When Doing Good Also Causes Harm: Inside the Ethical Crossroads of Oncology Pharmacy

Ethical dilemmas are woven into every corner of cancer care, but for oncology pharmacists, the pressures can be especially complex. Karen M. Fancher, PharmD, BCOP, says she entered the world of ethics almost by accident, only to realize how deeply these questions shape her daily practice—from balancing harm and healing to navigating family dynamics, patient autonomy, and her own moral distress. In this conversation, she reflects on the hidden ethical burden that pharmacists carry and why openly acknowledging it is essential for patient care—and for clinicians themselves.

Q: Ethical dilemmas in oncology are uniquely charged because the stakes are so high. What drew you to this topic, and how have you encountered these issues in your own practice?

Karen M. Fancher, PharmD, BCOP: ….I have no experience or training in ethics at all, at least no formal training. That is not something that’s part of most pharmacy school educations, certainly not something that’s discussed a lot at conferences like [the HOPA (Hematology/Oncology Pharmacy Association) one]. It’s just not something that pharmacists are typically exposed to or delve into. My experience came about when a faculty member at Duquesne [University], who was an ethics expert, needed some example patients, and he thought, What better area of oncology to delve [into] some ethics, right? So he and I worked together on a couple of projects, and it kind of spun into my interest. I think I was encountering way more ethical issues than I realized. I just didn’t have the terminology to quantify [them]? In retrospect, I didn’t know the words justice or autonomy, but I saw [them]. I just didn’t recognize it with the lack of training in that type of practice.

Q: The 4 classical bioethical principles—autonomy, beneficence, nonmaleficence, and justice—are foundational, but in practice they often pull in opposite directions. Can you give an example of how those tensions play out in a real oncology practice scenario and how you begin to work through which principle should take precedence?

Fancher: Sure. So of the 4 major bioethical principles, beneficence and nonmaleficence––so that would be doing good and not doing harm—in my mind are almost inseparable, right? Especially in the oncology pharmacy space. I’m a pharmacist because I want to do good. I want to help. I want to relieve suffering. But most, if not all, of my drugs cause harm…. So to help you, I have to hurt you. So those 2, in my experience, are almost impossible to separate…. We’re always going to have that tug-of-war between those 2.

We also see a lot of issues with patient autonomy…. In the United States, that is a highly valued part of ethics. It’s not such a big deal in some other cultures, but in our culture, the emphasis on the individual almost always takes priority. So we see a lot of issues as to whether the patient is making the decision, the family is driving the decision, or the patient is being coerced into a decision. But I’ve also learned that there’s such a concept of relational autonomy…—that very rarely does only the individual make the decision. It’s usually within the context of family and caregivers and such. So that was a new idea for me.

And then in oncology, we always think about justice—like, what is fair to a large group of patients—especially with our medications costing so much [and] taking so much time and medical resources. As to which one takes priority, I think every individual case is going to be different. But also, very rarely can we say the case is only about autonomy or only about nonmaleficence, because those 4 principles are almost always interwoven. It’s really hard to actually identify the most important one. I think maybe sometimes what’s easier is eliminating or…deprioritizing one of them, but most of the time it’s a…multifaceted problem.

Q: Oncology pharmacists occupy an interesting position in the care team—they have extensive pharmacological expertise but aren’t always at the bedside in the same way physicians and nurses are. How does that role shape the ethical responsibilities a pharmacist carries, and are there situations where you feel the pharmacist’s voice isn’t weighted appropriately in these conversations?

Fancher: In my conversations about ethics within my own institution, I’ve actually run into practitioners [who] have asked me if I speak to patients or…if I talk to patients about [adverse] effects. So I guess maybe one problem is many people don’t understand the role of the oncology pharmacist and how much we are involved in conversations with the patients,…family, and the financial office, and all those things. So one issue is [that] people still might not understand how deeply we’re involved….

But on the flip side, I also feel that many pharmacists, because of our lack of training in this area, might hesitate to raise a flag…. [They] might hesitate to say, “I think there’s an ethical problem here,” or, “I need to escalate the situation.” I think patients do reveal to us sometimes what they’re conflicted about, especially if we have a long-standing relationship with that patient. I also think we observe things that are worthy of escalation, but maybe we’re reluctant to do that because we don’t feel like we’ve had enough training. So both sides—people might not understand what we do, and we don’t always take the initiative to raise these kinds of issues. So hopefully just getting the conversation started here will do some good.

