Pharmacists play a role in the public health system and the provision of medical care public health system as critical as that of physicians. Most of the time, pharmacists only fill the prescriptions coming from physicians, but pharmacists often need to prescribe and dispense medicines on their own, especially over-the-counter drugs that people usually use for self-medication of common ailments. With less prudence and circumspection, pharmacists may prescribe medicines that do more harm than good. In recognition of these potential threats to the integrity of the pharmaceutical profession, the Royal Pharmaceutical Society of Great Britain (RPSGB) has developed a new code of ethics and performance framework, which provide that pharmacists and pharmacy technicians in the whole of UK receive quality education necessary for fostering the knowledge, skills, attitudes and values to provide a consistent and safe practice.
In formulating the new pharmaceutical code of ethics, the Society, as the RPSGB is more popularly known in UK, noted how the profession has been smeared by controversies involving some of its members, regarding issues on assisted suicide, making a prescription error, sedating an unruly patient, dispensing high-cost drugs and recommending treatment that would allow parole7,,8. This paper discusses the revised code of ethics for British pharmacists and pharmacy technicians as to the likelihood of its lifting the professional practice of pharmacy to new heights of ethical proficiency and integrity.
2. Literature Review
The requirements of the revised code reflect key issues for modern pharmacy practice, such as encouraging patients to be involved in decisions about their care, respecting patient choice and working in partnership with other healthcare professionals8. All the provisions of the code are supposed to reflect in the conduct, practice and performance of pharmacists and pharmacy technicians, designed as it is to promote and support a culture of accountability and professional judgment. For this reason, the code sets out seven principles of ethical practice that pharmacists or pharmacy technicians need to observe in the pursuit of their profession.
2.1. Key Principles
The revised code of ethics is based on seven principles, each of which is supported by requirements that explain the types of actions and behaviors expected of pharmacists and pharmacy technicians when applying said principles in practice. The seven principles are: 1) make the care of patients the pharmacist’s first concern; 2) exercise professional judgment in the interests of patients and the public, 3) show respect for others, 4) encourage patients to participate in decisions about their care, 5) develop professional knowledge and competence, 6) be honest and trustworthy, and 7) take responsibility for your working practices.
Unlike previous versions, detailed standards and guidance will be produced separately from the code. Seven professional standards and guidance documents have also been developed to support and expand on the principles of the new code of ethics in the following areas:
• Patient consent
• Patient confidentiality
• Sale and supply of medicines
• Pharmacist prescribers
• Pharmacists and pharmacy technicians in positions of authority
• Internet pharmacy
This means that people are forbidden to accept pharmaceutical work when they do not possess the necessary skills and competence7. If they do have the proper knowledge and experience, the code says that the pharmacist should start work by establishing the scope of his role and responsibilities and clarifying any ambiguities or uncertainties about where his responsibilities lie. In addition to complying with his legal and professional obligations, the pharmacist is also expected to keep up to date with and observe the laws, statutory codes and professional obligations relevant to his particular responsibilities8.
2.2. Role and Responsibilities
If subject is a pharmacy owner, superintendent pharmacist or pharmacy manager in a hospital, trust, or other field of practice, the code obliges him to set the standards and policies for the provision of pharmacy services by his organization. The idea is to make the organization – its premises, departments or facilities – properly maintained so that none of its activities would bring the pharmaceutical profession into disrepute. For this purpose, all the medicines, pharmaceutical ingredients, devices and other stocks at the pharmacy premises or facilities are stored under conditions appropriate to the nature and stability of these products. In hiring people, management of a pharmacy must conduct background check to ensure that they are qualified for the job and have no criminal records1.
The code deems it important that the people employed in a pharmacy are conscientious enough to raise concerns about risks to patients or the public. Thus, the pharmacy should emplace an appropriate and effective mechanism for staff to raise concerns about risks to patients or the public, including concerns about inadequate resources, policies and procedures, or problems with the health, behavior or the professional performance of others.
2.3. Ethical Development
Ethical practice in any profession is commonly perceived to be the outcome of good education and training. However, studies in the UK context reveal that classroom discussion and experiential clerkship training have no significant impact on the ethical decisions that pharmacists make later3. In an interview of pharmacy students regarding parole and drug rationing, it was found that majority would recommend treatment to allow parole and restrict the use of expensive drugs6.
