What Is the Source of Moral Judgments? - Case Study in Pharmacy Ethics (Veatch).pdf

sponsoring religious group. For Catholic hospitals in the United States, for instance, this would be the Ethical and Religious Directives for Catholic Health Care Services.¹

The pharmacist also may be aligned with a religious tradition, which may or may not be the same as that of the sponsoring hospital. Should a religious tradition be treated as an authoritative source for knowing what is ethical? If so, should it be the hospital’s tradition or the pharmacist’s? And how should either of these relate to the professional code of the pharmacist?

Finally, the pharmacist likely will confront ethical dilemmas involving a par-ticular patient who also has moral standards that he or she feels should be the foundation of moral judgments involving his or her medication. Is the patient’s ethical stance a defensible basis for grounding the ethical positions taken by a pharmacist? In this chapter cases are presented that provide an opportunity to examine alternative ways of grounding moral judgments. In each case, the impor-tant problem is not ﬁ guring out the right thing to do but, rather, determining the source of moral authority and upon what authority the pharmacist’s behavior should be shaped.

Grounding Ethics in the Professional Code

A pharmacist confronting an ethical problem that poses a significant difficulty may want to turn to the professional code of ethics to determine what it says regarding the issue at hand. Often the professional code will provide insight based on years of collective experience of the members of the professional group.

Sometimes the apparent answer from the code seems so appropriate that no further consideration is necessary. In other cases, though, it may not be obvi-ous to the individual pharmacist that the profession’s collective wisdom is mor-ally deﬁ nitive. One problem arises because the professional group’s code can change over the years. The APhA code, for example, was originally written in 1852² but was revised in 1922³ and again in 1952⁴ and 1969. Modest changes were made in 1975, 1981, and 1985.⁵ Finally, in 1994 a completely revised code was adopted.⁶ Each time the code changed did the ethically correct behavior for pharmacists really change or only what the APhA members believed was the cor-rect behavior?

What about pharmacists who are not members of the APhA? Does its code determine what is ethically correct for those who are not members or only for those who are members? Can what is ethically correct for pharmacists change depending on whether they are members of their professional association? And what about pharmacists in other nations? Does the American professional code or the other nation’s professional code determine what is right for these pharmacists? It seems odd that what is right for pharmacists should depend on the country in which they practice and when they practice. The following two cases ask what role the professional code should play in determining what is ethically correct conduct for pharmacists.

What Is the Source of Moral Judgments? 43

Commentary

Until its most recent revision, the APhA code permitted violations of confi dentiality when the pharmacist was convinced, as is Dr. Jenkins, that the patient’s interest would be better served by disclosure; it may even have demanded disclosure in such situa-tions. The earlier version of the Code of Ethics said that the pharmacist’s fi rst consid-eration should be the health and safety of patients. It is not implausible that disclosure would help protect the health and safety of Mr. Wilson. The present version of the APhA code is less clear about how Dr. Jenkins should respond. Its second principle is “A pharmacist promotes the good of every patient in a caring, compassionate, and confi dential manner.” The pharmacist is not only supposed to promote the good of the patient but, also, to do so in a confi dential manner. Dr. Jenkins’s problem is determining if he should break a confi dence in order to promote his patient’s good.

Here we see that the professional code changes from time to time and sometimes is ambiguous.

As we shall see in Chapter 8 when we look in more detail at cases of conﬁ dentiality, other professional codes, including that of the American Medical Association, insist in such

CASE 3-1 What Is “In the Best Interest of the Patient”?

Eighteen months ago, John Wilson was in an automobile accident that resulted in head trauma. After an acute hospitalization, Mr. Wilson responded fairly well to an extensive rehabilitation program. The only residual damage from the injury was grand mal seizure activity, which was adequately, though not completely, controlled with phenytoin sodium and valproic acid. Mr. Wilson wanted to return to work with the private rooﬁ ng contrac-tor with whom he had been employed for 10 years. Mr. Wilson spoke with the owner of the rooﬁ ng company, Mark Adamson, about returning to work.

