Martine Kruijtbosch

182 Chap t e r 5 for the patient. Moral reasoning involves a cognitive-affective reflection process: possible options for action are explored by reflection on professional values, taking into account the consequences for all parties involved. 22,23 It is a prerequisite that health professionals are committed to the professional values of their healthcare practice. These values are often expressed in professional documents such as the Hippocratic oath 55 , national codes of ethics, and the Charter of Professionalism for Dutch pharmacists 21 . Being competent in moral reasoning empowers professionals to know what can be done to resolve complex moral dilemmas. Moreover, moral reasoning guides them to professional behaviour which is in line with their social role. 56,57 However, in daily practice moral dilemmas often need quick settlement. Professionals do not have enough time to reflect on the values and perspectives, with the result that the most appropriate judgement is not always made. Therefore, they need to be competent in moral reasoning. For community pharmacists this is especially the case as most of the time the patient is waiting at the counter of the pharmacy. Pharmacists’ social role Community pharmacists continuouslymake judgements and choices regardingpharmaceutical treatments for their patients. These treatments should be safe and appropriate and meet patients’ medication-related needs and concerns. As a profession, community pharmacy is grounded in a specific knowledge domain and based on professional values. 21,58 Therefore, society grants pharmacists a monopoly on the provision of medicines and pharmaceutical care. Also society holds pharmacists accountable for the appropriateness of pharmacotherapy. This accountability is comparable to other health professions. 45,47 For appropriate pharmacotherapy pharmacists need to be competent in clinical reasoning. This competency involves that pharmacists think, reason and ultimately make decisions about pharmacotherapy. 59,60 Clinical reasoning deals with uncertainty with regard to clinical risks and benefits of pharmacotherapy. During the clinical reasoning process pharmacists combine scientific knowledge, clinical experience and critical thinking with information from the patient. 60 This process is (un) consciously guided by professional values. It is surprising that this guidance is not mentioned in studies on clinical reasoning. 59,61 Especially because the clinical reasoning process may be hampered by factors such as lack of information, and relationship issues with physicians or patients (Chapters 2.1 and 2.2). When personal, professional, institutional or societal values are in conflict, clinical problems turn into moral dilemmas. Moral doubt arises about what is the right thing to do. In such dilemmas where involved parties have different values and perspectives, clinical reasoning may not be sufficient and moral reasoning may be needed to come to a good clinical decision. In these situations pharmacists need to identify which professional values cannot be realised and for what reasons, to negotiate, incorporate conflicting ideas, and make effort to respect differences.