Case Studies in Pharmacy Ethics identifies and discusses the broad range of ethics issues pharmacists confront in practice. Case studies are increasingly used in pharmacy undergraduate as well as .. soundofheaven.info [Accessed 7 July ]. Pharmacists constantly face ethical choices -- sometimes dramatic matters of life- and-death decisions, but more often subtle, less conspicuous choices that are.
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Case Studies in Pharmacy Ethics This page intentionally left blank Case Studies in Pharmacy Ethics second edition. This book is a collection of those situations based on the real experiences of practicing pharmacists. The use of case studies in health care ethics is not new, but. The third edition of Case Studies in Pharmacy Ethics presents a comprehensive series of cases faced by pharmacists that raise ethical issues, with chapters.
It may be more reasonable to take some risk with a generic drug for a headache than for the control of seizure activity. The APhA code, for example, was originally written in but was revised in and again in and If every alternative is very unattractive, then assuming continued use has at least some additional weight-loss effect she might be willing to take on the risks of using the drug for a longer period. The pharmacist lists several such effects: If not treated immediately with appropriate drug therapy and other life-saving measures, Mr. Philosophical Ethics:
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Oxford Textbooks in Critical Care. Every pharmacist, aware or not, is constantly making ethical choices. Sometimes these choices are dramatic, life-and-death decisions, but often they will be more subtle, less conspicuous choices that are nonetheless important.
Assisted suicide, conscientious refusal, pain management, equitable and efficacious distribution of drug resources within institutions and managed care plans, confidentiality, and alternative and non-traditional therapies are among the issues that are of unique concern to pharmacists. One way of seeing the implications of such issues and the moral choices they pose is to look at the experiences of practitioners and the kinds of choices they have had to make in situations typically faced by pharmacists.
This book is a collection of those situations based on the real experiences of practicing pharmacists. The use of case studies in health care ethics is not new, but in pharmacy it is. This text is an important teaching tool that will help pharmacy students and pharmacists address the increasing number of ethical problems arising in their profession.
It is not merely a compilation of cases, but rather is organized for the systematic study of applied ethics. Part I shows how to distinguish ethical problems from other kinds of evaluative judgments and examines the sources of values in pharmacy, posing basic questions about the meaning and justification of ethical claims. Part II explores the basic principles of ethics as they have an impact on pharmacy.
Specific cases from clinical settings present in a systematic way the various questions raised by each of the major ethical principles -- benefiting the patient, distributing resources justly, respecting autonomy, dealing honestly with patients, keeping promises of confidentiality, and avoiding harm.
Part II examines some of the special problems of contemporary pharmacy such as the linkages between pharmaceutical care and professional practice, human experimentation, reproductive issues, genetic technology, death and dying, and mental health. Autonomy in Applied Ethics in Applied Ethics. Edit this record. Mark as duplicate.
Find it on Scholar. Request removal from index. Revision history. Google Books no proxy Setup an account with your affiliations in order to access resources via your University's proxy server Configure custom proxy use this if your affiliation does not provide a proxy. Do these emotional signs indicate that an ethical problem is in progress? The answer, as is often the case in ethics, is yes and no.
Just because people are emotionally upset with each other or under a lot of stress does not necessarily mean that an ethical problem is involved. In Mr. Fowler happened to notice the discarded IV bag that led to her discovery of a drug error that may or may not have contributed to Mr.
Fowler also experiences a sense of dread when she thinks about reporting the error to the intensivist in charge of both patients. She can certainly expect some type of negative reaction from Dr.
Mann based on past interpersonal interactions. She may also feel guilty about the error that has occurred. These negative emotions are indications that an ethical problem is present. One should then move on to the next step. Gather Information There is an old saw in ethics: To organize the numerous facts in the situation in which Dr. Fowler is involved, one can classify them into clinical and situational information. Clinical information deals with the relevant clinical data in the case in question.
The following types of clinical questions are relevant when reviewing a case: What is the medical status of the patient or patients involved in the situation? Medical history? What drugs are involved, and what are their actions, side effects, etc.? His illness was acute and life-threatening. If not treated immediately with appropriate drug therapy and other life-saving measures, Mr.
London would certainly die from hemorrhage and shock. Even if the treatment was effective in managing the bleeding, it would not resolve the underlying problem of cirrhosis. Additionally, the chance that treatment would be effective was small given the underlying condition. The administration of heparin to a patient who is already hemorrhaging would increase the risk of bleeding, but it may not have hastened Mr.
