Martine Kruijtbosch

109 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 patient may be impacted economically. In the Netherlands, every patient is compulsorily insured for their (pharmaceutical) healthcare. The insurer would either have to pay for the imported drugs, which would generally be more expensive, or patients would have to pay for the imported drug themselves. Of course a BO-MRP does not imply that the pharmacist who reasons from that perspective lacks patient-centredness completely. When pharmacists rank considerations about ‘patients’ ability or willingness to pay for the alternative medicine’ as very influential in handling a drug shortage, they might reason from the perspective that the patient cannot afford a drug, but might also reason from the perspective of their own business interests because this can imply that they won’t get paid. Lastly, pharmacists’ reasoning with respect to rules and regulations mainly concerned their adherence to drug shortage advice issued by the Royal Dutch Pharmacists Association, KNMP (RR-consideration C1: ‘That I adhere to the advice regarding this shortage on the Farmanco website,’ which was ranked by 133 pharmacists). This consideration can be explained by the Dutch drug shortage problem, which has increased substantially over the last 10 years. Between 2008 and 2018, new cases of drug shortages (mainly temporary shortages) increased from 190 medicines to 769, and the number of shortages nearly doubled to 1500 shortages in 2019. 63 Pharmacists are professionally supported by their professional organisation, which runs a website to provide advice on the expected duration of shortages and potential solutions. This information may save time and help pharmacists choose the optimal solution for an individual patient. Overall, pharmacists’ moral reasoning perspectives regarding the three drug shortages suggest that Dutch pharmacists are particularly challenged in their PE-MRP when an alternative treatment is either expensive and not covered by the health insurer or when they perceive the drug shortage’s impact on a patient’s health outcome as low to medium (Table 2). In these cases, a business orientation reasoning may become more prominent. Strengths and Limitations Because three methods to recruit community pharmacists to complete this study were used, it is expected that all community pharmacists (N ≈ 2900) in the Netherlands could have received at least one invitation. However, we are aware that many pharmacists receive large amounts of emails and newsletters every day and probably a significant proportion of the invited pharmacists might not have actually read the invitation. We achieved a response of 10%, which is reasonable for this type of study. The respondents were representative of all pharmacists working in Dutch community pharmacy except for the percentage of primary responsible pharmacists. Their relatively higher percentage may be due to two reasons: their