Chapter 3 Ethics and professional conduct

INTRODUCTION

Ethics can be described as the study of what should be done in a given situation. It can be argued that its application to pharmacy is to do no more or no less than guide practice. However, ‘ethics’ should not be seen as merely following a set of rules such as a code of professional conduct or professional practice. While adherence to such rules or codes is important, ethics also includes the study of concepts that may provide a framework for considering those questions that are not satisfactorily addressed by the application of a rule or code. Ethics also provides a structure within which such codes or rules may be developed. While roles or codes are useful in directing day-to-day professional practice, they may prove to be much less so in practice situations where a conflict arises between a ‘rule’ and the belief systems of individuals or groups.

ETHICS

As stated, ethics can be described as the study of what should be done in a given situation. The Macquarie Dictionary offers a definition of ethics as ‘a system of moral principles by which human actions and proposals may be judged to be good or bad or right or wrong’ and goes on to say ‘the rules of conduct recognised in respect of a particular class of human actions’.^[1] While these definitions may be superficially attractive, closer examination reveals other questions that need to be addressed. In the first part it could reasonably be asked which system of moral principles would be invoked when judging an action or a proposal; in the second, who defines the rules of conduct and whose interests are being served by those ‘rules’?

While it is difficult to concisely define ethics other than to say ethics is ‘what should be done in a given situation’ or consider it in the terms of ‘…do unto others as you would have them do unto you’, some authors, in an effort to further clarify matters, have found it useful to say what ethics is not.[2, 3]

The first thing that could be said about ethics is that it is more than just a set of rules (such as a code of conduct) or policies, or some other administrative authority. Historically, deontology was a rule-based philosophy that advanced the concept that things or actions were right or wrong. Rules were short and simple: ‘Do not kill’; ‘Do not lie’; ‘Do not steal’. It quickly became apparent that such rules were difficult, if not impossible, to apply in all situations. For example, in a situation of extreme conflict it may be necessary for a person to kill another person to enable family members to survive or to defend a country from attack, or to lie so members of a persecuted minority would remain hidden and safe from a totalitarian authority, or to steal so loved ones would not starve.

Second, ethics is not religion. Many religions are regarded in society as major sources of moral guidance and do advocate high ethical standards. However, if ethics equated to religion then only the religiously inclined would be bound by ethics. As it is, ethics applies to all. It is not a matter of ‘opting in’ to an ethical life or ‘opting out’ depending on religious persuasion.

Third, ethics is not the law. Laws usually incorporate ethical standards to which most of the public adhere to — or at least don’t object to. However, history is replete with examples of laws that have deviated from ethical principles: the laws of slavery in the United Kingdom and the United States; the apartheid laws of South Africa; and more generally where totalitarian regimes enact laws that are designed to serve only the interests of a privileged few to the detriment of the disadvantaged many.

Fourth, ethics is not the same as feelings. While feelings may provide an emotional or intuitive framework within which decisions are made it is important that feelings and emotions be balanced by a reasoned approach incorporating consistency and objectivity.

Fifth, ethics is not following culturally accepted norms or public opinion or consensus. Cultural norms, public opinion and consensus can be flawed as a source of ethical guidance. Public opinion can be easily swayed, and group decision-making biased by power imbalances and institutional demands.

Finally, ethics is not science. Science can provide data that is critical in the decision-making process when we are confronted with ethical problems, but data or information cannot tell us what is the good or ethical thing to do. Just because it is scientifically possible does not mean it is ethically desirable.

History records a number of major ethical constructs that have contributed to the development of the philosophy of ethics. While it is not intended to undertake a detailed discussion of such theories, it has been suggested there are five sources of ethical standards. These five sources are:

1. the utilitarian approach, a consequence-based philosophy having as its basic tenet that the ‘rightness’ or ‘wrongness of an action is based solely on its consequences, that ethical action is the one that provides the most good for the least harm or, the greatest good for the greatest number

2. the virtue approach, where ethical actions should be consistent with certain ideal virtues, where virtue refers to competence in the pursuit of moral excellence and character traits that are morally desirable such as honesty and integrity

3. the fairness or justice approach, that uses the idea that ethical actions should treat all persons equally, or if unequally then fairly, based on some defensible standard

4. the rights approach, which suggests an ethical action is one that best protects the moral rights of those affected

5. the common good approach, which suggests that the interlocking relationships of society are the basis of ethical reasoning and that respect and compassion for all others — especially the vulnerable — are the requirements of such reasoning.

Further consideration of ethics may reveal the ethical field can be divided into normative ethics and meta-ethics.^[4] ‘Normative ethics’ attempts to develop moral principles or rules to guide our action and judge our behaviour, while ‘meta-ethics’ is concerned with the meaning of terms such as ‘right’, ‘justice’, ‘common good’, and ‘virtue’. One class of normative ethics is ‘practical ethics’ which considers those questions that arise in specific contexts, such as the biological sciences. It is here that bioethics is located, which includes ‘medical ethics’, ‘nursing ethics’ and ‘pharmacy ethics’ as subsets.

Lewins has in fact argued that any study of bioethical issues is dichotomous in nature in that it contains two distinctly different approaches.^[5] The first he termed the academic approach, which poses and attempts to answer questions of an ethical nature in health care, such as those relating to issues of abortion, life support and the allocation of resources. The second, the imperative approach, is where behaviour is standardised via modification and control through the development of certain structures, such as hospital-based ethics committees or the formulation of codes of conduct.

As stated previously, ethics is not just a set of rules or policies. This raises the question: if ethics cannot be neatly encapsulated as a set of rules or a ‘code of practice’, then does it play any significant role in the practice of pharmacy? The question can be answered in the affirmative, in part by stating that ethics provides a starting point when professional dilemmas are faced and issues resolved in a given situation. For example, if a regulatory body such as a board or advisory committee was given the task of developing a ‘code of conduct’ for practitioners, it would be sensible to first decide the underlying philosophy; in other words, what moral principles or values were going to guide the development of such code. It might then be decided that due to legislative requirements it was necessary to place the public interest at the forefront rather than the interest of practitioners. It might also be decided that the code would promote actions that were consistent with providing the most good for the least harm, or the greatest good for the greatest number. So, if the first principle of the code stated ‘The primary concern of the profession must be the health and wellbeing of both clients and the community’ that statement would be consistent with the public interest requirement of the legislation. If the first principle was further expanded to state: ‘The practitioner must exercise professional judgment to prevent the supply of products likely to constitute an unacceptable hazard to health’, the concept of providing the most good for the least harm would also be satisfied.