As much as possible, it is important to clarify the relevant clinical information in the case before moving on to a more in-depth analysis of the moral relevance of these facts.
Situational information includes data regarding the values and perspectives of the principals involved; their authority; verbal and nonverbal communication, including language barriers; cultural and religious factors; setting and time constraints; and the relationships of those immediately involved in the case. An extensive discussion of value judgments is in Chapter 2. The main players in this case are the two patients, any family involved, Dr.
Fowler, Dr. Mann, the pharmacist s who prepared the drugs, and members of the nursing staff responsible for hanging the IV medications. All the individuals involved in the case possess values about many things, including values about health, honesty, professional competence, and loyalty, to name a few.
Do individuals who make mistakes lose their jobs? The case also includes a situational factor that impinges on the case—urgency and time constraints.
Two emergencies occurred almost simultaneously.
If the two admissions to the intensive care unit had been spaced further apart, it is possible that the error would not have happened. We know that responsibility for the error-free care of Mr. London and Mr. Lucas rested with various members of the health care team. As part of the information-gathering step it is important to sort out the A Model for Ethical Problem Solving 25 various responsibilities, not for placing blame but for identifying moral accountability.
For example, Dr. Fowler may not be the one who mislabeled the IV bags, but as evening supervisor she has overarching responsibility for all medications that leave the pharmacy. Second, she is the one who discovered the error. Knowledge of the error carries its own responsibility.
These are only some of the facts affecting ethical decision-making in this case. Once all the facts are outlined, they can be examined to see whether the situation has the characteristics of an ethical problem.
Ethical principles are relevant sources of ethical guidance and can serve as guidelines to identify the types of ethical problems involved in a case. The ethical principles most often involved in complex cases, such as Dr. Separate chapters presented in Part II develop each of these principles.
Clearly an error has occurred. In the case of Mr. London, the degree of harm caused by the error is still in question. Even an autopsy might not be able to determine whether the error contributed to his death. The error may have caused harm to Mr. Lucas as well. He too was deprived, at least for a while, of a treatment that could have helped him. Thus, harms have occurred that, at this point, are unknown to key players in the case. Mann but also to prevent further harm to Mr.
Lucas by making sure he begins to receive the right drug. As far as we know to this point, only Dr. Fowler knows about the error. As soon as she calls attention to the error by stopping the octreotide IV and ordering the correct medication from the pharmacy, others will become aware of the error too. She believes she is obligated to tell the truth to Dr.
Mann so that she can adjust Mr. But there are others involved in the case who have a claim on knowing the truth, the other members of the health care team, such as the nurses and pharmacists, as well as Mr. Fowler seems to feel quite certain that she has a duty to inform Dr.
One could propose arguments for either telling or withholding the truth from the family. The harm to 26 Ethics and Values in Pharmacy Mr. London has already occurred and is irreversible. Fowler to be concerned about causing unnecessary psychological stress on his family.
Traditionally, the Hippocratic ethic permits, or even requires, health professionals to remain silent whenever information would be needlessly disturbing to patients or families. Fowler owes it to Mr. At this point, exploring various courses of action requires both determining which principles are involved and what their implications are.
At that point, we can move to the fourth step in solving the problem at hand. Several courses of action are open to Dr. Mann about the error and other internal entities in the hospital but not inform Mr. Lucas; or 4 she could wait to tell Dr.
Mann about the error with Mr. These actions actually fall into the categories of telling, not telling, or waiting to tell, the last being a version of not telling. Because the error affected two patients, the range of possible actions doubles. This process involves the application of the ethical principles presented earlier and the ethical theories described below.
This option would be compatible with the respect, dignity, and equality that all human A Model for Ethical Problem Solving 27 beings deserve. Not telling the family members does not respect the dignity of the family members.
The third option of withholding the truth about the error and not doing anything else would be hard to justify from the perspective of these duty-based principles. Furthermore, not telling and trying to correct the error without telling anyone about it is fraught with problems, not the least of which is the great possibility of getting caught in the act of a cover-up.
The credibility of not only Dr.
Fowler but of the entire pharmacy would be at stake should that happen. The fourth option delays the truth but holds open the possibility that it will be disclosed at a later time.
