15.6 Personal Professional Ethics

Not all behaviors in pharmacy practice are done solely because of the law. Moral obligations exist that are not legal obligations, and vice versa. Laws and regulations governing the practice of pharmacy do not always dictate the proper behavior in every situation. Ethics puts communal values into standards (measures) of conduct and moral judgment based on accepted rights and wrongs of behavior and character. Ethics requires a process of reflection and analysis of options of behavior when the proper course of action is unclear. It is the basis on which to make judgments. In addition, particular individuals, groups, and professions have their own specialized codes of ethics based on their goals and values. Religion often has an influence on personal ethics, but it is not necessarily inherent to religious belief; those who subscribe to no religion also have a sense of right and wrong conduct.

The most important aspect of studying ethics is to internalize a framework or a set of guidelines based on high professional standards to guide your decision making and actions. The old saying is “Forewarned is forearmed.” Be aware of the variety of situations you could find yourself in, and discuss them with your professors, colleagues, and the pharmacists with whom you work. You want to act thoughtfully, not react on the spur of the moment. By thinking through your ethical options of response ahead of time, you can avoid the paralyzing quandary of being confronted with questionable circumstances and not knowing what to do.

Professional codes of ethics regarding professional behavior are often written as formal documents (see Figure 15.3) and supported by professional organizations. These statements provide language to aid in the decision-making process when an ethical issue presents itself in pharmacy practice.

Codes of Behavior

Ethical codes of behavior in pharmacy are based on a trusting relationship. Patients have to put their trust in the knowledge, competency, honesty, and integrity of the pharmacist and the technician each time they request a prescription. There are two reasons for this. First, the service and product provided are not standardized; they are unique and personal to the patient’s situation and condition. Second, the patient is very vulnerable and can be either physically helped or harmed by the service provided, and the patient does not possess the professional knowledge to oversee the outcome.

For these reasons, pharmacy personnel must be held to high standards of conduct and meet selected criteria. First, pharmacists must know well their specialized body of knowledge, and this enables them to perform their highly useful profession. Pharmacy technicians, as paraprofessionals, are also, by extension, held to higher standards of knowledge and conduct in their everyday practice, compared to cashiers or warehouse clerks. Pharmacy technicians who are certified and/or registered are held to an even higher level of expectations. Technicians, like pharmacists, have a duty to maintain their competence and continually enhance their knowledge through continuing education.

Second, the attitude you possess also influences your workplace behavior and the patient’s trust in you. The basic attitude needed is an unselfish concern for the welfare of others called altruism. Because many patients on a daily basis feel ill or have serious diseases, technicians and pharmacists can better serve if they can feel and express empathy with the patients and understand them.

Figure 15.3 Oath of a Pharmacy Technician

Third, knowing that there are consequences for bad behavior helps build trust in the profession. Social sanctions are negative repercussions provided by the profession and/or society if trust is broken. Social sanctions come in the form of disapproval of pharmacy colleagues; fines; loss of your job, license, or registration to practice; and legal repercussions.

Because pharmacists and technicians work together so closely and the pharmacist is legally bound for all prescriptions dispensed, society’s trust in the pharmacist is being transferred more and more by extension to the pharmacy technician. It is important, therefore, to honor that trust and always seek to do what is right for the patient—at times, that may mean helping the pharmacist fill a few doses of a prescription for a heart or blood pressure medicine for a patient in the middle of the night or on the weekends while awaiting refill permission.

Ethical Dilemmas Facing Technicians

A code of ethics assists healthcare professionals in choosing the most appropriate course of action when they are faced with an ethical dilemma. An ethical dilemma is a situation that calls for a judgment between two or more solutions, not all of which are necessarily wrong. Deciding which action to take in the pharmacy requires considering the circumstances, choosing an action, and justifying the action. To do this, you should ask questions such as:

• What is the dilemma?

• What options are available?

• What is the best action or pharmaceutical alternative, and can it be justified on moral grounds?

Pharmacy technicians must recognize and accept the ethical standards of pharmacy practice and apply them when working side by side with pharmacists. They must also understand decision-making processes and become personally involved in obtaining facts that are relevant to a dilemma, evaluating the alternatives, and determining the correct solutions. The following scenarios and the ethical dilemmas that they pose are commonly seen in the pharmacy setting and are worth discussing:

• A prescription or medication order is issued for an abortifacient drug (that is, a drug designed specifically to terminate a pregnancy). You are uncomfortable with meeting that request because you consider the action morally or ethically unsound based on your religious beliefs. Do you have the right to refuse dispensing the drug based on your beliefs? What are your options of action?

