Pharmacoethics

A Problem-Based Approach

David A. Gettman, Dean Arneson

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781135435691
• Edition: 1
• Topic: Medicine
• Subtopic: Pharmacology

Due to the changing nature of the practice of pharmacy, today's pharmacists, pharmaceutical scientists, and researchers are faced with an increasing amount of ethical dilemmas. Pharmacoethics: A Problem Based Approach not only introduces the current ethical issues, it also provides decision making tools that can be applied to any ethical issue that

chapter one
The student-centered problem-based learning process

The purpose of the problem-based learning cases

The problem-based learning (PBL) case sessions articulated in the appendices to this book have their roots in cases found in the literature for the past 30 years. These PBL cases have been put together to extend your learning experience to ethical problems that might not become available to you during your clinical rotations. Each PBL case contains a real legal case that will be disclosed to you in three staggered fragments. At the end of each of these fragments you will be asked to decide which questions you might ask the other person involved and which tasks you should perform.

The intent of the student-centered PBL discussion in this chapter is to challenge you to understand how to deal effectively with the ethical and behavioral problems that you will have to face in your future pharmacy practice. Most of the information in this chapter is based on the pioneering work of Barrows (see Barrows, 1994, 2000; Barrows and Tamblyn, 1980) and the practical experience of the faculty at the School of Medicine at the University of New Mexico (UNM) (see Mennin et al., 1996). The problems presented also revolve in an innovative way around concepts and principles relevant to pharmacoethics, motivational interviewing, ways of thinking, and conflict management.

Unfortunately, the term problem can be narrow in its implications for your learning; it wrongly suggests that it is problems of individuals that are exclusively used. It should be kept in mind that these are not the only problems you must face in your work as you also must understand and work with the more “macrolevel” problems of the community of individuals your pharmacy serves.

Before tackling the PBL cases in this book, it is essential to know what your objectives are or what you hope to accomplish so you can achieve your expectations. The primary objective of the 18 competency-related problembased learning cases is to make you a more competent pharmacist who can solve ethical and behavioral problems. Therefore, as you consider such an undertaking, you will have to consider carefully the kind of pharmacist you want to become. The methods used in these cases emphasize the development of those abilities, skills, and attitudes you will need during your future pharmaceutical health care practice. The rationale for student-centered problem-based learning as an educational method will become apparent when your educational goals are carefully considered.

Our deeply beloved democratic society has two fundamental expectations of you—a future pharmacist. These are:

1. Monitoring the medication-associated clinical and behavioral health care problems of your patients in an effective, efficient, and ethical manner. Effective monitoring means that your problem-solving skills must be sufficiently developed to facilitate the choice of an appropriate pharmaceutical health care plan. The pharmaceutical health care plan you choose must be designed to provide the most effective care possible, to improve the patient’s outcome, and to meet the expectations and needs of the patient with the least risk and cost. Efficient means that the care of your patient must be cost effective. This aspect of pharmaceutical health care becomes even more important in our nation’s trend toward controlling health care costs. Ethical means that you must have cultivated certain observable communication skills that will invoke confidence, trust, and satisfaction. Your care needs to be sensitive to the patient’s particular concerns, values, cultural needs, and finances.
2. Lifelong pharmaceutical health care learning to meet the often unique and changing needs of patients and the problems they present, to face the changing problems and demands of health care systems, and to keep up to date in the practice of the pharmacy profession. The increasingly complex use of drug entities, the ever-changing knowledge of disease processes, the increasingly complex ethical issues related to these advances, and the dramatic changes in information management and health care delivery systems make the task of self-education essential. It is not helpful to have your mind full of facts if you cannot apply them to the care of your patient. A requirement that you must have a rich and extensive knowledge foundation does not address the primary concern that the knowledge must be tailored to your particular patient’s circumstances to make a real difference.

The fundamentals of student-centered learning

You must cultivate the ability to continue learning throughout your entire professional life to meet the often unique and changing needs of patients and the problems they present, to face the changing problems and demands of the health care system, and to keep contemporary in the practice of the profession of pharmacy. Unfortunately, many practicing pharmacists may not have kept up with the developments in their profession, and their skills may have become outdated and potentially dangerous. This may lead to pharmacists losing their licenses or undergoing civil or criminal litigation.

