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Robert A. Buerki, R.Ph., Ph.D.

Louis D. Vottero, R.Ph., M.S.

In a 1989 paper titled Opportunities and Responsibilities in Pharmaceutical Care, Heplerand Strand1proposed a new philosophy of pharmacy practice that went far beyond theexpectations of most pharmacy practitioners, even those dedicated to the patient-oriented practices embraced by the term clinical pharmacy. They reviewed the alarmingextent of drug-related morbidity and mortality in the American health care system andconcluded that this problem could only be addressed by a fundamental change in thepharmacists professional function. They referred to this concept as pharmaceutical care,

which they defined as the responsible provision of drug therapy for the purpose of achievingdefinite outcomes that improve a patients quality of life. They stressed that the practiceof pharmacy must restore what has been missing for years: a clear emphasis on the patients

welfare, a patient advocacy role with a clear ethical mandate to protect the patient fromthe harmful effects of . . . drug misadventuring.

Rather than restrict the pharmacists professional role to merely supplying and moni-toring drug therapy, Hepler and Strand built upon concepts of clinical pharmacy to createa process in which a pharmacist cooperates with a patient and other health professionalsin designing, implementing, and monitoring a therapeutic plan that will produce specifictherapeutic outcomes for the patient. Central to their shared vision is the establishmentof a mutually beneficial exchange in which the patient grants authority to the provider,and the provider gives competence and commitment to the patient. Leaders in phar-macy have embraced the concept of pharmaceutical care because they see within it anopportunity to respond to critical health care needs of society and to renew the sense ofprofessional purpose in American pharmacy practice.

Pharmaceutical care involves professional care decisions beyond enhanced therapeu-tic outcomes. Practitioners who embrace the concept of pharmaceutical care will encoun-

ter increasingly complex moral and ethical situations which will require not only a deeperprofessional and personal commitment to patients as individuals but also a higher level ofclinical knowledge as they deal with more complex patient care decisions. As a result, thestatus of the practice of pharmacy will be further enhanced as a socially necessary healthcare profession.


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4 CH A P T E R 1

Professions are found wherever humans live together in socialized groups. Professionsemerged in the Middle Ages when specialized practitioners began to develop and providean array of significant, unstandardized personal services that were central to human val-ues. These servicessuch as health, education, religion, and welfarewere adapted tomeet the needs of individuals and required knowledge and skills that the typical persondid not possess. Pharmacy is among the oldest of the healing professions and its practitionersprovide unique, personalized services that meet the fundamental needs of individuals,communities, and society.

One approach to understanding the purpose of professions in our society is to exam-ine these unique, individual service needs and how an organized body of professionalsmeets those needs. We will begin by examining the nature of professions in general. We

will then explain how professions differ from other service occupations and from strictlycommercial enterprises. Finally, we will examine the unique power professionals possess,as well as their special prerogatives, duties, and obligations, and explain why pharmacy isproperly considered to be a profession.

The word profession means to testify on behalf of or to stand for something.Members of a profession pledge or profess their fundamental commitment to servingsociety. People who are professionals stand for something and vow not only to providetheir clients with knowledge but also to use a particular body of learning to solve a specificrange of human problems.2In this context, pharmacists not only profess to be experts ondrug therapy but also vow to help people make the best possible use of drugs.

In the medieval world, the term professional was not applied to lawyers, physicians,priests, or academics, who professed their commitment to apply their respective bodies of

knowledge to the service of human need, but to monks, who professed their faith in Godwhen they took up the contemplative life.2In the West, we trace our professional lineagemore directly to late medieval cities in Europe, especially Italy. As Europe became moreurbanized, artisans broke away from the manor estates and took up middle-class occupa-tions. Pharmacy was one of a number of occupations that developed guild-like associa-tions during this period.3At about the same time, occupations that had been confined tothe learned world of the medieval clergy became secularized.

Toward the close of the twelfth century, the physicians and pharmacists of Florence,together with some others, formed a single guild. Supervision was rigid. During annualinspections of pharmacies, guild commissions confiscated drugs not meeting the guildrequirements and excluded the culprits from professional practice for varying periods. 4

The separation of pharmacy/medicine practitioners and organization into different guildswas a prerequisite to professionalization; actual professionalization came more slowly.Historians date the legal recognition and regulation of pharmacy in the West, as an occu-pation separate from medicine, to the thirteenth century.3

In their practice, professionals use a variety of observable techniques and tangible goods.They also use intangibles, such as skill, knowledge, and previous experience, that often go


