Moral dilemmas of community pharmacists: a narrative study
International Journal of Clinical Pharmacy
Moral dilemmas of community pharmacists: a narrative study
Martine Kruijtbosch 0 1 2
Wilma GöttgensJ‑ansen 0 1 2
Annemieke Floor‑Schreudering 0 1 2
Evert van Leeuwen 0 1 2
Marcel L. Bouvy 0 1 2
0 Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University , Utrecht , The Netherlands
1 Radboud University Medical Center, Radboud Institute for Health Sciences (RIHS), Scientific Center for Quality of Healthcare (IQ Healthcare) , Nijmegen , The Netherlands
2 SIR Institute for Pharmacy Practice and Policy , Leiden , The Netherlands
3 Martine Kruijtbosch
Background Pharmacists are increasingly involved in patient care. This new role in a complex healthcare system with demanding patients may lead to moral dilemmas. There has been little research into pharmacy ethics, and existing data are limited by their retrospective nature and small sample sizes. A thematic overview of the moral dilemmas experienced by community pharmacists is still missing. Objective To make a thematic overview of moral dilemmas experienced in daily pharmacy practice. Setting Dutch community pharmacy. Methods Dutch community pharmacists wrote a narrative about a moral dilemma they had experienced in clinical practice. The narratives were analysed using qualitative content analysis to identify underlying themes. Main outcome measure Themes of moral dilemmas. Results Twenty-two themes were identified in 128 narratives. These moral dilemmas arose predominantly during pharmacists' contact with patients and other health professionals. The relationship between the pharmacist, patient and other health professionals was complicated by other parties, such as legal representatives, health insurance companies, and regulators. Conclusion The moral dilemmas experienced by community pharmacists are more diverse than previously reported. The main dilemmas arose in their professional contacts, frequently when their professional autonomy was challenged by the behaviour of patients and other health professionals.
Community pharmacists; Moral dilemmas; Netherlands; Pharmacy ethics
• The moral dilemmas for pharmacists are diverse, but
underlying is often a troubled relationship with
physicians and/or patients that hampers the pharmacist to
deliver appropriate pharmaceutical care.
• Reflection on moral dilemmas may help community
pharmacists to strengthen their professional autonomy.
• Investing in good professional relationships with other
health professionals and in a therapeutic relationship with
patients may benefit recognition of pharmacists’
Worldwide, the primary focus of pharmacists is
shifting from products to patients [
]. This patient-centred
approach means that pharmacists have to identify patients’
concerns and needs, and collaborate closely with other
health professionals in order to ensure effective and safe
use of medicines [
]. Lastly, pharmacists are responsible
for helping patients to achieve definite health outcomes.
Nowadays, health professionals such as pharmacists are
faced with ever more regulations, financial pressure, and
increased competition. At the same time, the demand for
health services is growing as a result of population ageing,
more chronic illnesses, and increased healthcare
]. Economic and legal constraints and
demanding patients challenge health professionals’ autonomy
to act in the best interests of society and the individual
]. In this complex setting, pharmacists
are frequently confronted with moral dilemmas [
arising from conflicting personal, professional,
institutional or societal values of the different parties involved
These moral dilemmas need to be studied in order to
address the challenges pharmacists face in their professional
24, 29, 30, 34–39
There have been few international studies of the moral
dilemmas experienced by community pharmacists, and
existing studies vary widely in aim, method and
presentation of results [
24–27, 29, 30, 40
]. In most existing studies,
pharmacists were presented with scenarios of moral
dilemmas and their moral reasoning was assessed. Pharmacists
found it difficult to recall moral dilemmas and most studies
interviewed a limited number of pharmacists [
]. Hence the themes of moral dilemmas experienced in
clinical practice may still be incomplete.