This option seems to be based on the assumption that disclosure is warranted only if the consequences require it. Two major versions of consequence-oriented ethics were presented in the introduction: London is dead; he cannot be affected one way or the other.
Lucas, conversely, is very likely to be affected. At least he needs to begin immediately receiving the right medication, but that may not require disclosure of the error.
Then, too, disclosure may be distressing to him. A good case can be made that the error should be kept between Dr. Fowler and those who need to know in order to correct it. Utilitarianism holds that the option that would bring about the greatest good for the greatest number should be chosen. If not, it would be bad and wrong. To decide whether the various options are right or wrong one would have to consider the effects of each on everyone concerned. Utilitarianism would consider the effects not only on the two patients, Mr.
Lucas and Mr. London, but also on the pharmacist who apparently made the error and the nurses who failed to check the medications and catch the error. It would consider the families involved. The same is true for ethical decisions. A better decision can be reached if the people who are legitimately involved have the opportunity to openly discuss their perceptions, values, and concerns. In a complex case such as this, Dr. Fowler should call on the input of colleagues in pharmacy, the physician, and the nursing staff.
On the other hand, the Hippocratic form of a consequence-based ethic provides the most plausible basis for supporting nondisclosure. London cannot be helped by the disclosure, and Mr.
Lucas probably can be helped as much without it. A more social form of a consequence-based ethic, such as utilitarianism, leaves us in an ambiguous spot. Harms can come—to the families who will be placed in distress and certainly to the pharmacist who made the error. Notes 1. Purtilo, Ruth.
Ethical Dimensions in the Health Professions. Saunders, ; Fletcher, John C. Frederick, MD: University Publishing Group, ; Haddad, A. Norwalk, CT: Appleton and Lange, ; Rule, James T.
Ethical Questions in Dentistry. Quintessence Books, Salladay, Susan, and Amy Haddad. In fact, there are pharmaceutical dimensions to almost all of the dramatic ethical problems in health care. Abortion can involve decisions about the use of abortifacient agents; euthanasia, about the use of barbiturates and narcotic analgesics to hasten death; pharmaceutical agents are used in producing superovulation that precedes in vitro fertilizations; and genetic engineering includes many pharmaceutical applications in drug manufacturing and decisions about alternative therapies.
Thus almost every dramatic and controversial issue in health care ethics can pose problems directly related to pharmacy. Nevertheless, many of the day-to-day ethical dilemmas faced by the pharmacist arise not in the context of these dramatic, ethically exotic cases, but in much more normal, routine pharmacy practice. Identifying Value Judgments in Pharmacy Normative judgments or evaluative judgments occur constantly in all health care decisions. It is impossible to get to a clinical conclusion—to prescribe a drug, use an over-the-counter medication, substitute a generic, check the accuracy of a dosage with the physician, include a medication in a formulary, or report a suspected drug abuser—without making a normative judgment.
Whenever someone decides to act or refrain from acting , some evaluation has taken place. A decision is made that a particular course is the right one. It is better than available alternatives. It is what one ought to do. One key to learning to recognize that evaluative judgments have taken place is to watch for value terms.
Words like right, better, and ought all signal a process of evaluation. It is the nature of a clinical science like pharmacy that these evaluations take place constantly. Case does not raise a dramatic or grave ethical issue. It may not raise any ethical issue at all. It does involve a number of evaluations, however.
In reading through this case, note all the words signaling that an evaluation is taking place. Williams had tried numerous diets over the years but always seemed to lose only a few pounds and then gain back even more. Also, she really hated exercise, so a quick-and-easy way to lose weight was what she had in mind. She stopped by the pharmacy she often patronized during her lunch hour. Krause noticed the weight control pills and looked up to see if the buyer was truly overweight.
He had noticed a seasonal increase in the sales of these pills following the holidays and leading into swimsuit season. Williams looked to be at least 50 pounds overweight for her height. Williams asked Dr. The formula also contains some bitter orange that will suppress your appetite to a certain degree. There is also guarana, and that has an effect similar to caffeine. These pills should be used on a short-term basis along with reduced caloric intake and exercise.
The amount of weight reduction usually is small. Williams groaned. They have a stimulant effect, which can result in nervousness, restlessness, insomnia, dizziness, and headache. There is also the possibility of an increase in blood pressure and heart rate. Williams was getting more and more discouraged. Williams stood in the checkout line with the diet pills in her hand, tapping them lightly on the counter as she decided what would be worse: The customer wanted the diet pills, and the pharmacist was in a position to provide her with some information about them.