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T H E PR O F E S S I O NO F PH A R M A C Y A N D PH A R M A C E U T I C A L CA R E 5

unrecognized by members of the public. The results of professional functions take theform of products, services, advice, opinion, and even a physical presence on behalf of

another person or group.5

There is a uniquely public nature to the work of professionals. Professionals must usetheir knowledge not simply to display their virtuosity but also to serve human needs.Professionals serve not only the needs of friends but also those of strangers. Professionalsmust act altruistically. The seventeenth-century idea of hanging out ones shingle sym-bolized this readiness to go public and to serve the needs of strangers.2

Secondly, there is a special nature to the functions professionals perform. These func-tions are always more complex than the mechanical activities a client may observe. Theseemingly simple chest tapping involved in auscultative percussion, for example, beliesyears of clinical experience. Furthermore, it is not unusual for professionals to practice inrelative isolation from the routines of daily life and provide their services to society inabstract ways.5

Finally, there is an exclusive nature to the functions professionals perform. Profession-als, through a representative body of peers sanctioned by the state, are given the unusualauthority to determine who may be permitted to practice and under what conditions. Forexample, state boards of pharmacy define the kinds of activities pharmacists are allowed toperform, outline the social privileges and professional prerogatives they may claim, andestablish controls to guarantee that these privileges and prerogatives are not abused.5

Although many professions trace their origins to European medieval guilds, health pro-fessions in the United States emerged from other occupational groups. This emergencetook place toward the end of the nineteenth century as a result of the expansion of urbansociety. These professions have since become integral parts of society. They have flour-

ished because most people find modern life too complex to live without the benefit ofexpert consultation and specialized services.5

The services provided by professionals depend upon the application of formal knowl-edge, sometimes in highly modified form, to complex problems of immediate impor-tance to clients. However, expertise in a profession extends beyond mere knowledge toinclude the skills, judgments, and experiences necessary to practice at a level of compe-tency determined by academics, regulators, and the public.5

The complex, ever-changing needs of American society in the twenty-first centuryprovide a special challenge to health professionals. In the murky world of managed com-petition, does a health professional still declare, promise, or vow anything that wouldmake a requirement of integrity clear and compelling? Should a profession be understoodas a value-free collection of knowledge and skills learned by training and accessible toconsumers or as a value-driven form of human activity constituted as much by the ends itseeks as by the skills it requires?6

Professionals exercise power over their clients and over other professionals through theservices they provide and the environment in which they practice. Expertise is sometimesequated with the power to control and master the formal knowledge of the profession.5


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6 CH A P T E R 1

Moreover, professionals often attempt to enhance their power of knowledge by trans-forming the formal knowledge base that is at the heart of their profession into a complex

vocabulary of technical terms.7

Society grants varying amounts of discretionary power to each profession based onthe value of the goods and services provided by the profession. These powers of position,once given, are very difficult to revoke. For example, pharmacists wield a certain power bycontrolling access to potent, often dangerous drugs. Physicians wield power by deciding

which types of patients they will treat. Society often has difficulty controlling or limitingsuch discretionary power even when this power exceeds the best interests of society. 5

Society also grants each profession certain functional powers that can have a pro-found impact on the professionalclient relationship. In pharmacy, these powers go farbeyond the traditional power to dispense to include developing and managing systems ofdrug distribution that provide access points to patients and ensure drug safety and com-pliance with legal and professional standards. These powers also extend to providing other

cognitive services solidly based on professional knowledge and skills. Health professionalsshould employ these powers to effect a good outcome for their patients as determinedby patients individual life-plans, their understanding of their illness, and their concept of

what constitutes appropriate treatment.8With this in mind, pharmaceutical care encour-ages pharmacists and physicians not only to agree upon a therapeutic plan but also toshare their functional power with their patients by including the patients in both theformulation and the implementation of the plan.

Dictionary definitions for the term profession more or less agree that a profession in-volves specialized, intellectual learning that is used to render a particular service either byguiding or advising others or by practicing an art. 3A. M. Carr-Saunders and P. A.

Wilson9point out that there is no single test or touchstone for professionalism, character-izing it as a complex of characteristics. Roy Lewis and Angus Maude10have written thata moral code is the basis of professionalism. Beyond this common thread of morality,however, the promulgation of a satisfactory definition of the term has progressed littlebeyond the five criteria proposed by Abraham Flexner11in 1915 and elaborated upon byIsador Thorner12 in 1942: 1) a relatively specific, socially necessary function upon theregular performance of which the practitioners depend for their livelihood and socialstatus; 2) a special technique, competence in which is demanded, resting upon; 3) a bodyof knowledge embracing generalized principles the mastery of which requires theoreticalstudy; 4) a traditional and generally accepted ethic subordinating its adherents immedi-ate private interest to the most effective performance of the function; and 5) a formalassociation fostering the ethic and improvement of performance.

