A question was posed to students of a pharmacy ethics class. In every case, the answers given by the students were different from the responses of the practicing pharmacists.
The problem I set was this. The student, now a graduate pharmacist, is directed by the boss, the pharmacist-in-charge (PIC), to fill a prescription by emptying the contents of a C III sedative capsule and replacing them with lactose. The PIC explains that the doctor is prescribing a placebo and that over the past few months the pharmacist and physician have been slowly replacing active ingredient with inactive ingredient, until now the capsules contain only lactose. The new capsules are working as well as the regular medication worked, and the patient reports that she is sleeping well throughout the night.
The PIC then tells the student/pharmacist to label the prescription with the name of the regular C III sedative and to stress, in counseling the patient, the strength of the drug and the importance of avoiding an overdose. In other words, the student is told to lie to the patient. Then the PIC departs; he will not return until his regular shift the following day.
Not one of the students was willing to fill the prescription or counsel the patient if it meant lying. They came to this conclusion in spite of the fact that they had been assigned to watch 2 videos extolling the necessity and use of placebos. Intellectually, the students understood the value of the placebo effect, but somehow the situation was different when it became a question of what the students were willing to do to make the patient believe in the placebo.
If a pharmacist believes that he or she cannot participate in a deception, what are the alternatives?
In this instance, the student/pharmacist could tell the patient that she will have to wait to pick up her prescription until the PIC is on duty.
Would the answer ever be to tell the patient the truth? In that case, the patient would learn that her doctor and her regular pharmacist had been lying to her.
When the same question was presented to 6 pharmacists who had been practicing for several years, they gave the opposite answer. Every one of them would fill the prescription by replacing the active ingredients with an inert substance. In addition, all of them would counsel the patient as if she were receiving the drug named on the label.
They all understood that the label was technically wrong and that there was a risk that the patient would someday discover the deception. However, all were strongly motivated to provide the patient with the full effect of the prescribed medication, even though it was the placebo effect that had actually been prescribed.
The practicing pharmacists saw no ethical problem in the concept that sometimes it is okay to lie, that issues are not always black and white, but can be gray, and that choices may depend on the consquences of the act.
Who is right? Perhaps it is heartening to find that at some early stage in our careers, our ethical values are absolute: It is never okay to lie to a patient. To students, virtues are pure and ethics are black and white, with little contrast.
Perhaps it is also good to find that as we move through life the choices become more difficult, as we discover when we deal with real patients and find that the consequences of our actions can have a real effect. The 6 older, practicing pharmacists have all had to make tough choices; some have actually participated in placebo treatment.
It would be interesting to ask today's students the same question in 20 years.
How would you answer?
These articles are not intended as legal advice and should not be used as such. When a legal question arises the pharmacist should consult with an attorney familiar with pharmacy law in his or her state.
KEN BAKER consults in the areas of pharmacy error reduction, communication, and risk management. He is a pharmacist and an attorney of counsel with the Arizona law firm Renaud Cook Drury Mesaros, PA. Contact him at firstname.lastname@example.org