The ethical choice here is between the benefits to the patient and the risks or costs to society. On physician-assisted suicide or euthanasia, few students expressed willingness to dispense any lethal dose of medication to terminally ill patients. In cases of unruly patients, however, more students would dispense the appropriate sedative. These responses give rise to questions so to whether pharmacy students are trained to be patient-focused in their future practice3.
The code also specifies training on such aspects of pharmaceutical practice as good consultation skills and meticulous record keeping. To the code, it matters if pharmacists forget to ask questions in a medication review or in dispensing a repeat prescription; or misinterpret body language and miss cues from patients about emerging problems. The reason is that pharmacists may be the only healthcare professional the patient is seeing routinely so it matters if they miss something or handle a clinical situation poorly.
2.4. Advertised Drugs
A recent randomized controlled trial using model patients found that patient requests for advertised drugs were a stronger determinant of prescribing decisions than whether or not the patient had the condition the drug aimed to treat2. Another study of prescribing decisions in response to patient requests found that if a patient asks for an advertised brand, he usually receives it, although the physician is more likely to be ambivalent about these prescribing decisions6. These studies suggest a need for physicians and pharmacists to receive adequate training on how to respond to patient requests.
The global withdrawal of the drug Rofecoxib from the market in 2004 illustrates this point. Rofecoxib was no more effective than alternative non-steroidal anti-inflammatory drugs in treating the symptoms of arthritis but it was widely promoted as safer and accepted by the public as such. Although there were studies that it brought the side effect of increased heart disease risks, the drug made it big in the market, with 80 million prescriptions worldwide3. The market success of the drug is a testament to the triumph of marketing over science. Only after the US Food and Drug Administration reported 35,000 cases of cardiac arrests and a congressional investigation was consequently held that the drug was pulled out. The incident highlighted the need to ensure that health professionals are adequately prepared to evaluate promotional claims, and to assess and understand interactions with the pharmaceutical industry2.
Educators in many countries are clearly aware of the influence of pharmaceutical promotion on the health professions and wish to prepare students for this aspect of their professional lives. As a physician educator from India said, “…Whatever rational things we want to inculcate in them, that should be done in the student period itself. Once they taste big money then habits develop and later die hard9.” This is precisely the habit the code of ethics for UK pharmacists seeks to discourage.
On pharmacy education, the literature agrees that there is no consistent, well-designed and deliberate approach to teaching students ethics during clerkship. Moreover, it has been observed that factors such as life experiences and normal maturation are likely to contribute to the students’ ethical development. Acknowledging these limitations, the code simply seeks to determine if there were noticeable changes in the ethical decisions made by students at different points in their education. Since it was seen that classroom and clerkship experiences do not impact on the ethical decisions made by pharmacy students, the code encourages pharmacy schools to attend to this problem. On top of the proposed agenda is a revision of the curriculum such that it can provide a deliberate and consistent ethical component to the clerkship experience5.
A review of ethics literature in medicine and pharmacy found that pharmacy schools lag considerably behind medical schools in the integration of ethics into the curriculum1. Additionally, medical schools were found to use a more patient-oriented approach to teaching ethics. It is believed that a patient-oriented, clerkship-based approach could enhance ethics education and is worthy of further study. The Society is thus currently making efforts to more effectively design and study alternative approaches to ethics education during clerkship, and throughout the pharmacy curriculum8.
The finding that pharmacy students do not learn ethical behavior from their classroom and clerkship experience in UK casts doubt on full compliance with the code of ethics for this type of healthcare professionals. The above studies conclude that students have a less defined professional ethical system, which may be due to a lack of pharmacy practice experience. They recommend that further studies be done to document the ethical growth and development of pharmacy students. Other authors have suggested that future studies longitudinally evaluate the influence of pharmaceutical education and training on the moral development and ethical behavior of students. Furthermore, it has also been suggested that ethics education should include both theoretical and practical components. If the code of ethics has to influence the practice of pharmacists and pharmacy technicians, concerned authorities must take these suggestions to heart. Otherwise, the code will only be good on paper.