Ethical Decision-Making Framework
Ethical dilemmas appear in every area of pharmacy practice. You cannot hide from them! Rather than hide, we should have an approach to dealing with these dilemmas, one that is easily applicable to different types of pharmacy practice. The following model has been adapted from the text Case Studies in Pharmacy Ethics (1). A few important steps have been added to ensure that you consider every factor from beginning to end:
Now let's talk a little bit more about each step in the process.
Step 1: Identify and respond to the feeling that something is wrong
Many times, the little nagging voice that will not leave you alone is enough indication that something is wrong. But just to ensure that ethical dilemmas are not passing you by in oblivion, you should ask yourself some questions to make sure everything is ethically sound when dealing with patients. For example, consider asking yourself some of these questions:
Step 1: Identify and respond to the feeling that something is wrong
Many times, the little nagging voice that will not leave you alone is enough indication that something is wrong. But just to ensure that ethical dilemmas are not passing you by in oblivion, you should ask yourself some questions to make sure everything is ethically sound when dealing with patients. For example, consider asking yourself some of these questions:
- Is the patient's autonomy being breached? Am I considering the patient's individual wishes and values? (Principle of autonomy)
- Am I maximizing benefit while minimizing harm for the patient (Principles of beneficence and non-maleficence)
Step 2: Collect more information
This is an essential step. I beg of you, do not make an assumption concerning what exactly the ethical dilemma is without gathering all relevant information! Collect all the details surrounding the dilemma. Who is involved? When did this occur? How have others responded to the dilemma? Collect and organize all your facts.
This is an essential step. I beg of you, do not make an assumption concerning what exactly the ethical dilemma is without gathering all relevant information! Collect all the details surrounding the dilemma. Who is involved? When did this occur? How have others responded to the dilemma? Collect and organize all your facts.
Step 3: Determine the ethical problem
At this point, you know something is wrong, and you have all the facts surrounding the incident. Now is the time to ask yourself, 'What exactly is the dilemma?'. Identify what the source of the concern is. What is at the heart of the issue? Are you concerned that Dr. Fowler is dismissing his patients' concerns about bleeding when starting warfarin therapy? Perhaps some of the clinicians you are working with provide more thorough care to patients who speak English as a first language as compared to patients who can not speak English well, and this makes you uncomfortable?
Once you have defined exactly what the problem is, you are on the right track to begin tackling the dilemma!
At this point, you know something is wrong, and you have all the facts surrounding the incident. Now is the time to ask yourself, 'What exactly is the dilemma?'. Identify what the source of the concern is. What is at the heart of the issue? Are you concerned that Dr. Fowler is dismissing his patients' concerns about bleeding when starting warfarin therapy? Perhaps some of the clinicians you are working with provide more thorough care to patients who speak English as a first language as compared to patients who can not speak English well, and this makes you uncomfortable?
Once you have defined exactly what the problem is, you are on the right track to begin tackling the dilemma!
Step 4: Seek a resolution
Easier said (or written) than done, right? This is the meat and flesh of it all, but do not become daunted by the task when you've come so far! When you factor in additional pieces to the puzzle, finding the best solution for everyone involved becomes easier to tease out.
To resolve the dilemma, consider the following:
There may be more factors to consider, or you may not find all applicable to your situation. Use your judgement, but try to consider all important factors.
Easier said (or written) than done, right? This is the meat and flesh of it all, but do not become daunted by the task when you've come so far! When you factor in additional pieces to the puzzle, finding the best solution for everyone involved becomes easier to tease out.
To resolve the dilemma, consider the following:
- 4 principles of medical ethics (autonomy, justice, beneficence, non-maleficence
- Laws (acts and regulations which govern the profession of pharmacy)
- Financial concerns
- Commitments to friends and families
There may be more factors to consider, or you may not find all applicable to your situation. Use your judgement, but try to consider all important factors.
Step 5: Work with others to determine the best course of action
Never make decisions regarding ethical dilemmas on your own. Similar to the collaborative approach of solving drug therapy problems, we should collaborate with other health care providers when encountered with ethical dilemmas. This is encouraged in the OCP Code of Ethics:
Principle Seven:
Each member collaborates with other health care professionals to achieve the best possible outcomes for the patient, understanding the individual roles and contributions of other health care providers and consulting with or referring to them as appropriate.