Aim of the study
We aimed to make a thematic overview of moral
dilemmas community pharmacists actually experienced in clinical
The Medical Ethics Review Committee of the University
Medical Centre Leiden concluded that the Dutch
Medical Research Involving Human Subjects Act (WMO) was
not applicable. All participants consented that their
narratives could be used for the purpose of the study. Data that
could give clues about the origin of dilemmas (e.g. names
of patients, cities, pharmacies, pharmacists or physicians)
Study design and setting
Pharmacists wrote a narrative of a moral dilemma they had
experienced in clinical practice, as an assignment during
either pre- or postgraduate training. The pharmacists were
asked to write this narrative immediately after they had
experienced the dilemma. A stratified random sample of
these narratives was taken. All pharmacists had been taught
how to recognise moral dilemmas. This study followed
scientific standards for reporting qualitative research (SRQR;
see “Appendix”) [
Definition of moral dilemmas
On the basis of the various definitions in the literature [
29, 35, 40, 44, 45
], a ‘moral dilemma’ was defined as: a
situation in which there is a choice between at least two courses
of action, neither of which is obviously morally preferable.
Narratives were checked against this working definition by
both the first author (MK) and a member of an expert panel
consisting of eleven senior pharmacists active in the
special interest group on pharmacy ethics of the Royal Dutch
Pharmacists Association. All panellists had been trained in
a half-day ethics course to identify moral dilemmas. If
consensus was not reached, a third pharmacist from the research
group (WG, MB or AF) was consulted. Narratives that did
not comply with our working definition were excluded.
Inductive content analysis of narratives to identify themes
of moral dilemmas was facilitated with ATLAS.ti
(version 7.5.17) [
]. Consensus on final themes and main
categories was reached in two rounds, during independent
validation by the research group and during a consensus
meeting with both the expert panel and research group.
Of the 220 narratives, 92 were excluded (Fig. 1). The
included 128 narratives were written by pregraduates (49%:
51% male, 49% female) and postgraduates (51%: 39% male,
61% female). Twenty-two themes were identified, divided
into three main categories (see Table 1). Below, we illustrate
the themes with a brief summary of a dilemma and quotes
from pharmacists that reflect the essence of the theme.
N = 220 Narra ves
128 Complied to the
working defini on*
of a moral dilemma
• 22 Not a community pharmacy perspec ve
• 10 Not coded by one panellist
• 1 Double
• Did not comply with the working defini on*
or were unclearly wri en
aIn this study dentists were also grouped as physicians
Category 1: The pharmacist–patient relationship
Drug abuse or addiction
Patients who had (or were suspected to have) drug abuse
or addiction problems requested for refills too soon. The
drugs involved were mainly controlled drugs such as
opioids or benzodiazepines. Pharmacists grappled with the
problem of possibly sustaining addictive behaviour on
the one hand and the need to retain patients’ trust and to
relieve pain or anxiety on the other.
PHARM-276: This patient is heavily addicted to an
opiate and regularly asks for, and gets, a refill too
early. “He always has excuses like ‘I carried a heavy
load yesterday’ or ‘I lost my medication during
holidays’. However, he does experience pain and needs
an analgesic. If he needs the opiate because he has
really lost it, he should get it. But how long should
I contribute to his opiate addiction.”
Drug misuse can lead to side effects or affect the
effectiveness of the prescribed medicine. Pharmacists expressed
concern about confronting patients without losing their trust.
Dispensing without addressing the issue also had drawbacks.
PHARM-1082: The pharmacist is aware that a student
has been collecting methylphenidate only twice a year
(coinciding with exams in January and June). The
prescriber is the patient’s father. “Should I cooperate,
give priority to the patient’s autonomy and dispense
this medicine when I doubt whether the drug is
actually indicated for a ‘chronic’ illness? Or do I need to
address this presumed off-label use?”
Deviating treatment preference
Patient treatment preferences might not be supported by
evidence-based medicine or professional guidelines. In these
situations, the pharmacists considered patients’ preferences
potentially ineffective or harmful.
share data, but patient’s consent to share data was absent or
patients even requested not to share these data.
PHARM-1235: A mother requested paracetamol for
her 1-year-old baby who had a high fever for a week.
“I tried to convince her to consult her GP as her baby
might have a dangerous infection. She didn’t agree.
Her attitude frustrated me. I want to do what is best
for the baby, but at the same time have to respect the
Claiming and/or aggressive behaviour
Claiming or aggressive behaviour of patients undermines
the trust-based relationship pharmacists have with patients
and frustrates pharmacists because it might prevent them
from providing adequate care. This is a complex situation,
especially if there are other patients waiting in the pharmacy.
