Code of Ethics

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Honesty and Ethics of ProfessionsPercentage
"very high" or "high"
CNN/USA Today/Gallup
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Code of Ethics

• Ethics vs. Laws
• Is a code of ethics necessary?
• Does a code of ethics guide professional
  behavior?
• Is being a good person enough?
• What would our profession be like without ethical
  practitioners?

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Why Regulate Healthcare?

• Laws exist because a purely market-driven system
  fails to protect the public health, safety, and
  welfare.
• Incentive to maximize profit can compromise and
  conflict with the best interest of
  patients/customers.
• The race to the bottom

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Why have a Code of Ethics?

• The code is to protect each professional from
  certain pressures (for example, the pressure to
  cut corners to save money) by making it
  reasonably likely...that most other members of
  the profession will not take advantage of her
  good conduct. A code protects members of a
  profession from certain consequences of
  competition. A code is a solution to a
  coordination problem.

Michael Davis Senior Research Associate at the
Center for the Study of Ethics in Professions,
Illinois Institute of Technology
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Business vs. Profession

• Is Pharmacy a business or a profession? Both?
• Differences between business and profession?
• Are there business/political ethics?
• Enron, Global Crossing, Adelphia, Martha Stewart,
  Jack Abramoff

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American Medical Association

• Principles of Medical Ethics 
• A physician shall be dedicated to providing
  competent medical care, with compassion and
  respect for human dignity and rights.    
• A physician shall uphold the standards of
  professionalism, be honest in all professional
  interactions, and strive to report physicians
  deficient in character or competence, or engaging
  in fraud or deception, to appropriate entities.
• A physician shall respect the law and also
  recognize a responsibility to seek changes in
  those requirements which are contrary to the best
  interests of the patient.
• A physician shall respect the rights of patients,
  colleagues, and other health professionals, and
  shall safeguard patient confidences and privacy
  within the constraints of the law.

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American Medical Association

• A physician shall continue to study, apply, and
  advance scientific knowledge, maintain a
  commitment to medical education, make relevant
  information available to patients, colleagues,
  and the public, obtain consultation, and use the
  talents of other health professionals when
  indicated.
• A physician shall, in the provision of
  appropriate patient care, except in emergencies,
  be free to choose whom to serve, with whom to
  associate, and the environment in which to
  provide medical care.
• A physician shall recognize a responsibility to
  participate in activities contributing to the
  improvement of the community and the betterment
  of public health. 
• A physician shall, while caring for a patient,
  regard responsibility to the patient as
  paramount.
• A physician shall support access to medical care
  for all people.
• Adopted by the AMA's House of Delegates June
  17, 2001

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Pharmacist Code of Ethics

• Adopted by APhA in 1994
• Endorsed by ASHP in 1996
• Actually read by very few practicing pharmacists!