A profession relies upon a body of knowledge organized into an internally consistentsystem of abstract propositions that describe its focus of interest. Theoretical knowledgeand understanding underpin the technique of every profession.3Moreover, as has beensuggested above, patients use and benefit from this body of knowledge, even though theydo not understand or use it directly.5


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A profession serves society by doing for society what society cannot do for itself. In turn,society grants professionals special privileges when they demonstrate skill and knowledge.Professional discretion represents evidence of a social contract wherein society receivesadequate professional services in return for granting professionals the privilege of internalcontrol. Some authors claim that professionals have abused and distorted the social privi-leges granted them through internal control and discipline.5

A profession serves a socially necessary function. It provides a service that has a high socialutility. This function is typically sanctioned through a system of professional licensure.This system of licensure is viewed by some social critics as a monopoly that screens andprotects the profession from censure rather than protecting society. Others argue thatlicensure serves as a positive influence for preserving professional commitment.5

A profession relies on formal and informal means of internal control and sanctions, tradi-tionally codes of ethics and peer review mechanisms. A profession accepts responsibilityto maintain a standard of conduct beyond compliance to law or demonstration of techni-cal skill. Society expects a profession to generate its own statement of acceptable andunacceptable behavior, usually in the form of a formal code of ethics.13

Professions employ a wide array of values, attributes, norms, symbols, and specializedvocabulary that make up their culture. Professions also rely upon a network of organiza-tions that foster the professional ethic and promote the improvement of performance. Inaddition to licensure, professional organizations often validate professional knowledge

and competence through a collegially organized community of peers.14Starr15 suggeststhat a professionals authority may be increased by membership in an organization that isgenerally recognized as being selective on the basis of consensually valid and profession-ally relevant competence criteria. For example, some professional associations have devel-oped their own specialty certification programs.

Professionalism is a concept that develops around a given profession. Its basic characteris-tics include four aspects. The psychological aspect comprises an individuals personal senseof worth, ambition, self-esteem, and self-concept. The social aspect is how professionalsevolve socially for a specific purpose. The sociological aspect centers on the professionsmodel, code of ethics, and theoretical knowledge base drawn from educational require-ments. The legalethical aspect includes laws and moral issues related to the public good.16

In contrast, professionalization is the dynamic process of becoming a professional.

The process of becoming a professional begins with admission to a professional schoolwhere students are exposed to a variety of educational materials and problem-solving


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8 CH A P T E R 1

skills that will enable them to function within the current standards of the profession. 16

Students gradually develop a professional self-image in the course of their training. This

professional development consists of learning and assimilating the traits they will need inorder to play the role of the professional after graduation. 17Rene C. Fox18has analyzedthe professional development of medical students and Mary Jean Huntington has shownthat with each succeeding year in school medical students were more likely to say that, onthe occasion of their last contact with a patient, they thought of themselves more as adoctor than a student.19

Professionals behave in a manner that embodies both their technique and their commit-ment to provide individualized service. Professionals also subscribe to a traditional andgenerally accepted ethic which subordinates their immediate private interests to the mosteffective performance of their professional function.12It is not unusual, for example, for a

pharmacist to be called in the middle of the night to fill an emergency prescription. In abroader sense, professionals also use their knowledge and skill to benefit mankind. Manyhealth professionals volunteer to serve on lay health advisory boards or participate incommunity health screening programs.

Professionals develop a public and moral sense of responsibility to others by internalizinga clear sense of purpose, a strong commitment to serve the public, and a deep understand-ing of the ethic of the profession. This responsibility is reflected in the way professionalsbehave toward their clients and toward each other. The true professional will understandand practice the virtues of his or her profession. Society expects its physicians to be com-petent, its lawyers to hold confidences, and its pharmacists to be trustworthyvirtues allthese professions share, to be sure. Professionals also strive to maintain their professional

competencegenerally through self-study or organized continuing professional educa-tion activitiesto improve their service to the public.

As we have indicated, professions have developed around the provision of services thathave three general characteristics: requirement of knowledge and skills that the typicalclient does not have, provision of personal services that are central to human values, andadaptation of these services to the needs of individuals.20Professionals must balance theprovision of these services with the countervailing forces of professional prerogatives,authority, and autonomy.

