Commentary: Ethical Decision Making During A Public Health .

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Commentary: Ethical DecisionMaking During a Public HealthEventCompanion document to the New Brunswick College of Pharmacists Code ofEthics (Policy GM-PP-CE-01)


ACKNOWLEDGEMENTSThe College appreciates the contributions of the following individuals and organisations:Peggy Yoston, University of Waterloo Pharmacy Co-Op student for drafting this documentSaskatchewan College of Pharmacy ProfessionalsNova Scotia College of PharmacistsCollege of Pharmacists of ManitobaUniversity of Toronto Joint Centre for BioethicsTimothy Christie, BA(hons), MA, MHSc, PhD, Director of Ethics, Horizon HealthAlison Thompson, PhD, Associate Professor, University of TorontoACRONYMSVBDMCOVID-19Values-Based Decision MakingSARS-CoV-2 2019LEARNING OBJECTIVESThis Commentary guides pharmacy professionals in making ethical decisions during a publichealth event and clarifies patient care priorities during an event that impacts societal health.After reviewing this document, the pharmacy professional will be able to:1. Identify and explain why aspects of pharmacy practice present ethical challenges during apublic health event2. Recognize the position of the New Brunswick College of Pharmacists regarding expectations ofpharmacy practice during a public health event3. Apply Values-Based Decision Making (VBDM) employing the ethical principles utility andsolidarity to practice issues in the context of a public health event4. Justify ethical decisions made during a public health eventAUDIENCE Pharmacy professionals practicing direct patient care during an emergencyPharmacy managers supervising staff during an emergencyPharmacy professionals practicing in non-direct patient care environmentsThe public of New BrunswickGovernment of New BrunswickOther healthcare professionals NBCP/OPNB 2020Published: September 2020Page 3 of 16

INTRODUCTIONThis Commentary supplements the New Brunswick College of Pharmacists Code of Ethics.1Commentary is authored for ethical dilemmas that require expansion due to their complexity,controversy, breadth, or magnitude of risk to stakeholders.This document was created in 2020 to provide guidance during the COVID-19 pandemica,however the scope is such that it can support ethical decisions in any future public health event.Public health events may be due to infectious disease, natural disaster, nuclear incidents, largechemical spills, power or communication grid outages, war or terrorist threats.3 Public healthevents can be localised or national in breadth and may or may not be formally declared by localor national government. This Commentary should be used in conjunction with applicableemergency regulations of the College and direction from the New Brunswick’s Department ofHealth.This Commentary:1. Describes practice demands during a public health event2. Presents relevant ethical concepts and how they interplay during a public health event3. Promotes the use of Values Based Decision Making (VBDM) in the context of a publichealth event and the expanded bioethical principles4. Applies VBDM and principles of utility and solidarity to a case exampleThe Commentary is intended for pharmacy professionals who provide health care directly topatients. However, those practicing in managerial and policy roles may also find the Commentaryrelevant. All practitioners must negotiate the tension between:a) Duties to self and family vs. duties to the public/patient vs. duties to other stakeholdersbb) Individual patient benefit vs collective societal health benefitStakeholders will share some values and interests and diverge on others. The common languageof ethics allows professionals to systematically analyse issues, plan and execute action,communicate transparently with stakeholders, and reassess decisions in light of newinformation. Decision-making based on ethical principles and values can be fair, accountable,inclusive, considered, and justifiable to stakeholders.The following material is provided with the goal of preparing and empowering pharmacypractitioners to provide ethically-informed patient care decisions in unique circumstances thatpresent during a public health event.aA pandemic is defined by the World Health Organization as “the worldwide spread of a new disease”. 2Other stakeholders may include employers, government, institutions such as long-term care homes, hospitals,private insurers, or corporate entities.b NBCP/OPNB 2020Published: September 2020Page 4 of 16

KEY MESSAGES In a public health event, utility is prioritized over beneficence, non-maleficence andsometimes respect for persons. Essentially, maximization of benefit for the public’s collectivehealth is often invoked and prioritized over the health of the individual, particularly whenresources are scarce.When necessary, pharmacy professionals may be limited to providing essential services tomaximize the benefits of care for the most patients, to preserve scarce resources, or toensure the safety of patients and the pharmacy team.A focus on stewardship and solidarity requires collective responsibility for the managementof the pharmaceutical supply chain regionally, nationally, and internationally. Redeploymentof professionals and non-professional staff and pharmaceutical products may be required toensure equitable access to resources for patients.Within reason, professionals have an ethical duty to care for patients despite facingpersonal risk, and potential risk to their family members.PRACTICE DEMANDS DURING A PUBLIC HEALTH EVENTA public health event compels pharmacy professionals to practice in possibly unfamiliar, complex,uncertain, and perilous conditions. A public health event may result in shortages of medicationsand supplies, human resource deficit, increased patient volume, time-pressure, and threats tooccupational health (e.g. lack of personal protective equipment during pandemic). The resultinganxiety experienced during a public health event adds to the challenge of making andimplementing good ethical decisions.4RELEVANT ETHICAL CONCEPTS DURING A PUBLIC HEALTHEVENTThe Code of Ethics provides two central paradigms that apply toethics whether a public health event is in progress or not. Professional Duties (center of Figure 1) Bioethical Principles (peripheral circles of Figure 1)Professional DutiesThe duties of the pharmacy professional are to patients, publicand the pharmacy profession:“to promote and protect the health, well-being, safety andinterest of the public.”and“to hold forth the independence, integrity and honour of theprofession1” NBCP/OPNB 2020Published: September 2020Figure 1: Professional Duties andBioethical PrinciplesPage 5 of 16