Searching for the value terms, however, reveals a number of judgments that are clearly in the realm of values.
According to this pharmacist the pills should be used on a short-term basis along with reduced caloric intake. Two judgments are implied here. But, second, it is acceptable to use them only in the short term. Both of these evaluations are controversial.
They rely in part on assessments of what the case refers to as side effects. The term is an interesting one. It is, in fact, a value judgment that certain effects are unintended and bad. The pharmacist lists several such effects: The judgment that these are bad effects is relatively noncontroversial. It is a value judgment nonetheless. Moreover, these effects are worse for some people than for other people. Someone suffering from hypotension might be less concerned than a hypertensive.
We already see how such evaluations take the pharmacist beyond what pharmacological science can provide. The move becomes even more significant when the pharmacist and patient begin to compare the risks of these harmful side effects with the possible benefits of using the diet pills. In deciding to use 32 Ethics and Values in Pharmacy any drug, the critical question is always how valuable the expected benefit is going to be. Normally that is not a medical issue. In this case, the critical question is how important it is to Ms.
Williams to lose weight through the use of the drug. In order to answer that question we need to know not only how she values weight loss, but also how she compares the harms from the possible side effects with what she perceives as the disadvantages of other ways of losing weight and of not losing weight at all.
If every alternative is very unattractive, then assuming continued use has at least some additional weight-loss effect she might be willing to take on the risks of using the drug for a longer period. However, if losing weight is not as important, or if other methods are not terribly burdensome, then even short-term use of the substances commonly found in diet pills would make little sense.
The evaluations are key, and it is hard to see how being trained as a pharmacist or any other health professional makes one an expert in making them. Williams what his personal opinions are about how one set of effects compares to another?
Or is he simply charged to give her the facts? It seems strange that he would be expected to give her his personal value judgments. However, giving her just the facts would create serious problems as well. In the case of nonprescription products, such as herbs and vitamins, it may be very difficult for the pharmacist to know what the facts really are, since there is little convincing, scientific evidence about the benefit of any ingredient in weight-loss products.
Also, stocking these products in the pharmacy implies a value of sorts, and that sends a message to patients when they look for assistance from the pharmacist. Moreover, in order to fully evaluate the risks, the pharmacist would have to know other important facts about the case, such as what products Ms. Williams had tried in the past and why she is worried about losing weight. Then, too, how can the pharmacist know exactly which medical facts to give her?
Surely, more could be said about diet pills than is reasonable to tell to a patient. In addition, this particular patient may be unusually interested in certain relatively rare risks that would not be of concern to most.
Case presents another opportunity to identify the evaluations taking place in a conversation between a pharmacist and a patient.
In this case try to identify the value judgments made by the prescribing dentist, the pharmacist, and the patient. Rudolph and Dr. Jones knew each other not only as pharmacist and patient, but as members of the same health club. The dentist said the stuff he used to numb my mouth will last a long time, maybe up to 6 hours. Would aspirin or something else overthe-counter work just as well? Are there any side effects from codeine? Jones believes that pain and pain relief are completely subjective.
He feels this is especially true in the case of dental patients who have received local anesthetic agents with a long duration of action.
Should Dr. Jones encourage Mr. Rudolph to try aspirin, acetaminophen, or ibuprofen to relieve the pain? Commentary As in Case there appear to be possible differences in value judgments about how to treat pain from a tooth extraction. Similar questions arise about what constitutes a side effect and how to determine just how bad the side effects could be. Rudolph seems to believe he will not need what he considers to be strong pain medication. Of course, the anesthetic has not worn off yet, but he may well know from past experience that he can tolerate the anticipated level of pain.
The judgment that he will not need the codeine is actually a judgment that he prefers the risk of pain controlled only with nonnarcotic analgesics to pain controlled by a narcotic. Jones apparently views these trade-offs differently.
He believes he is in a position to know not only how much pain Mr. Attitudes about pain vary tremendously from one culture to another and from one individual to another.
They may believe that the risk of addiction, no matter how small, is not worth it. They may also ground their judgments in even deeper cultural attitudes about the meaning of pain and its control.
Moreover, in some cultures pain is perceived as affording some advantage, as a warning of an underlying problem or as a character-building experience in which the sufferer learns to cope. For other cultures and ethnic groups, pain is something to be expressed openly. This generates an attitude of sympathy while providing a rationale for explaining unusual behaviors related to pain.
