Ethical considerations and concerns in the implementation of AI in pharmacy practice: a cross-sectional study.

BACKGROUND: Integrating artificial intelligence (AI) into healthcare has raised significant ethical concerns. In pharmacy practice, AI offers promising advances but also poses ethical challenges. METHODS: A cross-sectional study was conducted in countries from the Middle East and North Africa (MENA) region on 501 pharmacy professionals. A 12-item online questionnaire assessed ethical concerns related to the adoption of AI in pharmacy practice. Demographic factors associated with ethical concerns were analyzed via SPSS v.27 software using appropriate statistical tests. RESULTS: Participants expressed concerns about patient data privacy (58.9%), cybersecurity threats (58.9%), potential job displacement (62.9%), and lack of legal regulation (67.0%). Tech-savviness and basic AI understanding were correlated with higher concern scores (p < 0.001). Ethical implications include the need for informed consent, beneficence, justice, and transparency in the use of AI. CONCLUSION: The findings emphasize the importance of ethical guidelines, education, and patient autonomy in adopting AI. Collaboration, data privacy, and equitable access are crucial to the responsible use of AI in pharmacy practice.

Participating doctors' perspectives on the regulation of voluntary assisted dying in Victoria: a qualitative study.

OBJECTIVES: To investigate the perspectives of doctors involved with voluntary assisted dying in Victoria regarding the Voluntary Assisted Dying Act 2017 (Vic) and its operation. DESIGN, SETTING, PARTICIPANTS: Qualitative study; semi-structured interviews with 32 doctors who had participated in the voluntary assisted dying system during its first year of operation (commenced 19 June 2019). Doctors were interviewed during April-July 2020. RESULTS: Three major themes related to problems during the first year of operation of the Act were identified: the statutory prohibition of health professionals initiating discussions with their patients about voluntary assisted dying; the Department of Health and Human Services guidance requirement that all doctor-patient, doctor-pharmacist, and pharmacist-patient interactions be face-to-face; and aspects of implementation, including problems with the voluntary assisted dying online portal, obtaining documentary evidence to establish eligibility, and inadequate resourcing of the Statewide Pharmacy Service. CONCLUSIONS: Doctors reported only limited concerns about the Victorian voluntary assisted dying legislation, but have had some problems with its operation, including implications for the accessibility of voluntary assisted dying to eligible patients. While legislative change may resolve some of these concerns, most can be ameliorated by improving the processes and systems.

Research on developing environmental ethics in pharmacists' activities.

BACKGROUND: Authors of various backgrounds are preoccupied with the meaning of environmental ethics, which refers to specific values, norms, attitudes, and practices with respect to all beings and elements of nature. Many international organizations have adopted important documents proclaiming the ethical obligation to protect the environment in all professional activities. At the national level, professional associations should include and develop this obligation in their codes of conduct. This study aimed to analyze and compare elements of environmental protection included in codes of conduct for pharmacists, to find ways to integrate environmental ethics into their activities. METHODS: Seven codes of conduct for pharmacists were analyzed using the comparative method and methods of legal interpretation. Based on acknowledged values and principles of environmental ethics, a framework model for developing environmental protection in pharmacists' activities was created via an iterative process of reflection and discussion. RESULTS: Explicit provisions for environmental ethics were found in codes in force in three countries and in a Romanian project. These provisions refer, in general, to an ethical duty of environmental protection in pharmacists' activities. Regarding the other codes, the study could only interpret stipulations of public health ethics to deduce an ethical environmental obligation. Considering the need for developing such provisions, an ethical framework was proposed as a model for professional associations of pharmacists. CONCLUSIONS: The studied codes demonstrate a preoccupation of the professional associations with environmental protection in pharmacists' activities, with different degrees of interest in developing environmental ethics. To this end, the codes of conduct for pharmacists should include environmental values, principles, and ethics guidelines. Those guidelines should indicate the ethical attitude in relation to the environment for each activity. Further research is needed to stimulate, shape, and develop an environmental ethical behavior in pharmacists' practice.

