Introduction
The pharmacist-patient interaction has dramatically increased due to the expanding pharmaceutical services, and therefore greater attention is now paid to the proper relationship between them [1]. Knowledge of legal and ethical obligations when providing pharmaceutical services will improve the quality of treatment, as well as the pharmacist-patient interaction and increased cooperation, resulting in fewer patient’s complaints from pharmacists regarding prescription [2,3]. However, little attention is paid to the above-said matter and role of the pharmacist in Iran’s health system, which not only causes financial loss to patients and the national financial resources but also huge damage to patients’ health [2-6]. In the present article, in addition to introducing the ethical principles governing the pharmacist-patient interaction, certain ethical challenges associated with these principles are also addressed.
Ethical Principles of Pharmacy
With progress of science and emergence of new horizons in medical techniques and pharmaceutical services, greater attention is paid to modern concepts such as “professionalism” and “professional ethics”. Accordingly, issues such as patient’s rights, autonomy and satisfaction, the relationship of trade and business with pharmaceutical services, and the quality, safety, and effectiveness of medications, ethical issues specific to pharmaceutical services, scientific monopoly, and their hidden potential harms are now more important [7-10]. Like a physician, a pharmacist has legal as well as ethical obligations. It seems that ethical principles and guidelines are more effective tools for pharmacists than ethical theories in the face of ethical predicaments [11,12].
Equity and Justice
Equity is one of the key principles of ethics in the health system. Equity in health happens when all social strata are able to maintain their full health, have access to the necessary resources, and their socioeconomic status does not affect their health [13]. In the pharmacy sector, although equity requires that pharmacists should equitably provide the necessary care, in practice these care are not equally provided for patients [14,15]. Various factors such as economic, social, cultural, religious, and racial sometimes affect the type of services provided [16]. For instance, is it ethically acceptable to vend a new and expensive medication, even when an identical, cheaper, and equally effective medication is available? In response, it should be said that a profiteering attitude to pharmacy only considers the profit to be made. However, it should be noted that the net profit increases when distribution is equitable [17]. Another group of profiteers believe that equity is separate from profit and do not consider calculation of profit and loss necessary before reaching the results [18,19]. There are situations when the patient’s interest and well-being are in conflict with other matters and the pharmacist has to choose one or the other [20]. One of the main ethical challenges in pharmacy is equity in allocation of resources, especially in relation to the much needed and rare medications [21]. What should the pharmacist do when faced by a needy patient who cannot afford an expensive medication? Should he give that medication to a patient who can afford it, regardless of the needy patient, or should he support the needy patient? The problem of allocation of pharmaceutical resources lies in the health system’s planning and management of medication distribution systems [22,23]. In fact, health care should be allocated in such a way to give priority to the most needful people, so they can receive the required services [18].
Autonomy and Self-Determination
Pharmacists should consider that their prescriptions may affect people’s life [24]. The ethics are challenged when a patient’s autonomy is ignored, he is not told the truth, his secrets are disclosed, or measures are taken to end his life [25]. Many patients do not have the ability to make their own decisions. Children and those with mental disorders may be able to decide to some extent about their interests and values, but they are inadequately independent to determine their fate [26,27]. Regarding autonomy, ethical challenges include autonomy of adult patients with no consciousness. When patients lack sufficient will to disagree about the prescription, the pharmacist should not decide on behalf of him/her [28]. The assumption with children is that only parents or those decided by authorities such as courts can make a decision on behalf of them [29]. Sometimes pharmacists refrain from telling the patient the name of the medication, administer placebo, or do not vend high-risk medications, and consider this to violate the principle of patient autonomy. This group are concerned about other people’s well-being, equity, and not harming the patient [7,30]. Legally, there is no need for the patient’s consent in emergency cases [31]. The question arises that “Is this autonomy permanent and should it be always respected?” In response, it can be said that it should be respected for as long as these people’s autonomy does not threaten other people’s interests, or it is not in conflict with other people’s well-being, otherwise, it can be violated [32].
Honesty and Truthfulness
The principle of honesty emphasises the obligation, to tell the truth, and not to lie [33]. There are different views on telling the truth and conveying bad news to patients [34-36]. The principle of self-determination seems to have made the obligation, to tell the truth to the patient as acceptable [37]. Religious teachings also emphasise the patient’s right to know the truth, even though ethical considerations account for not causing the patient concern unnecessarily [38]. In some countries, special guidelines have been developed and implemented that facilitated telling the truth to the patient [39]. Various pharmacy codes emphasise telling the truth to the patients and consider truthfulness as an attribute of a pharmacist [40]. The 18th century philosopher, Immanuel Kant is one of the people who consider lying and not telling the truth to patients as wrong and a violation of a patient’s autonomy [41]. What is important with regards to truthfulness is that, what kind of things a patient should be told, and when is better not to tell the truth [42]. In the healthcare system, some patients might not have enough knowledge about the prescriptions; clinical caregiver or pharmacist may not be able to decide what exactly he/she must do. This uncertainty may occur during diagnosis or in the course of treatment [43]. The pharmacist may not have sufficient information about the outcome of some medications, or cannot provide the patient with the necessary information [44]. Sometimes, a care provider gives the patient wrong information because he thinks that the patient is best not to know the truth, and thus refrains from telling the truth [45]. However, sometimes well-being of the patient is not the only issue, and other people such as family members, or people in contact with the patient should also be considered [17,46].