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Code of Ethics for Pharmacists
PREAMBLE Pharmacists are health professionals who
assist individuals in making the best use of
medications. This Code, prepared and supported
by pharmacists, is intended to state publicly the
principles that form the fundamental basis of the
roles and responsibilities of pharmacists. These
principles, based on moral obligations and
virtues, are established to guide pharmacists in
relationships with patients, health
professionals, and society.
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Code of Ethics for Pharmacists
I. A pharmacist respects the covenantal
relationship between the patient and
pharmacist. Considering the patient-pharmacist
relationship as a covenant means that a
pharmacist has moral obligations in response to
the gift of trust received from society. In
return for this gift, a pharmacist promises to
help individuals achieve optimum benefit from
their medications, to be committed to their
welfare, and to maintain their trust.
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Code of Ethics for Pharmacists
II. A pharmacist promotes the good of every
patient in a caring, compassionate, and
confidential manner. A pharmacist places
concern for the well-being of the patient at the
center of professional practice. In doing so, a
pharmacist considers needs stated by the patient
as well as those defined by health science. A
pharmacist is dedicated to protecting the dignity
of the patient. With a caring attitude and a
compassionate spirit, a pharmacist focuses on
serving the patient in a private and confidential
manner.
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Code of Ethics for Pharmacists
III. A pharmacist respects the autonomy and
dignity of each patient. A pharmacist promotes
the right of self-determination and recognizes
individual self-worth by encouraging patients to
participate in decisions about their health. A
pharmacist communicates with patients in terms
that are understandable. In all cases, a
pharmacist respects personal and cultural
differences among patients.
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Code of Ethics for Pharmacists
IV. A pharmacist acts with honesty and integrity
in professional relationships. A pharmacist
has a duty to tell the truth and to act with
conviction of conscience. A pharmacist avoids
discriminatory practices, behavior or work
conditions that impair professional judgment, and
actions that compromise dedication to the best
interests of patients.
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Code of Ethics for Pharmacists
V. A pharmacist maintains professional
competence. A pharmacist has a duty to maintain
knowledge and abilities as new medications,
devices, and technologies become available and as
health information advances.
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Code of Ethics for Pharmacists
VI. A pharmacist respects the values and
abilities of colleagues and other health
professionals. When appropriate, a pharmacist
asks for the consultation of colleagues or other
health professionals or refers the patient. A
pharmacist acknowledges that colleagues and other
health professionals may differ in the beliefs
and values they apply to the care of the patient.

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Code of Ethics for Pharmacists
VII. A pharmacist serves individual, community,
and societal needs. The primary obligation of a
pharmacist is to individual patients. However,
the obligations of a pharmacist may at times
extend beyond the individual to the community and
society. In these situations, the pharmacist
recognizes the responsibilities that accompany
these obligations and acts accordingly.
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Code of Ethics for Pharmacists
VIII. A pharmacist seeks justice in the
distribution of health resources. When health
resources are allocated, a pharmacist is fair and
equitable, balancing the needs of patients and
society.
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APhA Conscience Clause

• Pharmacist Conscience Clause
• 1. APhA recognizes the individual pharmacists
  right to exercise conscientious refusal and
  supports the establishment of systems to ensure
  patients access to legally prescribed therapy
  without compromising the pharmacists right of
  conscientious refusal.
• 2. APhA shall appoint a council on an as needed
  basis to serve as a resource for the profession
  in addressing and understanding ethical issues.

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Choices!
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Choice

• Ethical decisions occur when choices are made
  among all possible courses of action
• Not all choices involve ethical issues
• When they do, how do we make decisions?
• Using ethical principals
• Respect for autonomy
• Nonmaleficence
• Beneficence
• Justice

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Conflict of Interest

• Also called competing interests
• When an individual has an interest in two (or
  more) conflicting responsibilities, desires,
  goals, desired outcomes
• Examples Physician ownership of medical
  laboratories, pharmacies, or other services
• Authorship of an editorial review for a drug made
  by a company in which you own stock.

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Hospital Ethics Committee

• Assists medical staff with difficult cases
• Makes policy recommendations
• Provides education to physicians hospital staff
• Members
• Physicians, chaplains, nurses, social workers,
  public members

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Veracity

• Comprehensive, accurate, and objective transfer
  of information
• Depends on obligation of respect for others
• Closely related to fidelity
• Essential for trusting relationship

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Privacy

• A human right the Right to Privacy
• Informational privacy
• Personal information
• Physical privacy
• Personal space
• Decisional privacy
• Personal choices
• Proprietary privacy
• Property (e.g. tissue samples)

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Confidentiality

• Keeping information from being known
• informational privacy
• Medical confidentiality occurs upon disclosure
  from one person to another (usually patient to
  doctor)
• Information is private and imparted in confidence
  and trust

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Fidelity

• Act in good faith
• Keep vows and promises
• Fulfill agreements
• Maintain relationships
• Discharge fiduciary responsibilities (act in the
  patients best interest)