Self-monitoring

You should be able to monitor your progress with a patient’s problem continuously and should note points at which you may be puzzled or lack sufficient knowledge or skills. This requires deliberate awareness of how well you are handling different aspects of each patient’s problem or the appropriateness of the pharmaceutical health care plan you have undertaken.

Self-assessment

In addition to monitoring your performance, you should be able to determine if your functioning is appropriate for your level of training and experience and for the type of patient problems you are encountering. It might become too easy for you later in your practice to just ignore a patient’s problem or to refer the patient to the patient’s physician and then serve your next patient without considering whether the care of the first patient was sufficient. Of greater concern might be that you might not even be aware of the inadequacies in your work with your patients and that you do not ask for help when it is warranted.

Defining learning needs

Once inadequacies are recognized in your abilities, these weaknesses should be translated into defined learning needs so that the appropriate learning resource can be identified. What specific areas of information or skills do you need to augment?

Determining the appropriate learning resource

You should determine which available learning resource would be the most effective and practical for your defined learning needs to obtain up-to-date and accurate information (e.g., from textbooks, peer-reviewed journal articles, computerized information resources, videotapes, computer programs, mentor pharmacists, and accredited continuing pharmaceutical education courses).

Using the resource effectively

It is one thing to select the right resource; it is quite another to use the same resource effectively. This is particularly true with computerized information resources. Even the effective and efficient use of a library or a reference book requires you to develop certain skills.

Evaluating the accuracy and value of resource information

It is important for you to question the findings or opinions of your patient’s physician. You should evaluate the validity of any conclusions drawn. You should be knowledgeable about the methods used to generate findings or opinions in a printed article. This is increasingly important with the availability of computer databases that, unlike those in the library, are often not peer reviewed.

Recording or filing the information for future reference

Once information has been obtained, you should have a systematic way to file it for future reference so it can be conveniently found when you need it again.

Applying what has been learned to the present patient problem and future problems

You have to apply what has been learned to the care of your patients. You must assume responsibility for your future learning. To do this, these unique skills need to be developed and practiced under your instructor’s guidance and assistance while in pharmacy school. Student-centered problem-based learning that is self-directed should become a habit so you remain contemporary in your practice and meet the changing problems presented by patients.

The skills required to overcome ethical and behavioral problems and the skills required for student-centered problem-based learning will need to be practiced and feedback given so you achieve the competencies expected of a registered pharmacist. Knowledge acquired in pharmacy school will have to be recalled and applied to the care of your patients.

The five-step student-centered problem-based learning process

The use of the 18 patient problem cases later in this book will help you utilize specific reasoning processes to achieve your clinical ethics and research ethics competencies. This is the most defining characteristic of student-centered problem-based learning. There have been many studies of this reasoning process (see Norman and Schmidt, 1992; Vernon and Blake, 1993). Most have shown that, when encountering an unfamiliar, difficult, complex, and ill-structured problem, the expert will use a hypothetico-deductive reasoning process. The significance of terms like unfamiliar, difficult, or complex is important here because experts who work repeatedly with the usual and straightforward problems in their fields might tend to take certain shortcuts with these problems. This happens only after working through problems many times before using the hypothetico-deductive process. Undoubtedly, you might have taken shortcuts with repetitive problems and do not think through all possibilities. Instead, you might plunge into what you believe to be the heart of the matter. However, this forward thinking can lead you to err if the problem encountered has unusual features not detected in your shortcut.

The following steps are identifiable in the hypothetico-deductive process: generation of multiple hypotheses, inquiry strategy, data analysis, data synthesis, and preliminary development of a pharmaceutical health care plan. The manner in which you use each stage to meet the challenge of your patient’s problems will be stressed with each stage. The emphasis here will be on acquiring this complex skill in pharmacy school to ensure that you can provide effective, efficient, and ethical pharmaceutical health care to your patients.

Most ethical and behavioral reasoning activity occurs quickly and almost unconsciously for experienced pharmacists. However, on reflection, most pharmacists will recognize the presence of these steps.

Step 1: The generation of multiple hypotheses

As soon as you listen to your patient during an encounter and ask a few questions to clarify a problem, you will almost automatically generate hypotheses. These hypotheses are brought to mind by associations with the patient’s complaint and a number of other observations, such as the patient’s sex, age, and behavior. These hypotheses could be explanations of the patient’s problem. The hypotheses have also been called hunches or ideas. Whatever they are called, each represents a label for a collection of facts assembled in your mind. Usually, two or more hypotheses are generated. Among these is the worst-case scenario possible with the patient’s complaint; even if remote, it cannot be overlooked. The other hypotheses usually represent the most likely hypotheses, especially conditions that are treatable with medications.