Loyalty and Confidentiality
Confidentiality is ethically an obligation, even if ignoring it provides better outcomes [47]. The pharmacist-patient is a contract, but the important point is that even if it is considered as a contract, the professional principles including confidentiality should be observed and by no means should the patient’s secrets be disclosed [48,49]. Deliberately providing the patient with the wrong information is unethical [12]. Generally, pharmacists who are in continuous contact with patients are obliged to tell the truth to patients who want to know their condition and this knowledge affects their decisions [50]. A series of obligations are formed as a result of the interaction between the pharmacist and a patient or a group of patients. This relationship is beyond a legal contract and is not considered as a business relationship, but an ethical agreement that is obligatory for both sides [51]. The obligations of this relationship included patient confidentiality. Adherence to the codes of professional ethics and being by the patient’s side when required are the most important obligations of the pharmacist. It should be said that observing the principle of patient confidentiality is the key to the continuity of such a relationship, and the pharmacist should do his best to make this possible. However, there are cases when violation of confidentiality is necessary [18,52]. In accordance with the Pharmacists’ Association’s codes of ethics of 1995, a pharmacist should respect confidentiality of the patient’s medical information, unless the patient’s interests are at risk, or the law has made an exception for violation of confidentiality [53]. Sometimes disclosure of information is in the patient’s interest and his interest lies in the violation of confidentiality [54]. In the healthcare system, not only the patient’s interests should be considered, but other people’s well-being is also important. Thus, when confidentiality is a serious threat to other people’s interest, the pharmacist is allowed to disclose information. This does not only apply to medical interventions but also include clinical research.
Avoid Providing Life-Ending Medications
Pharmacists are currently increasingly asked to provide life-ending medications [55]. This action is legal in some American states such as Oregon and some countries such as Netherlands or in the jurisdiction of the courts. With the legalisation of “Assisted suicide” in some countries (often through injection), pharmacists appear to have a greater share in patients’ euthanasia than other medical groups [56]. Life is a divine blessing and the right to live is one of the most fundamental of human rights on which other rights are based. Therefore, no one can be deliberately deprived of this divine blessing, and all people and societies are obliged to support this right and stand against its violation [57]. Killing humans are in fact a kind of harming them and challenges the principle of not harming, which is one of the key principles of medical ethics. There are many opposing views on killing incurable patients, which recalled as “Euthanasia” or “kind killing” [58]. Many societies, both secular and religious have condemned the denial of the right to live, even if it is requested. Not all measures taken to shorten or end life are regarded as killing, and in some cases, it is regarded as support and help. Even if for instance injection of a common medication suddenly causes an unusual and fatal reaction in the patient, it cannot be considered as an unethical act, although legally such an act may not be justifiable [59]. Actions taken with a direct intention to end someone’s life are different from “kind killing” or “compassionate killing”. What is important is obtaining the consent of patient or people who can decide in his place to give consent [60]. Some secular and religious people consider it wrong to kill a patient. The Hippocrates’ oath refers to active killing through administration of a fatal medication and prohibits physicians from this unethical action. In addition, modern pharmacy ethics also prohibits pharmacists from this action, which is in fact participation in killing a patient [61,62].
Benefiting the Patient and Others
In accordance with the ethical codes of the American Association of Pharmacists, a pharmacist should act in such a way to provide the patient with the most benefit. While, it seems that the principle of good will and not harming has always been considered by health care authorities as a key ethical principle, which also entails many ethical challenges [63]. The question is: should pharmacists only consider the patient’s benefits? Should he not think about the consequences of his actions for other people and the community? What should be done if a pharmacist’s actions for benefiting the patients have substantial risks for the community or a particular group? What should a pharmacist do when the patient’s interest is in conflict with the community interest? What should be done when a pharmacist’s actions taken in support of the patient are in conflict with his family’s interests? Should the patient’s interest be preferred over his family’s interest, or the family’s interest should first be considered? These are examples of ethical challenges and predicaments, which cause problems for the pharmacist. In their profession, pharmacists come across many cases when they should decide between benefiting and not harming, and also determine the weight of the benefit using available rules and regulations, and assess various cases. Although health workers regard promotion of health as one of the key clinical measures, they cannot claim to be fully considering factors such as financial status, understanding, social well-being in order to enhance people’s well-being and health [64]. The current ethical codes of the American Association of Pharmacist require the pharmacist to benefit and not harm the patient, and consider no limitations on enhancing health and safety of the patient. Yet, health workers are not in the position to recommend whatever is in the interest of the patient. It should also be considered that rational people do not just think about their own health, but their overall well-being as well. Thus, although pharmacists are obliged to promote patient’s health and safety, they have different priorities and goals in relation to patients. Hence, while attending to the patient’s interests and priorities, a pharmacist should also try to promote his health and overall well-being [2,65].
Conclusion
The pharmacist is one of the important part among the medical fraternity and is commercially viable for the benefit of the pharmacist who sells the drug to the patient. Since the pharmacists are accessible for the patients without intermediaries, and due to the financial benefits, moral challenges must be considered. In dealing with patients, respect for human dignity and their informed consent must be taken into account. Protecting the secrets of patients, respecting their rights and respecting religious values and differences must always be considered by the pharmacist. Therefore, there are important ethical principles governing the relationship between the pharmacist and the patient.
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