Ethical Issues in Patient
Counseling
Sample Questions: We will come back to these later.
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Your patient presents a prescription for 30 lisinopril 10mg, with 12
refills. The patient asks you to fill it for 90 tablets at a time so they
will have a reduced co-pay. The insurance company allows a 90
day supply, but only if the original prescription is written for a
quantity of 90 tablets. What would be the best approach to making
this patient happy?
A close friend who is having a prescription for Adderall filled at your
pharmacy confides she had to lie to the physician to get her to write
her daughters prescription for the drug.
During a review of the insurance log, you notice that a customer
who picked up 7 prescriptions for his mother failed to sign the log
book. If you get audited it will be a problem.
Your district manager has just sent out a memo that the chain has
purchased a large supply of Vitamin D with “short dating” and he
wants all pharmacists to recommend this product to customers to
avoid the risk of it expiring on the shelves.
Principles of Ethics
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Beneficence
Autonomy
Honesty
Informed Consent
Confidentiality
Fidelity
Ethical Principles
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Beneficence
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Acting in the patients best interest
Past models doctor made decision
 Current thinking is to involve patient letting the
patient determine what is in their best interest
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Autonomy
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Letting the patient have the final decision, even if
it is not in their best interest – i.e. refusing
treatment, surgery, etc.
Ethical Principles
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Honesty
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The patient has the right to the truth
Medical condition, course of the disease
 Treatments
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Code of ethics states:
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A pharmacist: “has the duty to tell the truth and
to act with conviction of conscience”
Rapport is built on trust, which is based on
honesty
Ethical Principles
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Informed consent
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Requires honesty and autonomy to exist
Patients have the right to full information of
all relevant facts and must give explicit
consent before treatment
Ethical Principles
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Informed consent exists when:
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All relevant information has been provided
The patient understands the information
Consent is freely given and there is no coercion
The patient is capable of understanding the
information
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Note: Often, practitioners rely only on the disclosure part of
this list!
Ethical Principles
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Confidentiality
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From the patients perspective this is “selfdisclosure” and they should be the ones
making this decision.
Patients are expected to divulge information
to practitioners, the only choice is which one
Trust in confidentiality becomes very
important
Ethical Principles
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Fidelity
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The right of patients to have practitioners
provide services that are in the patients best
interest
Infidelity from an Rx’er could be:
Recommending vitamins patients don’t need
 Failing to confront a doctor with an inappropriate
prescription out of fear that the doctor will direct
his/her patients elsewhere
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Principles of Ethics
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Beneficence
Autonomy
Honesty
Informed Consent
Confidentiality
Fidelity
Return to the Sample Questions:
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


Your patient presents a prescription for 30 lisinopril 10mg, with 12
refills. The patient asks you to fill it for 90 tablets at a time so they
will have a reduced co-pay. The insurance company allows a 90
day supply, but only if the original prescription is written for a
quantity of 90 tablets. What would be the best approach to making
this patient happy?
A close friend who is having a prescription for Adderall filled at your
pharmacy confides she had to lie to the physician to get her to write
her daughters prescription for the drug.
During a review of the insurance log, you notice that a customer
who picked up 7 prescriptions for his mother failed to sign the log
book. If you get audited it will be a problem.
Your district manager has just sent out a memo that the chain has
purchased a large supply of Vitamin D with “short dating” and he
wants all pharmacists to recommend this product to customers to
avoid the risk of it expiring on the shelves.
Case 1
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Ms. Edwards, a 67yo female, is starting on a new
medication for schizophrenia (Zyprexa by Lilly). The
drug has a number of side effects, some of which are
serious. She asks you several questions about the
purpose of the medication and possible side effects.
When you ask her what the physician told her about
the medication, she reports that he said “I’ve got a
lot of patients on this medication and they are doing
fine.” It is obvious to you that she is unclear about
the purpose of this drug or any possible problems.
Your concern is that Ms. Edwards may be
noncompliant if told about possible side effects.
What will you do?
Points for Case 1:
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Ms. Edwards does not understand the purpose / side
effects.
No informed consent can exist under these
circumstances.
If she knew, she might not take the medication.
(beneficence)
May see it as the doctors duty to inform her about
the disease and treatment
Fear about doctor getting mad at you if you tell the
patient things s/he didn’t.