Professional prerogatives may be defined as those rights that belong to specific groups orclasses of individuals, as sanctioned by society. Professional prerogatives address issues

within the professionals discretion that are not specifically addressed by law. Within phar-macy, for example, many pharmacists draw attention to their right to decide whether ornot to fill a prescription order and often speak of exercising or not exercising their


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professional prerogatives, demonstrating the voluntary nature of this activity.21The con-cept of professional autonomy is a basis for exercising professional prerogatives. That is,

professionals practice in a manner that cannot accommodate external interference. Indaily practice, the knowledge and skills needed are esoteric, the tasks performed are com-plex, and the professional judgments made are sophisticated; thus professionals could notpractice effectively if they had to contend with such interference.5

Professionals not only exercise discretionary powers over their individual actions but alsosupervise the actions of their peers. For example, physicians professional practices areregularly reviewed by peer-review committees composed of other physicians. Profession-als also accept a social contract underlying their discretionary powers, balancing discre-tion and societal interest. Thus, pharmacists have the discretionary power to distributecertain dangerous or potentially habit-forming drugs within the community but typically

exercise this power in a manner that is in the best interest of society.

Society is reluctant to permit any profession to be completely autonomous. Full autonomywould provide professionals with a mechanism to define, control, and eventually mo-nopolize the services of other interdependent professions to such an intolerable level thatsocietal intervention would become inevitable. Thus, the virtual monopoly on prescrib-ing medications enjoyed by generations of physicians is now shared by osteopaths, den-tists, optometrists, nurse practitioners, andin some statesby pharmacists. To avoidsocietal intervention, professionals typically seek to balance the relationship between theirdiscretionary powers and the exercise of their professional autonomy. 5

Health professions exist because there is illness. When they are ill, people are suffering anattack on their wholeness, their humanity, and often their very identity. This vulner-ability is unique in that a lack of health robs people of the ability to deal with their othervulnerabilities, such as the loss of personal freedom or privacy in a hospital setting. More-over, because they do not have the knowledge or skills necessary to effect their own cure,ill people are forced to place themselves under the care of the health professionals whohave these skills. Unfortunately, these health professionals may also inadvertently bringharm to their patients.22Health professionals should be alert to the sense of powerlessnessthat often accompanies illness and be prepared to respond to it.8

As health professionals, pharmacists make moral decisions that affect human purposes.Edward C. Elliott,23director of the deeply probing Pharmaceutical Survey (194649),made this point clear when he concluded that the profession of pharmacy is fundamen-tally moral in nature. In his 1981 analysis of pharmacys societal purpose, pharmacyeducator Donald C. Brodie24stressed a pattern of professional behavior that demonstratesa commitment to the common good. That same year, Pellegrino and Thomasma25el-


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egantly encapsulated the moral dimension of the pharmacistpatient relationship whenthey declared that any act which applies knowledge to persons involves values and conse-

quently falls into the moral realm.

For centuries, the profession of pharmacy has provided service of fundamental value tosociety. During the first half of the twentieth century, American pharmacy gradually lostthree of the four professional functions that had characterized the work of pharmacists fornearly one thousand yearsthe procurement, storage, and compounding of drug prod-ucts. At midcentury, pharmacists concentrated on the remaining professional functiondispensing drug products and managing the supply of medicines.5As drugs became morepotent and federal and state legislation became more stringent, pharmacists took justifi-able pride in being responsible and accountable for controlling drug distribution.

In the mid 1960s, pharmacists began to focus their professional attention upon as-

suring safe, effective, and cost-efficient therapeutic outcomes for their patients. By thelate 1960s, the profession began to draw sharp criticism that it had become too commer-cialized.26By the mid 1970s, however, bolstered by challenging interprofessional practicesettings and freer access to clinical data and other patient information, the professionopened a new clinical role for itself in the area of consultation. In recent decades, thesocietal need for both the distributive and the more highly specialized professional ser-vices provided by pharmacists has been well documented.27Today, American pharmacistsface the challenge of providing pharmaceutical care, which requires accepting responsibil-ity for providing drug therapy for the purpose of achieving definite outcomes that im-prove a patients quality of life.28

As we have suggested, at the turn of the century, American pharmacy began to move awayfrom the path that had characterized its professional function since the earliest times, afunction centered upon the knowledge and skills needed to compound drug products.The mechanized processes of industry and the emergence of new drugs placed the com-plexity of drug preparation far beyond the reach of the average pharmacist. Because drugsare inherently dangerous substances and the pharmacists knowledge about their properpreparation, storage, and handling is greater than that of any other professional group,pharmacists began to develop a more technologically advanced role in quality assurance asit applied to drug distribution. This evolving professional function, as defined by societyand the profession, ensured that the drugs provided to patients were safely and accuratelydispensed.5

