Ethics, decisions and patient-centred care

Adam La Caze

Semester 2, 2022

Objectives

  1. Apply a model for ethical decision-making in pharmacy
  2. Be able to identify a patient-centred approach to pharmacy practice, and provide its ethical justification
  3. Be able to identify the ethical aspects of a decision
  4. Be able to make a decision and justify that decision with reference to ethical theories, standards of professional practice and/or published cases.

System 1 and System 2 example

Program A or B

Imagine Brisbane is about to be exposed to a new virus, which is expected to kill 600 people.1

Two alternative programs to combat the disease will bring about the following consequences

If Program A is adopted, 200 people will be saved.

If Program B is adopted, there is a one-third probability that 600 people will be saved and a two-thirds probability that no people will be saved.

Write down which program you would choose.

Program C or D

Imagine Brisbane is about to be exposed to a new virus, which is expected to kill 600 people.

Two alternative programs to combat the disease will bring about the following consequences

If Program C is adopted, 400 people will die.

If Program D is adopted, there is a one-third probability that nobody will die and a two-thirds probability that 600 people will die.

Write down which program you would choose.

Case 1: Responsibility and patient care

Samara Aktari

Samara Aktari is a regular customer in your pharmacy.

Samara is 35 and dotes on her three children, aged 11, 10 and 7.

Samara suffers regular migraines and depression. Samara presents to the pharmacy with a prescription for the following treatments

  1. Nitrazepam 5mg 25, “Take mdu”
  2. Mersyndol Forte 20, “Take mdu”
  3. Tramadol SR 200mg 10, “1 d”

Some background information

You have some concerns regarding her medication use. Samara uses quite a few pain medications, and seems to rely on benzodiazepines for sleep and anxiety.

However…

  • You are confident that you are the only pharmacy Samara visits
  • Several GPs prescribe medicines for Samara, but all work at the same practice
  • She is always pleasant, and appears to be functioning fine providing she doesn’t have a migraine
  • She has been on these medications for a long time
  • There is a note from the previous manager who queried Samara’s use of benzodiazepines and pain medicines with her GP. The GP said she was fine and asked that the medicines are dispensed.

Samara’s recent dispensing history

Dispensed Drug Dose
14/08/2022 Amitriptyline Tablets 50mg, 50 1 n mdu
14/08/2022 Tramadol SR 200mg, 10 1 d
14/08/2022 Mersyndol Forte 20 1–2 tds prn
11/08/2022 Zolpidem 10mg, 14 1 n mdu
11/08/2022 Tramadol SR 200mg, 10 1 d
7/08/2022 Amitriptyline Tablets 50mg, 50 1 n mdu
7/08/2022 Mersyndol Forte 20 1–2 tds prn
7/08/2022 Diazepam Tablet 5mg, 50 1 d mdu
5/08/2022 Tramadol SR 200mg, 10 1d
30/07/2022 Tramadol SR 200mg, 10 mdu
28/07/2022 Amitriptyline Tablets 50mg, 50 mdu
28/07/2022 Mersyndol Forte 20 1–2 tds prn
28/07/2022 Nitrazepam Tablet 5mg, 25 1 d prn
24/07/2022 Tramadol SR 200mg, 10 1d

Task

Are there any ethical issues in dispensing Samara’s medications?

Will you dispense Samara’s medications?

A model for ethical decision-making

  1. Identify the problem and possible consequences of the problem
    • What facts are available?
    • What facts are still required?
    • What is the ethical problem? (Is there a conflict between two or more guiding principles?)
    • What harms are you concerned about? Who is affected?
  2. Identify relevant law and professional standards that apply to the case
    • What are your legal responsibilities?
    • What are your professional responsibilities?
    • How can you fulfil your legal and professional responsibilities in a way that brings about the best outcome in the situation?
  3. Identify the available options for resolving the problem and the reasons for or against each one
  4. Formulate a plan of action to resolve the problem
    • What do you need to put in place to improve the chances of a successful outcome?
    • How will you mitigate any risks you have identified?

Resources

Case 2

Will this supplement help my eyes?

Jenny is 52 years old, she is short-sighted and has worn glasses since she was a child. She has a healthy diet and doesn’t have cataracts or macular degeneration.

She asks you for a supplement that will assist her eye-health.

One of the pharmacy assistants over hears Jenny’s request and recommends Blackmores Macu-Vision Plus, suggesting that research has shown it to be beneficial for eye health.

The information provided with the product is:

Macu-Vision(R) Plus is a vitamin, mineral and antioxidant eyes formula that provides nutrients important to the macula. It incorporates two new ingredients - lutein and zeaxanthin – which help protect the macula from oxidative damage.

Jenny thanks you for the advice and buys the product.

A model for ethical decision-making

  1. Identify the problem and possible consequences of the problem
    • What facts are available?
    • What facts are still required?
    • What is the ethical problem? (Is there a conflict between two or more guiding principles?)
    • What harms are you concerned about? Who is affected?
  2. Identify relevant law and professional standards that apply to the case
    • What are your legal responsibilities?
    • What are your professional responsibilities?
    • How can you fulfil your legal and professional responsibilities in a way that brings about the best outcome in the situation?
  3. Identify the available options for resolving the problem and the reasons for or against each one
  4. Formulate a plan of action to resolve the problem
    • What do you need to put in place to improve the chances of a successful outcome?
    • How will you mitigate any risks you have identified?

Identify the problem and possible consequences

The pharmacy assistant’s advice is misleading.

A formulation like that used in Macu-Vision Plus has been shown to be beneficial for people with diagnosed age-related macular degeneration.

There is no evidence supplements like Macu-Vision Plus:

  • Prevent the development age-related macular degeneration in people without the condition
  • Prevent progression of age-related macular degeneration in people with mild disease
  • Prevent other eye diseases

The formulation contains high-doses of several nutrients linked to eye health. The link above provides information regarding adverse effects.

Some relevant professional guidance:

PSA Code of Ethics, Integrity Principle 1

provides accurate, truthful, relevant and independent information in a form that is appropriate for and not misleading to patients
…
will only purchase, supply or promote any medicine, complementary medicine, herbal remedy or other healthcare product where there is credible evidence of efficacy and the benefit outweighs the risk

There are limitations on the indications that products listed on the Australian Register of Therapeutic Goods can make.

Identify options and reasons for/against each one

  1. Rely on the advice on the pharmacy assistant
  2. The advice provided is close enough
  3. Clarify the evidence with Jenny and the pharmacy assistant.

Formulate a plan of action

Check the details (the key studies are AREDS and AREDS2).

Clarify the evidence with staff.

Resources

References

Kahneman, Daniel. 2011. Thinking, Fast and Slow. Macmillan.

  1. This example is a modified version of the “Asian Disease” case discussed by Kahneman (2011, 367).↩︎