Professional judgement, best interests.
The doctor meant to write this…
A patient has a prescription for a drug dosage that you believe is unpractical to dispense. For
example, the prescription recommends 18 mg and you know that it is more practical to
dispense 20mg. In usual circumstances when you have a query about a dosage you contact
the doctor to confirm it. The doctor is not contactable however and you are very busy. You
know increasing the dosage will be safe for the patient. Should you go ahead and prescribe
20mg because you believe it will be in the patient’s best interests?
TUTOR NOTES
Responsibility to maintain personal integrity
Dilemma: Whether or not to supply medicine considered to be in the best interests of the
patient
Some possible areas for discussion include:
Duties and Responsibilities
Patient - welfare/best interests prime concern
Rights of Healthcare Professionals and Professionalism
Distinction between legal responsibilities and ethical responsibilities
Accountability
Patient – civil law
Society – criminal law
Profession and peers – regulatory/disciplinary body
Employer – contract of employment
Other healthcare professionals
Self – professional and personal integrity
Professional judgement
Acting ethically usually means acting legally, and vice versa
Acts can be ethical but not legal and vice versa
Ethical aspects
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Pharmacists primary responsibility the wellbeing and safety of patient and the
public
Protect rights and interests of patients
Relationship between healthcare professional and patient
Special obligations - professional-patient
Duties of beneficence/non-maleficence
Informed consent
Principles
o
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Non-maleficience duty to patient to ensure no harm is done
Beneficience - act to benefit patient
o
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 paternalism
Respect for autonomy
 Veracity - truthfulness
 Faithfulness – faithful to patient’s best interests
Justice
Deontology: assumes a duty of care to patients to protect from harm
Consequentialism: considers consequences of actions for all parties involved
Virtues: integrity, honesty, trustworthiness, veracity, courage, fortitude, respect for others,
respects patient’s confidences, compassion, fairness, self-control, prudence, etc.
Professional aspects
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Professional duties
Professional guidance – professions self-imposed standards
o GMC; BMA; RPSGB: NHS/DoH
Professional misconduct
Professional judgement and accountability
Code of Ethics –
o 15. Emergencies
Risk-benefit analysis
Prescription errors
o risk management
o protocols
o audit
Dispensing practice and procedures
o NB “…and you are very busy.”
Legal aspects
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Medicines Act 1968 and regulations
Emergency supply regulations
Criminal/civil liability
Duty of care and negligence
Pharmacist liability for dispensing errors
Summary points
Those involved in healthcare must be able to provide logical and sustainable
explanations for why they acted in the way they did when carrying out their
professional duties
Accountability applies to all facets of a healthcare professionals work including
ethical considerations and judgements
Professionals must act within their personal expertise; self-awareness/recognise
limits
A pharmacist must use his/her professional judgement to decide what course of
action is in the best interests of the patient
ETHICAL DECISION-MAKING
Is the question an ethical one?
Legal and professional issues but also ethical issues: Avoiding harm, Doing good, Integrity
Step 1 – Gather relevant information
Step 2 – Identify type of ethical problem
 rights and best interests of patient
 avoiding harm/doing good
 personal and professional integrity
Step 3 – Analyse problem
 principles of autonomy, non-maleficence; beneficence; virtues
Step 4 – explore options/solutions
 deontological approach – weighing of conflicting principles/conflict of duties –
which course of action best respects duties and rights?
 utilitarian approach – consider all potential consequences (to all parties involved)
– what benefits and harms will each course of action produce and which will lead
to best overall consequences?
 virtues approach – which course of action develops moral virtues?
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alternative courses of action, e.g.
supply medication ↪ risks? ↪safety? ↪ quantity? ↪ legal consequences ↪ duty of
care/assume greater liability ↪ extend depends on facts
refuse to supply ↪ risks? ↪ judgment to determine lack of legitimacy ↪ dosage clue
to prescription error?
advise patient how to obtain medical care ↪ risks?
make an emergency supply ↪ procedure, etc.
contact another GP in the practice
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N.B. frequently, there are no definitive right answers, only answers that are more
or less reasonable, more or less defensible: two people may come to an opposite
decision using the same information - it depends on how important each
consideration is to each person and also the degree to which an individual takes a
“deontologist“ or a “consequentialist” approach.
Step 5 – make decision
Step 6 – assess and reflect
Discussion review/links
Pharmacist duties, responsibilities and accountability
Controlled Drug legislation (and proposals post-Shipman Inquiry)
Emergency Supply procedures
Protocols
Pharmacist’s civil liability and extended duty of care (Amoxil case etc)
Prescription interpretation and dispensing
Patient medication records