In recent years, pharmacy practice has experienced a gradual shift away from thetechnical paradigm, which emphasized drug products and their preparation, toward a

more disease- and patient-oriented approach to pharmaceutical decision-making. Thisshift in favor of more active, direct involvement with patient care came about more natu-rally in institutional settings than it did in community practice settings. Pharmaceuticaldecision-making has been strengthened by the institutional pharmacists access to clinicaldata and the underlying interprofessional support of changing practice patterns and func-tions of pharmacists.5


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T H E PR O F E S S I O N O F PH A R M A C Y A N D PH A R M A C E U T I C A L CA R E 11

In his analysis of the shift of moral values over time, Daniel Callihan29

envisioned aresurgence in social ethics of an emphasis on community, on the common good, on thehazards of an excessive dependence on the language of rights, and on an exultation ofindividual over community. Although human values are more commonly associated withsuch humanistic disciplines as philosophy and religion, health professionals are beginningto realize that the success of their medical interventions with their patients depends asmuch upon interpersonal, value-based relationships as it does upon technical compe-tence. When the full range of personal and societal values associated with pharmacy prac-tice is taken into consideration, even the seemingly benign activity of recommending anonprescription medication takes on an added meaning. Rather than making a quickclinical judgment and recommending a product, pharmacists sensitive to their patientsindividual needs may defer a sale, recommend medical intervention, suggest a changein lifestyle, or just offer comfort and reassurance.

To what extent, for example, does the perceived socioeconomic status of the patientdetermine the extent and nature of the professional services pharmacists provide? To whatextent does the pressure for cost-containment influence pharmacists drug-product selec-tion process? How does the acceptance of the concept of pharmaceutical care affect thevalue system of American pharmacists? Indeed, human values seem to be so completelyintegrated with modern health care practices that one might argue that the so-called idealof a highly technical, purely clinical, and value-free practice of pharmacy is neitherpossible nor even desirable.

Values may be defined as beliefs or ideals to which an individual is devoted andwhich ultimately guide that individuals behavior. A closely held value system will becontinually reflected through an individuals attitudes, personal qualities, and a consistentpattern of behavior. Unfortunately, value identification and acceptance are not included

to any great extent in the curricula of our schools and colleges of pharmacy or in theprograms of its professional pharmaceutical associations.30Indeed, becoming a profes-sional is a socialization process, although often there is no formal process in place to makesure that professionalization actually occurs. Schools and colleges of pharmacy need toidentify the attitudes and behaviors they expect, why they are necessary and important,and ensure that they are being taught.31

Table 1.1depicts a set of essential values that might be acceptable to professionalpharmacists. The table was adapted from a set of values and behaviors that were intendedto guide educational programs for professional nursing. It is clear that the same set ofvalues prevails for all of the health professions, although some professions may need tostress some areas in different ways.

In practice, professional pharmacists assign priorities to these values as they encoun-ter their patients or when they engage in specific decision-making situations. Individualpharmacists, relying on and guided by these values, will demonstrate a behavior that isconsistent with the strength of conviction that they hold for these values. It is often dur-ing these testing periods that individual novice pharmacists will grope for a suitable,satisfying response. Experience may provide some guidance, yet many pharmacists whoare unable to act based upon a consistent, internalized value system, will attempt to deal

with each new problem as it arises and may not approach similar problems in a consistent


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Altruism Commitment Gives full attention to patients

(concern for the Compassion Assists other health care personnel

welfare of others) Generosity Sensitive to social issues

Perseverance

Equality Fairness Provides services based on needs

(having the same Self-esteem Relates to others without discriminating

rights, privileges, Tolerance Provides leadership in improving access to

or status) health care

Esthetics Appreciation Creates supportive patient care environments

(qualities of objects, Creativity

events, and persons Sensitivity

that provide satisfaction)

Freedom Openness Respects each individuals autonomy

(capacity to exercise Self-direction

choice) Self-discipline

Human Dignity Empathy Respects the right of privacy (inherent worth and Kindness Maintains confidentiality

uniqueness of an Trust

individual)

Justice Integrity Acts as a health care advocate

(upholding moral Morality Allocates resources fairly

and legal principles) Reports incompetent, unethical, and

illegal practices

Truth Accountability Documents actions accurately

(faithfulness to Honesty Protects the public from misinformationfact or reality) about pharmacy

Rationality

aAdapted from American Association of Colleges of Nursing. The Essentials of Baccalaureate Edu-cation for Professional Nursing Practice. Washington, DC: American Association of Colleges ofNursing; 1998.


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manner. For this reason, professional pharmacists need to both identify the basic valuesthat impinge upon their professional practice and use these values in a consistent, rational

manner when they make professional judgments.