In addition, there are those who hold the worldview that pain makes no sense other than, perhaps, as a signal of a potential medical problem. According to this 34 Ethics and Values in Pharmacy point of view, humans should have dominance over nature and make use of technology to suppress suffering.
The dentist in this case seems to gravitate toward this view, while the patient is more cautious. In effect, Dr. Jones is being asked to arbitrate a debate about which of these two worldviews is more appropriate for treating someone experiencing dental pain. In that case, the pharmacist is being asked as a friend to give counsel on a matter of personal preference, a role he might want to take on as a friend but surely not as a pharmacist.
It is a question of aesthetics, of what kind of lifestyle is best. It may also be a question of what kind of lifestyle is ethical. This raises the question of the relationship between ethical judgments and other kinds of evaluative judgments, a question we address in the second half of this chapter.
Pierce took the time to counsel patients about the side effects of medications and often stepped out from behind the counter to assist a customer in selecting a nonprescription drug product. However, Dr. Kelly noted that Dr. Pierce seldom asked patients if they preferred generic or brandname medications. Kelly had strong negative feelings about the bioequivalence of some generic drugs to innovator drugs, in particular, drugs with a narrow therapeutic index. Her suspicions had been fostered by several pharmacy school instructors who emphasized their personal biases against using generics for critical-dose drugs, such as immunosuppressive agents.
Kelly asked Dr. The sign on the cash register is not very large. Commentary Once again the problems of this case may appear to raise questions of medical science. Kelly and her instructors in pharmacy school have been impressed by Values in Health and Illness 35 the pharmacological data reportedly showing inconsistent bioequivalence of generic drugs as compared with name-brand medications. Furthermore, Dr. However, even if one assumes that there is less consistency in generic compounds as well as a greater risk of getting an ineffective dose, it does not automatically follow that the patient should prefer the brand name compound.
Kelly concludes that one can buy greater reliability by paying a higher price, she still must consider whether it is wise to spend more money for the extra margin of advantage from the brand name drug.
It is a question of values. Different patients are likely to make different value judgments. If a patient is quite wealthy and has a high degree of concern about the effectiveness and safety of the drug being taken, it would certainly be understandable for that patient to spend the extra money to achieve an additional level of safety. It may be more reasonable to take some risk with a generic drug for a headache than for the control of seizure activity.
The value trade-off is in large part not medical. If one assumes that the generic drug is supposed to have met some minimal standards in the manufacturing process, the risk may be less than Dr. Kelly fears. But Dr. Pierce seems to be engaging in evaluative judgments as well.
He simply may not share Dr. His may simply be a different value judgment. There is a complicating factor, however. When the right of the patient to be informed and to choose among alternatives is violated by the pharmacist, the problem is no longer simply one of nonmoral value preferences.
It is to cases that will help distinguish between ethical and nonethical evaluations that we now turn. Separating Ethical and Other Evaluations We have seen that evaluative judgments arise constantly in the practice of pharmacy, not just in the ethically dramatic cases, but also in making routine judgments about whether an effect is good or bad, whose good or bad it is, and whether the risk is worth taking given the alternatives available.
Not all evaluations are ethical judgments, however. This section examines the relationship between ethical and other kinds of evaluations. In order for an evaluation to be an ethical evaluation, certain criteria must be met.
First, the judgment must be about a human action, or character, or about norms 36 Ethics and Values in Pharmacy generally governing actions or character.
When we say a painting is good, we do not make an ethical judgment; we make an aesthetic one. When we say a person is good, however, we can mean many things. When we say a person is good, however, we may mean that that person is morally good.
By contrast, a person may be good according to the standards of the local community or the culture.
Or the person may be good according to a certain legal standard. An ethical evaluation is made according to the ultimate standard. For religious people that standard is most likely the will of God. For secular people it may be reason or natural law or some similar nonsacred standard. The following cases provide an opportunity to try to separate ethical judgments from other kinds of evaluations.
In reading them, try to identify the issues you consider to be ethical and those you think involve nonethical evaluations. For the past 7 days, Mr. Vickers had been taking Bactrim DS twice daily for a painful urinary tract infection. His physician emphasized the necessity of taking the medication faithfully and completing the course of therapy, so Mr. Vickers explained to the local pharmacist, Pat Martin, Pharm.