PHARM-1062: A patient asked the pharmacist for a
prescription of oxazepam that had been faxed 2 months
ago. The electronic patient record, however, suggested
that the prescription had already been dispensed.
The patient became furious and insisted that he had
never received the drug and needed it urgently. “I felt
attacked, but also had my doubts because of his
convincing manner of speaking. Did we make a mistake?
Should I dispense once again without a prescription?”
Patients (or their carers) who had difficulties understanding
drug information because of language deficiency or limited
health literacy, posed a particular problem. Pharmacists
doubted whether these patients would use the drug safely,
but not dispensing was not an option if the patient clearly
PHARM-314: An elderly Spanish speaking patient
did not understand the pharmacist who explained
the need for gastroprotection during NSAID use. She
kept repeating that she was in pain and only needed
the NSAID. This situation did not change even with
a translator. “I wanted to assist and advise her
correctly but poor communication made that impossible.
I had my doubts about dispensing the NSAID without
gastroprotection because of the possible health risks.”
Patient’s privacy/sharing relevant patient data
Sharing patient data with either health professionals or
informal carers may be necessary from a clinical
perspective. Dilemmas occurred when the pharmacist felt a need to
PHARM-252: A woman treated for a bipolar
disorder told her pharmacist that she wanted to discontinue
mirtazapine. She explicitly asked the pharmacist not
to notify her psychiatrist. “I explained to her that I
couldn’t provide proper pharmaceutical counselling
because I didn’t have relevant background
information.” Although the pharmacist wanted to respect her
autonomy, he also felt he should notify the psychiatrist.
Public health policy and third‑party payer regulations
In general, current health policy is directed at curbing
increasing health expenditure. Dutch health insurance
companies reimburse only generic products unless the
physician has medical reasons for prescribing a branded drug.
While pharmacists recognised their responsibility to reduce
health expenditure, this also disturbed their relationship with
patients who strongly objected to generics.
PHARM-84: A patient, objected strongly to generic
salbutamol. “After persistently trying to explain the
drug reimbursement policy to him, I convinced him to
try the generic for at least 14 days. A few hours later,
he reported numerous complaints. Later the patient
came with a prescription for the branded aerosol and
a statement from his physician declaring the necessity
of him having the original drug. Somehow, I felt the
patient had never really tried the generic.” The
pharmacist had doubts about whether he should start the
conversation with the patient again or fill the
Category 2: The pharmacist–colleague relationship
Disruptive behaviour of a physician/a troubled relationship with the physician
Pharmacists described situations in which the relationship
with physicians was troubled. Sometimes physicians even
behaved disruptively e.g. by not listening to the pharmacists’
pharmacotherapy suggestions. This deprived the
pharmacists of relevant information and caused frustration because
their expertise was not appreciated. Pharmacists had
reservations about the safety or effectiveness of prescribed
treatment. Not dispensing, however, was equally problematic
because reasons for the chosen treatment might have been
valid. Moreover, pharmacists were anxious to further disrupt
their professional relationship with the physician.
PHARM-54: A cardiologist deviated from the
guideline for combining antiplatelet drugs. When the
pharmacist requested clarification, the cardiologist’s
replied: “Do you mind if I continue with my patients
now?” The pharmacist could not properly inform the
patient about his doubts about the therapy. “I had
strong doubts about the safety of this combination.
Informing the patient about the risks, however, might
worry the patient and undermine his confidence in the
Disruptive behaviour of a colleague
Pharmacists reported disruptive behaviour of colleagues,
such as gossip, lying or suspected fraud. Both neglecting and
addressing such behaviour could influence the work climate
in the pharmacy.
PHARM-1084: A pharmacy is reimbursed for every
patient who receives instructions about a new inhaler. The
senior pharmacist asked a junior pharmacist to send a list of
all patients who had received a new inhaler with instructions
to the insurance company for reimbursement. The junior
pharmacist was reluctant to do this, struggling with going
against his senior colleague’s request as well as his
responsibility to society. “I was uncertain whether the instructions
had always been given. Technicians didn’t always document
this and patients sometimes refused the instructions or had
already received them elsewhere.”