The practice of pharmacy in the United States has always been associated with the mer-chandising of unrelated goods. The sale of general merchandise in drugstores was neces-sary to build an adequate cash volume to subsidize the pharmacists professional func-tions. Moreover, having items besides drugs available in the pharmacy helped to establishthe corner drugstore in the community. People could obtain in one place not only theprescriptions and other health goods needed in times of illness but also sundries andconvenience items needed in times of health. The presence of departments beyond theprescription counter was not seen by pharmacists as deprofessionalizing when compounding

was still an important part of their daily activities. Indeed, many pharmacists saw these

departments as a natural extension of the prescription department.In 1899, pharmacist George J. Seabury32noted, Unlike the grocer, who is a . . . mereexchanger of articles that are daily requested of him, the pharmacist is expected, by hiseducation and profession, to examine every article sold in his establishment and to be ac-countable for its quality. Over four decades later, sociologist Isador Thorner33agreed: Dis-tribution may be in the process of becoming scientific and is being taught in schools ofbusiness administration but it cannot become a profession until the sellers interest is insti-tutionally subordinated to that of the user of drugs. The grocer has no moral obligation tohis customers parallel to that of the physician, lawyer or pharmacist toward his client.

As the dispensing of prescriptions became a more centralized professional functionof American pharmacists, however, many practitioners became torn over which of theirfunctionsprofessional or mercantileshould assume primacy. Many sought to achievean uneasy balance, a dilemma compounded by the commercial setting in which much of

pharmacy is still practiced. The business and professional concerns of the pharmacistoften conflict, and these conflicts can cause ambiguity in the way patients view pharma-cists and their functions.

Pharmacists have also had to contend with the pressures of competing public and profes-sional expectations. Some indication of how the public views pharmacy is given by publicopinion polls conducted during the last two decades. These polls show that the publicaccords pharmacists a high professional standing in terms of honesty and ethical stan-dards. It is significant that the prime source of influence on the views of individuals wastheir personal experience with pharmacists and the quality of each individual patientpractitioner interaction. Pharmacists who demonstrate technical expertise and provideservices consistent with their patients views of professional services will be deemed pro-fessional. It is the collective judgment of the public that determines whether pharmacy isan occupation or a profession.34,35

Within the past 50 years, health care delivery in the United States has evolved from acottage industry to one dominated by large corporations, managed care processes, and


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14 CH A P T E R 1

government regulation.36During this time, the practice of pharmacy has undergone dra-matic changes as well: in the 1950s, most pharmacists either enjoyed the freedom of

owning their own pharmacy or worked in small groups in the burgeoning institutionaland drug chain settings, reporting directly to another pharmacist; professional decisionsrelated to patient care reflected the personal values and ethics of one or, at most, a handfulof pharmacists. In todays practice environment, whether they practice in community,institutional, mail-order, or Internet settings, a majority of American pharmacists areemployed by corporations that are controlled by executives and administrators who makebusiness decisions calculated to satisfy their stockholders. Many of these executives donot have a professional background in pharmacy, and their corporate policies tend toreflect a bottom-line mentality. Corporate employee pharmacists are often torn betweenexercising their personal value system and complying with a corporate ethic that may befar removed from the individual pharmacistpatient encounter.

For example, corporate pharmacists may be asked to dispense generic equivalent

products routinely without regard for the wishes of their patients or downplay the offer tocounsel patients guaranteed by federal law. This is not to say that corporate practice isethically challenged by definition. Many corporations have pioneered systems which im-prove both the efficiency of drug distribution and the scope of patient-oriented healthcare services while respecting and supporting their employee pharmacists personal valuesystems; still, many pharmacists are asked to carry out corporate policies that are in directconflict with their own deeply held personal valuessuch as dispensing a morning aftercontraceptive medicationat the risk of being dismissed for not complying with a corpo-rate policy. In all cases, pharmacists must decide whether they are advocates for theirpatients or merely agents of their employer.

The key ingredients of the notion of covenant are promise and fidelity to promise. A

covenantal relationship is based upon the concepts of indebtedness and responsiveness.37

The work of a health professional begins with a response to a patients request for assis-tance or care. The patient thus provides the gift of a personal sanction to the healthpractitioner to initiate professional service. This gift creates a sense of indebtedness onthe part of practitioners, providing them with an opportunity to perform their profes-sional functions. Implicit in this covenant is the commitment not only to maintain a highquality of technical skill but also to safeguard patients from possible untoward effectsrelated to drug therapy.