Facilitating ethical, legal, and professional deliberations to resolve dilemmas in daily healthcare practice: A case of driver with breakthrough seizures.

OBJECTIVE: The present study was conducted among pharmacy students to use an 8-step systematic approach to facilitate discussions, deliberations, and decision-making on what to do when facing a dilemma of a patient with epilepsy who drives while having breakthrough seizures. METHODS: A hypothetical case was developed using the 12-tips for developing dilemma case-based assessments in health education. A mixed method was used in this study. A serial group discussions based on the nominal group technique (NGT) method were applied. A thorough review of the literature and interviews with key experts in the domain (n = 12) were conducted to obtain pertinent data to inform discussions, deliberations, and decision-making. The analytic hierarchy process (AHP) was used to pairwise compare countervailing arguments and alternative courses of action. RESULTS: In this study, 3 nominal groups were held, and for each 3, discussion rounds were conducted. A total of 27 panelists took part in the nominal groups. Compared with other alternative courses of action, significantly higher weight scores (p-value < 0.001) were given to the course action, "the pharmacist could counsel/educate the patient on the dangers/risks of driving while experiencing breakthrough seizures, inform the patient to refrain from driving in this period, and make a shared decision with the patient to refrain from driving in this period and inform the state authorities". CONCLUSION: This study demonstrates that the 8-step approach when combined with the AHP can be a handy method in facilitating decision-making while addressing and resolving ethical/legal/professional dilemmas in daily healthcare practice.

Pharmacists' Assessment of the Difficulty and Frequency of Ethical Issues Encountered in Community Pharmacy Settings.

Researching ethical problems and their frequency could give us a complex picture and greater insight into the types of ethical issues that pharmacists face in providing health care. The overall aim of this study was to assess the pharmacist's perception of difficulty and frequency of selected ethical issues encountered by the community pharmacists in their everyday practice. A quantitative cross sectional multicenter study was performed using a validated survey instrument - Ethical Issue Scale for Community Pharmacy (EISP). The results of the analysis of 690 completely filled out instruments (response rate 78.49%) showed the difference between the ethical issues which always occurred ("A pharmacist is prevented from dispensing a medicine to the patient due to an administrative error in the prescription"), and the ones that pharmacists found most difficult ("A pharmacist dispenses a medicine he/she personally considers inadequate for the therapeutic treatment of the patient, in order to avoid any conflicts with the physician" and "A pharmacist is considering violating the rules and regulations in order to perform an act of humanity"). The majority of respondents (84.78%) were familiar with the Code of Ethics but the correlation between the familiarity and the perceived usefulness of the code in resolving problems in everyday practice was negative (ρ = -0.17, p < 0.001). Results showed that patients' well-being had a high influence on pharmacists' behavior. The results provided quantitative data by the examination of specific ethical issues and their occurrence. Further empirical research is recommended in order to systematically identify the ethical issues faced by community pharmacists.

RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities.

OBJECTIVE: To assess the impact of a multi-strategic, interdisciplinary intervention on antipsychotic and benzodiazepine prescribing in residential aged care facilities (RACFs). Design, setting: Prospective, longitudinal intervention in Australian RACFs, April 2014 - March 2016. PARTICIPANTS: 150 RACFs (with 12 157 residents) comprised the main participant group; two further groups were consultant pharmacists (staff education) and community pharmacies (prescribing data). Data for all RACF residents, excluding residents receiving respite or end-stage palliative care, were included. INTERVENTION: A multi-strategic program comprising psychotropic medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months; final audit at 6 months. MAIN OUTCOME MEASURE: Mean prevalence of regular antipsychotic and benzodiazepine prescribing at baseline, and at 3 and 6 months. Secondary measures: chlorpromazine and diazepam equivalent doses/day/resident; proportions of residents for whom drug was ceased or the dose reduced; prevalence of antidepressant and prn (as required) psychotropic prescribing (to detect any substitution practice). RESULTS: During the 6-month intervention, the proportion of residents prescribed antipsychotics declined by 13% (from 21.6% [95% CI, 20.4-22.9%] to 18.9% [95% CI, 17.7-20.1%]), and that of residents regularly prescribed benzodiazepines by 21% (from 22.2% [95% CI, 21.0-23.5%] to 17.6% [95% CI, 16.5-18.7]; each, P < 0.001). Mean chlorpromazine equivalent dose declined from 22.9 mg/resident/day (95% CI, 19.8-26.0) to 20.2 mg/resident/day (95% CI, 17.5-22.9; P < 0.001); mean diazepam equivalent dose declined from 1.4 mg/resident/day (95% CI, 1.3-1.5) to 1.1 mg/resident/day (95% CI, 0.9-1.2; P < 0.001). For 39% of residents prescribed antipsychotics and benzodiazepines at baseline, these agents had been ceased or their doses reduced by 6 months. There was no substitution by sedating antidepressants or prn prescribing of other psychotropic agents. CONCLUSIONS: The RedUSe program achieved significant reductions in the proportions of RACF residents prescribed antipsychotics and benzodiazepines. TRIAL REGISTRATION: Australian New Zealand Clinical Trials, ACTRN12617001257358.