Involving others in your decision-making process helps you to filter out any personal biases you may have but do not recognize (we all have them, don't beat yourself up about it too much). Ultimately, consulting with others protects you from making any rash, uninformed, biased, or paternalistic decisions. Instead, your decisions will be thoughtful, well-informed, and sensitive to all members involved in the ethical dilemma.
Never make decisions regarding ethical dilemmas on your own. Similar to the collaborative approach of solving drug therapy problems, we should collaborate with other health care providers when encountered with ethical dilemmas. This is encouraged in the OCP Code of Ethics:
Principle Seven:
Each member collaborates with other health care professionals to achieve the best possible outcomes for the patient, understanding the individual roles and contributions of other health care providers and consulting with or referring to them as appropriate.
Involving others in your decision-making process helps you to filter out any personal biases you may have but do not recognize (we all have them, don't beat yourself up about it too much). Ultimately, consulting with others protects you from making any rash, uninformed, biased, or paternalistic decisions. Instead, your decisions will be thoughtful, well-informed, and sensitive to all members involved in the ethical dilemma.
Step 6: Document your decision-making process, final decision, and outcome
Phew. Steps 1-5 were a lot of work. Don't you wish you could put that down on paper and store all that hard work? Well you should! And I am certain your professors have hammered this into your minds. Mine most definitely have. A constant stream of yells and shouts over the past 4 years, all harmoniously coming together like your fifth grade choir group: "DOCUMENTATION, DOCUMENTATION, DOCUMENTATION!"
I am quite happy to tell you that it is no different with ethical dilemmas. Documentation is important! Documenting all the steps you have taken to reach a decision demonstrates a thorough and logical thought process. It also illustrates who you consulted with, and what factors you considered to reach a final decision. If possible, also document what the final outcome was of the ethical dilemma.
Most importantly, documentation also serves as a form of protection for you. If after all that straining of your ethical reasoning skills, the outcome of the ethical dilemma was an unfortunate one, that documentation will come in handy.
A Documentation Tool for Ethical Dilemmas is available on this website. You can click on the link below to access it.
Phew. Steps 1-5 were a lot of work. Don't you wish you could put that down on paper and store all that hard work? Well you should! And I am certain your professors have hammered this into your minds. Mine most definitely have. A constant stream of yells and shouts over the past 4 years, all harmoniously coming together like your fifth grade choir group: "DOCUMENTATION, DOCUMENTATION, DOCUMENTATION!"
I am quite happy to tell you that it is no different with ethical dilemmas. Documentation is important! Documenting all the steps you have taken to reach a decision demonstrates a thorough and logical thought process. It also illustrates who you consulted with, and what factors you considered to reach a final decision. If possible, also document what the final outcome was of the ethical dilemma.
Most importantly, documentation also serves as a form of protection for you. If after all that straining of your ethical reasoning skills, the outcome of the ethical dilemma was an unfortunate one, that documentation will come in handy.
A Documentation Tool for Ethical Dilemmas is available on this website. You can click on the link below to access it.
So far...
We have examined the theories and principles which are the basis for ethics in pharmacy practice. We also developed a practical framework for ethical decision-making.
Now what?
I know you're probably thinking that. Well I'll tell you what. It's time for some cases!
We have examined the theories and principles which are the basis for ethics in pharmacy practice. We also developed a practical framework for ethical decision-making.
Now what?
I know you're probably thinking that. Well I'll tell you what. It's time for some cases!
References
1. Haddad A, Veath RM. Case Studies in Pharmacy Ethics. 2nd ed. New York: Oxford University Press; 2008.
2. Hebert BC. Doing Right. 2nd ed. Toronto: Oxford University Press Canada; 2009.
1. Haddad A, Veath RM. Case Studies in Pharmacy Ethics. 2nd ed. New York: Oxford University Press; 2008.
2. Hebert BC. Doing Right. 2nd ed. Toronto: Oxford University Press Canada; 2009.