Trust is also inherent in the relationship between health care professionals and theirpatients. This condition is a reflection of the system of licensure that is imposed by soci-etya system that permits patients to place their most intimate thoughts, as well as theirbodies, in the hands of professionals whose competency they cannot easily judge. In con-

trast to the practices of medicine and nursing, which are characterized by direct patientcontact, the pharmacist often fills prescription orders in seclusion or partially shieldedfrom the patient. Therefore, the patient must have even greater faith in the pharmacistscompetence than he does in the physicians. As the practice of pharmacy expands to in-clude more intense patientpharmacist encounters, this trust will be increasingly chal-lenged as patients have expanded opportunities to scrutinize and evaluate the professionalservices they receive.


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In a contractual relationship, two parties agree upon some joint project in which bothderive some benefit for the goods or services contributed by each party. Are the goods andservices offered by pharmacists to their patients defined by such a relationship and re-duced to simple transactional events? Doesnt the practice philosophy of pharmaceuticalcare imply a pharmacistpatient relationship that extends beyond a mere contractual ar-rangement?

Some of the aims of a contractual relationship might be desirable in the context ofpharmacy practice: a clear expression of rights, clearly defined self-interests, the possibil-ity of legal enforcement. Unfortunately, a contractual relationship suppresses the gift oftrust that is essential in professional relationships. Furthermore, a contractual relation-ship may undermine pharmacists attitudes toward professional behavior by encouraginga restrained response to patient care. Pharmacists could construe such a relationship tomean that they should do no more for their patients than what their contract calls for or

to perform only specified services for certain fees, no more, no less.

Professional services in the health professions are directed to subjects who are by naturerather unpredictable as they deal with their own sickness or the ills of their loved ones. Theseservices cannot be exhaustively specified in advance for each patient; pharmacists must beready to deal with the contingent, the unexpected. Patients may require services that exceedthose anticipated in the contract or incur additional costs beyond those originally agreedupon. Moreover, the services associated with pharmaceutical care are more likely to achievethe desired therapeutic results if they are delivered in the context of a fiduciary relationshipin which patients have full trust in the pharmacists serving them.38

Care and medicine have become closely identified, if not synonymous, in the minds of

many. For example, medicine, nursing, and other health-related activities are often re-ferred to as caring professions. Care often appears to be a more important regulativenotion for determining the basis and direction of health-related activities than might bemorally justified. Care, however, is a significant notion that reminds us that medicineserves as one of the ways we can help others maintain basic physical and psychologicalintegrity. Moreover, care directs our attention to the concrete patient in need withoutsubjecting him or her to manipulation for the good of others. However, it is importantthat the care given the patient be based on the respect due each of us, well or ill, forotherwise our attempts to care can lead to sentimental or paternalistic perversions.39

Accepting the mandate of pharmaceutical care will greatly increase the pharmacists re-sponsibility to patients; discharging that responsibility will require philosophical, organi-zational, and functional change in the practice of pharmacy.1Today, the profession ofpharmacy faces daunting challenges to its traditional functional autonomy. The profes-sion has responded to these pressures by increasingly relying upon paraprofessional help,robotics, and computer-assisted patient information systems to manage its interpersonalpatient care functions. Just as pharmacy has learned it can no longer focus exclusively


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16 CH A P T E R 1

upon the safe distribution of drugs or even upon expanded clinical functions to justify itssocietal function, it may also learn it cannot solely rely upon the enhanced service man-

date suggested by the concept of pharmaceutical care for its raison dtre.

1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care.Am J Pharm Educ. 1990; 53:7S15S.

2. May WF. The beleaguered rulers: the public obligation of the professional. KennedyInst Ethics J. 1992; 2:2541.

3. Sonnedecker G. To be or not to beprofessional.Am J Pharm. 1961; 133:24354.4. Sonnedecker G. Kremers and Urdangs history of pharmacy. 4th ed. Philadelphia:

J. B. Lippincott Company; 1976.

5. Mrtek RG, Catizone C. Pharmacy and the professions. In: Wertheimer AI, Smith

MC, eds. Pharmacy practice: social and behavioral aspects. 3rd ed. Baltimore: Will-iams & Wilkins; 1989:2357.

6. Lammers SE, Verhey A, eds. On moral medicine: theological perspectives in medicalethics. Grand Rapids: William B. Eerdmans; 1987.

7. Freidson E. Professional powers: a study of the institutionalization of formal knowl-edge. Chicago: Univ. of Chicago Press; 1986.