[The Significance of Pharmacist Intervention Focused on Improvement of Adverse Events and Cancer Pain].

It was reported that focusing on palliative care for patients with cancer improved their anxiety and depression and prolonged their survival. Similarly, the pharmacist intervention for cancer patients suggested the improvement in anxiety and depression; but, such improvement has not yet been demonstrated by focusing on pharmacist attitudes and behaviors of which the patients were the primary beneficiaries. Therefore, we evaluated the significance of pharmacist intervention focusing on improvement of adverse events and cancer pain. We randomized patients to pharmacist intervention group or no intervention group and evaluated whether the pharmacist intervention improved patients' anxiety and depression. Patients receiving new chemotherapy in the outpatient chemotherapy room were invited to enroll in this study between July 2015 and February 2017. The patients were assessed for their quality of life using the Structured Clinical Interview for ACD and for anxiety and depression using the Structured Clinical Interview for HAD at baseline and again at the 4th chemotherapy. The difference between the baseline and 4th chemotherapy scores was calculated and compared between the pharmacist intervention and no intervention groups. HAD depression subscale and HAD scale scores decreased in the pharmacist intervention group compared to the no intervention group,(-1 versus 0.5, p=0.024)and(-3 versus 0.5, p=0.011)respectively. We demonstrated that the pharmacist intervention focused on improvement of adverse event and cancer pain decreased cancer patients' anxiety and depression.

A model for a drug distribution system in remote Australia as a social determinant of health using event structure analysis.

BACKGROUND: The social determinants of health include the health systems under which people live and utilize health services. One social determinant, for which pharmacists are responsible, is designing drug distribution systems that ensure patients have safe and convenient access to medications. This is critical for settings with poor access to health care. Rural and remote Australia is one example of a setting where the pharmacy profession, schools of pharmacy, and regulatory agencies require pharmacists to assure medication access. Studies of drug distribution systems in such settings are uncommon. This study describes a model for a drug distribution system in an Aboriginal Health Service in remote Australia. The results may be useful for policy setting, pharmacy system design, health professions education, benchmarking, or quality assurance efforts for health system managers in similarly remote locations. The results also suggest that pharmacists can promote access to medications as a social determinant of health. The primary objective of this study was to propose a model for a drug procurement, storage, and distribution system in a remote region of Australia. The secondary objective was to learn the opinions and experiences of healthcare workers under the model. METHODS: Qualitative research methods were used. Semi-structured interviews were performed with a convenience sample of 11 individuals employed by an Aboriginal health service. Transcripts were analyzed using Event Structure Analysis (ESA) to develop the model. Transcripts were also analyzed to determine the opinions and experiences of health care workers. RESULTS: The model was comprised of 24 unique steps with seven distinct components: choosing a supplier; creating a list of preferred medications; budgeting and ordering; supply and shipping; receipt and storage in the clinic; prescribing process; dispensing and patient counseling. Interviewees described opportunities for quality improvement in choosing suppliers, legal issues and staffing, cold chain integrity, medication shortages and wastage, and adherence to policies. CONCLUSION: The model illustrates how pharmacists address medication access as a social determinant of health, and may be helpful for policy setting, system design, benchmarking, and quality assurance by health system designers. ESA is an effective and novel method of developing such models.

