Martine Kruijtbosch

16 Chap t e r 1 manager and professional. These competencies are defined in the Canadian Medical Education Directions for Specialists (CanMEDS), and adopted by pharmacy educators in many countries. 26-28 Professionalism includes a reflective and ethical approach to practice. Professional accountability can only take place through reflection. In the literature on health professionalism some believe that reflection is the core competency involved in ethical decision-making and identity formation. 29,30 When taking ethical decisions in situations of moral dilemmas a health professional makes use of four cognitive-affective processes according to Rest’s Four Component Model of ethical decision-making: (1) moral sensitivity, (2) moral reasoning, (3) moral intention and (4) moral character. 31,32 See also Figure 1. The cognitive-affective process moral sensitivity involves that health professionals recognise moral dilemmas in their practice by being aware of the conflicting (professional) values and perspectives of all parties involved in these dilemmas. It requires that professionals are sensitive to the feelings, concerns, interests and reactions of others, firstly those of the patient, and be able to interpret these. In the decision-making process moral sensitivity involves that professionals are aware of action options and know how each of these could have (negative) implications for the well-being or interests of parties involved in the dilemma. Professionals are thus in this process able to see things from the perspective of others (individuals as well groups). Subsequently, moral reasoning entails that through contextual and value-based reflection health professionals are able to judge which of the action options of the moral dilemma is morally justifiable. Differently stated it means that they explore what ought to be done and on the basis of which (professional) values, taking into account the consequences for all parties involved. Moral intention means that health professionals are willing and motivated to do the morally right thing. This means that they will prioritize professional values over other (personal) values. At the end moral character by the health professional is required. 32,33 The health professional perseveres, to actually carry out what he morally intended to do. An ethical competent health professional is able to reflect on the professional values in each of the four ethical processes in situations of moral dilemmas (moral reflectivity). As such the professional shows professional behaviour. 29,34