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Parental Consent/Disclosure

• ORS 109.640
• Right to medical or dental treatment without
  parental consent physicians may provide birth
  control information to any person
• Any physician may provide birth control
  information and services to any person without
  regard to the age of such person and a minor 15
  years of age or older, may give consent to
  hospital care, medical or surgical diagnosis or
  treatment by a physician licensed by the Board of
  Medical Examiners for the State of Oregon, and
  dental or surgical diagnosis or treatment by a
  dentist licensed by the Oregon Board of
  Dentistry, without the consent of a parent or
  guardian, except as may be provided by ORS
  109.660.

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Parental Consent/Disclosure

• ORS 109.680
• Disclosure without minor's consent civil
  immunity
• A physician, psychologist, nurse practitioner,
  licensed clinical social worker or community
  mental health and developmental disabilities
  program described in ORS 109.675 may advise the
  parent or parents or legal guardian of any minor
  described in ORS 109.675 of the diagnosis or
  treatment whenever the disclosure is clinically
  appropriate and will serve the best interests of
  the minor's treatment because the minor's
  condition has deteriorated or the risk of a
  suicide attempt has become such that inpatient
  treatment is necessary, or the minor's condition
  requires detoxification in a residential or acute
  care facility. If such disclosure is made, the
  physician, psychologist, nurse practitioner,
  licensed clinical social worker or community
  mental health and developmental disabilities
  program shall not be subject to any civil
  liability for advising the parent, parents or
  legal guardian without the consent of the minor.

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Parental Consent/Disclosure

• ORS 109.610
• Right to treatment for venereal disease without
  parental consent
• (1) Notwithstanding any other provision of law, a
  minor who may have come into contact with any
  venereal disease may give consent to the
  furnishing of hospital, medical or surgical care
  related to the diagnosis or treatment of such
  disease, if the disease or condition is one which
  is required by law or regulation adopted pursuant
  to law to be reported to the local or state
  health officer or board. Such consent shall not
  be subject to disaffirmance because of minority.
• (2) The consent of the parent, parents, or legal
  guardian of such minor shall not be necessary to
  authorize such hospital, medical or surgical care
  and without having given consent the parent,
  parents, or legal guardian shall not be liable
  for payment for any such care rendered.

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Death With Dignity Act 2004 Report
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ETHICS CASES/EXAMPLES
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Suspected Impairment

• You are an intern in a hospital pharmacy .
• You notice that the pharmacist you work with in
  the IV Room frequently comes to work with an odor
  of alcohol on his breath.
• You report your suspicions to the pharmacy
  manager, who says that he will talk to him

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Suspected Impairment

• Two weeks have passed and nothing appears to have
  been done and the pharmacist begins exhibiting
  bizarre behavior.
• What options do you have?

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Academic Ethics

• You are taking a pharmacology exam and notice
  that one of your fellow students appears to be
  referring to note cards in her purse.
• The fellow student is also the wife of one of the
  pharmacy faculty members.
• How would you handle this situation?

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Institutional Review Board

• You are the member of an Institutional Review
  Board reviewing an proposal for a clinical trial
  of a new blood pressure medication.
• The budget for the trial includes 30 per weekly
  visit for unreimbursed expenses for the patient.
• Is this coercive?

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Institutional Review Board

• You review a study for an FDA-approved drug used
  for an off-label indication.
• The study protocol states that the patient will
  be asked to pay for the drug.
• What phase clinical trial is this?
• Is it ethical to require the patient to pay for
  the drug?

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Genetic Testing

• Should the public have access to a test to
  uncover all genetic predisposion to disease?
• Total body CT Scans?
• The market-based system says YES
• if you can afford it, you can buy it!

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Oregon Health Plan - Rationing

• Rationing not allowed under Federal Medicaid
  rules
• Oregon received a waiver in early 90s for OHP
• List of diagnoses by medical necessity
• Covered to a specific level based on funding
• Ways to cut costs
• decrease covered patients, diagnoses, payments
• Distributive justice issues?