[A pilot study of the professional ethical thinking of Quebec hospital pharmacists and pharmacy students]. / Étude pilote du niveau d'accord à des énoncés sur l'éthique pharmaceutique d'étudiants en pharmacie et pharmaciens hospitaliers québécois.

OBJECTIVE: The main objective was to assess the position of Quebec pharmaceutical community about pharmaceutical ethics statements. The second objective was to compare the level of agreement of pharmacy students and hospitals pharmacists. METHOD: Survey conducted one day given in 2012 and 2013 for students in 2013 and from 29/08/2014 to 02/09/2014 for pharmacists. A questionnaire of eight themes and 43 statements was developed: training and education (5 questions), clinical research (7) advertising and marketing (5) evaluation (5) dispensing medication (4), pharmaceutical care (9) economic aspect (6) and code of ethics (2). A Likert scale with four choices was used to measure the level of agreement. The primary outcome was the difference between the level of agreement of pharmacy students and hospital pharmacists. The Chi2 test was used. RESULTS: A total of 347 students and 398 pharmacists responded to the survey. There was a statistically significant difference regarding the level of agreement with 28 statements on 43. The differences focused on eight themes of the questionnaire, or training and education (3/5 significantly different questions), clinical research (2/7), advertising and marketing (2/5), Evaluation (4/5) dispensing medication (4/4), pharmaceutical care (5/9), economic aspect (6/6) and ethics (2/2). CONCLUSION: This study shows that there is a difference between pharmacists and pharmacy students about pharmaceutical ethics statements.

An Ethical Issue Scale for Community Pharmacy Setting (EISP): Development and Validation.

Many problems that arise when providing pharmacy services may contain some ethical components and the aims of this study were to develop and validate a scale that could assess difficulties of ethical issues, as well as the frequency of those occurrences in everyday practice of community pharmacists. Development and validation of the scale was conducted in three phases: (1) generating items for the initial survey instrument after qualitative analysis; (2) defining the design and format of the instrument; (3) validation of the instrument. The constructed Ethical Issue scale for community pharmacy setting has two parts containing the same 16 items for assessing the difficulty and frequency thereof. The results of the 171 completely filled out scales were analyzed (response rate 74.89%). The Cronbach's α value of the part of the instrument that examines difficulties of the ethical situations was 0.83 and for the part of the instrument that examined frequency of the ethical situations was 0.84. Test-retest reliability for both parts of the instrument was satisfactory with all Interclass correlation coefficient (ICC) values above 0.6, (for the part that examines severity ICC = 0.809, for the part that examines frequency ICC = 0.929). The 16-item scale, as a self assessment tool, demonstrated a high degree of content, criterion, and construct validity and test-retest reliability. The results support its use as a research tool to asses difficulty and frequency of ethical issues in community pharmacy setting. The validated scale needs to be further employed on a larger sample of pharmacists.

[Prick of conscience in the pharmaceutical profession]. / Výhrada svedomí v profesi farmaceuta.

The work of the pharmacist in a pharmacy requires from him not only to solve professional and economic issues, but often the ethical ones as well. For a patients good it is necessary to choose a morally correct decision, but the fulfilment of any patients wish according to his or her own ideas of good is not a law for the health worker. The paper describes the situations when the pharmacist when fulfilling the requirement of the patient (often in the form of a medical prescription) may feel prick of conscience. A questionnaire survey has revealed that prick of conscience confronts more often those who are being trained for the profession than those who already practise it. The right for prick of conscience is considered unfounded by some pharmacists with practical experience, whereas undergraduates view it as a possibility of expressing ones own attitude. The paper analyzes the issues which in both categories of respondents are considered to be prick of conscience: oral hormonal contraception, including postcoital contraception, and preparations produced from the cells of aborted embryos.