Autonomy would require you to tell her because she
has a right to choose what happens to her body.
May need to call doctor to discuss – how to approach
this – assertiveness?
Case 2
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Your district manager requires techs to say: “It may
be a while before you can talk with the pharmacist,
do you really want to talk to the pharmacist about
the medicine?” You’ve argued with the DM saying
this approach is not appropriate. You want to talk to
patients personally to verify what they know about
their medications. The DM’s position is clear: his
method meets the legal requirements, your store is
too busy to do more and financially he can’t afford
any more staff to solve the problem. The store is in
danger of being closed due to competition in the
area. But, he encourages you to counsel, in depth,
anytime you have time and no other patients are
waiting.
Points for Case 2:
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Conflict of interest
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Your self interest (pleasing your boss) and the
patient’s need for information.
Should hold the patients interest as
paramount.
Decision to counsel should be based on
patient need, not time, waiting lines,
managers preferences, etc.
Case 3
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James Bently, a 17 year old patient was diagnosed
with epilepsy and prescribed phenytoin 6 months
ago. You understand that he is embarrassed by his
disease and is not convinced the doctor is right about
the diagnosis. He thinks he does not need the drug.
You have tried to educate him on the med and the
importance of taking it properly but it has not worked
– he still omits doses frequently. He also continues
to drive, and was recently in a non-injury accident.
His father sometimes picks up his meds, but does not
seem to have knowledge of his son’s denial of the
disease or his non-compliance. Should you disclose to
the father, physician, or the police that the patient is
not taking the medication?
Points for Case 3:
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Confidentiality
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Should be up to James on whether or not the
information is shared with his parents or doctor.
(self-determination)
Beneficence (acting in patients best interest) could
justify breaking confidence in this case – to
protect the patient.
Also have a duty to protect the innocent people he
could harm if his behavior continues.
May want to press James to give you permission
to tell his doctor. You could do this without his
permission and without breaking confidentiality,
but you would break trust.
Case 4
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You are a pharmacist who works for a chain. A
close family friend recently lost her father to a
heart attack. She calls you and asks you if you
would mind coming over and disposing of his old
meds. You agree. While disposing of the meds
come across his bottle of propranolol. You open
the bottle, pour the contents into the waste
container, and are surprised to see Coumadin
5mg. You check the label and find that the
wrong meds were in this bottle. The
prescription was filled at another outlet of your
chain – you recognize the pharmacists name.
Supplemental Information
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Propranolol is a beta-blocker and should
be tapered before discontinuation.
Coumadin is a potent anticoagulation
medication.
Your friend’s father was not prescribed
Coumadin.
Points for Case 4:
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Beneficence
Autonomy
Honesty
Informed consent
Confidentiality
Fidelity
Case 5
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Mary is a school teacher at a local public
school. You have known her for years. You
know she has a handicapped child who she must
provide most of the care for, since her husband
chooses not help. You also know she has fought
a very minor, self perceived, weight problem for
a long time. You are also aware that she has
tried plenty of fad diets in attempts to loose
some weight. She has also purchased diet aids
from the OTC isle on occasion. When prompted,
she confides that she thinks she needs to loose
10-20 pounds to look the way she wants to look.
Case 5
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Today she presents a prescription for
phentermine 15mg capsules. The tech took the
prescription in while you were on the
phone. You become aware of the prescription
when the tech can't find the medication on the
shelf. You immediately react and think to
yourself, "What is she getting this for?" You
know her profile well and are concerned that the
phentermine is not going to be compatible with
her thyroid or BP medications, even though
there are not outright contraindications or
interactions.
Case 5
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Questions:
Should you tell the patient you don't think she
needs the medication or not?
Will you be able to communicate without being
judgmental?
How do you approach communication with the
patient since you already know her well?
What do you say to the patient - to get the
message to her that you don't think she needs
this medication?
How will you handle the problem of the doctor's
view on all of this? Will you call her MD?
Case 6
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A good friend of yours stops by the pharmacy
one day - right before a big vacation they are
planning. They've booked a flight to San
Francisco, and admit to you that they are afraid
to fly because of all the media attention to the
airlines and all the controversy over
security. Your friend asks if you can give them 2
valium 10mg so they can "chill out" before they
get on the plane on the way out and back. You
know, and your friend does too, that no one will
ever miss the 2 pills. You think to yourself that
a real friend wouldn't ask - and are mad that
they have put you on the spot like this.