Pharmacist and physician have a different opinion about appropriate pharmacotherapy
In these dilemmas physicians ‘overruled’ pharmacists’
proposals, although not necessarily in a brusque manner.
Pharmacists had the idea that the physician did not really
consider their suggestions and doubted the suboptimal or
unsafe pharmacotherapy. Pharmacists felt at a disadvantage
because they lacked sufficient knowledge about the patient’s
condition. Moreover pharmacists did not want to further
disrupt their professional relationship with the physician.
PHARM-22: The pharmacist had suggestions about
alternative therapy options for a patient with serious
pain complaints. However, the physician said that he
had tried everything and that nothing more could be
done and did not want to change the medication. “In
the end, it is the physician who prescribes. I wanted to
help the patient but suggesting these options directly
to the patient also did not feel appropriate.”
Deviating from a prescription or missing relevant data with the physician absent
Pharmacists had a moral dilemma when they wanted to
deviate from a prescription because of potential drug related
problems such as interactions or allergy warnings, or to
discuss the treatment because lack of relevant clinical data, but
could not contact prescribers. Both situations impeded their
judgement on the appropriateness of pharmacotherapy.
PHARM-350: A dentist prescribed amoxicillin. The
pharmacist knew that the patient had previously had an
allergic reaction on amoxicillin. The dentist could not
be reached, but the patient urgently needed medication.
“What if the dentist does not agree with the alternative
Pharmacists had a conflict of loyalty when their decisions
would either affect their professional relationship with
colleagues or result in suboptimal patient care.
PHARM-115: A physician asked the pharmacist to
urgently prepare a midazolam infusion to start
palliative sedation for a patient registered at a neighbouring
pharmacy. The physician explained that the
pharmacist of that pharmacy was not able to prepare the
infusion that day. “In my opinion not dispensing wasn’t an
option because of the condition of the patient. On the
other hand, I didn’t want to overrule the decision of my
colleague-pharmacist who is the responsible
professional for this patient.”
Although this is a well-known issue [
], only one case of
physician self-prescribing was reported:
PHARM-1176: A physician prescribed midazolam for
himself. “Dispensing felt problematic because sleep
medication might have negative effects on the
physician’s daily functioning. Moreover, the pharmacist
did not want to become the accomplice of an addicted
physician. However, not dispensing could damage the
professional relationship and future collaboration.
Category 3: Various relationships or involved parties
The previous categories of dilemmas involved patients or
health professionals. In the following themes other
‘stakeholders’ were involved, such as health insurance
companies and manufacturers. We also included dilemmas with
(unborn) children and adolescents in this category, as
pharmacists in these situations have a complex responsibility
towards these unborn children, minors and their parent(s)
or legal representatives.
Reimbursement for a pharmaceutical product/care activity or additional service
sedation and the expectations of physicians that pharmacists
would have the necessary drugs readily available.
Pharmacists experienced dilemmas when patients were not
insured and not able to pay their medication out of pocket,
because these patients needed their medicines. Also,
concerns about pharmacy workload sometimes conflicted with
pharmacists’ wish to deliver optimal but time-consuming
patient care. Providing additional services for some patients
would mean compromising on other services.
PHARM-278: A nursing home requested multidose
drug dispensing systems for every patient. This would
include anticoagulant medication, the dosing of which
often has to be adjusted. The pharmacy did not have
the capacity to change the multidose drug dispensing
systems manually each week. “I realise the importance
of this request, but it would almost take an extra
technician without getting any reimbursement.”
Risk of harm to (unborn) children
Pharmacists confronted with off-label prescriptions for
children and adolescents felt they could not appropriately assess
the risk–benefit ratio or the correct dosing of drugs. Another
dilemma was when children collected medication.
Pharmacists worried about the possibility of the child misusing the
medication, but also did not want the patient to be left
without medication. Even more complicated moral dilemmas
arose when medication was prescribed to pregnant women.
In these cases, pharmacists had to weigh the benefits for the
mother against the potential risks for the unborn child.