These hypotheses, generated in your head at the outset of the encounter, set the boundaries for your search for more information. Since there is not enough information initially for you to develop a pharmaceutical health care plan for the patient, a guide is needed to determine what additional information is needed. The potential boundaries for information about a patient problem are enormous, and hours could be spent asking all questions possible of your patient. This would be very impractical and tiresome. Hypotheses provide you with guidelines to the kinds of information on a pharmaceutical health care record that would be of most benefit in establishing care decisions.

Hypothesis generation is the creative aspect of patient problem solving. It is an inductive thinking activity used by the experienced pharmacist to think of the possible conditions that might be suggested by the patient’s problem.

Step 2: Inquiry strategy

Using the hypotheses generated as a guide, you need to carry out an inquiry to obtain more data from the patient that will support or weaken these hypotheses. The energy of this inquiry is fueled by taking the patient’s medication history. Inquire about the observations that would be expected with the hypotheses considered as well as observations that would tend to separate alternative hypotheses. This is disciplined, logical, deductive, problem-oriented reasoning. An efficient inquiry strategy is of paramount importance when time is limited, as it often is in the real world of pharmacy practice, and there is no time to ask all possible questions.

Mixed together with this problem-oriented inquiry is a more menu-oriented inquiry used when obtaining information about the patient’s prior health and family history and to uncover other bits of data that could suggest problems other than those suspected. This inquiry does not require careful reasoning and is mostly a matter of memorizing lists of questions. To provide time to think further about the patient’s problem and consider other hypotheses, you also need to use this menu-driven inquiry.

As described, with the ill-structured problems that a patient presents, more information needs to be obtained to understand the patient’s problem, and there is no one right way to obtain that information. Hypotheses serve as suggestions to what might actually be responsible for your patient’s problem. Therefore, they are a guide to the kinds of clinical and behavioral information needed and the use of a logical deductive inquiry to get the information that will identify the most likely hypotheses. If this is done correctly, the ill-structured problem is efficiently and effectively tackled.

Step 3: Data analysis

As your patient provides answers to questions and information is obtained for the pharmaceutical health care record, new information beyond that initially present becomes available. As new information is obtained, you have to analyze it against the hypotheses considered. Does it strengthen or weaken any of the hypotheses being considered, or does it suggest a new or unsuspected hypothesis?

Step 4: Data synthesis

When this ongoing analysis of newly obtained information suggests that the information is significant in terms of understanding or caring for your patient’s problem, it is added to the information you are accumulating in your mind about the patient’s problem. This growing mental representation of the patient’s problem is more than a collection of the important facts learned about the patient during the patient encounter. You organize these facts in a cause-and-effect relationship that suggests the chain of events that led to the patient’s present problem and the clinical and behavioral issues responsible. This synthesis records the present and changing shape of the structure of the patient’s problem. It is a vehicle for communication between you and other health care practitioners.

In describing a patient’s problem to another health care professional for consultation or new ideas, you might present this synthesis in a concise way. The physician with whom you are consulting might incorporate that synthesis and will generate hypotheses based on different experiences or expertise. The physician might say, “Have you thought of so and so?” (hypothesis), or “Did you ask such and such a question or perform such a test?” (inquiry strategy) based on hypotheses generated as a listener. The lack of a synthesis to organize the oral presentation of your patient’s case is a frustrating experience because it might make the presentation sound like an immeasurable jumble of facts.

These are the elements of clinical and behavioral reasoning with which you must struggle concerning the patient’s ill-structured problem: inductive reasoning, followed by deductive reasoning (hypotheses/inquiry), analysis, and synthesis. This is not necessarily a linear process, as might be suggested by the description above. Inquiry might lead to a blind alley, and new hypotheses need to be generated. An unsuspected finding might suggest new hypotheses. Menudriven inquiry might need to be employed to find new clues about the problem when problem-based inquiry fails to substantiate the hypotheses considered. The initial hypotheses might be too broad to initiate any care plan, and more refined hypotheses might need to carry the inquiry further.

