High-level ethical decision making considers various ethical components and all stakeholders.
The situations and decisions faced in health care delivery are seldom black and white. More often than not, these decisions are shrouded in ethical and moral complexities that not only influence the decisions made at the time, but also impact future decisions through the processes of learning, reflection, and contextual development. Even in times where the choices do not appear complex, everyday circumstances might make them more difficult to follow than anticipated.
For example, providing the highest level of care to each and every patient is clearly the ethical thing to do. But what does “highest level of care” really mean? Even if pharmacy staff work efficiently and are adept at handling patients’ problems, wouldn’t the “highest quality of care” dictate that you might spend quite a long time (several minutes, even up to an hour or so) with that patient? Can you be absolutely convinced that every patient who leaves the pharmacy with a prescription understands everythingthey need to know and that they will be adherent? The reality is that this is quite difficult to achieve, given that we have to provide at least some level of quality care to each and every patient we encounter, in spite of ethically needing to devote time with some patients that we don’t really have.
It is not very often you find the work of pharmacists evaluated in a peer-reviewed journal on epilepsy. Researcher Ramzi Shawahna, PhD, examined the ethical, legal, and professional deliberations in daily health care practice by multiple practitioners, including pharmacists.1 He devised a case study of a patient, 32 years of age, married with no children, who presented a prescription for valproic acid to refill. The patient had been diagnosed with juvenile myoclonic epilepsy at the age of 14 and was seizure-free until beginning a new job with a high stress level and more traveling. He missed doses and had experienced 3 breakthrough generalized tonic-clinic seizures in the preceding month. He commuted to the pharmacy using his car. When bringing up the issue of driving, the patient indicated that he uses his car also to commute to and from work and did not want to rely on alternative transportation.
Shawahna used a reflective tool to facilitate deliberations and to promote making justifiable decisions when professionals face dilemmas in daily practice. This included several questions such as identifying the ethical issue in the case, the potential course of action, the information that needs to be gathered, who the various stakeholders are, how strong the arguments are in the case, and how the preferred course of action can be implemented. The pharmacists and students who took part answered these questions and their arguments were matched up against various ethical tenets, such as justice, trust, efficiency, respecting patient autonomy, legal liability, beneficence, and health maximization. Weighted most importantly was that the pharmacist could counsel the patient on the dangers or risks of driving while experiencing breakthrough seizures, inform them to refrain from driving during this period, and make a shared decision with the patient to inform state authorities. Whether to voluntarily file a report to authorities was also considered.
High-level ethical decision making considers various ethical components and all stakeholders, such as the patient’s family, the patient’s obligations, employers, friends, law enforcement, and others. Unfortunately, some pharmacists might not even discuss the issue of driving with the patient at all. The decision on the extent to go further and offer knowledge to authorities can be seen as a shared, voluntary, or compulsory obligation. These are areas of gray.
It is best to involve the patient in joint decision-making as much as possible, and this would include other cases such as when the patient might be engaging in other contraindicated behaviors or even contraindicated therapeutic modalities. Ethical decision making is not an innate trait; but rather, it is something upon we can continually improve.
Additional information about Ethical Decision Making can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.
Shawahna R. Facilitating ethical, legal, and professional deliberations to resolve dilemmas in daily healthcare practice: A case of driver with breakthrough seizures. Epilepsy and Behavior. DOI: 10.1016.i.yebeh.2019.106703
About the Author
Shane P. Desselle, RPh, PhD, FAPhA, is a professor of social and behavioral pharmacy at the Touro University California College of Pharmacy.