Martine Kruijtbosch

151 Mo ra l case de l i be ra t i on ‘ I had no information about the indication, so was I doing the right thing by just dispensing what is mentioned on the prescription? I did not know what was best for the patient. ’ (CP, step 4) The dialogue and factual questions in the different steps revealed that the CP felt her dilemma most strongly in her communication with the wife when hearing the wife’s worries about her husband’s health and not knowing how to deal with these worries. This feeling was substantiated by the CP in the professional values pharmaceutical expertise and reliable and caring: ‘ The wife told me about her husband’s suffering. I had doubts about the double anticoagulant therapy. I did not know the indication and could only contact the first prescriber after a few days. The wife needed my knowledge and expertise to take away her worries and demanded advice about the best medicines for her husband. ’ (CP, step 2) The moral question that was underlying her dilemma and that the CP wanted to answer in this MCD session was reformulated from ‘ Should I advise the wife of this patient now directly to continue using the double anticoagulant therapy in this situation? ’ into ‘Do the concerns of the wife justify stopping one of the two anticoagulants?’ (step 4). Step 5 consolidated the image of the CP’s dilemma with the value perspective of the geriatrician in the rehabilitation centre and the reason why that geriatrician could not help the CP in her decision of what to tell the wife. One participant formulated this: ‘ He had to say that the double anticoagulation is right to continue because otherwise others would think of him that he had acted wrongly with continuing it all six weeks the patient stayed in the rehabilitation centre without knowing the indication.’ (Participant, step 5) In step 6, the participants formulated four alternative action options: (C) ‘ I advise the patient to contact the surgeon himsel f’, (D) ‘ I only stop the Pradaxa and advise to continue the acetylsalicylic acid ’, (E) ‘ I contact the patient myself ’ and (F) ‘ I contact the alternate specialist in the hospital again ’. Alternative action option E shed new light on answering the CP’s moral question as is described below in phase 3, decision-making. The CP had not seen that as an action option and substantiated this with the argument that she knew the situation of this patient from the recent past and was convinced no new information could be gathered from the alternate specialist. In MCD session 2, the picture the participants received in the image-formation phase was that the CP had emotional difficulty with the repeated disruptive attitude of the primary care physician and simultaneously had emotional problems because of an anxious patient who had fled the pharmacy. The participants also understood that the CP felt very bad that no