Ethics and Pharmacy Advocacy

DECEMBER 01, 2004
James C. McAllister III, MS, FASHP, Pharmacy Times Editor, Health-Systems Pharmacy Section

"We live in a time of unlimited needs and limited resources." This observation is attributed to a leader of the University of North Carolina Hospital who is concerned about the commitment to uncompensated care provided by the hospital. This past year the retail pharmacy staff dispensed almost $8 million worth of prescription drugs to the pharmaceutically indigent enrolled in the indigent access program. Over the past 3 years, the hospital has instituted a variety of changes in this program in an effort to eliminate waste and fraud and has reduced unreimbursed drug expense by at least 50%. Nevertheless, growing unemployment, the aging of the population, increasing utilization, and increases in the prices of newer pharmaceuticals ensure that unreimbursed expenses will continue to rise.

I have come to realize that this hospital's challenge represents a microcosm of the societal predicament the nation faces. As scientists and providers discover new ways to cure disease and improve the quality of life of the infirm, patients will expect these new treatment modalities. The one reality everyone knows is that health care spending will rise.

We as pharmacists, as well as our health care colleagues, are inculcated from the beginning of our professional education and training that our responsibility is to provide the best care available. Like the patients we serve, we individually prefer to ignore the cost implications of our decisions. Regrettably, health care costs will eventually threaten the very existence of hospitals, insurers, and governmental agencies that are at risk for health care resource consumption.

It seems inevitable that health care will have to be rationed at some level, unless members of the public are willing to pay higher taxes for government health care coverage ? and I personally doubt that they will. Therefore, "somebody" will have to decide where the line will be drawn—a daunting notion. Obviously, individuals will not be comfortable or willing to make these decisions on a patient-by-patient basis.

We as pharmacists will need to be patient advocates and contribute expertise to pharmacotherapy-related rationing debates. Each one of us has personal opinions on the topic, but our involvement needs to be evidenced-based. Perhaps even more importantly, those most involved in these debates need to develop expertise and experience with the tools and strategies related to ethical decision making that can help in applying the evidence. I suspect that, as a profession, we are not yet prepared to contribute to these debates with consistency and reliability, much less take a firm stand.

This issue is so complicated, personal, and gut-wrenching. Yet it seems as if a fantastic opportunity exists for educational institutions, professional associations, and pharmacists to collaborate and eventually speak with one voice. We need continuing education programs on ethical decision making. We need to create forums for debates within the profession. Most of all, we need to begin thinking about the issue and assuming responsibility for joining the debate. This is one important issue we cannot, and must not, let be decided by others without our input.

Are we ready?

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