Step 5: Preliminary development of a pharmaceutical health care plan

You will have to come to a decision about developing the patient’s pharmaceutical health care plan. The time in the encounter it takes to do this relates to the time you have available and the urgency of your patient’s situation. Many activities can be sacrificed with time pressure, such as chatting with your patient to get to know the patient as a person, checking into family and personal sociodemographics, reviewing your patient’s symptoms again to be sure they are understood, and beginning to carefully develop a pharmaceutical health care plan.

The decision to end the encounter is also determined by the impression that no additional helpful data can be obtained from your patient or the patient’s caregiver during the present session, or that enough data of sufficient specificity have been obtained to develop your patient’s pharmaceutical health care plan. Despite all the ambiguities that might be present and the need for more data for certainty, you will have to make a decision and act. Your patient cannot be told that her or his problem is not well enough understood at this time and to come back later.

This process is well adapted to the challenge of the ill-structured problembased learning cases in which you cannot be sure that a particular patient’s pharmaceutical health care plan is the most perfect one. You have to face ambiguities and insufficiency of data and make decisions on the basis of prevalence, probability, treatment of the treatable, and awareness of the worst possibilities that could be present.

Metacognitive skills

The term metacognitive skills refers to thinking about your own thinking. It is deliberation or pondering and is the direct opposite of impulsivity. Metacognition is the hallmark of the expert pharmacist: “Do I have the right ideas?” “What questions should I ask next?” “Can this pharmaceutical health care problem be put together differently.” “Is there something I need to learn to understand my patient’s medication-related problem better?” “What would be the correct laboratory tests to order?” These are metacognitive thoughts.

Metacognition is the hallmark of the expert pharmacist when a patient problem is difficult or unusual. It is a skill you must develop in guiding your reasoning process. As mentioned, this reasoning process is often not apparent to you because it is performed almost below awareness and is often executed quickly and nearly automatically. Only when you are confronted by a patient problem that is unusual, difficult, or confusing are you aware of contemplating the problem. This can occur only by actually considering alternative hypotheses, questions that should be asked, laboratory tests that should be ordered (inquiry strategy), reviewing the findings obtained (analysis), or puzzling about what may be going on with the patient (synthesis).

In fact, as mentioned, experienced pharmacists may be so familiar with certain common, recurrent patient problems that they may take quick shortcuts to establish and care for their patient’s problem. This has been called using heuristics, rules of thumb, or forward reasoning (the hypothetico-deductive method is considered backward reasoning). However, put an unfamiliar or troublesome problem in front of the experienced pharmacist and you will see metacognition and the hypothetico-deductive process.

The presence of the hypothetico-deductive process may also be unapparent to those watching you perform because they do not know what is actually going on in your mind. The observer can only guess as to the hypotheses being entertained by the questions you ask of your patient. You may jump back and forth from a problem-oriented inquiry to a menu-driven inquiry as you are thinking, and the observer never knows which questions are hypothesis related. The observer also does not know how the data you obtain are being analyzed. Techniques such as asking you to talk aloud during the patient encounter or interviewing you about your thinking immediately after the patient encounter can be helpful in analysis of your reasoning...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Preface
• Acknowledgments
• About the Authors
• Introduction
• Chapter One: The Student-Centered Problem-Based Learning Process
• Chapter Two: The Challenge of the Patient’s Clinical and Behavioral Problem
• Chapter Three: The Challenge of the Patient’s Ethical Problem
• Chapter Four: Creating a Framework for Student-Centered Problem-Based Learning Sessions Involving Pharmacoethics
• Case One: Professional Responsibility
• Case Two: Patients’ Rights
• Case Three: Privacy and Confidentiality
• Case Four: Ethics Committees
• Case Five: Patient Privacy
• Case Six: Truth Telling
• Case Seven: Reproductive Ethics
• Case Eight: Genetic Screening
• Case Nine: Seriously Ill Neonates
• Case Ten: Distributive Justice
• Case Eleven: Unethical Experimentation
• Case Twelve: Research Principles
• Case Thirteen: Scientific Integrity
• Case Fourteen: Research on Human Subjects
• Case Fifteen: Research/Testing on Animals
• Case Sixteen: Intellectual Property
• Case Seventeen: Germline Therapy
• Case Eighteen: Medical Surveillance