Case 6
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Questions:
What do you do? If you choose not to
give the medication how will you tell your
friend no? If you do give the pills, how do
you justify this?
What if the request was for antibiotics for
your friend’s child with an obvious ear
infection? Would this make a difference?
Case 7
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Mr. Heyward is one of your favorite customers. He lives
alone, but his 20 year old grandson Mark visits him
almost daily. Mark helps Mr. Heyward with chores, picks
up groceries, etc., and just seems to like spending time
with his grandpa. Mr. Heyward's grandson is probably
his best friend and he talks about him all the time. One
afternoon, Mark stops by the pharmacy to pick up some
Maalox, Tylenol and has a note with a number on it that
he hands to you and asks you to refill his grandpa's
prescription. It's a refill, so you tell Mark to have his
grandpa call if he has any questions. You have him sign
the counseling log book. About a week later, Mr.
Heyward calls and tells you his arthritis is acting up and
he needs to get a refill on his Lortab. You pull up Mr.
Heyward's profile and instantly realize this is the same
prescription Mark had picked up just a few days ago.
Case 8
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Mrs. Sheen been using your pharmacy for a couple of
years. During this time she has been on antidepressants,
tranquilizers and occasional pain medications . You have
noticed that she seems to be very accident prone. She
has reportedly been in at least two traffic accidents
where she was injured and she has fallen at least a time
or two. It's been a while since she has been in, but
today she presents with bruises on her face. While
writing the check to pay for her prescriptions you notice
that she has significant bruising on her wrists. You ask if
she is OK and she just looks at you and says, "I'll be
fine". She takes her prescriptions and leaves quickly.
Your technician leans over and says - you need to report
this!
Case 9
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A 16 year old make customer comes by to pick up his
prescription for erythromycin which he uses to fight
acne. His mom, a long time friend of yours, usually
comes in with him, but today he is alone. Since he has
been taking the erythromycin he has been having
stomach pains. He does not know that the erythromycin
can cause this, and he does not mention the stomach
pain to you. While counseling him on the refill you ask if
he has any other questions or concerns. He hesitates,
the asks "What will happen if I used any other drugs
with this? Your response is that it would be very
important for him to check with you first - before using
any other medication. He says OK then leaves. A few
minutes later he comes back in and very hesitantly asks
if smoking pot with his prescription could be causing his
stomach to hurt?
Case 10
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You have a male patient at the community pharmacy
who has several prescriptions filled for HIV
infection. Your long time friend Susan is over for dinner
one night and she tells you about this great new guy she
has met. She's falling fast, and through the course of
the conversation you realize that this new fellow is an
HIV patient at your pharmacy. From her comments, you
are able to discern Susan has no idea that he is HIV
positive. What, if anything can or would you do?
Case 11
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You are a pharmacist for CVS. A 15 year old high school student presents
her prescription for birth control pills to you at the pharmacy drop off
window. You fill it, counsel her and provide an information leaflet on the
medication. She pays the $25 medication co payment with a Visa card. A
few days later, the young girls dad notices the Visa charge from CVS in the
exact amount of his co payment, while reviewing his monthly charges. He
is confused and thinks a mistake has been made because he uses another
pharmacy for his prescriptions. So, the Dad picks up the phone and calls
CVS to ask about the charge. The call is directed to you. When he asks
about the prescription, you look it up for him, then notice that it was for the
daughter - and you apologize, but, refuse to provide any further
information about the situation. The father insists, but, you hold your
ground. His last words had something to do with getting you fired.
Case 12
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A female patient presents you with a prescription for Plan B, the morning
after pill. You have thought a lot about this, and even talked to your
colleagues, and your boss. Your boss has told you company policy which is
vague and could go either way - for or against you. Your good friend Tom
at CVS has made it clear that he has no problem with the
medication. Having never been faced with actually making a decision
you've not really decided what you would do under these
circumstances. The pharmacy does carry Plan B. You look at the
prescription and then simply state that you can not fill the prescription
because of your beliefs, and direct the patient to Tom at CVS, and
apologize for any inconvenience. The patient is furious. She insists you
have no right to refuse to fill her prescription and demands that you fill
it. You hold your ground. She threatens to sue you and the pharmacy if
you do not comply.