Martine Kruijtbosch

107 Mo ra l r eason i ng pe r spec t i ves i n s i t ua t i on s o f d rug s ho r t ages DISCUSSION This study indicates that professional ethics (PE-MRP) is the dominant moral reasoning perspective for Dutch community pharmacists in the three presented drug shortages. The business orientation perspective is the least important perspective but was more important in pharmacists’ reasoning in the Contraceptive and Osteoporosis scenarios than in the Parkinson’s scenario. This result is also reflected in how pharmacists handle the three drug shortages. Pharmacists prefer to take responsibility for solving a drug shortage problem (by, for example, proposing alternatives to prescribers and patients or by importing drugs) instead of leaving the patient or physician to solve the drug shortage problem. That pharmacists in this study reasoned mostly through PE-MRP considerations is in line with a recent study in which pharmacists received an educational intervention aimed at improving moral reasoning competence 41 but contrasts with earlier studies in which community pharmacists predominantly had very low post-conventional MRP scores 23,38,52 and studies that suggested that pharmacists were more influenced by a rules and regulation or legal perspective. 35,36,53 This difference in moral reasoning perspective may be rooted in (national) pharmacists’ professional guidance (e.g. education, policy) and in the professional culture in each country (e.g. the role of community pharmacists). 49,54-58 In the Netherlands professional ethics entails that pharmacists are professionally autonomous in providing the best pharmaceutical care for the patient. They are responsible for dispensing medicines and have a role which is comparable with clinical pharmacists in many other countries. 59,60 Also, their professional relationship with primary care physicians is often stronger than in other countries. 61,62 In Australia pharmacists seem to be influenced in their PE-MRP reasoning by the principle of patient rights, as a study regarding the validation of the Professional Ethics in Pharmacy (PEP) test among Australian pharmacists showed. 46 In the Netherlands, where the applicability of the PEP test was studied among Dutch pharmacists, pharmacists’ PE-MRP was not influenced by these patient rights considerations. 49 The PE considerations that were ranked by a large number of pharmacists as being the most influential in handling the shortages suggest that during drug shortages, pharmacists base their moral reflections especially on their professional values. For example, the professional value ‘commitment to the patient’s well-being’ is reflected in the frequently ranked PE- consideration P5 (‘That Parkinson’s can get worse when the patient receives alternative treatment’), which was ranked by 235 out of 267 pharmacists (Appendix, Table 9). Similarly, pharmacists base their moral reasoning on the professional values ‘pharmaceutical expertise’ and ‘responsibility to society’. These values are respectively reflected by the often-ranked PE