Martine Kruijtbosch

181 Gene ra l d i s cu s s i on are not directly related to care for individual patients. Professional values are not (directly) involved in these situations. General professional training may help pharmacists to improve other competencies than ethical competencies when dealing with complex situations. Pharmacists experienced many moral dilemmas due to disruptive behaviour of either patients or physicians (Chapter 2.1). For example, within the themes ‘Drug abuse and addiction’ and ‘Claiming and aggressive behaviour’ pharmacists often experienced difficulties to maintain a trust-based relationship with patients having drug abuse and addiction problems or showing claiming and aggressive behaviour. Underneath these dilemmas limited experience of pharmacists with behavioural issues and communication techniques may play an important role. Within the themes ‘Disruptive behaviour of physicians’ and ‘Pharmacist and physician have a different opinion about appropriate pharmacotherapy’ pharmacists had worries regarding their relationship with physicians. Often the professional value of reliable and caring (acting reliable within the pharmacist-physician relationship) was in conflict with the professional value commitment to the patient’s well-being. Although we have not systematically studied which values prevailed in these moral dilemmas, we have the impression that the first value often was decisive in many cases. Pharmacists being overruled by physicians has also been signalled in other studies 19,46,47 and has been described as a form of moral passivity 46 . Pharmacists who are being overruled in their moral intentions compromise what is in patients’ best interest. 46 An explanation could be that pharmacists do not want to jeopardize their relationship with physicians as that might also affect the care for other patients. Pharmacists may thus be constantly weighing the importance of the well-being of individual patients to the well-being of all their patients. These dilemmas exemplify that pharmacists may find it difficult to adopt the right attitude when the professional relationship with either patients or other health professionals is troubled. Professional education could help pharmacists to foster professional competencies that make others grant their professional autonomy. 52 Although community pharmacists and primary care physicians in the Netherlands often collaborate fruitfully, there is ample room for improvement of mutual trust in each other’s expertise and inter-professional communication. 53 The best practices of inter-professional collaboration, are the result of a long process. Good inter-professional communication was a prerequisite for such a process. 53 This may prevent the perpetuation of a perceived asymmetrical relationship with physicians. 54 The focus will then shift from managing a troubled relationship to achieving a common patient-centred perspective. Moral reasoning Once a health professional has identified a moral dilemma, moral reasoning - also known as moral judgement formation - is required to judge what morally would be the best care