PHARM-1202: “A psychiatrist told me he did not
want to tell a pregnant woman with a major
depressive disorder about the teratogenic risks of paroxetine
because he was afraid that she would not take the drug.
The psychiatrist considered that the mother not taking
paroxetine would potentially be riskier for the unborn
child than the small teratogenic risk. I struggled with
End‑of‑life pharmaceutical care
These dilemmas concern euthanasia or palliative sedation.
Dutch Pharmacists’ and Physicians’ Associations have a
joint guideline on providing euthanasia [
physicians did not adhere to the guideline recommendations;
e.g. a physician requested euthanasia drugs without timely
communication with the pharmacist. Pharmacists were then
reluctant to cooperate. However not dispensing felt wrong
because the patient was suffering.
The dilemmas that dealt with palliative sedation
concerned both disagreement about the dose of palliative
PHARM-57: This pharmacist did not dispense drugs
for euthanasia because of religious objections.
Surrounding physicians knew about this. A physician from
another area, unaware of the objections, requested
these drugs too late in the day to find another
pharmacist. “Should I remain faithful to my personal
values but then trouble both the patient and physician, or
should I dispense the drugs this one time?”
Dispensing without a prescription
Patients regularly requested (restricted) medicines without a
(valid) prescription. In these situations, pharmacists had to
balance the necessity and risks of dispensing. Pharmacists
felt it hard to make this balance because they had insufficient
clinical information and were reluctant to deviate from laws
PHARM-71: The middle-aged son of an elderly patient
visited the pharmacy just before closing time. He
showed a picture on his mobile phone of an
oxycodone prescription for his father who had just been
discharged from hospital. He said his father suffered from
severe pain and he could not get the real prescription
in time before the pharmacy closed. “The prescription
does not comply with the law but this patient could
suffer unnecessarily if I don’t dispense.”
These moral dilemmas were related to uncertainty about the
quality of a pharmaceutical product and the risks of
dispensing a product that might be ineffective or harm patients.
PHARM-309: A patient visited the pharmacy with
three golimumab injections worth €3500 which had
been outside the refrigerator for about 1 day. “The
manufacturer told me they expected no quality issues
but could not give any guarantee.” The pharmacist
doubted whether the patient would be harmed by using
the injections, and felt that, given their cost, discarding
the injections was not socially responsible.
This study presents moral dilemmas experienced by
community pharmacists in clinical practice. The underlying themes
address the challenges pharmacists face while providing care
in a complex setting with economic and legal constraints,
demanding patients and limited professional autonomy.
Analysis showed that most moral dilemmas concerned
the relationship between pharmacists, patients and
physicians. This is not surprising considering that pharmacists
are responsible for helping patients achieve positive health
outcomes, and this responsibility requires that they work
with patients and other health professionals [
As far as we know, no previous study used narratives to
understand the moral dilemmas that pharmacists experience
in clinical practice [
26, 29, 40
]. Writing a narrative shortly
after a dilemma occurred avoids recall problems and enables
pharmacists to reflect directly on their feelings. Previous
studies generally interviewed pharmacists and asked them
to recall dilemmas that occurred in the past [
may be the reason why, in those studies, pharmacists mainly
recalled dilemmas with a high legal impact. For example,
pharmacists expressed fear of breaking the law when a
patient asked for a controlled drug without a (valid)
26, 29, 40
]. When legal issues occurred in this
study, pharmacists were more concerned about the patient’s
well-being and the mutual trust in the treatment relationship
than about breaking the law.
Pharmacists experienced dilemmas during their
professional contacts because the behaviour of patients and
physicians made it difficult for them to act autonomously,
according to their professional core values [
]. Since the days of
Hippocrates, health professionals’ core value is not to harm
patients and to act in their best interest. However, conflicts
may arise when more than one health professional aims
to act according to that value. The degree of professional
autonomy of an individual health professional depends on
the extent to which other health professionals grant that
]. Regular collaboration between pharmacists
and other health professionals may promote mutual trust and
respect for each other’s knowledge and expertise [
Pharmacists’ autonomy may also be challenged because
pharmacists are often the last link in a multidisciplinary care
chain, e.g. in end-of-life pharmaceutical care issues. In that
position pharmacists’ expertise comes into play too late or
is not recognised [
]. Pharmacists in these situations
described that their expertise was disregarded and that they
were expected to dispense only. These moral dilemmas
demonstrate that pharmacists need more training to convince
physicians of their expertise.