“Are you up to it, John?” Mark asked.

“Sure, sure,” Mr. Wilson replied, “I’m just like new.”

Later that week, Mr. Wilson returned to his neighborhood pharmacy for a refi ll on his anticonvulsant medications. In the course of fi lling the prescriptions, Mr. Wilson told the pharmacist that he had returned to work at the roofi ng company. The pharmacist, Ralph Jenkins, Pharm.D., was more than surprised because he knew that Mr. Wilson was not completely seizure free on his present medication regimen. Dr. Jenkins asked Mr. Wilson if he had told his employer about the possibility of seizure activity. “No way,”

Mr. Wilson replied, “I know when I’m going to have a seizure because I get this funny taste in my mouth and then I get dizzy. If that happens, I’ll go ﬁ nd a safe place to lie down.

Dr. Jenkins is troubled by Mr. Wilson’s response. He knows that the APhA Code of Ethics states that “a pharmacist promotes the good of every patient in a caring, com-passionate, and conﬁ dential manner.” Dr. Jenkins feels it would be in Mr. Wilson’s best interest to warn Mr. Wilson’s employer about the potential for grand mal seizure activity, yet he doesn’t want to hurt Mr. Wilson’s reputation or ability to work. Dr. Jenkins shud-ders to think what might happen if Mr. Wilson had a convulsion while working on a roof.

Further, Dr. Jenkins is certain that Mr. Wilson’s employer would be held at least partially responsible should Mr. Wilson sustain an injury. The Code of Ethics seems unclear about the ethically correct course of action in this type of situation.

cases that, even if the patient’s interest would be better served by breaking conﬁ dence, the conﬁ dence should still be kept, unless that patient gives permission to disclose.

The problem raised here is whether the professional association code is neces-sarily always the defi nitive authority for determining what is ethical for pharmacists. It seems to make sense to consult the code in diffi cult cases, but is that because the code defi nes what is right for pharmacists or because the code simply summarizes the judg-ment of the pharmacist’s colleagues who have faced somewhat similar situations?

It could be that what is the right behavior for a pharmacist is whatever the code says. If the code literally deﬁ nes what is ethical for members of the profession, then it is logically impossible for it to be wrong. Moreover, whenever the code is changed, then what is right for pharmacists changes. The alternative is that the foundation for ethics in pharmacy is something more basic than the current professional agreement.

For example, for those standing in a religious tradition, what is ethically right and wrong might be determined by the approval or the will of the deity. For some secular thinkers what is right is determined by reason, by the moral laws of nature, or by other fundamental standards. The idea is that the standard for ethics is the ultimate appeal one can make, the point beyond which no further appeal is possible.

Some people have given up hope of recognizing the will of a deity, the moral laws of nature, or what reason requires. They may be convinced that the standard of ethics is a societal one. In that view, an act is right if one’s society says it is. That, of course, leaves open the possibility that for other people in other societies, some other behavior would be ethical (because in their society some other behavior is approved). Still, there is possi-bly a difference between what society says a pharmacist should do regarding a problem, like breaking a conﬁ dence, and what the profession says a pharmacist should do.

Dr. Jenkins’s problem is whether he is prepared to treat the professional associa-tion’s statement of what is ethical regarding breaking a conﬁ dence as a standard beyond which there is no conceivable appeal. Is he prepared to say that whatever the APhA says ethically settles the matter? Or does he believe that the real standard of ethics lies elsewhere: in the will of God, in reason, in the laws of nature, in the broader society’s judgment, or perhaps his own judgment? Where should Dr. Jenkins turn to ﬁ nd the ultimate standard for moral matters? A similar question arises in the following case.