[Euthanasia and/or medically assisted suicide: Reflection on the new responsibility of the hospital pharmacist]. / Euthanasie et/ou suicide médicalement assisté : réflexion sur la nouvelle responsabilité du pharmacien hospitalier.

CONTEXT: Concern about euthanasia and medically assisted suicide is currently growing around the world and particularly in France. Though not authorized at present in France, the role of hospital pharmacist in this issue needs to be discussed. OBJECTIVES: This article aims to gather medical and legal literature of European Union member states on these issues and particularly in France. To propose a practical thinking on the possible role of hospital pharmacist. RESULTS: Among European Union, euthanasia and/or assisted suicide have already been introduced in some member states' laws. In France, Leonetti law currently sets the legal framework for the management of end of life. To address the society's demand on these issues, French President F. Hollande made two ethics committees responsible for working on it. Both were mainly against euthanasia and assisted suicide. Though a bit forgotten in this debate, hospital pharmacist needs to be associated in the thinking, as the main "drug-keeper". Indeed, guidelines are necessary to outline and ensure a safe drug use, complying with professional ethics, if lethal doses are voluntarily prescribed. CONCLUSION: Pharmaceutical work is in constant evolution and is addressing new issues still unanswered, including assisted suicide and euthanasia. French pharmaceutical authorities should seize upon them, in order to guarantee pharmaceutical ethics. These practices, if authorized by law, should remain exceptional, and law strictly enforced. The pharmacist could be one of these "lawkeepers".

Speak no evil? Conscience and the duty to inform, refer or transfer care.

This paper argues that the type of conscience claims made in last decade's spate of cases involving pharmacists' objections to filling birth control prescriptions and cases such as Ms. Means and Mercy Health Partners of Michigan, and even the Affordable Care Act and the Little Sisters of the Poor, as different as they appear to be from each other, share a common element that ties them together and makes them fundamentally different in kind from traditional claims of conscience about which a practical consensus emerged in the 1980s and 1990s. This difference in kind is profoundly significant; so much so, we contend, that it puts them at odds with the normative basis for protecting conscience claims in United States health care settings in the first place, making them illegitimate. Finally, we argue that, given the illegitimacy of these contemporary claims of conscience, physicians and other health professionals must honor their well-established standing obligations to provide informed consent and refer or transfer care even if the service requested or needed is at odds with their own core moral beliefs-a requirement that is in line with the aforementioned practical consensus on traditional claims of conscience.

[A prescription for yourself or acquaintances, a good idea?] / Een recept voor jezelf of een bekende, een goed idee?

Many doctors regularly write a prescription for themselves or for family members or friends. In this article, we discuss the legal and ethical considerations surrounding these prescriptions. We also discuss the role of the pharmacist who receives the prescription. Although there is no legal obstacle, codes of conduct and guidelines state that prescribing to acquaintances or yourself is undesirable, especially because it is often not possible to maintain sufficient professional distance, necessary to provide proper treatment. If the GP or other care providers have no knowledge of the prescription and no medical file is kept, undesirable situations may arise for the patient. A prescription for yourself or acquaintances can be made occasionally and under special circumstances (acute situation, no serious problem, short-term), but then requires a quick transfer of treatment to regular practitioners.

[Japanese Code of Ethics for Pharmacists and Professionalism].

In their role as providers of pharmaceutical products to society, pharmacists must demonstrate professionalism if they are to gain the trust of the community. The Japan Pharmaceutical Association has published the Pharmacist Platform in Japan and the Japanese Code of Ethics for Pharmacists; these resources provide clear guidelines for pharmacists and are an important component of the profession. Becoming a pharmacist involves joining a professional community and thereby pledging to accept a set of ethical standards. This concept of the pharmacy profession is shared by other countries, and the International Pharmaceutical Federation has indicated that professionalism is an issue that should be addressed in every country. This review introduces the Pharmacist Platform in Japan, the Japanese Code of Ethics for Pharmacists established by the Japan Pharmaceutical Association, and the background of each establishment.