The professional autonomy of pharmacists may also be
restricted by patients or parties such as insurance
companies or the health inspectorate. Patients may also consider
physicians to have more authority than pharmacists. This
can sometimes lead to claiming and/or aggressive behaviour
of patients. This behaviour undermines the trust
relationship between the pharmacist and the patient. This resembles
healthcare consumerism, which is reported to challenge the
ability of health professionals to optimally fulfil patients’
and societal needs [
]. Dilemmas under the theme public
health policy and third-party payer regulations showed
that health insurance companies can also undermine
pharmacists’ autonomous professional decision-making and
actions. Insurance companies oblige pharmacists to replace
expensive branded drugs with cheaper generics. Although
pharmacists do not object to dispensing cheaper medicines
whenever possible, this responsibility also disturbed their
relationship with patients who strongly objected to
generics. This finding confirms a worldwide trend that
economically motivated health policies challenge the professional
autonomy of all health professionals [
12–14, 17, 18
policy makers should realise that weakening health
professionals’ autonomy, for example due to reimbursement
policies, may negatively affect patients’ trust in health care .
This study has some limitations. Firstly, the moral dilemmas
were reported by ‘early career’ pharmacists. These
pharmacists may be more committed to patients’ well-being,
because of more advanced training on the patient
perspective than earlier generations of pharmacists. Moreover, the
training provided might have influenced their sensitivity
for moral dilemmas [
]. The themes underlying the moral
dilemmas were not less numerous than those in previous
studies involving more experienced pharmacists. Exceptions
to this are primary business dilemmas. The underreporting
of these types of dilemmas might be explained by the fact
that the early career pharmacists in our study generally do
not own a pharmacy. A second limitation is that saturation
of themes was not formally assessed. We did, however,
have no clues on additional themes from the excluded
narratives. Moreover, screening of an additional stratified
random sample of 50 narratives by two authors (MK and MB)
neither gave clues on missed themes. Therefore, we are of
the opinion that the most important themes for the Dutch
context are identified. This does, however, not imply that
every individual pharmacist will identify these dilemmas.
Furthermore, our results are not completely generalizable
to countries with different health systems and a different
position of the community pharmacist in health care. Lastly,
the written narratives contained much richer information
than reported in our brief summaries; some narratives were
excluded because they were unclear. As we were primarily
interested in the themes, we did not analyse the feelings of
pharmacists in depth.
Implications for practice
This study suggests that a short training enables pharmacists
to write narratives on moral dilemmas they experience in
clinical practice. Reflecting on these dilemmas may help
pharmacists to increase their professionalism. Hence, we
suggest to integrate such ethical training in experiential
learning within both pre- and postgraduate education. This
will raise pharmacists’ awareness on moral conflicts and will
support the profession’s transition to delivering
Pharmacists experience a number of moral dilemmas in
clinical practice. The narrative method enables pharmacists
to reflect directly on their feelings at the time these
dilemmas occur. Most dilemmas involve the pharmacists’
professional relationships and often arise when the professional
autonomy of pharmacists is challenged by patients’ and
other health professionals’ behaviour.
Acknowledgements We express our gratitude to all the participating
pharmacists who shared their moral reflections with us. Also, we want
to thank the pharmacists who participated in the expert panel.
Funding We received unrestricted grants from the Royal Dutch
Pharmacists Association (KNMP) and from the foundation ‘Stichting
Management voor Apothekers en voor de Gezondheidszorg’ (MAG).
Conflicts of interest All authors declare that they have no conflict of
interests that are directly relevant to the content of this study. Further,
all authors are aware of this submission and agree with it.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
Appendix: Standards for reporting qualitative research [42, 43]
Purpose or research question X
Included in ‘Introduction’
Included in ‘Introduction’
Qualitative approach and
Ethical issues pertaining to
Data collection methods
Data collection instruments
Units of study
Techniques to enhance
Synthesis and interpretation
Links to empirical data
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