Q: Caregiver and family dynamics can complicate ethical decision-making enormously. Sometimes a family’s wishes and a patient’s wishes aren’t aligned, or a patient’s decision-making capacity is unclear. How do you approach those situations as a pharmacist, and where do you see your role beginning and ending?

Fancher: OK, that’s a fantastic question, because the example case we did in the session was about a patient who lacked the capacity to make his own decision, and the family was…adamant that the patient would have wanted these interventions, but we had no way of confirming that. So that’s a perfect setup for what we talked about in this session.

So I guess [there are] a couple of things here. Families and caregivers should always be involved, especially at the invitation of the patient. I think sometimes, though, patients and families may be on different pages about what their goals are, and maybe that’s where we need some assistance with the conversation, whether that’s with palliative care or with our medical ethics team. But I think there are so many big feelings involved here that sometimes we just need some assistance getting everybody on the same page. Of course, we pharmacists can be a part of that as well.

Something else we discussed in the session today was that in the United States, the implication is always that you go down fighting, right? There is always the implication that you keep trying, you do more, you go to the ends of the earth. And I think families project that sometimes onto their loved one, whether intentionally or unintentionally. So can we start a conversation about maybe thinking it’s brave to stop therapy…? It’s just as brave to stop as it is to keep going, but that’s not typically the way we see medicine. It’s specifically the way we see cancer treatment in this country. So again, maybe just starting the conversation [by saying] it’s an equally valid option to say you’ve had enough. But how do we get the patients to feel comfortable saying that? How do we get the family to feel comfortable accepting that? These are all things I think we struggle with every day. There’s—

Q: Moral distress is well documented in oncology nursing, but less discussed among pharmacists. Do you think oncology pharmacists experience moral distress at a meaningful rate, and is the profession doing enough to acknowledge and address it?

Fancher: There’s probably a formal definition,…but my definition would be: Am I uncomfortable with what’s happening here, and how does that color or influence my decision-making moving forward? Am I getting too jaded? Am I getting tired, and I’m not thinking clearly? Or am I letting my previous experience influence the current situation?

So does that happen? I think absolutely that happens to pharmacists, especially those of us [who] are deeply involved with individual patients, deeply involved in patient care and clinical situations. I think we’re doing a better job acknowledging that than when I started in pharmacy school. I’m dating myself, but when I was a resident, we never would have used the words “wellness” or “resiliency” or “mental break” or anything. That just wasn’t part of the conversation. Right now, I think we’re talking about it, but I don’t think we’re doing enough as a profession; but we’re getting there.

I do want to acknowledge [that] I think we are making some strides toward that. Right? HOPA and other organizations are doing a really good job of encouraging everybody to think about wellness and resiliency and some things to maybe digest what we deal with on a daily basis. I think what’s been very helpful for me, again, is relying on my institution’s medical ethics committee for reassurance…. Even if we don’t reach a resolution, I get reassurance that I’ve asked the right questions [and] brought the right things to the right people’s attention. But also, my colleagues serve as a sounding board for just talking this over, letting this out…. Sometimes just talking about it makes me feel better, even without resolving it. I just talk to somebody [who] understands the same situation, and that has always been a great comfort to me.

Q: After working through an ethical dilemma with a team, there’s rarely a clean resolution that satisfies everyone. How do you process those situations, and what advice would you give to a newer oncology pharmacist who is struggling with a decision they had to be part of—one they are still not sure was right?

Fancher: I think there’s never going to be a solution that everybody feels comfortable with or [an outcome that everyone] is pleased with…from all sides. I think we have to [have] a lot of faith that if we’ve asked the right questions, if we’ve involved the right people, and we have done the very best we can do, there’s got to be some peace with that.

But in terms of moving forward, I know some institutions do a debrief after this is over, or sometimes [it’s] called a post mortem—like, how could we have avoided the situation in the future? How could we have seen these events in real time, as opposed to afterward? So participating in those conversations has always been very helpful to learn what…I could do better the next time around, but also [because] of the group mentality that we did the best we could. Again, health care is never going to be perfect, but we did the best we could with what we knew at [that] time.