Ethics vs Morality November/December 1999 Vol 17 No 11/12

We are proud to publish the following beautifully written article about dilemmas for community pharmacists written by Raj Vaidya, a community pharmacist in Goa, India.

ETHICS V/S MORALITY A DILEMMA : DISTURBING THOUGHTS

Raj Vaidya M.Pharm.
Community Pharmacist,
Hindu Pharmacy,P.B.No. 149,
Panaji - Goa - India 403001
Email : rajvaidya@bigfoot.com

I am a community pharmacist, and there are a lot of obstructions and dilemmas which come to mind, as I stand at my pharmacy counter and serve patients – with or without a prescription. And the thoughts continue when I lay down to rest in my bed.

I am bound by certain Ethics laid down by my pharmaceutical association, which I proudly hung in my cabin when I graduated and began my practice of pharmacy.

I am also bound by certain Morals which I follow, and sometimes do not. My conscience bites me every time I do not. When laid down Ethics cross swords with Morals, I am at a loss…

1. People read and see the widely advertised claims for so called Ayurvedic medicines for STRESS, DIABETES, SEX-TONICS, ENERGISERS, SLIMMING, BUILDING BODY WEIGHT, and so on… Do I tell the patient the truth that these are more of selling gimmicks than health care ? That the advertisements care more for the companies’ pocket than his health ?

• If I don’t tell – the patient buys, and I am monetarily satisfied. Morally, I am not satisfied – My Apron, the label on it and my Pharmacy degree have failed. Morality has failed.

• If I tell him:

• a) If he believes me – I lose my business (accepted) – but the percentage of such clients is very low.

• b) If he does not believe me – I am half happy, half sad – I know I tried in his best interest (happy), but he did not listen (sad).

Ethics take a beating amidst the tall claims made by advertisers, who mesmerize the public into buying products they should not have !

 

II) Lately, there are attempts to convert some drugs into the OTC [Over-The Counter] category.

• Vitamins – People will ask me, which vitamins are good and I will say that good nutritious food is the best, and that no textbook recommends multivitamin preparations. Patient is not ready to believe this. He is hyped by the tall claims of vitamins – and the pharmacist has failed again.

• Cough syrups – the most common cough syrups contain a cough suppressant as well as an expectorant. Which way do we want the cough to
  go ? In or out ? This is an irrational combination. My morality says I should not recommend it to the patient. Instead of banning it, there seem to be plans to make it OTC. Unfortunately, people are more influenced by advertisements – they will buy it, even if I say that it is not recommended. How can that be ? What is advertised, and so famous, and on everyone’s lips (however irrational or useless it may be) – it has to be GOOD !. Marketing Ethics have come crashing down !

3. POLYPHARMACY : What do I do if I get a prescription containing 10 drugs ? Ethics say that I do not tell the patient that the prescription is irrational, because I have to respect the doctor’s decision to prescribe so many drugs – "He must have prescribed because he felt that the patient needs them !"

Morally, I know that this is an irrational prescription, and I had better tell the patient that you do not need most of the prescribed drugs – they do not fit into the WHO’s Essential Drugs List, nor in our National Essential Drugs List (list is made but kept in the shelves). I know what is Rational Drug Therapy, but what do I do ? What do I follow ? Ethics or Morality ? Can anyone answer me ?

 

I know the doctor has prescribed 10 drugs for various reasons :

1. 1. He seriously believes he is doing the patient good, and that he needs all those medications.
   2. He wants the patient to believe that he is a good doctor because he has prescribed so many medicines.
   3.  
   4. He has to oblige the pharmaceutical companies, for they have been giving him gifts and samples, sponsored his airfare for a conference or holiday, and what not..
   5.  
   6. I find it difficult to find any fourth possible reason.

Putting the 10 drugs in an ADR and DI format – I find that there are MANY possible Drug Interactions and Adverse Drug Reactions. Do I have to report to the patient, or the doctor ? The patient will be scared of the ADRs, not take the medicines, lose faith in the doctor, and the doctor will come catching my throat for disrupting the prescription and creating discomfort. Will the doctor begin prescribing only two or three drugs henceforth, if I point out the Drug Interactions to him ? Should I take the bold decision of telling the doctor about this – every time ? Or should I leave it to professional organisations of doctors and pharmacists ? (and hope it happens soon)

3. What advice to give ?

• When the doctor prescribes Serratio-peptidase or trypsin-chymotrpsin, to be taken t.i.d., (costing Rs. 9 per tab), and the patient asks me "for what is this tablet ?", what do I answer ?. Do I say that it is for reducing inflammation (so costly ??), or do I say that its claimed uses are unscientific, with no strong clinical backing ?

• What do I answer when the patient asks me whether combination of Vit. B1+B6+B12 is good for nerves ? Do I say yes, or no ?