During a public health event, personal duties (to self and family) must be carefully balanced withprofessional duties. Stakeholders have a duty to support pharmacy professionals’ practice. Theterm reciprocity is used to denote the obligation of employers, public health authorities,government, and pharmacy advocacy bodies to provide resources (human, personal protectiveequipment) and policy to support pharmacy professionals to practice in a safe environment andminimize their personal (and family) risk in caring for patients during a public health event.4,5 Thepublic also has a duty to be respectful towards pharmacy professionals serving their communitiesduring public health events. The references and suggested resources at the end of thisCommentary contain further reading on these other non-professional duties.Bioethical PrinciplescThe Code of Ethics includes four bioethical principles that form the basis for the normal courseof patient care: Beneficence, Non-Maleficence, Respect for Persons, and Justice.c Public healthevents cause professionals to consider two other bioethical principles: Utility and Solidarity.UtilityUtilitarianism is:“a theory that the aim of action should be the largest possible balance of pleasure over pain orthe greatest happiness of the greatest number.”6According to the theory of utilitarianism, utility should guide actions, programs, and policies.7 Ina public health event utility is prioritized over beneficence and non-maleficence and often overrespect for persons. Essentially, population-centered care is prioritised over patient-centeredcare. Utility provides flexibility in light of the risks so that no rule is absolute.Resources and time will be scarce during a public health event. Decisions should be made thatwill benefit the most people possible. Some examples of prioritisation of utility over beneficence,non-maleficence, and respect for persons are contained within each of these following sections.SolidaritySolidarity is:“unity (as of a group or class) that produces or is based on community of interests, objectives,and standards.”8During a public health event, pharmacy professionals are simultaneously presented with multiplecompeting interests, values, and priorities in making patient care decisions. In the context ofcReaders are referred to the Code of Ethics for explanation of each bioethical principle. 1 NBCP/OPNB 2020Published: September 2020Page 6 of 16

public health, solidarity results in a collective commitment to assisting others who are linked bymeans of a shared situation or cause.9 Because there is potential for profound system failureduring public health events, the competition, self-interest, and territoriality among pharmacyprofessionals, pharmacies, and institutions must become secondary to maintaining the healthand well-being of the community and society. Specific examples of solidarity include: Sharing of medication supply (as opposed to stockpiling) between pharmacies.Area pharmacies coordinating and communicating opening times to maintain localservice while facilitating health and well-being for all staff.Collaboration between multiple organizations messages and strategies to maintainingpublic health.Minimizing risk of infection in vulnerable pharmacy professionals through reassignmentof these professionals to non-patient care duties to ensure ongoing human resourcingexists to maintain patient care.Beneficence and Non-MaleficenceTo protect the public from harm during a public health event, actions may need to be takenwhich impinge on individual patient benefit or preferences. Collective societal health benefitoutweighs individual patient benefit during a public health event.10 Examples include: Distribution decisions on a COVID-19 vaccine will need to initially ensure priority is givento vaccinating populations (both internationally and domestically) that maximize societalbenefit rather than simply providing it to any given individual (beneficence) requesting it. Health practitioners might be inclined (for interests of self or patient) to providetreatment with little or no research on safety and/or efficacy (non-maleficence andbeneficence) during a public health event. Pharmacists are obliged to provide evidencebased care during a public health event.10 Experimental treatments must be providedthrough research protocols to establish evidence for use. During public health event related staffing shortages, pharmacy professionals may beneeded outside of their normal area of practice in order to achieve the greatest benefitto the greatest number of patients (utility). Establishing basic competency is necessary todo no harm to patients (non-maleficence) while positively impacting on patient’s health(beneficence). Pharmacy professionals should feel supportedd in competencydevelopment in unfamiliar aspects of pharmacy practice.10Respect for PersonsPatient-centered care attempts to meet (respect) patient needs and preferences. Patientcentered care does not mean meeting all patient preferences. The principle of utility makesit clear that not all patient demands will be met in a public health event. Instead, pharmacyprofessionals shift to ensuring population health through maintaining essential services.dSee “Stand on Guard for Thee” in the recommended readings for information on reciprocal duty. NBCP/OPNB 2020Published: September 2020Page 7 of 16