CASE 3-2 Professional and Public Views on Closing a Pharmacy

Sidney Kalman had worked as a pharmacist-in-charge at the pharmacy of the Grand Union grocery store in Paramus, New Jersey, since September 1970. In early June of 1978, his supervisor, Stanley Brumer, informed him that, although the rest of the store would be open, the pharmacy section would be closed for the July Fourth holiday. Since the phar-macy section was not separated by a partition and was not capable of being secured, this disturbed Mr. Kalman. In fact, because of the inability to secure the prescription section, the entire store was licensed as a pharmacy.

When Mr. Kalman protested, the supervisor told him that the Board of Pharmacy had given its permission to close the pharmacy section, but Mr. Kalman, suspecting this was not true, phoned the Board and conﬁ rmed that the pharmacy was indeed required to be open if the rest of the store was. The pharmacy was kept open July Fourth with another pharmacist on duty.

What Is the Source of Moral Judgments? 45

Commentary

The problem facing Mr. Kalman involves a complex combination of moral, legal, and public policy questions. For our purposes, it is important to focus on the moral ones.

It seems sensible to say that the rule or regulation requiring Mr. Kalman to report the violation constitutes clear public policy. What, however, is the relation between the APhA Code of Ethics and the moral and legal dimensions of this case?

Professional organizations, such as the APhA, are not public agencies. They are private professional groups. They are not, in any way, under public control. In this sense, they are quite different from public agencies. By contrast, the Board of Pharmacy is a public agency normally appointed by and formally accountable to public ofﬁ cials. It would appropriately have authority to establish public policy not normally granted to private groups, even professional groups.

A public body, such as a state board of pharmacy, could adopt as its public policy a rule that whatever the professional group declares is ethical is automatically public policy as well. If it did, it would still have to determine whether it is endorsing the state association, the national association, or some international professional body’s code of ethics. The underlying question, however, is whether it makes sense for the public to permit private professional groups to shape public policy, regardless of which group is selected. There is always the possibility that the public’s view of what the policy should be will be different from the profession’s view. In the event of a dispute between the public and the professional perception of public policy, it would seem strange to hear the public insist that the professional formulation should automatically prevail.

CASE 3-2 Continued.

Upon reporting to work on July 5, Mr. Kalman was informed that his employment at Grand Union was terminated. Mr. Kalman eventually sued his former employer claim-ing he was discharged “solely for attemptclaim-ing to vindicate a state regulation and his own code of professional ethics.” Mr. Kalman was what is called an “at will” employee, that is, one without a formal contract. In general an employer can dismiss such employees at will except when doing so violates public policy. Firings on blatant racial grounds or for refusal to grant sexual favors to a supervisor are examples of ﬁ rings that have been held to violate public policy.

A lower court granted a dismissal of Mr. Kalman’s case on the grounds that neither the state regulation nor the code of professional ethics was a clear expression of public policy that would prohibit ﬁ ring of Mr. Kalman. The case was then appealed, at which time the higher court had to determine whether the mandates of state regulation and the professional code of ethics provided such clear expressions.

The appeals court ﬁ rst held that the state rules regulating the practice of pharmacy did impose a duty on the pharmacist to report the violation of the Pharmacy Act. It then turned to the question of whether the APhA Code of Ethics could also be a “source” of public policy. The question at this point is whether Mr. Kalman, in deciding whether to report the decision to open the store on the Fourth of July without opening the phar-macy section, should be guided by the APhA Code as well as by the rules of the Board of Pharmacy and, if so, whether the state should recognize such guidance.⁷

Even if the APhA was recognized as a legitimate source of public policy, the question remains of the relation between what is public policy and what is ethics.

Since the courts were only dealing with the matter of what was the source of public policy, the question of what is ethical may not have been directly relevant. It is con-ceivable that opening the store without a pharmacist present was permitted by public policy but was still unethical. What should Mr. Kalman do in this case?