How Might Antibiotic Stewardship Programs Influence Clinicians' Autonomy and Organizations' Liability?

Federal and state governments mandate some health care organizations to implement antibiotic stewardship programs (ASPs). Some early adopters developed model ASPs that have helped set industry standards; other benchmarks will likely be forged in subsequent regulation, legislation, and jurisprudence. This article considers how ASP designs can affect professional autonomy, especially of frontline antibiotic stewards who are usually physicians and pharmacists. This article also considers how ASP development and implementation might influence standards of care and malpractice liability.

How Should Clinicians Navigate Interprofessional Tension in Their Roles as Antimicrobial Stewards?

Pharmacists and physicians play key roles in antimicrobial stewardship. This commentary on a case describes these health professionals' need to collaborate to optimize therapeutic use of antimicrobials in clinical settings. Prescription preauthorization is one antimicrobial stewardship strategy that can meet with some physicians' frustration and generate conflict between pharmacists and prescribing physicians, particularly when pharmacists make alternative treatment recommendations. This commentary considers interprofessional tension concerning prescription preauthorization and suggests strategies for navigating such conflict.

The fox and the grapes: an Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription.

Emergency hormonal contraception (EHC) has been available from pharmacies in the UK without prescription for 11 years. In the Republic of Ireland this service was made available in 2011. In both jurisdictions the respective regulators have included 'conscience clauses', which allow pharmacists to opt out of providing EHC on religious or moral grounds providing certain criteria are met. In effect, conscientious objectors must refer patients to other providers who are willing to supply these medicines. Inclusion of such clauses leads to a cycle of cognitive dissonance on behalf of both parties. Objectors convince themselves of the existence of a moral difference between supply of EHC and referral to another supplier, while the regulators must feign satisfaction that a form of regulation lacking universality will not lead to adverse consequences in the long term. We contend that whichever of these two parties truly believes in that which they purport to must act to end this unsatisfactory status quo. Either the regulators must compel all pharmacists to dispense emergency contraception to all suitable patients who request it, or a pharmacist must refuse either to supply EHC or to refer the patient to an alternative supplier and challenge any subsequent sanctions imposed by their regulator.

Conscientious objections in pharmacy practice in Great Britain.

Pharmacists who refuse to provide certain services or treatment for reasons of conscience have been criticized for failing to fulfil their professional obligations. Currently, individual pharmacists in Great Britain can withhold services or treatment for moral or religious reasons, provided they refer the patient to an alternative source. The most high-profile cases have concerned the refusal to supply emergency hormonal contraception, which will serve as an example in this article. I propose that the pharmacy profession's policy on conscientious objections should be altered slightly. Building on the work of Brock and Wicclair, I argue that conscientious refusals should be acceptable provided that the patient is informed of the service, the patient is redirected to an alternative source, the refusal does not cause an unreasonable burden to the patient, and the reasons for the refusal are based on the core values of the profession. Finally, I argue that a principled categorical refusal by an individual pharmacist is not morally permissible. I claim that, contrary to current practice, a pharmacist cannot legitimately claim universal exemption from providing a standard service, even if that service is available elsewhere.

Whose self-determination? Barriers to access to emergency hormonal contraception in Italy.

In Italy, Emergency Hormonal Contraception (EHC) is a prescription drug, available only in pharmacies. Evidence suggests that a number of doctors and pharmacists refuse to provide EHC, on grounds of conscience, although the exact frequency of this phenomenon is unknown. This creates a barrier to access to EHC for women, thus risking undermining their right to reproductive self-determination. In this article, we aim to offer a clearer empirical and theoretical understanding of the situation and to assess the force of doctors' and pharmacists' claims against providing EHC. Unlike standard discussions of the issue, we argue that the category of conscientious objection is not the most appropriate one for making sense of these claims, because they are not grounded in a conflict between two contrasting moral duties. The seemingly forced choice between protecting doctors' and pharmacists' professional self-determination and women's reproductive self-determination could be prevented by distributing EHC without medical prescription and in a number of outlets (including supermarkets), thus relieving doctors and pharmacists from the legal duty to provide it.