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Zevalin

• yttrium-90 (90Y) ibritumomab tiuxetan
• low-grade, follicular, and transformed
  non-Hodgkin's lymphoma (NHL) - rare
• Approx. 30,000 per monthly treatment
• Longer duration of remission by approximately 3
  months
• No improvement in survival

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Erbitux

• Treatment for colon cancer - common
• 17,000 per month
• No evidence of improved survival or quality of
  life
• Shrinks tumors in 10 of patients
• Covered under most health plans

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Ethics Case 1

• CC AB is a 47 yof was admitted to the hospital
  on 3/6 with recurrent seizures.
• HPI This patient was diagnosed with metastatic
  cervical carcinoma in January and has been
  treated with comfort measures only. She has had
  a progressive decline in her ability to care for
  herself over the last three weeks.

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Ethics Case 1

• SH Non-smoker, occasional EtOH, mother
  hypertension, father prostate CA, diabetes
• FH She is married with two children in their
  early twenties.
• PE/ROS Neuro patient lethargic and confused.
  Unable to communicate.

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Ethics Case 1

• AB was admitted to the oncology ward, no code
  status per husband and POLST.
• Over the next several hours her seizures became
  more frequent and severe. The family asked the
  MD if there is anything you can do to stop the
  seizures.
• The MD suggested a barbiturate (pentobarbital)
  infusion to induce sleep and stop the seizures.

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Ethics Case 1

• The physician writes an order for pentobarbital
  infusion per pharmacy titrate to comfort

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Ethics Case 1

• What ethical principles are involved
• for the patient?
• for the family?
• for the physician?
• for the pharmacist?

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Ethics Case 1

• The pentobarbital infusion was started and the
  patients seizures stopped and she was deeply
  sedated
• After four hours of pentobarbital infusion, the
  patient stopped breathing and was pronounced dead

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Ethics Case 1

• What distinguishes this case from assisted
  suicide?
• Might some people legitimately consider this
  assisted suicide?
• Could the physician be investigated by the DEA?

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Ethics Case 2

• You read an article in the morning paper that
  half of this years flu vaccine will be lost due
  to a manufacturers violation of GMP.
• Fortunately, your community pharmacy did not
  contract with the manufacturer involved and you
  have received 1000 doses of vaccine.
• The State Health Division tells vaccine providers
  that vaccinating patients who are not in a high
  risk category will be fined 500 per vaccination.

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Ethics Case 2

• The local hospital calls and says that they are
  unable to get vaccine because they contracted
  with the violating manufacturer and ask (beg!)
  for as many doses as you can spare.
• What is your answer?
• Any ethics issues involved?

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Ethics Case 3

• You are working in a busy community pharmacy and
  the technician calls you over to counsel on a new
  prescription.
• The customer is a woman picking up her own
  prescriptions and there is also one for her
  husband that she had not known about.
• The technician set it out for the pharmacist with
  the womans prescriptions

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Ethics Case 3

• The prescription for her husband was an antiviral
  drug commonly used for herpes infection.
• What should the pharmacist do in this situation?
• What if the prescription was for their sixteen
  year-old daughter?

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Ethics Case 4

• A customer brings a prescription bottle to the
  pharmacy counter and tells the clerk that he
  would like to speak with the pharmacist.
• The pharmacist approaches the counter and the
  patient gives her the bottle and says he thinks
  that a mistake has been made.
• The pharmacist discovers that the bottle was
  labeled for ibuprofen 600 mg tablets (30) and
  contained warfarin 5 mg tablets.

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Ethics Case 4

• What steps should the pharmacist take in this
  situation?

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Ethics Case 4

• The customer gives you additional information
  that their 13 year-old son has taken six tablets
  over the last four days for pain related to a
  sprained ankle.
• Now what??

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