Martine Kruijtbosch

108 Chap t e r 3. 2 considerations O5 (‘Whether not using alendronic acid for a few weeks is a problem’), which was ranked by 192 pharmacists, and P1 (‘That every patient has equal access to the medicine’), which was ranked by 174 pharmacists. When dealing with the Parkinson’s scenario, pharmacists ranked PE-considerations more frequently than in the other drug shortage scenarios. This difference is not surprising as we purposely selected three drug shortages with potentially different impacts (i.e. perceived relevance) on patients’ health outcomes (Table 2). We envisaged that pharmacists’ intended actions and moral reasoning may be dependent on the scenario. A patient with Parkinson’s disease is more likely to experience serious health complications from switching drugs, which may explain why professional ethics considerations were most prominent and why more pharmacists intended to import a drug that was not originally authorized for the Dutch market in this scenario than in the other two scenarios. Further, when the pharmacists reason from a BO-MRP in these drug shortage scenarios, it was mainly because they perceived the following considerations to be of importance in the handling of these shortages: (1) a patient’s willingness to pay the extra cost for the imported medicine (BO-consideration C5: ‘Whether the patient is willing to pay the extra costs of an imported oral contraceptive,’ which was ranked by 101 pharmacists) or (2) whether the health insurer would reimburse an alternative (BO-consideration O13: ‘Whether the health insurer will reimburse the/an alternative,’ which was ranked by 119 pharmacists). The former consideration was ranked in the Contraceptive scenario, the latter, in the Osteoporosis scenario. In the Netherlands, contraceptives are not reimbursed for women who are above 20 years. Although more pharmacists were inclined to import the contraceptive (Table 3, intended action option 5), pharmacists may have reasoned that this would only make sense when women are willing to pay the extra costs. At the time of the contraceptive shortage, the relative price of the imported contraceptive was higher than the listed price in the Netherlands. Pharmacies would incur an economic burden as the higher price of the imported medicine would not be reimbursed. 20 The large number of contraceptive users may also have influenced the reasoning of some pharmacists. The frequently ranked BO-consideration C5 can be better understood in this context. For the osteoporosis medicine (Table 3, intended action option 5), alternatives were available in the Netherlands, so importing was not necessary for most of the patients. However, these alternatives were either less practical (e.g. daily doses of 10 mg alendronic acid instead of 70 mg once a week) or more expensive (e.g. combining alendronic acid with vitamin D). Besides, from a pharmacotherapeutic perspective, a patient may experience no negative health effects from temporary ceasing to take a bisphosphonate such as alendronic acid. Nevertheless, the pharmacist would have to explain these options to the patient. If the pharmacist and the patient decide together that importing the 70 mg alendronic acid is the most appropriate decision, the pharmacist or the