The Importance of Teaching Ethics in Pharmacy Education

INTRODUCTION

All faculty members should have a general understanding of ethics, even if they have had no formal training in the field, since instruction and training in ethical decision-making is an accreditation expectation by the Accreditation Council for Pharmacy Education (ACPE) for students and by the American Society of Health-System Pharmacists (ASHP) for residents.^1,2 Additionally, whether they recognize it or not, pharmacy faculty themselves are involved in ethical decision-making on an almost daily basis.

No published research documents the preparation of US pharmacy faculty in teaching ethics. One recent study in Australia and New Zealand revealed a lack of faculty expertise, a dearth of resources, and a lack of standardization in teaching ethics in schools of pharmacy in those countries.³ However, the findings are not necessarily applicable to US schools and colleges of pharmacy. For example, the Australian study cited a lack of pharmacy ethics syllabi³; however, the AACP Health Care Ethics Special Interest Group hosts a library of structured syllabi (including learning objectives), which at the time of this commentary included syllabi from 15 different ethics courses.⁴

In the United States, there is a need for the Academy to examine faculty training and qualifications for teaching ethics, and how ethics is taught and assessed, as this information is currently unavailable. As educators and mentors, pharmacy educators should have the same foundations for ethical decision-making that we expect of our students.

The situation does not appear to be much better in medicine, as discussed in a review of medical ethics education in Western English-speaking countries.⁵ Ethics education in medicine is focused primarily on cognitive (ie, competency) and attitudinal (ie, virtue) objectives; however, ethics coursework is not mandatory. Also, a shortage of faculty with expertise in ethics is a major challenge in implementing ethics in the curriculum.⁵

How do faculty who are relatively unfamiliar with the field of ethics teach others about ethical behavior? For interested faculty, there are several useful websites that provide definitions and descriptions of important terms related to philosophical issues, including ethics.⁶⇓^-8 In particular, a Brown University website provides an excellent distillation of the important issues related to decisions about what is right or wrong.⁷ These sites have information on ethical decision-making that is not specific to pharmacy but can provide a foundational understanding of ethics that can supplement the limited number of available publications on ethics instruction more specific to pharmacy education.⁹⇓⇓⇓^-13

Of the ethics instruction articles found that were specific to pharmacy education, two were about elective courses, one evaluating the use of debates to deliver ethics content to undergraduate pharmacy students in the United Kingdom⁹ and the other evaluating the use of facilitated discussion groups to deliver ethical content.¹⁰ A third article described a structured format for teaching ethics and professionalism,¹¹ and a fourth discussed ethical and legal issues pertaining to social media.¹² Stratton discussed evidence from other health professions demonstrating that multiple exposures to ethics is preferred over students completing a single course.¹³ Additionally, Stratton provided a decision-making approach to working through ethical dilemmas that can be used by any group of faculty who are familiar with basic ethics principles rather than relying on a single faculty member with recognized expertise.

The aims of this commentary are to expand on the basic approach to ethical decision-making provided by Stratton, using examples involving students or faculty in each of the triad areas of teaching, research, and service,¹³ and serve as a starting point to enable all faculty to teach students how to work through an ethical dilemma. This commentary will focus on the initial three steps of the Stratton approach that concern identifying an ethical dilemma, determining the facts of the dilemma, and identifying the principles and values that play a role in the dilemma. References are provided for more in-depth review of some of the subject matter beyond the scope of this commentary.

The first step is to determine if an ethical dilemma exists. Using teaching as an example, ethical issues commonly faced by educators include problems such as professionalism or fairness concerns raised by students about testing and other forms of assessment. Lack of professionalism may be manifest by student or faculty behavior that is disrespectful (including email messages or postings on social media), breaks a promise (eg, faculty failure to follow the syllabus) or threatens existing or future relationships. Issues of fairness can arise where faculty or student actions could lead to harm (emotional or physical, or in case-based situations, theoretical), or where an action might compromise somebody’s rights by providing one party with an unfair advantage (eg, cheating). As discussed by Stratton,¹³ questions to consider in this step relate to issues such as fairness, promises, harm, relationships, rights, benefits, and respect. Where any of these concepts have been violated, the situation constitutes an ethical dilemma, and one moves on to the next step.

The second step is to determine the facts related to the dilemma. Technical facts may need clarification and should not be confused with differences of opinion. Using the example of human subjects’ research, there are differences of opinion as to the optimal application of general ethical principles (ie, respect for persons, beneficence, justice) in any specific study, but the need to consider all these principles when considering and conducting such research is not debatable. Additionally, legal, regulatory, or policy constraints on the behavior or behaviors leading to the dilemma need consideration. For example, faculty conducting research involving human subjects are required to receive training in the ethical principles underlying federal regulations that protect research participants, the foundations of which are presented in the Belmont Report.¹⁴

The basic ethical principles discussed in the Belmont Report include respect for persons, beneficence, and justice as applied to informed consent procedures, assessments of risks and benefits, and equitable selection of subjects. Respect for persons requires that researchers acknowledge and treat individuals as autonomous and protect individuals whose autonomy is limited. Beneficence obligates researchers to treat persons in an ethical manner by respecting their decisions, protecting them from harm, and securing their well-being. Justice obligates researchers to treat people fairly with equitable distribution of burdens and benefits.