Pharmacy professionals can assist patients in recalibrating their expectations of thehealthcare system (e.g., rationing of medication supply, eliminating face-to-faceconsultation, wait times) so that even in times of scarcity and changes to standard ofpractice, therapeutic relationships and public trust are maintained.10A patient’s right to privacy is foundational to the public’s trust in the profession ofpharmacy; however, public health events may necessitate the prioritization of protectingthe public from harm over privacy rights.5 Practitioners faced with divulging patientinformation must carefully considere how to divulge the minimal amount of informationin order to achieve the necessary outcome. For instance, during a pandemic, contacttracing of infection cases may require the provision of patient information to public healthto prevent disease transmission.JusticeRestrictions and allowances during a public health event should be proportionate to theactual or potential threat and should not exceed what is necessary.10 An example of aproportionate response could be:o only deferring administration of non-essential injections rather than all injections.Non-essential injections are those that are assessed as not posing immediate risk topatient health. Stewardship is important during a public health event where resources are scarce. 5Allocation decisions must attempt to achieve the best patient and public healthoutcomes. Allocation can pertain to goods or services. Examples where stewardship isevident include:o Conservation of unused portions of pharmaceutical products used in sterilepreparation of unit doses to reduce wastage.o Managing rational use of personal protective equipment (PPE) during a public healthevent through formalized assessment of a service as ‘essential’ and requiring PPEenabled patient-professional contact.o Preserving pharmaceutical supply chain through careful apportioning of medicationsto prevent patient stockpiling and coordination across jurisdictions and betweenwholesalers, distributors, and manufacturers. Canadians expect equitable healthcare access. Public health events may justify difficultdecisions on deferring care, providing less effective medication therapy, and rationing ofscarce resources. Where care is not provided equitably it can be provided fairly. Specialattention must be paid to inequitable distribution that results from resource allocationdecisions on already disadvantaged populations. Actions that can lead to justifiable andfair provision of care include:o Application of resource allocation principles to ethically justify provision of patientcare resources to those most likely to benefit, those considered most critically ill orindividuals providing essential services.eConsulting with other authorities such as Public Health, the College and/or legal counsel may be advisable. NBCP/OPNB 2020Published: September 2020Page 8 of 16

o Provision of drugs in short supply should be made in accordance with provincial andnational guidelines regarding medication supply. These decisions should also bemade using available evidence at the time.10o Prioritization of continuing medication therapy rather than optimizing therapy. Theexpertise required for optimization of therapy may prevent other patients fromreceiving attention. Note: The opposite applies when stewardship is of importance asoptimization might allow for conservation of critical drugs.10,11o Provision of minimally acceptable levels of care rather than striving for perfection. 10Time and resources are limited during a public health event and pharmacyprofessionals must strive to provide services to as many patients as possible to a safeand acceptable degree.Trust in the pharmacy profession is strengthened when professionals fulfill their duty to thepublic during a public health event. Competing personal interests of professionals and competingobligations to other stakeholders challenge pharmacy professionals in achieving their duty tocare especially during public health events. The prioritisation of utility can result in moral distressfto both patients and the professionals involved in ethical decisions as some individual patienthealth outcomes may be poor. The following section on ethical decision making provides someguidance to professionals in navigating these challenging decisions.5ETHICAL DECISION MAKINGThe emotional energy, pressure and responsibility associated with caring for individual patients,maintaining collective public health, and caring for self and family during a public health eventmakes for challenging decisions on the part of pharmacy professionals. With use, the VBDMprocess provides a familiar thought process that focuses on a best possible outcome. 1 Duringpublic health events, when ethical decisions abound, using VBDM to apply ethical values andprinciples can help guide the decisions of pharmacists, pharmacy technicians, and their teams.Pharmacy professionals may worry about being penalized for less-than-ideal outcomes resultingfrom their decisions. Pharmacy professionals are reassured that any decision called into questionwill be evaluated based on the circumstances and information available at the time of thedecision and not with the benefit of hindsight.10 Decisions during a public health event must bebased on pure motivations for the good of society. They should be reasoned and informed by thebest available evidence and information at the time. It is conceivable that in order to achieve thebest outcome for the greatest number of patients, a departure from strict legal requirementsmight be justifiable. Pharmacy professionals should use the VBDM process as a tool forreasonable, justifiable decisions, especially during public health events. VBDM can effectivelycommunicate facts and possible options with peers and authorities regarding an ethicalfMoral distress occurs when a clinician makes a moral judgment about a case in which he or she is involved and anexternal constraint makes it difficult or impossible to act on that judgment, resulting in “painful feelings and/orpsychological disequilibrium”12 NBCP/OPNB 2020Published: September 2020Page 9 of 16

dilemma.5 Collaborative discussion and decision-m

The College appreciates the contributions of the following individuals and organisations: Peggy Yoston, University of Waterloo Pharmacy Co-Op student for drafting this document Saskatchewan College of Pharmacy Professionals Nova Scotia College of Pharmacists College of Pharmacists of Manitoba University of Toronto Joint Centre for Bioethics

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