Martine Kruijtbosch

183 Gene ra l d i s cu s s i on Moral reasoning involves the following processes: inquiring what the moral dilemma constitutes, identifying gaps in medication-related patient information, identifying the relevant parties involved, identifying the perspectives and values of these parties, and identifying possible courses of action and moral consequences of these actions (i.e. possible harms and benefits affecting all parties involved). 62 Moral reasoning guides professionals to choose the best possible treatment also taking into account evidence-based-medicine. 36-38,62 Moral reasoning perspectives In the moral reasoning process pharmacists also integrate their own perspectives and values (moral reasoning perspectives [MRPs]). Pharmacists have to be transparent about their MRP to maintain the trust of patients, health professionals and society when they advise regarding pharmacotherapy. 63 Both qualitative and quantitative studies have investigated pharmacists’ MRPs when they handle moral dilemmas. 18,20,64 The qualitative studies showed that pharmacists generally found it evident to work in patients’ best interest. However, the science-based background of pharmacists results sometimes in a tendency to paternalism. 47,65 Also pharmacists’ reasoning was rather based on personal values and common sense than professional values, or was oriented towards keeping with rules and laws rather than towards the healthcare needs of patients. 19,47,65 Another study showed pharmacists also reasoned from a business perspective. 66 Although there is a negative image of community pharmacists being both business- and care- oriented 67-70 , the business orientation is part of a professional ethics orientation. 71 Pharmacists need a business orientation because they have the responsibility to society to contribute to the sustainability of access to medicines (Chapters 2.1, 2.2, 3.1 and 3.2). The quantitative studies predominantly use the Defining Issue Test (DIT ). 18,20 The DIT is able to measure three developmental levels of moral reasoning perspectives (MRP): a pre- conventional perspective (reasoning focused on personal interest), a conventional perspective (reasoning focused on maintaining norms) and a post-conventional perspective (reasoning focused on universal principles beyond personal interest and norms). In the US, studies using the DIT showed that pharmacists had the lowest post-conventional scores compared to other health professionals such as physicians and nurses. 56 The author suggested that the relatively low post-conventional moral reasoning perspective scores among community pharmacists can be explained from their business perspective. 56 In contrary, others suggested this business orientation is not the perspective of the pharmacist, but results from social, economic, and cultural factors in which pharmacy practice is embedded. 47,72 These contextual factors challenge the patient-centred perspective and should be considered when one aims to understand how both society and pharmacists perceive pharmacists’ social