8. Brody H. The healers power. New Haven: Yale Univ. Press; 1992.

9. Carr-Saunders AM, Wilson PA. The professions. Oxford: Clarendon Press; 1933.

10. Lewis R, Maude A. Professional people. London: Phoenix House; 1952.

11. Flexner A. Is social work a profession? Sch & Soc. 1915; 1:90111.12. Thorner I. Pharmacy: the functional significance of an institutional pattern.Am J

Pharm Educ. 1942; 6:30519.

13. Buerki RA, Vottero LD. Ethics. In: Wertheimer AI, Smith MC, eds. Pharmacy prac-tice: social and behavioral aspects. 3rd ed. Baltimore: Williams & Wilkins; 1989:32949.

14. Starr P. The social transformation of American medicine. New York: Basic Books;1982.

15. Hepler CD. Pharmacy as a clinical profession.Am J Hosp Pharm. 1985; 42:12981306.

16. Sogol EM, Manasse HR Jr. The pharmacist. In: Wertheimer AI, Smith MC, eds.Pharmacy practice: social and behavioral aspects. 3rd ed. Baltimore: Williams &

Wilkins; 1989:5988.

17. Buerki RA. Pharmacist Smyth and druggist Smitha study in professional aspira-tions.Am J Pharm Educ. 1977; 41:2833.

18. Fox RC. Training for uncertainty. In: Merton RK, Reader GG, Kendall PL, eds. Thestudent physician: introductory studies in the sociology of medical education. Cam-bridge: Harvard Univ. Press; 1957:20741.

19. Huntington MJ. The development of a professional self-image. In: Merton RK, ReaderGG, Kendall PL, eds. The student physician: introductory studies in the sociology ofmedical education. Cambridge: Harvard Univ. Press; 1957:17987.


15/15


20. Larson MS. The rise of professionalism: a sociological analysis. Berkeley and LosAngeles: Univ. of California Press; 1977.

21. Buerki RA, Vottero LD. The changing face of pharmaceutical education: ethics andprofessional prerogatives.Am J Pharm Educ. 1991; 55:714.

22. Pellegrino ED. Toward a reconstruction of medical morality: the primacy of the actof profession and the fact of illness. J Med Philos. 1979; 4:3256.

23. Elliott EC. The general report of the pharmaceutical survey, 194649. Washington,DC: American Council on Education; 1950.

24. Brodie DC. Pharmacys societal purpose.Am J Hosp Pharm. 1981; 38:18936.

25. Pellegrino ED, Thomasma DC. A philosophical basis of medical practice: toward aphilosophy and ethic of the healing professions. New York and Oxford: Oxford Univ.Press; 1981.

26. Francke DE. Lets separate pharmacies and drugstores.Am J Pharm. 1969; 141:1619.

27. Trinca CE. Does pharmaceutical care respond to societys mandate for professionalpharmacy services? Proc NABP/AACP Dist IV. 1991:[3137].

28. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care.Am J Hosp Pharm. 1990; 47:53343.

29. Callihan D. Ethics and health care: the next twenty years. In: Bezold C, Halperin JA,Binkley HL, Ashbaugh RA, eds. Pharmacy in the 21st century: planning for an un-certain future. Bethesda, MD: Institute for Alternative Futures and Project HOPE;1985:7986.

30. Smith MC, Smith MD. Instruction in ethics in schools of pharmacy.Am J PharmEduc. 1981; 45:147.

31. Berger B. Pharmacistphysicianpatient relationships: caring, covenants, codes andcommitment: Part 4a profession changes. US Pharm. 2001; 26:80,82,85.

32. Seabury GJ. Shall pharmacists become tradesmen? 3rd ed. New York: George J.Seabury; 1899.

33. Thorner I. Comments on Pharmacy, the functional significance of an institutionalpattern.Am J Pharm Educ. 1942; 6:6179.

34. Smith MC, Knapp DA. Pharmacy, drugs and medical care. 4th ed. Baltimore: Wil-liams & Wilkins; 1987.

35. Hughes EC. The study of occupations. In: Merton RK, Broom L, Cottrell LS Jr, eds.Sociology today: problems and prospects. New York: Basic Books; 1959:44258.

36. Schommer JC. Pharmacist workload and time management. Drug Topics. 2001;145:4554.

37. May WF. The physicians covenant. Philadelphia: Westminster Press; 1983.

38. May WF. Code, covenant, contract, or philanthropy. In: Haddad AM, Buerki RA,eds. Ethical dimensions of pharmaceutical care. New York and London: Pharmaceu-tical Products Press; 1996:4972.

39. Hauerwas S. Care. In: Lammers SE, Verhey A, eds. On moral medicine: theologicalperspectives in medical ethics. Grand Rapids: William B. Eerdmans; 1987:2626.