He gave Dr. Martin the name of his physician back home and the name and daily dosage of the drug. Martin was able to access Mr. Martin then called the physician and found out he was out of town and would return in 4 days. Martin relayed this information to Mr. Vickers stated. On the other hand, Bactrim DS is not the type of drug that has a serious potential for abuse.
Besides, the adverse effects of the drug are minimal. Martin knows there are risks from stopping antibacterial therapy midcourse. It is really up to her to decide whether she will give a complete course of antibacterial therapy to Mr. Values in Health and Illness 37 Commentary Many value judgments take place as this scene unfolds. Try to identify them. Martin also makes evaluative judgments. She no doubt would like to help Mr. Vickers but feels an obligation to obey the law. Both judgments require evaluating not only the likelihood of certain risks occurring, but also how serious the risks are.
In addition, the use of Bactrim DS has its own underlying value judgments. These are medical value judgments, but they are value judgments nonetheless. There are also nonmedical value judgments. Vickers could have chosen other approaches to his problem. He must have decided that the problem was not serious enough to force him to return home or to seek out help from a local physician.
Martin could have pursued Mr. The value of the vacation in the mountains entered into the judgment as well. She evaluates the side effects as minimal and considers the drug to have a low potential for abuse. Deciding that the side effects are minimal requires an evaluation of them.
Determining what the predicted side effects are is pharmacology. Deciding that they are bad and how bad they are is not. Likewise, some legal judgments were made by the pharmacist. More importantly, the law does not settle the ethical question.
When asking about the morality of dispensing without a prescription we are appealing to a different standard. In distinguishing between the moral and the legal we could have in mind that in some cases it could be moral to violate the law. If the pharmacist chose to break the law after careful moral deliberation in such a case, we might say that the pharmacist conscientiously violated the law.
We might also have in mind that sometimes we offer moral evaluations of existing law not for the purpose of considering whether to conscientiously violate it, but rather to determine whether it is a good law. Sometimes it is important to 38 Ethics and Values in Pharmacy separate morality and law in order to purposely make legal certain actions that are believed to be immoral. Some people take this view about abortion, for example.
We might even insist that the law be obeyed as long as it exists while simultaneously working to change it. When we ask whether Dr. Martin would be wrong to dispense the Bactrim DS, we seem to be asking if it would be immoral as well as illegal. Martin might conclude, for instance, that Mr. Vickers is a reasonably competent adult who should have the moral right to be self-determining regarding the risks he takes with his own body.
If so, she might conclude that morality requires that he have access to drugs, even legend drugs, provided that the risk is only to himself. One who believes strongly in the priority of the moral principle of autonomy might reach that conclusion.
A libertarian one who gives absolute priority to autonomy would reach that conclusion regardless of whether Mr. Vickers understood the actual risks and benefits of the drug. Others, utilitarians, for example, would give moral priority to making sure that the greatest good resulted. Even they, however, might support access to legend drugs, at least when the risks are small and the patient seems to understand them, especially, as in this case, when the risk of harm from not getting the drug also is real.
Both of these reasons for supporting access are moral in character. They appeal to standards that can be taken by their proponents to be ultimate standards of action. Martin may have moral reasons for refusing access. First, she is probably convinced that dispensing the drug without authorization is illegal. Since the time of Socrates, people have believed that if one agrees to live in a society one also agrees, or promises, to abide by its laws. We can be said to have a moral obligation to keep such commitments, even if we think the law is foolish, even if we think the law is immoral.
A second moral reason why Dr. Martin might oppose giving Bactrim DS to Mr. Vickers is that in calculating the consequences she could adopt the position that they should be assessed not on the individual case alone, but also by taking into account what would happen if everyone were to follow a similar rule.
This position, based on what is known as rule utilitarianism, would ask that we consider whether society would work better if a rule was in place that allowed pharmacists to dispense legend drugs without a prescription whenever they thought the consequences would be positive and the risks minimal. Whichever conclusion we reach, we should recognize that in this case, real moral issues are at stake. For those who favor dispensing, there are appeals to autonomy and to consequences. For those who oppose dispensing, there are appeals to the keeping of promises and to the consequences of alternative rules.
Whichever conclusion is reached, we should recognize these appeals as moral. Jose Emilio, Pharm. On a Sunday afternoon when Dr.