• When doctors rampantly prescribe Norfloxacin – Tinidazole and Cipro-floxacin-Tinidazole combination for diarrhoea, what do I tell the patient if he asks "for what is this medicine
  prescribed ?". Do I tell him that mixed infections very rarely occur and that most diarrhoeas are viral and self resolving ? And if, on questioning the patient if I find that his stools are neither bloody nor having mucous ? Would it still be justifiable to give a "Gunshot therapy" of such higher antibiotics and antiameobics ? With no stool culture taken ?

• What do I do when a patient comes to me insisting for an antibiotic for a cough and throat infection, and says that he does not want to go to a doctor for various reasons (primarily high fees) ? Ethics will say – advise him to go to a doctor with the statement "I am not authorized to give you an antibiotic without a prescription". The patient will then go to a nearby doctor, pay Rs. 50 as fees (sometime Rs. 100, 150), be prescribed nothing less than Ciprofloxacin, or Sparfloxacin, or Cefadroxil without a swab, culture and a sensitivity test, some dextromethorpan lozenges, an irrational cough syrup, an anti-oxidant (Rs. 3 per capsule) and possibly a multivitamin / B.Complex tab or a "Tonic" (Rs. 50 – 60). And the patient would then come to me, but not have sufficient money, so he would buy the tonic, but only few of the antibiotics, and probably not come back for the remaining.

Would it have been better then if I myself had examined the throat of the patient with a torch, and for a suspected infection given the patient a 6 day course of Amoxycillin, along with warm salt water gargles, a little rest, steam inhalations, a request to drink warm water in large quantities, so as to liquefy the cough/sputum and help in its expulsion ? And if necessary to take a home remedy of lime juice, ginger mixed in honey ? And taken no fees ? How much the patient could have saved in terms of money, less dose of toxic drugs, an affordable full course of antibiotic… ? Well that was morality ! Unfortunately, I have to follow Ethics and not Morals !

3. Imagine the pity that comes across my heart when the doctor prescribes Ceftibuten suspension (costing Rs. 350), for a child, without a sensitivity test, and without trying out lower antibiotics, just because the medical representative had visited the doctor and requested him to liquidate the stock because the expiry date was the end of the month ! How can I be a party to this ? Legally, and ethically, I can – but then, where is Morality gone ?

Well, I certainly am in a dilemma. I wonder whether to proudly call myself a pharmacist or not ? When all I see around me ( and through my own hands too..) is booming sales of non-essential drugs, new costly molecules (with no specific advantages) being launched and promoted with extravagant marketing policies and expenses. No proper clinical trials and post-marketing surveillance…

When I talk to Product Managers, they say they know only one thing "Sell and only sell – Targets", and health of the people takes a back seat !

Sometimes I feel it is better to be ignorant of all the above jargon. Better to be an ordinary Diploma in Pharmacy, forget all the counselling and clinical pharmacy. Give what the patient wants, and the doctor prescribes. How much of Ethics and Morals should I follow, if being completely Ethical and Moral will stop bread and butter for my family ! This profession in India has no place for people like me. Is it better if I quit the profession and start a grocery ? I will be at peace at least with my mind !

 

Raj Vaidya reported the following example of the prescriptions that he is concerned to the E-drug e-mail network on 11 October 1999.

We warmly recommend E-drug. To join or to browse visit: www/healthnet.org/programs/edrug.html

Dear E-Druggers,

I thought you should know what prescriptions we sometimes have to deal with in India. Here is an example (PLEASE, this is NOT concocted by me to teach Drug Interactions to my students. It is a prescription I received two days back) :

Dr: An Ex-Asst. Prof of Medicine, Degree : M.D. Medicine

Patient : around 60 years old female.B.P. - 130/80, Blood sugar – 227

The drugs were prescribed by brand name but I have written the generic names for you to understand):

All for 30 days (till next visit)

RxInj. Huminsulin 30/70 - 35 units before breakfast, 18 units before dinner

Gama Linolenic capsules 120 mg - 1 b.d

Capsules of chromium picolinate with Vitamins and Zinc - 1 in afternoon

Vitamin E capsules 400 mg - 1 b.d.

Alprazolam 0.5 mg - 1 at 8 p.m.

Tab Cinnarizine 75mg - 1 at night

Tab pentoxifylline 400 mg - 1 b.d.

Tab piribedil SR 50 mg - 1 in morning

Ramipril 5 mg - 1 hs

Losartan potassium 50 mg - 1 in morning

Levadopa 250mg + Carbidopa 25 mg - 1/2 b.d.

Gliclazide 80 mg - 1 in afternoonTab

Carvedilol 12.5 mg - 1 in morning

Aspirin enteric coated 150 mg - 1 in afternoon

Pyridoxine SR 100mg - 1 daily

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