmacists must make their own judgements as different challenges arise. Way back in ancient Athens, the philosopher Aristotle argued that ethics isn’t an exact science. Instead of searching for a formula for ‘right’ actions, he proposes focusing on the larger good that we are trying to achieve and using virtues like courage, kindness, generosity and moderation to guide our actions. Critically, as understanding and experience grows, we must continually re-appraise our decisions if we are to consistently make good judgements in new and unforeseen situations – a skill Aristotle calls practical wisdom.
Pharmacists have no shortage of hard choices to make. Giving due consideration to the ethical frameworks that inform their decisions will lead to better outcomes – and reward the community for the trust it places in its pharmacists.