It is possible that Mr. Kalman would conclude that he should engage in civil disobe-dience, to violate public policy in order to do what is ethical. That is a major decision, however, one that should not be undertaken lightly. In this case, since public policy seems to concur with Mr. Kalman’s ethical judgment, the problem probably would not arise.

This leaves us with the question, however, of how Mr. Kalman should judge what is ethical in such cases. If ethics sometimes requires civil disobedience, this implies that what is ethical is not determined solely by public policy of the society. However, it is not clear that the codes of the profession automatically determine what is ethical any more than they determine what is public policy. If the profession determined what was ethical for professionals, then the profession could never be wrong, yet many people would acknowledge that the profession is occasionally wrong. Perhaps the profession is no more an appropriate source of the ethics of professional conduct than it is a source of public policy. We are left with the question of whether the society, the courts, or Mr. Kalman should view the professional codes as a “source”

of either public policy or of ethics. Does it make sense for Mr. Kalman to claim in defense of his behavior regarding the Fourth of July incident, that he was grounding his sense of obligation in the code of the profession of pharmacy?

Grounding Ethics in the Physician’s Orders

In some situations a pharmacist is presented with ethical decisions that seem to be grounded not so much in either public policy or professional codes, but in the beliefs of practicing physicians. Of course, in reaching his or her moral conclusion, the physician may have to decide how important the professional code is, but by the time the physician has decided on a course of action, the pharmacist may be presented only with the doctor’s order. The following two cases raise the question of whether the pharmacist should treat the physician’s instruction as a grounding of moral positions taken in the practice of pharmacy.

CASE 3-3 Whether to Dispense a Potentially Lethal Drug

Jane Travis, Pharm.D., worked closely with the local hospice program. She was very familiar with pain-management protocols for terminally ill patients. Most of the patients were maintained at home on ambulatory infusion pumps that delivered continuous or bolus doses of morphine. As the patients developed tolerance to the morphine, the dosage was adjusted accordingly. Dr. Travis understood that opiate doses were determined by balancing analgesic effectiveness and side effects. She followed the National Cancer Institute recommendations that, at lower doses of opioids, for patients with uncontrolled

What Is the Source of Moral Judgments? 47

CASE 3-3 Continued.

pain, daily doses usually should increase by 25–50%, whereas for patients already on high-dose formulations, daily doses usually should increase by 20–30% from the previ-ous dose.⁸ Therefore, Dr. Travis was surprised when she received a phone order from Dr. John Crampton, who was caring for Mrs. Reynolds, a terminally ill hospice patient.

Mrs. Reynolds had been receiving 100 mg/hour intravenous morphine and oral amitripty-line hydrochloride 20 mg/qd. Dr. Crampton increased the morphine dose to 275 mg/hour infusion. Dr. Travis had participated in hospice rounds earlier that morning and learned that although Mrs. Reynolds’s blood pressure and heart rate were low, she was receiving adequate pain control at the 100 mg/hour rate.

Dr. Travis shared this information with Dr. Crampton and questioned his rationale for increasing the morphine so drastically. Dr. Crampton stated, “I have known the Reynolds family for a long time. Rebecca Reynolds has been slowly dying for 6 months, and the family is exhausted. Rebecca has no quality of life to speak of and certainly is ready to die.

I have given this a lot of thought and feel it is the humane and moral thing to do. I take full responsibility for this decision.” Dr. Travis was not comforted by Dr. Crampton’s willing-ness to take responsibility for this decision. She wondered about her personal responsibil-ity regarding dispensing a drug in a dosage that, regardless of Dr. Crampton’s justiﬁ cations, was patently lethal.

CASE 3-4 Respecting the Wishes of the Terminally Ill

Linda Marley, Pharm.D., worked in the intensive care area of a large, university hospital.

Dr. Marley had been involved in the care of Oscar Donham, a 71-year-old patient who two months earlier had suffered a massive cerebral vascular accident (CVA). Mr. Donham

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