• You do not have problems dispensing a drug but the pharmacist does. Does the pharmacist have the right to refuse to fill the drug? What are the options you have, and what do you consider to be the pharmacy’s responsibility to the patient in this case? If a pharmacist elects not to fill and dispense the substance, should you refer the patient to another pharmacist who is “on call” to come in and fill the prescription? Or to another local pharmacy?

• Although the physician wrote a prescription for three tablets a day of a blood pressure medication, after conferring with the patient you find out that they are is taking only one tablet a day as directed by the pharmacist. Is this endangering the patient? Was the prescription deliberately written so that the patient can stockpile the medication to last for a longer time to reduce prescription costs? What steps would you take to inquire further into this situation and to work with the pharmacist and the physician about this issue?

• You notice that the technician with whom you work has made numerous errors in calculations of days’ supply and dilutions. You don’t want to get him in trouble, but you are afraid for patients’ health. What do you when you see an error? What do you do when you see a trend? What are your options?

• A friend who is a technician with you boasts about how good her memory is and how all the extra safety checks are a waste of time and she is far more productive than anyone else by cutting just a few unnecessary corners. How do you respond to her? Do you take any additional actions and, if so, why and which ones?

• A patient confides that she has asked the prescriber for several prescriptions that are not needed, because she is giving the extra doses of the prescription to a friend with a similar medical condition who cannot afford insurance or is agoraphobic and is afraid of going out of her home to see a doctor. Are you bound by patient confidentiality and HIPAA regulations not to reveal this confidence? What are the legal (and ethical—later in this chapter) ramifications of this scenario? What are the options and best course of action?

• An out-of-town customer is requesting that you sell him some insulin syringes. Since you do not have a medication profile on this patient, you do not know if the syringes are for the treatment of diabetes or if he is requesting the needles for illegal drug use. What are the legal issues in this situation? What are the ethical considerations?

• An out-of-state customer comes in saying that she is on vacation and her whole family has come down with severe colds, so she is buying a variety of OTC pseudoephedrine products. She does not appear to have a cold herself. What are your options, and how would you respond?

• Someone who has hurt someone you love comes in for a prescription, and now you know that he is being prescribed mental health drugs. You could shame this person for what he did by posting on Facebook that rumor has it that this person is under the care of a psychiatrist and that is why he is so mean. This would make your friend look better and make up for some of what has happened to her. Is this legal, even if you never mention any drugs he is on? What would you do if you found out a colleague had posted something like this?

Other ethical dilemmas with narcotics to consider:

• You receive a legal narcotic prescription from an individual who you are fairly certain is selling the drugs on the street. What are some of your options? Do you tell the pharmacist and refuse to fill the prescription or contact the physician?

• You are asked to fill narcotic or sedative prescriptions for a patient who is slurring words and appears to be physically dependent on the drugs. Is intervention necessary or ethically sound? How would you and the pharmacist proceed to intervene? Have the pharmacist check the regional database? Contact the physician? The police? A family member?

• A patient receives three prescriptions from a “pain clinic” but elects to get only the narcotic filled, leaving the other drugs “on profile” for future use. A review of the profile indicates that the patient has not filled any profile drugs for the past six months. What are your options for action? Which is the best one and why?

• A patient is receiving the same or similar narcotic from two physicians and a dentist. Do you alert the prescribers? Why or why not?

• A specific prescriber seems to be consistently prescribing opioids, not seeming to follow the stair-step approach to analgesics and painkillers. You’ve heard about the problems of overprescribing these drugs leading to addiction and transferal to heroin. Is this your concern? What options do you have, and which is the best one?

• A patient on Medicaid has received five narcotic prescriptions from three different doctors in the past four weeks. Insurance will not pay for the sixth prescription until next month, but the patient is willing to pay cash. What would you do?

• Your partner is pressuring you as the technician to take just “a few” select drugs because they know you work at a pharmacy. You know that you could probably steal a few tablets of hydrocodone or alprazolam without anyone noticing. Do you keep your relationship or your job?

Ethical problems can come up unexpectedly. When unsure how to respond to an ethical problem, consult a supervisor.

Each state has its own laws to address ethical dilemmas that come up in pharmacy practice. Be sure that you understand these laws and any internal policies that may cover gaps in the law.

As modern pharmacy practice continues to evolve, new questions will arise that challenge pharmacy personnel in new decision-making deliberations. The answers to such ethical practice questions should certainly come under scrutiny by pharmacy personnel and professional pharmacy organizations. As with any politically, professionally, and emotionally charged topic, a variety of opinions will surface.