In common with ethical decision-making in research contexts, applying these principles to arrive at an ethically permissible decision may lead the individual to recognize that at times the principles may present as competing claims. Such a quandary necessitates using a balanced approach that may not resolve all ethical concerns. An example involving teaching is useful to illustrate the latter point. Assume that the professional code of a school of pharmacy has a clause related to justice (fairness), which mandates students to report cheating by other students. A student who reports cheating may worry that it could lead to some sort of retribution (ie, harm) by the student accused of cheating. Both justice and beneficence (maximizing benefit, limiting harm) are core ethical principles, but in this scenario, they conflict with each other. A professionalism committee involved in this situation may need to prioritize one of these core principles over the other unless additional confirmation of cheating from another source is available.

With regards to service, many institutions of higher learning have professional conduct policies that address ethics standards for integrity, honesty, and fairness by faculty. While acknowledging academic freedom, these policies often refer to responsibilities associated with civil discourse when participating in university service activities. Examples of such responsibilities include treating other individuals with dignity and respect, being compassionate and courteous (eg, not monopolizing a conversation), and exhibiting the previously mentioned characteristics of integrity, honesty, and fairness. Similarly, all of the major pharmacy organizations either have codes of ethics or ethical standards for behavior as part of their core values. Failure to abide by these codes and standards within either the Academy or pharmacy profession may have legal implications.¹⁵⇓⇓^-18

The third step is to identify the principles and values that play a role. Are the personal, professional, institutional, or societal values of the moral agents on either side of the dilemma in conflict with one another? Returning to the question of professional behavior, is the behavior or behaviors of one party in conflict with behavior that would be expected of all others in a similar cohort? Expected behaviors by individual students and faculty in the classroom might be stipulated in a course syllabus. At the institutional level, a university’s faculty handbook might outline expected faculty behaviors regarding the free exchange of ideas at campus events, or a practice site’s policies and procedures might proscribe certain responses to specific patient requests. A profession’s code of ethics that outlines expected behaviors for student pharmacists and preceptors might reflect societal expectations of that profession. With respect to professionalism, the reader is referred to a few papers in the Journal that discuss professionalism attributes and ways to promote and assess them in students in the didactic and experiential settings.¹⁹⇓⇓^-22

Similar to issues of professionalism, many faculty members have encountered student concerns and complaints about the fairness (justice) of assessments. Unfortunately, there is no professional consensus on ethical judgments related to assessments, although there is general agreement that one of the keys to avoiding complaints of unfairness is to provide clear verbal and written expectations and guidance at the beginning of course and to employ valid assessments consistent with course objectives.²³ More specific guidance is available in papers published in AJPE that address issues of testing and other forms of assessment.²⁴⇓⇓^-27

There are seven remaining steps in the basic ethical decision-making process by Stratton¹³ that cannot be adequately covered in this commentary but might be appropriate for an AACP webinar series (Figure 1). Step 4 is to identify your goal in resolving the dilemma. What do you hope to accomplish, keeping in mind that any well-defined goal is specific, measurable, and time-bound, and as a resolution to an ethics problem, should be as fair as possible to all parties involved. Step 5 is to generate potential reasonable solutions to the dilemma. This is a brainstorming exercise to explore what could be done. Step 6 is to analyze the pros and cons of each alternative using ethical concepts and principles. Faculty who are familiar with basic ethics terminology, codes of ethics, and possibly the teachings of some philosophers will be in the best position to help students work through this step. Step 7 is to select one of the alternatives. Based on the findings from the analysis undertaken in the previous step, what should be done? This step is often skipped by students who are reluctant to commit to a tough decision. Faculty and students alike must learn to become comfortable with “commitment with uncertainty,” where one commits to a course of action despite having lingering concerns that, because of incomplete information, there may be a better choice that has not been considered.²⁸ Step 8 is to anticipate potential objections to the selected course of action. This exercise helps ensure that a person has considered both sides of a dilemma as well as potential adverse consequences arising from the approach chosen to resolve the dilemma.

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Figure 1.

Steps in the ethical decision-making process.¹³

Step 9 is to evaluate the results. Of course, this activity needs to occur after a solution has been implemented. While possible to undertake in a live situation, evaluating results is generally not possible in a classroom scenario unless the scenario incorporates an extended timeline that updates the situation based on the selected course of action. Step 10 is to address how this ethical dilemma could have been avoided in the first place. Given that hindsight is often “20-20,” upon reflection, what steps might have been taken earlier to prevent this dilemma from arising in the first place?